Prof.

Dr Shahenaz Mahmoud Hussien

Historical and Physical Findings in poisoning
Ocular signs:
Miosis: Organophosphates, narcotics, chloral hydrate,
barbiturates(late)
Mydriasis: Atropine, alcohol. Antihistamines, carbon monoxide,
cyclic antidepressants, cyanide.
Nystagmus: Phenytoin, barbiturates, ethanol, c.o.
Lacrimation: Organophosphates, irritant gas or vapor.
Odor:
Odor Poison
Bitter almonds Cyanide
Acetone Salicylate, alcohol.
Paraldehyde. methanol
Alcohol Ethanol
Garlic Arsenic, thallium,
organophosphates
Violets Turpentine
Cardiac signs:
Tachycardia: Atropin, Aspirin, Theophyllin, Cyclic
antidepressants
Bradycardia: Digitalis, narcotics, organophosphates,
B-blocker.
Hypertension: Amphetamin, cocain, Lesergic acid
diethylamin.
Hypotension: Iron, barbiturates, cyclic
antidepressant, blockers

SKIN SIGNS:

Bullae Carbon monoxide,
barbiturates
Dry, hot skin Anticholinergic. botulism
Diaphoresis Organophosphates,
Aspirin
Alopecia Arsenic, lead, mercury
Erythema Anticholinergic, boric
acid, cyanide, mercury.
Respiratory signs:
Depressed respiration: Alcohol, narcotics, barbiturates.
Increased respiration: Aspirin, carbon monoxide, amphetamines
Pulmonary edema: Hydrocarbons, organophosphates, aspirin.
CNS signs:

Ataxia Alcohol, antidepressants,
Barbiturates, phenytoin
Coma Sedatives, narcotics, salicylate,
CO., Lead, cyanide, barbiturate
Hyperpyrexia Anticholinergics, quinine,
salicylates, amphetamin
Muscle fasciculation Organophosphates,
theophylline
Muscle rigidity Cyclic antidepressant,
haloperidol
Peripheral neuropathy Lead, arsenic, mercury.
Altered behavior LSD, amphetamines,
anticholinergics, camphor
Laboratory clues for diagnosis of poisoning
Metabolic acidosis: Methanol, Paraldehyde, phenformin, Iron,
Isoniazid, salicylates, ethanol.
Hypoglycemia: Ethanol, Isoniazid, Insulin, Propanolol, oral
hypoglycemics
Hyperglycemia: Salicylates, Iron, Sympathomimetics
Hypocalcemia: Oxalate, floride, ethylene glycol

Drugs amenable to therapeutic monitoring
-Antibiotics: Aminoglycosides Gentamycin Tobramycin
and Amikacin
Chloramphenicol
Vancomycin
-Immunosuppression: Methotrexate Cyclosporin
-Antipyretics: Acetaminophen Salicylate
-Other drugs: Digoxin Lithium Theophylline
Anticonvulsant drugs
TOXIC SYNDROMES
Acetaminophen: Nausea, vomiting, pallor, jaundice, hepatic
failure.
Anticholinergics: Mania delirium, fever, red dry skin, dry
mouth tachycardia, mydriasis, urine retention
Iron: Vomiting (bloody), diarrhea, hypotension, hepatic failure,
hyperglycemia, late intestinal stricture.
Narcotics: Coma, respiratory depression, hypotension,
pinpoint pupil.
Organophosphates: Miosis, salivation, urination,
diaphoresis, lacrimation, bronchospasm muscle weakness,
pulmonary edema, bradycardia, confusion and coma.
Salicylates: Tachycardia, fever, vomiting, diaphoresis,
lethargy, coma, alkalosis (early) acidosis (late).
Cyclic antidepressant: Coma convulsion, mydriasis,
hyperreflexia, arrhythemia (prolonged Q/T interval).
Carbon monoxide: Headache, dizziness, coma, skin bullae.
EMERGENCY ANTIDOTES

Poison Antidote Dosage Comments
Cyanide Amyl nitrate 1-2 pearl /2
min.
Then Na nitrat
Acetaminophen N-Acetyl
cystiene
140mg/kg PO
then 70mg/kg
/4h. 17 doses
Effective within 16 h of
ingestion
Atropine Physostigmine 0.01-
0.03mg/kg IV
Possible seizures,
bradycardia
Benzodiazepine Flumazenil

0.01-
0.02mg/kg IV
0.2 max.

Possible seizures,
arrhythemia
-Blocking
agents
Atropine 0.01-0.1mg/kg
IV
Min. dose 0.1mg
Calcium channel
blockers
Glucagon 0.05-0.1mg/kg
IV
Carbon monoxide
Oxygen
100%,hyperparic
Coumarin Vitamin K 2-5mg IV/ SC Monitor PT
Cyclic antidepressants Sodium bicarbonate 0.5-1mEq/kg IV
Digoxin Digoxinspecific Fab
antibody fragments
1 vial (40mg)
neutralizes 0.6mg
digoxin
Iron Deferoxamine 15-15mg/kg /hr IV
Isoniazid Pyridoxine Up to 250mg/kg/d for
5days
Lead EDTA= Edetate
calcium BAL=Birish-
anti-Lewisite
DMSA=Dimercaptosu
ccinic acid.
Penicillamine.
1500mg/m2/d for 5
days iv 3-
5mg/kg/dose/4hr 3-7
d. 10mg/kg/day PO
tid X5 d 20-
30mg/kg/day PO
/8hr
Mercury, Arsenic, Gold BAL
5mg/kg IM as soon as
possible.
Nitrites/ methemoglobinemia
Methylene blue
1-2mg/kg repeat 1-4 hr
Opiates,Darvon,Lomotil Naloxone 0,1mg/kg IV,ET,SC,IM up
2mg in children
Organophosphates Atropin 0.02-0.05mg/kg IV

Supportive care:
-Protect and maintain the airways.
-Establish effective breathing and circulation.
-If the consciousness is depressed IV glucose, 100%
oxygen, and naloxone should be administered.
-Gastric emptying by syrup of ipecac or oro-gastric
lavage within the first hour of poison ingestion,
and the airway is protected.
-Gastric lavage is not used if the ingested substance
is caustic or hydrocarbon, or foreign body.
Activated charcoal :
Single dose: 1g/kg with chocolate milk or
cola to improve palatability.
Multiple doses : 1g/kg initially with Sorbitol
,then 2-3 h without sorbitol. Sorbitol help to
avoid electrolyte imbalance.
Beneficial in an overdose involving ;
Carbamazepine, Dapsone, Theophylline,
Phentoin, and quinine, also in salicylate
overdose.

Whole bowel irrigation:
Used with Iron, Lead, packets of illicit drugs
and button batteries.
Dose: 500ml/hour for ages 9months to 6
years , and 1000ml/h in ages 7-12 years
until the effluent is clear, which occur in most
cases within 6 hours.
It is best accomplished by placing a
nasogastic tube.