Download Poisoning / overdose

Poisoning / overdose
Recommend
 Consult MO first if a substance is known to be toxic and a toxic quantity is known or
suspected to have been taken before Poisons Information Centre 13 11 26 (24
hour)
 Do not undertake any gastrointestinal decontamination until a full risk assessment
has been completed
 Do not give Oxygen to patients with suspected PARAQUAT/DIQUAT poisoning
 Consider poisoning in any patient who is confused, drowsy, unconscious or fitting
 Remember that someone who is conscious and talking after taking a poison could
still be in the early stages of severe poisoning
Related topics:
 Fits / convulsions / seizures, page 63
The unconscious patient, page 48
 Acute alcohol intoxication, pages 188, 372
 Hypoglycaemia, page 68
 Heat exhaustion / heat stroke / hyperthermia, page 160
1.
May present with:
 Confusion, drowsiness, altered conscious state or fitting
 Vomiting
 Cardiac arrhythmia
 Conscious and fully orientated with a history or circumstances suggestive of deliberate or accidental
poisoning
2.
Immediate management:
 Assess the patients:
 Airways
 Breathing
 Circulation
 Manage any seizures
 Correct hypoglycaemia
 Correct hyperthermia
 Use universal precautions in all poisoning cases (gloves, plastic gown and mask). Refer to Cyanide,
Organophosphates and Parquat / Diquat poisoning for specific advice
 If breathing, turn on to side in recovery position while obtaining more information (some poisons may
cause both vomiting and sedation sufficient to compromise the airway)
 Give oxygen as per clinical condition (except if PARAQUAT/DIQUAT poisoning) (see O2 Delivery
systems) to maintain O2 saturation >94%. If
Sa O2 >94% not maintained Consult MO
 Do not undertake any gastrointestinal decontamination until a full risk assessment has been
completed
Clinical assessment:
 Undertake a “Risk Assessment” by obtaining a full history including details of poisoning
3.
Agent taken?
Name of product, its ingredients/components, manufacturer
Look for container if possible. Ask relatives or witnesses.
Overdoses of drugs often involve more than one substance. Inquire specifically if alcohol has
been taken in all instances as it may greatly affect the toxicity of other exposures
Also inquire specifically about Paracetamol and any other over the counter products
Route of
exposure?
Oral, topical, eye, inhaled, injected
Dose?
Try to work out exactly how much was taken; this may require manually counting out the amount
remaining in the container from the amount initially thought to be there. It is always important to
consider the worst case scenario
Time of
exposure?
Exact time if possible
Intent of
exposure?
Accidental or deliberate
Has any
Has substance been diluted, skin been washed, eyes irrigated, etc
treatment been
attempted?
Patient factors?
Does the patient have any pre-existing illness, heart disease etc.
Clinical status of
patient?
BP, heart rate, respiratory rate, temperature, O2 saturation
Conscious state (see Glascow comma scale or AVPU)
Gag Reflex
4.
Management:

In cases of suspected poisoning, contact Poisons Information Centre (PIC) 13 11 26 (24 hours)
to determine if an exposure is likely to be toxic. However, if the substance is known to be toxic and
a toxic quantity is known or suspected to have been taken, Consult MO first. The PIC can help
determine the contents and other characteristics of the agent involved in the exposure, and then
advise on the likely clinical effects, and appropriate management in conjunction with the MO

The PIC has available up-to-date information on toxicology and management – many reference
books in common use are actually out of date

Supportive care and monitoring: Following stabilisation of the patient, good supportive care and
monitoring is sufficient for the majority of poisoned patients. Some patients may require further
investigations and decontamination as follows.
 investigations: All patients with intentional poisonings require a 12 lead ECG and a
paracetamol level (refer to Paracetamol poisoning for specific advice).

Decontamination: decontamination may be considered when:
 the risk assessment indicates severe or life threatening toxicity
 supportive care or antidote treatment alone may not ensure a good outcome
 the poison is still in the gastrointestinal tract (usually within an hour of ingestion)
 the poison is able to be removed by chosen method
 the patient has a secure airway
Activated charcoal
The PIC should be consulted on 131126 for more information on the appropriate use of activated
charcoal.
The administration of activated charcoal to paediatric patients should be a very rare event, as most
children are not exposed to life threatening doses of poisons and can be safely managed with good
supportive care.
Activated charcoal binds to poisons in the gut and prevents absorption. It is not effective for cyanide,
alcohols, iron, lithium, acids, alkalis or petroleum products.
Activated charcoal is usually ineffective if given more than 1.5 hours post-ingestion, although with some
drugs there may be advantage in administering activated charcoal after this time, or even in repeat
doses. Caution is required with the use of activated charcoal in patients who are not intubated because
of problems with aspiration. An important example is the drowsy patient with an unstable airway,
particularly those who are reluctant to take the activated charcoal, given that it may cause vomiting.
All patients who are or at risk of becoming drowsy, unconscious or fitting will need airway
protection and may need intubation prior to administration of activated charcoal
Adding ice cream to activated charcoal to improve palatability can assist in administration to children.
There is no evidence that the use of sorbitol or other cathartic agent provides any benefit over activated
charcoal alone.
Schedule
Nil
Form
Strength
Suspension
(50g/250mL)
Activated charcoal
Give on advice of Poisons Information Centre
or MO
Recommended
Route of Administration
Dosage
Oral
Adult 50 g
Giving the Activated charcoal to
Child 1g/kg
a child from a covered container
may increase its acceptance (the
colour can be off putting)
Note: if unable to drink, MO may
advise to place a NG tube and
the Activated charcoal mix be
given through the tube. Correct
placement of the NG tube is
essential
NON
DTP
Duration
Activated charcoal can
be repeated on MO’s
orders.
There are some drugs
(Carbamazepine,
Theophylline, Quinine
and Phenobarbitone)
whose elimination may
be enhanced with repeat
dosing eg. half the
original dose every 2 - 4
hrs.
Contact the PIC on 131126 for advice
Provide Consumer Medicine Information if available: Activated charcoal is unpalatable – but can be mixed with ice cream to
improve this
Management of Associated Emergency: Consult MO
Ipecac Syrup is rarely required, and should only be administered on the advice of a PIC or Clinical Toxicologist. Ipecac
induces vomiting within 15-30 minutes of administration. Its use has been largely abandoned in the treatment of poisoning.
Use of Ipecac may delay the administration of activated charcoal.
5.
Follow up:
 All patients who are or at risk of becoming drowsy, unconscious or fitting, or who may require specific
management or antidotes as detailed below may need to be evacuated/hospitalised
 An effort should be made in each case to prevent another accidental poisoning, including
encouragement to read the safety directions, follow medication directions carefully, and ring the PIC
for advice if poisoning occurs
 From time to time a public education effort should be made to prevent accidental poisoning of
children. Parents should be advised to keep toxic chemicals and medications out of the reach of
children. Medications in the home that are no longer being used should be disposed of safely. Never
transfer poisons into food or drink containers.
 The Queensland Poisons Information Centre has a useful website on the first aid treatment and
prevention of poisonings and can be found at: www.health.qld.gov.au/poisonsinformationcentre
6.
Referral / Consultation:
 Consult MO on all occasions if the substance taken is known or suspected to be toxic
 The PIC can help to clarify toxicity and give up to date advice on the urgency and the specifics of
management