SlideShare a Scribd company logo
1 of 11
Clinical Toxicology Management Protocols
A simple bulleted list approach
By
Kerolus Ekram Gad Shehata
Management protocol for Hydrocarbons intoxication
 Examples: Benzene, Kerosene, Gasoline, paint strippers…etc.
 High volatility with low surface tension leading to increased risk for aspiration
and rapid absorption even from skin exposure.
 Mode of intoxication: mainly accidental especially in children.
 Main symptoms: GI e.g. Nausea, vomiting & Respiratory e.g. dyspnea, distress.
 Main signs: tachypnea, characteristic odor, vomitus on clothes and CNS e.g.
drowsiness
 Skin decontamination under running tap water is of high priority in our
management.
 Oxygen flow: nasal cannula or through face mask.
 Antiemetics e.g. cortiplex B6.
 Assess the grade of respiratory distress through intercostal retractions, nasal
flaring, tachypnea (rapid shallow breathing). If > 40-60/min. it indicates
impending respiratory failure.
 We may use stool softeners e.g. Glycerin pediatric suppository to decrease GI
distension so that decreasing the elevation of the diaphragm to decrease the
work of breathing.
 Assess for associated co-ingestion e.g. organophosphorus insecticides.
 Nebulized B2 agonists bronchodilators if wheezy chest is found.
 On admission, Beside symptoma c TTT and follow up e.g. nebulizer/6h,
antiemetics, regular follow up of vital data and IV fluids, we may add
prophylactic antibiotics.
 Watch for the development of chemical pneumonitis with its sequalae up to
ARDS and respiratory failure which may require mechanical ventilation.
 Watch for skin lesion that may appear e.g. blisters and bullae and manage
accordingly.
 Labs: Glucose, Na, K, LFTs, ABG
 Imaging: CXR and ECG
 N.B. gastric lavage and emesis are generally C/I in these cases BUT if there is a
clear history of large volume ingestion along with disturbed conscious level,
we may perform gastric lavage ONLY under ETT coverage to minimize the risk
of aspiration.
Management protocol for Organophosphorus & Carbamate intoxication
Examples: Malathion, black granules rodenticide…etc.
Mode: Accidental, suicidal or Homicidal ( Carbamate ).
Main symptoms: Muscarinic e.g. pinpoint pupil, sweating,
lacrimation, salivation, diarrhea, urination, vomiting and
pulmonary secretions & Nicotinic e.g. fasiculations and muscle
weakness.
Once symptomatic equals admission.
If the patient is very weak, we intubate and administer the
obidoxime.
Life saving measure is Atropine..Till the chest secretions Dry.
GI decontamination via Emesis or gastric lavage according to the
degree of weakness.
Oxygen is preferred prior to atropine administration to preserve
the cardiac oxygen supply adequate.
After decontamination and stabilization, admit the symptomatic
pt. for symptomatic ttt, follow up + atropine + obidoxime course
if indicated.
Avoid severe atropinization that presents with blurred vision,
urinary retention and hallucinations.
Labs: Glucose, Na, K, serial pseudocholinesterase measurement,
LFTs and renal function tests.
No use of Oximes for Carbamate.
Imaging: CXR esp. if mechanically ventilated, ECG.
N.B. rising of the cholinesterase level may be deceiving due to
redistribution of the toxin.
Long term follow up for the development of intermediate
syndrome and neuropathy..etc.
Management protocol for opiate and opioids
 Examples: Morphine, Heroin…etc.
 Mode: mostly accidental overdose
 Route: ingestion, injection or snuffing
 Firstly, assess the vital date i.e. airway, breathing, B.P, pulse
 Assess the neurological system and exclude other causes of
disturbed conscious level i.e. detect whether signs of
lateralization are present or not.
 Assess for the need of intubation and mechanical ventilation e.g.
if GCS<8 TO Protect the airway.
 If available, Naloxone can be given to reverse the respiratory
depression take care not to cause acute withdrawal that may end
up with seizures. N.B. the t1/2 of naloxone is short so, you must be
ready to intubate if indicated.
 Main signs: pinpoint pupil, bradypnea, hypotension and
bradycardia along with disturbed consciousness.
 Order CT scan to exclude possible intracranial bleeding as a cause
of the disturbed consciousness especially if there are signs of
lateralization.
 Labs: Glucose, Na, K, urine screen for opiates and possible co-
ingestions, ABG
 If you suspect aspiration or ARDS: order CXR
 Order ECG to detect potential arrhythmias
 If you suspect rhabdomyolysis: order CK
 If prolonged coma prior to arrival, suspect ischaemic
encephalopathy and order MRI
 Care of the coma in ICU.
Management protocol for Carbon Monoxide intoxication
Circumstances: mainly in winter. Closed space, fire to warm up or
during showering, fires, running vehicles in garage…etc.
Main presentation: Nausea, vomiting, abdominal pain,
HEADACHE, dizziness, disturbed consciousness…etc.
Assess the vital data e.g. B.P, pulse and R.R and assess the GCS
Exclude other causes of disturbed consciousness.
Firstly, apply high flow OXYGEN as soon as possible.
We may add measures to decrease the ICT e.g. steroids and
Mannitol (1-2 gm/kg) provided that the B.P and renal function
allow that.
Antiemetics to stop the vomiting.
Labs: Glucose, Na, K, ABG, CarboxyHB level, renal function tests
and cardiac biomarkers.
Imaging: CT scan to exclude intracranial bleeding, ECG
If disturbed conscious level that doesn't improve with the above
mentioned measures, intubate and mechanically ventilate the pt.
with 100% oxygen for 6 h. then gradual weaning.
Symptomatic TTT and regular follow up of the vital data and labs
in the ICU.
Assess the need for Hyperbaric oxygen sessions e.g. cardiac
arrhythmias, changes in the mental status, pregnant females and
persistent non-improving symptoms.
If there is cardia ischaemia: the main line of TTT is
oxygen/Hyperbaric oxygen.
If you suspect rhabdomyolysis: order CK
If you suspect permanent neurological sequalae e.g. affection of
the basal ganglia: order MRI
 Order long term follow up for potential future neurological
sequalae.
intoxicationTheophyllineagement protocol forMan
 Mode: mostly suicidal or accidental overdose
 Main symptoms: repeated vomiting, dyspnea, palpitation, tremors
and dizziness.
 Main signs: Tachycardia, hypotension, agitation, tremors, tachypnea
 Take careful history about the drug( amount, form e.g. SR,
delay…etc.) and assess the vital data including the B.P, pulse and R.R.
 Gastric decontamination via induction of emesis (without Epicac) or
gastric lavage especially for the sustained release forms.
 Multiple Dose Activated Charcoal.
 Admission of the patient is mandatory.
 Order Glucose, Na, K, ABG, Theophylline level
 Order ECG along with cardiac biomarkers to detect possible
arrhythmias or ischaemia.
 If you suspect rhabdomyolysis, order Creatine Kinase level
 For intractable vomi ng, give cor plex B6 , primperan or even
Ondansetron for severe cases. Avoid phenothiazines as they decrease
the threshold of seizures.
 Fluid replacement is of major priority with correction of the
underlying electrolyte abnormalities e.g. low K.
 For severe agitation or seizures, give Diazepam or phenobarbital.
 Assess for the need of hemodialysis e.g. very high level, non-
correctable metabolic acidosis, severe CNS or cardiac manifestations.
 If there is hypotension, IV fluids then norepinephrine if no adequate
response.
 For SVT, give propranolol or verapamil.
 For ventricular arrhythmias, give Lidocaine.
Management of Acetaminophen intoxication
Take careful history and assess for co-ingestion e.g.
salicylates…etc.
Assess the vital data e.g. pulse, B.P and R.R.
Main symptoms: Asymptomatic or GI symptoms.
Gastric decontamination if the delay period allows i.e.
usually done if < 2h delay.
Assess the toxic dose: > 150 mg/kg or usually > 7.5 gm.
If the time since ingestion is between 4 h- 24 h, order
acetaminophen level and compare it to the normogram.
If the level is high, admission is mandatory.
If the level is not toxic, Discharge the patient with
outpatient follow up of Liver function tests and you may
also prescribe N-acetyl Cysteine sachets as a measure for
any potential liver damage.
Labs: Glucose, Na, K, Liver function tests, acetaminophen
level, kidney function tests and ABG
Start N-Acetyl Cysteine course orally or intravenously if
there is repeated vomiting. We may also give the oral form
through a Ryle tube.
Oral dose: Loading 140 mg8/kg then maintenance 70
mg/kg for 17 doses with serial acetaminophen level and
LFTs.
Watch for any allergic reactions if the IV form is used.
Management protocol for Calcium Channel Blockers Intoxication
 Take careful history and assess for co-ingestions.
 Assess the vital data including the B.P, pulse and R.R.
 Admission is mandatory.
 Gastric decontamination via induction of emesis or gastric lavage
is done if the vital data are stable & the delay < 2h (Except for the
sustained release forms) then activated charcoal is given as
MDAC.
 ECG is done on admission and serially thereafter.
 CNS manifestations sometimes occur e.g. dizziness, syncope or
seizures.
 If brady-arrhythmias are present, start Calcium gluconate or
chloride slowly intravenous. Atropine also can be given
concurrently.
 If the brady-arrhythmias are resistant to TTT, urgent cardiology
consultation for temporary pacing.
 If Hypotensive, start IV crystalloids or colloids and administer
dopamine if there is inadequate response.
 If there is resistant hypotension, we may revert to intra-aortic
balloon pump as a temporary measure to help tissue perfusion
via the failing heart.
 Order: Glucose, Na, K, ABG and serial electrolyte panel
monitoring.
 If you suspect cardiogenic pulmonary edema: order CXR and
monitor the CVP.
 If cardiogenic shock develops, Dobutamine is a better option
than dopamine.
intoxicationBeta BlockersManagement protocol for
 Take careful history and assess for co-ingestions.
 Assess the vital date especially the pulse, B.P and R.R.
 Main symptoms: dizziness, syncope and dyspnea.
 Main signs: Bradycardia, hypotension and wheezy chest (most
specific).
 CNS manifestations may occur e.g. coma or seizures!!
 GI decontamination via induction of emesis is done only if the vital
data are stable and the delay is < 2h.
 Multiple Dose Activated Charcoal is used thereafter.
 Admission of the patient is mandatory.
 Order ECG on admission and serially thereafter.
 If there is bradycardia, administer atropine IV.
 If atropine resistant or accompanied with hypotension and other
features of hemodynamic instability, administer Glucagon as an
antidote IV.
 If bradycardia is still resistant to TTT, Urgent cardiology consultation
for temporary pacing.
 For hypotension, give IV crystalloids or colloids, dopamine,
Norepinephrine if the response is inadequate.
 If the hypotension in resistant to all of the above measures, Urgent
cardiology consultation to put an intra-aortic balloon pump as a
temporary life-saving measure.
 Order: Glucose, Na, K, ABG and serial electrolyte panel monitoring.
 If you suspect cardiogenic pulmonary edema, order CXR and monitor
the CVP.
 For seizures, administer BZP or phenobarbital.
 For bronchospasm, administer regular nebulized B2 agonists.
intoxicationDigitalisManagement protocol of
 Take careful history and assess for co-ingestions.
 Assess the hemodynamic status of the patient i.e. Pulse, B.P and R.R.
 Main symptoms: Nausea, vomiting, diarrhea, dizziness.
 Main signs: irregular brady-arrhythmias, hypotension. Patient may
come with manifestations of heart failure if the toxicity occur on top
of the already compromised cardiac functions.
 Admission of the patient is mandatory.
 Induction of emesis is done only if the patient is hemodynamically
stable and the delay is <2 h. Atropine is preferred to be given before
emesis to reverse the reflex vagal stimulation during emesis.
 Multiple dose activated charcoal is of a high priority in management.
 ECG is done on admission and serially thereafter.
 Any type of arrhythmias can occur with digitalis toxicity. Down
sloping of the ST segment is usually seen but it is not specific.
 The most specific arrhythmia is: Atrial tachy-arrhythmia with A-V
block
 If pt. is bradycardic, atropine is administrated and repeated as
needed.
 If there is no response to atropine, Urgent cardiology consultation for
temporary pacing.
 For Hypotension, administer IV fluids BUT Never to order any ca++
containing fluids e.g. Ringer's...etc.
 Dopamine can be used for resistant hypotension.
 Fab fragment antidote is highly expensive so, it is not usually
available BUT it is the best line of TTT if available.
 Order: Glucose, Na, K, Mg++
, ABG, Renal function tests. Electrolyte
panels should be ordered serially and corrected promptly.
 If you suspect cardiogenic pulmonary edema, order CXR and serially
measure the CVP and manage accordingly.
Food poisoningManagement protocol of
 The first step is to take a detailed history of the circumstance, the type of
food, the presenting symptoms…etc.
 The most important step is to EXCLUDE other causes of the presenting
symptoms e.g. Organophosphorus, Botulism, Carbon Monoxide….etc.
before you establish a diagnosis of acute gastroenteritis.
 Careful examination especially of the abdomen to EXCLUDE surgical
causes of the presenting complaint(s).
 Assess the vital date including the pulse, B.P and R.R.
 Assess the degree of dehydration if present and order IV fluid
resuscitation if needed (preferably with Panthol or Ringer's lactate
solutions).
 Symptomatic TTT in the ER via antispasmodic, antiemetic and H2 blocker
ampoules.
 Establish the need to get admitted or discharged on outpatient TTT or
referral to the Fever hospital according to the presenting complaints &
the severity of the case.
 Presence of blood and mucus in the diarrhea suggest a bacterial (e.g.
shigella, EHEC) or protozoal (e.g. E.histolytica) which need specific TTT in
addition to the other symptomatic and supportive measures.
 If the main complaint is dyspnea with history of eating preserved food
products, think of MetHb and manage accordingly.
 If symptoms develop after ingestion of some plant materials, keep them
under observation or admit them as the symptoms are usually severe and
fluctuating in appearance.
 If there is history of perioral and limb numbness & weakness along with
dizziness and other neurological manifestations, think of Ciguatera or
Tetradoxin toxicity and manage accordingly ( may need gastric lavage up
to mechanical ventilation).
 If there is itching, blistering, skin rash, wheezing after fish ingestion, think
of Scombroid poisoning and manage with antihistamines, steroids and
other supportive measures if needed.
 Prescribe outpatient TTT if the case is mild and recommend some dietary
instructions for the next few days.

More Related Content

What's hot

Medicine 5th year, all lectures/drug poisoning (Dr. Mohammad Shaikhani)
Medicine 5th year, all lectures/drug poisoning (Dr. Mohammad Shaikhani)Medicine 5th year, all lectures/drug poisoning (Dr. Mohammad Shaikhani)
Medicine 5th year, all lectures/drug poisoning (Dr. Mohammad Shaikhani)College of Medicine, Sulaymaniyah
 
General approach to treating poisoning cases with life threatening problems
General approach to treating poisoning cases with life threatening problemsGeneral approach to treating poisoning cases with life threatening problems
General approach to treating poisoning cases with life threatening problemsSam George
 
Approach to drug poisoning in adults by Dr Alaa Elmassry
Approach to drug poisoning in adults by Dr Alaa ElmassryApproach to drug poisoning in adults by Dr Alaa Elmassry
Approach to drug poisoning in adults by Dr Alaa Elmassryalaa massry
 
Poisonpptx 140504003359-phpapp01
Poisonpptx 140504003359-phpapp01Poisonpptx 140504003359-phpapp01
Poisonpptx 140504003359-phpapp01uptu
 
Poisons and principle for treatment of poisoning
Poisons and principle for treatment of poisoningPoisons and principle for treatment of poisoning
Poisons and principle for treatment of poisoningM Ramzan Baloch
 
Toxicological emergencies ppt
Toxicological emergencies pptToxicological emergencies ppt
Toxicological emergencies pptMichelle Harris
 
Management of poison(Emergency Medicine)
Management of poison(Emergency Medicine)Management of poison(Emergency Medicine)
Management of poison(Emergency Medicine)kalyan ram
 
Approach to the poisoned patient part one
Approach to the poisoned patient part oneApproach to the poisoned patient part one
Approach to the poisoned patient part oneDomina Petric
 
Toxico Overdose Lec07.
Toxico Overdose Lec07.Toxico Overdose Lec07.
Toxico Overdose Lec07.Shaikhani.
 
Poisoning plus MCQs 2012.
Poisoning plus MCQs 2012.Poisoning plus MCQs 2012.
Poisoning plus MCQs 2012.Shaikhani.
 
Principles of Management of Acute Poisoning
Principles of Management of Acute PoisoningPrinciples of Management of Acute Poisoning
Principles of Management of Acute PoisoningTahar Abdulaziz Suliman
 
Treatment of poisoning
Treatment of poisoningTreatment of poisoning
Treatment of poisoningvisheshrohatgi
 
Acute poisoning guidelines for initial management
Acute poisoning   guidelines for initial managementAcute poisoning   guidelines for initial management
Acute poisoning guidelines for initial managementDr. Saad Saleh Al Ani
 
Approach to patient with unknown overdose
Approach to patient with unknown overdoseApproach to patient with unknown overdose
Approach to patient with unknown overdoseHanan Fathy
 

What's hot (20)

Toxicology 101
Toxicology 101Toxicology 101
Toxicology 101
 
Medicine 5th year, all lectures/drug poisoning (Dr. Mohammad Shaikhani)
Medicine 5th year, all lectures/drug poisoning (Dr. Mohammad Shaikhani)Medicine 5th year, all lectures/drug poisoning (Dr. Mohammad Shaikhani)
Medicine 5th year, all lectures/drug poisoning (Dr. Mohammad Shaikhani)
 
General approach to treating poisoning cases with life threatening problems
General approach to treating poisoning cases with life threatening problemsGeneral approach to treating poisoning cases with life threatening problems
General approach to treating poisoning cases with life threatening problems
 
Approach to drug poisoning in adults by Dr Alaa Elmassry
Approach to drug poisoning in adults by Dr Alaa ElmassryApproach to drug poisoning in adults by Dr Alaa Elmassry
Approach to drug poisoning in adults by Dr Alaa Elmassry
 
Poisonpptx 140504003359-phpapp01
Poisonpptx 140504003359-phpapp01Poisonpptx 140504003359-phpapp01
Poisonpptx 140504003359-phpapp01
 
Poisons and principle for treatment of poisoning
Poisons and principle for treatment of poisoningPoisons and principle for treatment of poisoning
Poisons and principle for treatment of poisoning
 
Toxicological emergencies ppt
Toxicological emergencies pptToxicological emergencies ppt
Toxicological emergencies ppt
 
Management of poison(Emergency Medicine)
Management of poison(Emergency Medicine)Management of poison(Emergency Medicine)
Management of poison(Emergency Medicine)
 
Toxicology Lecture
Toxicology LectureToxicology Lecture
Toxicology Lecture
 
Acute poisoning
Acute poisoningAcute poisoning
Acute poisoning
 
Approach to the poisoned patient part one
Approach to the poisoned patient part oneApproach to the poisoned patient part one
Approach to the poisoned patient part one
 
Toxico Overdose Lec07.
Toxico Overdose Lec07.Toxico Overdose Lec07.
Toxico Overdose Lec07.
 
Poisoning plus MCQs 2012.
Poisoning plus MCQs 2012.Poisoning plus MCQs 2012.
Poisoning plus MCQs 2012.
 
Principles of Management of Acute Poisoning
Principles of Management of Acute PoisoningPrinciples of Management of Acute Poisoning
Principles of Management of Acute Poisoning
 
Treatment of poisoning
Treatment of poisoningTreatment of poisoning
Treatment of poisoning
 
Acute poisoning
Acute poisoningAcute poisoning
Acute poisoning
 
Acute poisoning guidelines for initial management
Acute poisoning   guidelines for initial managementAcute poisoning   guidelines for initial management
Acute poisoning guidelines for initial management
 
Approach to patient with unknown overdose
Approach to patient with unknown overdoseApproach to patient with unknown overdose
Approach to patient with unknown overdose
 
Toxicology
ToxicologyToxicology
Toxicology
 
Poisoning & Drug overdose
Poisoning & Drug overdosePoisoning & Drug overdose
Poisoning & Drug overdose
 

Viewers also liked

Most commons in medicine sample
Most commons in medicine sampleMost commons in medicine sample
Most commons in medicine samplemedpgnotes ebooks
 
Points about medical topics sample
Points about medical topics samplePoints about medical topics sample
Points about medical topics samplemedpgnotes ebooks
 
238944609 lip-cases-4
238944609 lip-cases-4238944609 lip-cases-4
238944609 lip-cases-4homeworkping4
 
Medical tabular columns sample
Medical tabular columns sampleMedical tabular columns sample
Medical tabular columns samplemedpgnotes ebooks
 
Agents for Brain Injury
Agents for Brain InjuryAgents for Brain Injury
Agents for Brain InjuryBrian Piper
 
Vaccines: A guide for medical students
Vaccines: A guide for medical studentsVaccines: A guide for medical students
Vaccines: A guide for medical studentsMedical Educator
 
Poisoning management guidelines
Poisoning management guidelinesPoisoning management guidelines
Poisoning management guidelinesKerolus Shehata
 
241573114 persons-cases
241573114 persons-cases241573114 persons-cases
241573114 persons-caseshomeworkping4
 
Neuropharmacology: Affective Disorders
Neuropharmacology: Affective DisordersNeuropharmacology: Affective Disorders
Neuropharmacology: Affective DisordersBrian Piper
 

Viewers also liked (20)

Points about drugs sample
Points about drugs samplePoints about drugs sample
Points about drugs sample
 
Most commons in medicine sample
Most commons in medicine sampleMost commons in medicine sample
Most commons in medicine sample
 
Medical timelines sample
Medical timelines sampleMedical timelines sample
Medical timelines sample
 
Points about medical topics sample
Points about medical topics samplePoints about medical topics sample
Points about medical topics sample
 
Hema
HemaHema
Hema
 
238944609 lip-cases-4
238944609 lip-cases-4238944609 lip-cases-4
238944609 lip-cases-4
 
Medical tabular columns sample
Medical tabular columns sampleMedical tabular columns sample
Medical tabular columns sample
 
Agents for Brain Injury
Agents for Brain InjuryAgents for Brain Injury
Agents for Brain Injury
 
Respiratory failure
Respiratory failureRespiratory failure
Respiratory failure
 
04 non malignant lymphocyte disorders
04 non malignant lymphocyte disorders04 non malignant lymphocyte disorders
04 non malignant lymphocyte disorders
 
02 neutropenia
02 neutropenia02 neutropenia
02 neutropenia
 
Vaccines: A guide for medical students
Vaccines: A guide for medical studentsVaccines: A guide for medical students
Vaccines: A guide for medical students
 
Poisoning management guidelines
Poisoning management guidelinesPoisoning management guidelines
Poisoning management guidelines
 
Liver Enzymology
Liver EnzymologyLiver Enzymology
Liver Enzymology
 
Cardiovascular System Pathology 2014 edited by @jennings argwing
Cardiovascular System Pathology 2014 edited by @jennings argwingCardiovascular System Pathology 2014 edited by @jennings argwing
Cardiovascular System Pathology 2014 edited by @jennings argwing
 
Hemopoiesis
HemopoiesisHemopoiesis
Hemopoiesis
 
241573114 persons-cases
241573114 persons-cases241573114 persons-cases
241573114 persons-cases
 
Respiratory system sample
Respiratory system sampleRespiratory system sample
Respiratory system sample
 
Neuropharmacology: Affective Disorders
Neuropharmacology: Affective DisordersNeuropharmacology: Affective Disorders
Neuropharmacology: Affective Disorders
 
Unit 2 respiratory system 2014edited by @jennings argwing
Unit 2 respiratory system 2014edited by @jennings argwingUnit 2 respiratory system 2014edited by @jennings argwing
Unit 2 respiratory system 2014edited by @jennings argwing
 

Similar to Clinical toxicology management protocols

Drug Overdose
Drug OverdoseDrug Overdose
Drug OverdoseMed Bee
 
Management protocol of organophosphoprus intoxication
Management protocol of organophosphoprus intoxicationManagement protocol of organophosphoprus intoxication
Management protocol of organophosphoprus intoxicationKerolus Shehata
 
Diabetic ketoacidosis ppt
Diabetic ketoacidosis pptDiabetic ketoacidosis ppt
Diabetic ketoacidosis pptPriyanka Karnik
 
Acuterenalfailure management in children
Acuterenalfailure management in childrenAcuterenalfailure management in children
Acuterenalfailure management in childrenVinayak Hegde
 
Neonatal shock
Neonatal shockNeonatal shock
Neonatal shock. .
 
Gastroenterology icu management protocol
Gastroenterology icu management protocolGastroenterology icu management protocol
Gastroenterology icu management protocolAshish Shrestha
 
common poisioning.pdf
common poisioning.pdfcommon poisioning.pdf
common poisioning.pdfPrakashRaut15
 
Managment guideline of common Poisioning
Managment guideline of common PoisioningManagment guideline of common Poisioning
Managment guideline of common PoisioningShivshankar Badole
 
cardiac emergencice im pediatrics
cardiac emergencice im pediatricscardiac emergencice im pediatrics
cardiac emergencice im pediatricsSheikah Bawazir
 
Diagnosis and management of Hyperkalemia
 Diagnosis and management of Hyperkalemia Diagnosis and management of Hyperkalemia
Diagnosis and management of HyperkalemiaDr Ramesh Krishnan
 
Approach to management of Hyperkalemia
Approach to management of  HyperkalemiaApproach to management of  Hyperkalemia
Approach to management of HyperkalemiaDr Ramesh Krishnan
 
Hypokalemiaandhyperkalemiaindorepedicon2014final 140112051537-phpapp01(1)
Hypokalemiaandhyperkalemiaindorepedicon2014final 140112051537-phpapp01(1)Hypokalemiaandhyperkalemiaindorepedicon2014final 140112051537-phpapp01(1)
Hypokalemiaandhyperkalemiaindorepedicon2014final 140112051537-phpapp01(1)FarragBahbah
 
1618256660403_hypokalemia and hyperkalemia.pptx
1618256660403_hypokalemia and hyperkalemia.pptx1618256660403_hypokalemia and hyperkalemia.pptx
1618256660403_hypokalemia and hyperkalemia.pptxVignesKm1
 
Toxicology pgy 1+2 2013
Toxicology pgy 1+2 2013Toxicology pgy 1+2 2013
Toxicology pgy 1+2 2013chricres
 
potassiumimbalanceandmanagement-171224181212.pdf
potassiumimbalanceandmanagement-171224181212.pdfpotassiumimbalanceandmanagement-171224181212.pdf
potassiumimbalanceandmanagement-171224181212.pdfCutiePie71
 

Similar to Clinical toxicology management protocols (20)

Drug Overdose
Drug OverdoseDrug Overdose
Drug Overdose
 
Management protocol of organophosphoprus intoxication
Management protocol of organophosphoprus intoxicationManagement protocol of organophosphoprus intoxication
Management protocol of organophosphoprus intoxication
 
Diabetic ketoacidosis ppt
Diabetic ketoacidosis pptDiabetic ketoacidosis ppt
Diabetic ketoacidosis ppt
 
Acuterenalfailure management in children
Acuterenalfailure management in childrenAcuterenalfailure management in children
Acuterenalfailure management in children
 
Pulmonary Embolism
Pulmonary EmbolismPulmonary Embolism
Pulmonary Embolism
 
DKA in children
DKA in childrenDKA in children
DKA in children
 
Neonatal shock
Neonatal shockNeonatal shock
Neonatal shock
 
Gastroenterology icu management protocol
Gastroenterology icu management protocolGastroenterology icu management protocol
Gastroenterology icu management protocol
 
common poisioning.pdf
common poisioning.pdfcommon poisioning.pdf
common poisioning.pdf
 
Managment guideline of common Poisioning
Managment guideline of common PoisioningManagment guideline of common Poisioning
Managment guideline of common Poisioning
 
cardiac emergencice im pediatrics
cardiac emergencice im pediatricscardiac emergencice im pediatrics
cardiac emergencice im pediatrics
 
Diagnosis and management of Hyperkalemia
 Diagnosis and management of Hyperkalemia Diagnosis and management of Hyperkalemia
Diagnosis and management of Hyperkalemia
 
Approach to management of Hyperkalemia
Approach to management of  HyperkalemiaApproach to management of  Hyperkalemia
Approach to management of Hyperkalemia
 
Hypokalemiaandhyperkalemiaindorepedicon2014final 140112051537-phpapp01(1)
Hypokalemiaandhyperkalemiaindorepedicon2014final 140112051537-phpapp01(1)Hypokalemiaandhyperkalemiaindorepedicon2014final 140112051537-phpapp01(1)
Hypokalemiaandhyperkalemiaindorepedicon2014final 140112051537-phpapp01(1)
 
1618256660403_hypokalemia and hyperkalemia.pptx
1618256660403_hypokalemia and hyperkalemia.pptx1618256660403_hypokalemia and hyperkalemia.pptx
1618256660403_hypokalemia and hyperkalemia.pptx
 
Toxicology pgy 1+2 2013
Toxicology pgy 1+2 2013Toxicology pgy 1+2 2013
Toxicology pgy 1+2 2013
 
Diabetic ketoacidosis
Diabetic ketoacidosisDiabetic ketoacidosis
Diabetic ketoacidosis
 
Shock In Children
Shock In ChildrenShock In Children
Shock In Children
 
shock ppt final.pptx
shock ppt final.pptxshock ppt final.pptx
shock ppt final.pptx
 
potassiumimbalanceandmanagement-171224181212.pdf
potassiumimbalanceandmanagement-171224181212.pdfpotassiumimbalanceandmanagement-171224181212.pdf
potassiumimbalanceandmanagement-171224181212.pdf
 

More from Kerolus Shehata

Invasive Hemodynamics: Assessment and interpretation
Invasive Hemodynamics: Assessment and interpretationInvasive Hemodynamics: Assessment and interpretation
Invasive Hemodynamics: Assessment and interpretationKerolus Shehata
 
Guideline‐Directed Medical Therapy in HFrEF
Guideline‐Directed Medical Therapy in HFrEFGuideline‐Directed Medical Therapy in HFrEF
Guideline‐Directed Medical Therapy in HFrEFKerolus Shehata
 
Cholesterol Management Guidelines
Cholesterol Management GuidelinesCholesterol Management Guidelines
Cholesterol Management GuidelinesKerolus Shehata
 
Complete EKG Interpretation Course
Complete EKG Interpretation Course Complete EKG Interpretation Course
Complete EKG Interpretation Course Kerolus Shehata
 
Evaluation of Chest Pain in the Ambulatory Setting
Evaluation of Chest Pain in the Ambulatory SettingEvaluation of Chest Pain in the Ambulatory Setting
Evaluation of Chest Pain in the Ambulatory SettingKerolus Shehata
 
Management of hypertension
Management of hypertensionManagement of hypertension
Management of hypertensionKerolus Shehata
 
Anticoagulation in venous thromboembolism
Anticoagulation in venous thromboembolismAnticoagulation in venous thromboembolism
Anticoagulation in venous thromboembolismKerolus Shehata
 
Hyperglycemic crises and hypoglycemia
Hyperglycemic crises and hypoglycemiaHyperglycemic crises and hypoglycemia
Hyperglycemic crises and hypoglycemiaKerolus Shehata
 
Left Bundle Branch Block (LBBB)
Left Bundle Branch Block (LBBB)Left Bundle Branch Block (LBBB)
Left Bundle Branch Block (LBBB)Kerolus Shehata
 
Non-Astherosclerotic Spontaneous Coronary Dissection
Non-Astherosclerotic Spontaneous Coronary DissectionNon-Astherosclerotic Spontaneous Coronary Dissection
Non-Astherosclerotic Spontaneous Coronary DissectionKerolus Shehata
 
Make your life worth living
Make your life worth livingMake your life worth living
Make your life worth livingKerolus Shehata
 
First Aid, illustrated & simplified
First Aid, illustrated & simplified First Aid, illustrated & simplified
First Aid, illustrated & simplified Kerolus Shehata
 
Get inspired and motivated
Get inspired and motivated Get inspired and motivated
Get inspired and motivated Kerolus Shehata
 
General Toxicology, All In A Nutshell
General Toxicology, All In A NutshellGeneral Toxicology, All In A Nutshell
General Toxicology, All In A NutshellKerolus Shehata
 

More from Kerolus Shehata (20)

Invasive Hemodynamics: Assessment and interpretation
Invasive Hemodynamics: Assessment and interpretationInvasive Hemodynamics: Assessment and interpretation
Invasive Hemodynamics: Assessment and interpretation
 
Infective Endocarditis
Infective EndocarditisInfective Endocarditis
Infective Endocarditis
 
Stress Echocardiography
Stress EchocardiographyStress Echocardiography
Stress Echocardiography
 
Exercise ECG Testing
Exercise ECG Testing Exercise ECG Testing
Exercise ECG Testing
 
Guideline‐Directed Medical Therapy in HFrEF
Guideline‐Directed Medical Therapy in HFrEFGuideline‐Directed Medical Therapy in HFrEF
Guideline‐Directed Medical Therapy in HFrEF
 
Atrial Fibrillation
Atrial FibrillationAtrial Fibrillation
Atrial Fibrillation
 
Preoperative evaluation
Preoperative evaluationPreoperative evaluation
Preoperative evaluation
 
Cholesterol Management Guidelines
Cholesterol Management GuidelinesCholesterol Management Guidelines
Cholesterol Management Guidelines
 
ASPREE Trial
ASPREE TrialASPREE Trial
ASPREE Trial
 
Complete EKG Interpretation Course
Complete EKG Interpretation Course Complete EKG Interpretation Course
Complete EKG Interpretation Course
 
Evaluation of Chest Pain in the Ambulatory Setting
Evaluation of Chest Pain in the Ambulatory SettingEvaluation of Chest Pain in the Ambulatory Setting
Evaluation of Chest Pain in the Ambulatory Setting
 
Management of hypertension
Management of hypertensionManagement of hypertension
Management of hypertension
 
Anticoagulation in venous thromboembolism
Anticoagulation in venous thromboembolismAnticoagulation in venous thromboembolism
Anticoagulation in venous thromboembolism
 
Hyperglycemic crises and hypoglycemia
Hyperglycemic crises and hypoglycemiaHyperglycemic crises and hypoglycemia
Hyperglycemic crises and hypoglycemia
 
Left Bundle Branch Block (LBBB)
Left Bundle Branch Block (LBBB)Left Bundle Branch Block (LBBB)
Left Bundle Branch Block (LBBB)
 
Non-Astherosclerotic Spontaneous Coronary Dissection
Non-Astherosclerotic Spontaneous Coronary DissectionNon-Astherosclerotic Spontaneous Coronary Dissection
Non-Astherosclerotic Spontaneous Coronary Dissection
 
Make your life worth living
Make your life worth livingMake your life worth living
Make your life worth living
 
First Aid, illustrated & simplified
First Aid, illustrated & simplified First Aid, illustrated & simplified
First Aid, illustrated & simplified
 
Get inspired and motivated
Get inspired and motivated Get inspired and motivated
Get inspired and motivated
 
General Toxicology, All In A Nutshell
General Toxicology, All In A NutshellGeneral Toxicology, All In A Nutshell
General Toxicology, All In A Nutshell
 

Recently uploaded

SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 

Recently uploaded (20)

SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 

Clinical toxicology management protocols

  • 1. Clinical Toxicology Management Protocols A simple bulleted list approach By Kerolus Ekram Gad Shehata
  • 2. Management protocol for Hydrocarbons intoxication  Examples: Benzene, Kerosene, Gasoline, paint strippers…etc.  High volatility with low surface tension leading to increased risk for aspiration and rapid absorption even from skin exposure.  Mode of intoxication: mainly accidental especially in children.  Main symptoms: GI e.g. Nausea, vomiting & Respiratory e.g. dyspnea, distress.  Main signs: tachypnea, characteristic odor, vomitus on clothes and CNS e.g. drowsiness  Skin decontamination under running tap water is of high priority in our management.  Oxygen flow: nasal cannula or through face mask.  Antiemetics e.g. cortiplex B6.  Assess the grade of respiratory distress through intercostal retractions, nasal flaring, tachypnea (rapid shallow breathing). If > 40-60/min. it indicates impending respiratory failure.  We may use stool softeners e.g. Glycerin pediatric suppository to decrease GI distension so that decreasing the elevation of the diaphragm to decrease the work of breathing.  Assess for associated co-ingestion e.g. organophosphorus insecticides.  Nebulized B2 agonists bronchodilators if wheezy chest is found.  On admission, Beside symptoma c TTT and follow up e.g. nebulizer/6h, antiemetics, regular follow up of vital data and IV fluids, we may add prophylactic antibiotics.  Watch for the development of chemical pneumonitis with its sequalae up to ARDS and respiratory failure which may require mechanical ventilation.  Watch for skin lesion that may appear e.g. blisters and bullae and manage accordingly.  Labs: Glucose, Na, K, LFTs, ABG  Imaging: CXR and ECG  N.B. gastric lavage and emesis are generally C/I in these cases BUT if there is a clear history of large volume ingestion along with disturbed conscious level, we may perform gastric lavage ONLY under ETT coverage to minimize the risk of aspiration.
  • 3. Management protocol for Organophosphorus & Carbamate intoxication Examples: Malathion, black granules rodenticide…etc. Mode: Accidental, suicidal or Homicidal ( Carbamate ). Main symptoms: Muscarinic e.g. pinpoint pupil, sweating, lacrimation, salivation, diarrhea, urination, vomiting and pulmonary secretions & Nicotinic e.g. fasiculations and muscle weakness. Once symptomatic equals admission. If the patient is very weak, we intubate and administer the obidoxime. Life saving measure is Atropine..Till the chest secretions Dry. GI decontamination via Emesis or gastric lavage according to the degree of weakness. Oxygen is preferred prior to atropine administration to preserve the cardiac oxygen supply adequate. After decontamination and stabilization, admit the symptomatic pt. for symptomatic ttt, follow up + atropine + obidoxime course if indicated. Avoid severe atropinization that presents with blurred vision, urinary retention and hallucinations. Labs: Glucose, Na, K, serial pseudocholinesterase measurement, LFTs and renal function tests. No use of Oximes for Carbamate. Imaging: CXR esp. if mechanically ventilated, ECG. N.B. rising of the cholinesterase level may be deceiving due to redistribution of the toxin. Long term follow up for the development of intermediate syndrome and neuropathy..etc.
  • 4. Management protocol for opiate and opioids  Examples: Morphine, Heroin…etc.  Mode: mostly accidental overdose  Route: ingestion, injection or snuffing  Firstly, assess the vital date i.e. airway, breathing, B.P, pulse  Assess the neurological system and exclude other causes of disturbed conscious level i.e. detect whether signs of lateralization are present or not.  Assess for the need of intubation and mechanical ventilation e.g. if GCS<8 TO Protect the airway.  If available, Naloxone can be given to reverse the respiratory depression take care not to cause acute withdrawal that may end up with seizures. N.B. the t1/2 of naloxone is short so, you must be ready to intubate if indicated.  Main signs: pinpoint pupil, bradypnea, hypotension and bradycardia along with disturbed consciousness.  Order CT scan to exclude possible intracranial bleeding as a cause of the disturbed consciousness especially if there are signs of lateralization.  Labs: Glucose, Na, K, urine screen for opiates and possible co- ingestions, ABG  If you suspect aspiration or ARDS: order CXR  Order ECG to detect potential arrhythmias  If you suspect rhabdomyolysis: order CK  If prolonged coma prior to arrival, suspect ischaemic encephalopathy and order MRI  Care of the coma in ICU.
  • 5. Management protocol for Carbon Monoxide intoxication Circumstances: mainly in winter. Closed space, fire to warm up or during showering, fires, running vehicles in garage…etc. Main presentation: Nausea, vomiting, abdominal pain, HEADACHE, dizziness, disturbed consciousness…etc. Assess the vital data e.g. B.P, pulse and R.R and assess the GCS Exclude other causes of disturbed consciousness. Firstly, apply high flow OXYGEN as soon as possible. We may add measures to decrease the ICT e.g. steroids and Mannitol (1-2 gm/kg) provided that the B.P and renal function allow that. Antiemetics to stop the vomiting. Labs: Glucose, Na, K, ABG, CarboxyHB level, renal function tests and cardiac biomarkers. Imaging: CT scan to exclude intracranial bleeding, ECG If disturbed conscious level that doesn't improve with the above mentioned measures, intubate and mechanically ventilate the pt. with 100% oxygen for 6 h. then gradual weaning. Symptomatic TTT and regular follow up of the vital data and labs in the ICU. Assess the need for Hyperbaric oxygen sessions e.g. cardiac arrhythmias, changes in the mental status, pregnant females and persistent non-improving symptoms. If there is cardia ischaemia: the main line of TTT is oxygen/Hyperbaric oxygen. If you suspect rhabdomyolysis: order CK If you suspect permanent neurological sequalae e.g. affection of the basal ganglia: order MRI  Order long term follow up for potential future neurological sequalae.
  • 6. intoxicationTheophyllineagement protocol forMan  Mode: mostly suicidal or accidental overdose  Main symptoms: repeated vomiting, dyspnea, palpitation, tremors and dizziness.  Main signs: Tachycardia, hypotension, agitation, tremors, tachypnea  Take careful history about the drug( amount, form e.g. SR, delay…etc.) and assess the vital data including the B.P, pulse and R.R.  Gastric decontamination via induction of emesis (without Epicac) or gastric lavage especially for the sustained release forms.  Multiple Dose Activated Charcoal.  Admission of the patient is mandatory.  Order Glucose, Na, K, ABG, Theophylline level  Order ECG along with cardiac biomarkers to detect possible arrhythmias or ischaemia.  If you suspect rhabdomyolysis, order Creatine Kinase level  For intractable vomi ng, give cor plex B6 , primperan or even Ondansetron for severe cases. Avoid phenothiazines as they decrease the threshold of seizures.  Fluid replacement is of major priority with correction of the underlying electrolyte abnormalities e.g. low K.  For severe agitation or seizures, give Diazepam or phenobarbital.  Assess for the need of hemodialysis e.g. very high level, non- correctable metabolic acidosis, severe CNS or cardiac manifestations.  If there is hypotension, IV fluids then norepinephrine if no adequate response.  For SVT, give propranolol or verapamil.  For ventricular arrhythmias, give Lidocaine.
  • 7. Management of Acetaminophen intoxication Take careful history and assess for co-ingestion e.g. salicylates…etc. Assess the vital data e.g. pulse, B.P and R.R. Main symptoms: Asymptomatic or GI symptoms. Gastric decontamination if the delay period allows i.e. usually done if < 2h delay. Assess the toxic dose: > 150 mg/kg or usually > 7.5 gm. If the time since ingestion is between 4 h- 24 h, order acetaminophen level and compare it to the normogram. If the level is high, admission is mandatory. If the level is not toxic, Discharge the patient with outpatient follow up of Liver function tests and you may also prescribe N-acetyl Cysteine sachets as a measure for any potential liver damage. Labs: Glucose, Na, K, Liver function tests, acetaminophen level, kidney function tests and ABG Start N-Acetyl Cysteine course orally or intravenously if there is repeated vomiting. We may also give the oral form through a Ryle tube. Oral dose: Loading 140 mg8/kg then maintenance 70 mg/kg for 17 doses with serial acetaminophen level and LFTs. Watch for any allergic reactions if the IV form is used.
  • 8. Management protocol for Calcium Channel Blockers Intoxication  Take careful history and assess for co-ingestions.  Assess the vital data including the B.P, pulse and R.R.  Admission is mandatory.  Gastric decontamination via induction of emesis or gastric lavage is done if the vital data are stable & the delay < 2h (Except for the sustained release forms) then activated charcoal is given as MDAC.  ECG is done on admission and serially thereafter.  CNS manifestations sometimes occur e.g. dizziness, syncope or seizures.  If brady-arrhythmias are present, start Calcium gluconate or chloride slowly intravenous. Atropine also can be given concurrently.  If the brady-arrhythmias are resistant to TTT, urgent cardiology consultation for temporary pacing.  If Hypotensive, start IV crystalloids or colloids and administer dopamine if there is inadequate response.  If there is resistant hypotension, we may revert to intra-aortic balloon pump as a temporary measure to help tissue perfusion via the failing heart.  Order: Glucose, Na, K, ABG and serial electrolyte panel monitoring.  If you suspect cardiogenic pulmonary edema: order CXR and monitor the CVP.  If cardiogenic shock develops, Dobutamine is a better option than dopamine.
  • 9. intoxicationBeta BlockersManagement protocol for  Take careful history and assess for co-ingestions.  Assess the vital date especially the pulse, B.P and R.R.  Main symptoms: dizziness, syncope and dyspnea.  Main signs: Bradycardia, hypotension and wheezy chest (most specific).  CNS manifestations may occur e.g. coma or seizures!!  GI decontamination via induction of emesis is done only if the vital data are stable and the delay is < 2h.  Multiple Dose Activated Charcoal is used thereafter.  Admission of the patient is mandatory.  Order ECG on admission and serially thereafter.  If there is bradycardia, administer atropine IV.  If atropine resistant or accompanied with hypotension and other features of hemodynamic instability, administer Glucagon as an antidote IV.  If bradycardia is still resistant to TTT, Urgent cardiology consultation for temporary pacing.  For hypotension, give IV crystalloids or colloids, dopamine, Norepinephrine if the response is inadequate.  If the hypotension in resistant to all of the above measures, Urgent cardiology consultation to put an intra-aortic balloon pump as a temporary life-saving measure.  Order: Glucose, Na, K, ABG and serial electrolyte panel monitoring.  If you suspect cardiogenic pulmonary edema, order CXR and monitor the CVP.  For seizures, administer BZP or phenobarbital.  For bronchospasm, administer regular nebulized B2 agonists.
  • 10. intoxicationDigitalisManagement protocol of  Take careful history and assess for co-ingestions.  Assess the hemodynamic status of the patient i.e. Pulse, B.P and R.R.  Main symptoms: Nausea, vomiting, diarrhea, dizziness.  Main signs: irregular brady-arrhythmias, hypotension. Patient may come with manifestations of heart failure if the toxicity occur on top of the already compromised cardiac functions.  Admission of the patient is mandatory.  Induction of emesis is done only if the patient is hemodynamically stable and the delay is <2 h. Atropine is preferred to be given before emesis to reverse the reflex vagal stimulation during emesis.  Multiple dose activated charcoal is of a high priority in management.  ECG is done on admission and serially thereafter.  Any type of arrhythmias can occur with digitalis toxicity. Down sloping of the ST segment is usually seen but it is not specific.  The most specific arrhythmia is: Atrial tachy-arrhythmia with A-V block  If pt. is bradycardic, atropine is administrated and repeated as needed.  If there is no response to atropine, Urgent cardiology consultation for temporary pacing.  For Hypotension, administer IV fluids BUT Never to order any ca++ containing fluids e.g. Ringer's...etc.  Dopamine can be used for resistant hypotension.  Fab fragment antidote is highly expensive so, it is not usually available BUT it is the best line of TTT if available.  Order: Glucose, Na, K, Mg++ , ABG, Renal function tests. Electrolyte panels should be ordered serially and corrected promptly.  If you suspect cardiogenic pulmonary edema, order CXR and serially measure the CVP and manage accordingly.
  • 11. Food poisoningManagement protocol of  The first step is to take a detailed history of the circumstance, the type of food, the presenting symptoms…etc.  The most important step is to EXCLUDE other causes of the presenting symptoms e.g. Organophosphorus, Botulism, Carbon Monoxide….etc. before you establish a diagnosis of acute gastroenteritis.  Careful examination especially of the abdomen to EXCLUDE surgical causes of the presenting complaint(s).  Assess the vital date including the pulse, B.P and R.R.  Assess the degree of dehydration if present and order IV fluid resuscitation if needed (preferably with Panthol or Ringer's lactate solutions).  Symptomatic TTT in the ER via antispasmodic, antiemetic and H2 blocker ampoules.  Establish the need to get admitted or discharged on outpatient TTT or referral to the Fever hospital according to the presenting complaints & the severity of the case.  Presence of blood and mucus in the diarrhea suggest a bacterial (e.g. shigella, EHEC) or protozoal (e.g. E.histolytica) which need specific TTT in addition to the other symptomatic and supportive measures.  If the main complaint is dyspnea with history of eating preserved food products, think of MetHb and manage accordingly.  If symptoms develop after ingestion of some plant materials, keep them under observation or admit them as the symptoms are usually severe and fluctuating in appearance.  If there is history of perioral and limb numbness & weakness along with dizziness and other neurological manifestations, think of Ciguatera or Tetradoxin toxicity and manage accordingly ( may need gastric lavage up to mechanical ventilation).  If there is itching, blistering, skin rash, wheezing after fish ingestion, think of Scombroid poisoning and manage with antihistamines, steroids and other supportive measures if needed.  Prescribe outpatient TTT if the case is mild and recommend some dietary instructions for the next few days.