Poisoning

Sharjah Unit Code 1104422 –

Clinical Pharmacy IIB
 TBL

Based on Clinical Toxicology Chapter in

DiPiro

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Learning Objectives
To be familiar with accidental and intentional poisoning, the
agents involved (drugs, household chemicals, etc.) and the
proportion of poisonings that involve children
To understand the major changes in pharmacokinetics that
may occur for drugs taken in overdose
To recognise the important role of Poison Information Centres
(PICs) in providing advice on management of poisoning, and
the information required by PICs to evaluate a poisoning case
and provide accurate advice
To understand the management of poisoning cases, including
methods to decrease the absorption of poisons from the
gastrointestinal tract, to enhance elimination and agents that
may be used as antidotes
To understand the role of pharmacists in promoting the safe
use and storage of medicines and household chemicals and in
the management of overdose

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Accidental Poisoning
Majority of accidental poisoning occurs in
children less than 5 years
Most children ingesting poisons do so in
small quantities – and suffer only minor
symptoms
There is a small incidence of serious and,
in some cases, potentially life-threatening
poisoning
Often difficult to establish the exact amount
taken Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
 Intentional Poisoning
Largely confined to adolescents and adults
Often involves one or more medicines
together with alcohol
All cases should be referred to a hospital
or medical practitioner
Histories related by these patients often
inaccurate

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Facts and Figures
About 95% of poisonings in children under
5 years occur at home

– Highlights importance of safe use and storage

of medicines and household chemicals in the
home

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Facts and Figures
Calls to Victorian Poisons Information
Centre concerning children under 5 years
Proportions
Prescription medicine related calls 1
OTC medicine related calls 2-3
Other poisons 4-5

– Highlights role of OTC medicines in

poisonings
– Importance of being vigilant with all medicines
and household chemicals Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
 Facts and Figures
Emergency Department presentations in Victoria for
OTC medicine ingestion in children under 5 years
1996-2000 (% total)
Paracetamol 493 (38.0)
Cough/cold 341 (26.3)
Antihistamines 72 (5.5)
Aromatic Oil 68 (5.2)
Anti-inflammatory 59 (4.5)
Vitamins 45 (3.5)
Nasal/Eye Drops 45 (3.5)

Total 1299
Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
 Pharmacokinetics in Drug
Overdose
PK often different to that in normal clinical
use of the drug
Slow absorption
– Stomach emptying may be delayed
– Limited solubility due to large amount of drug
(concretion in the gut)
– SR preparations may exacerbate situation
– Consider methods to decrease absorption

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Pharmacokinetics in Drug
Overdose
Elimination
– May be non-linear PK even if this is not a
feature of the PK of the drug in normal clinical
use
– Clearance may be lower and half-life longer
than normal
– Consider methods to increase elimination

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
Poisons Information Centres (PICs)
PICs provide:
– Phone assessment for people exposed to poisons, including
advice on first aid with referral to a medical facility when
necessary
– Information for health professionals on the formulation of
products and the management of poisoned patients
– Advice on the treatment of bites and stings by venomous
animals, insects and marine creatures
– Information to the public on all aspects of poisoning
– The PDIC Provides a Poison Help hotline throughout the
entire U.A.E. The call is free and confidential. The PDIC can
be reached at the national toll - free number (800 424) from
7:00 am- 3:00 pm, Sunday – Thursday.
– Website for PDIC: PDIC@[Link]

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
Poisons Information Centres (PICs)
Strongly recommended that pharmacists
use the expertise of PICs when they are
asked for assistance in the event of
poisoning
Poisoning management information
changes over time and PICs are the best
source of current information

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
Assessment of Likely Severity of
Poisoning
Treatment should generally be delayed
until the advice of a PIC or medical
practitioner has been obtained

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
Assessment of Likely Severity of
Poisoning
Information that may be required by PIC to
enable an accurate assessment of likely
toxicity:
– Substance involved in suspected poisoning
(and manufacturer, if available)
– Quantity of poison taken or amount of
exposure (may include strength of product
and size of container)
– Accidental or deliberate poisoning

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
Assessment of Likely Severity of
Poisoning
Information that may be required by PIC to
enable an accurate assessment of likely
toxicity:
– Type of exposure to the poison (e.g. ingested,
inhaled, skin or eye contact, bite or sting)
– When the exposure occurred
– Patient details (e.g. age, weight, existing
illness and current medication)
– Any current signs and symptoms
– Treatment already given (if any)
– Phone number Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
Assessment of Likely Severity of
Poisoning - Additional Comments
Poison identification
– Constituents
May be medicines or household goods
May involve more than one poison
Consider different salt forms where relevant (e.g. 65mg Fe in
200mg ferrous sulfate and 35mg Fe in 300mg ferrous
gluconate)
– Dose
May be difficult to ascertain
Compare number of tablets/volume of liquid with amount
remaining
Assume the maximum likely dose consumed
– With poisonings in children, consider possible
involvement of other children
Prevent harm or further harm Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
General Principles of Management
for Poisoning
Management decisions
– Admit to hospital or not?
– Subsequent management?

– Advice of PIC very valuable in both of the

above

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Minimising intestinal absorption
– Activated charcoal
Oral or nasogastric:1-2 g/kg up to 50 g for children
and 50 g for adults
Each gram diluted with 6-10 mL of water
Ready-mixed preparations available (Carbosorb®
suspension)
Activated charcoal tablets or capsules no good

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Minimising intestinal absorption
– Activated charcoal
Will adsorb a range of drugs and decrease
absorption
Will NOT adsorb:
– Acids, alkalis, alcohols (ethanol, isopropanol, methanol),
bleach, essential oils, fluoride tablets, glycols, heavy
metals, iron salts, lithium, potassium salts, petro-solvents
– NOT indicated for poisonings with these substances
alone
– May be indicated where other substances are thought to
have been ingested

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Minimising intestinal absorption
– Activated charcoal
Should not be given if bowel sounds absent
If level of consciousness is depressed, there is risk
of charcoal aspiration (can be fatal)
– Endotracheal intubation required to protect airway

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Minimising intestinal absorption
– Whole bowel irrigation
Nasogastric administration of 30 mL/kg per hour of
physiological colonic lavage solution containing
PEG (Golytely®, Colonlytely®, Glycoprep®)
Treatment is continued until rectal effluent is clear
(usually 4-8 hours)
May be useful in decreasing absorption:
– From SR formulations taken in overdose
– For medications not adsorbed by activated charcoal (e.g.
iron preparations)
May be considered if severe toxicity is anticipated
and patient has presented to hospital within one
hour of ingestion Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
General Principles of Management
for Poisoning
Minimising intestinal absorption
– Emetic (ipecacuanha syrup)
No longer routinely recommended
Less effective than activated charcoal for many poisons and
can interfere with subsequent management of the patient in
severe poisoning
May occasionally be used in remote regions or if activated
charcoal not available
Should only be used on specific advice of medical practitioner
or Poisons Information Centre
All methods for gastrointestinal decontamination carry a
significant risk of aspiration pneumonitis if the patient’s level
of consciousness is impaired Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
General Principles of Management
for Poisoning
Enhancing excretion
– Techniques
Repeated oral doses of activated charcoal
– Adult: oral or nasogastric 50 g initially, then 25 g every 2-
4 hours over the first 24 hours
– Child: oral or nasogastric, 1-2 g/kg up to 50 g initially,
then 1 g/kg up to 25 g every 2-4 hours over the first 24
hours
– May adsorb poisons undergoing enterohepatic
circulation or secreted into intestinal lumen
– May be useful in potentially life-threatening ingestion of
carbamazepine, dapsone, phenobarbitone, quinine or
theophylline
– Care to avoid bowel obstruction and perforation
Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
General Principles of Management
for Poisoning
Enhancing excretion
– Techniques
Forced diuresis with either acidification (for weak
bases) or alkalinisation (for weak acids) of urine
– May work for drugs with certain physicochemical and PK
properties only
– Carries risk of fluid overload and disturbance to acid-
base balance

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Enhancing excretion
– Techniques
Haemodialysis or haemoperfusion
– Requires that the poison has certain properties, in
particular that the extracorporeal clearance is capable of
increasing the total body clearance substantially
– Haemodialysis may be of value where concomitant
electrolyte and/or acid-base disturbance exists

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Enhancing excretion
– In general, a limited role
– Use should be restricted to situations where
prolonged exposure to high concentrations of
poison is predictably deleterious and where
the procedure is likely to enhance excretion
and not likely to cause more harm than good

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Specific antidotes Poison Antidote
Benzodiazepines

Carbon monoxide

Digoxin

Iron

Lithium

Methanol

Opiates

Organophosphates

Paracetamol

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Specific antidotes Poison Antidote
Benzodiazepines Flumazenil

Carbon monoxide

Digoxin

Iron

Lithium

Methanol

Opiates

Organophosphates

Paracetamol

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Specific antidotes Poison Antidote
Benzodiazepines Flumazenil

Carbon monoxide Oxygen

Digoxin

Iron

Lithium

Methanol

Opiates

Organophosphates

Paracetamol

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Specific antidotes Poison Antidote
Benzodiazepines Flumazenil

Carbon monoxide Oxygen

Digoxin Digoxin antibodies

Iron

Lithium

Methanol

Opiates

Organophosphates

Paracetamol

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Specific antidotes Poison Antidote
Benzodiazepines Flumazenil

Carbon monoxide Oxygen

Digoxin Digoxin antibodies

Iron Desferrioxamine

Lithium

Methanol

Opiates

Organophosphates

Paracetamol

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Specific antidotes Poison Antidote
Benzodiazepines Flumazenil

Carbon monoxide Oxygen

Digoxin Digoxin antibodies

Iron Desferrioxamine

Lithium Na replacement

Methanol

Opiates

Organophosphates

Paracetamol

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Specific antidotes Poison Antidote
Benzodiazepines Flumazenil

Carbon monoxide Oxygen

Digoxin Digoxin antibodies

Iron Desferrioxamine

Lithium Na replacement

Methanol Ethanol

Opiates

Organophosphates

Paracetamol

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Specific antidotes Poison Antidote
Benzodiazepines Flumazenil

Carbon monoxide Oxygen

Digoxin Digoxin antibodies

Iron Desferrioxamine

Lithium Na replacement

Methanol Ethanol

Opiates Naloxone

Organophosphates

Paracetamol

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Specific antidotes Poison Antidote
Benzodiazepines Flumazenil

Carbon monoxide Oxygen

Digoxin Digoxin antibodies

Iron Desferrioxamine

Lithium Na replacement

Methanol Ethanol

Opiates Naloxone

Organophosphates Atropine,
pralidoxime
Paracetamol

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Specific antidotes Poison Antidote
Benzodiazepines Flumazenil

Carbon monoxide Oxygen

Digoxin Digoxin antibodies

Iron Desferrioxamine

Lithium Na replacement

Methanol Ethanol

Opiates Naloxone

Organophosphates Atropine,
pralidoxime
Paracetamol N-acetylcysteine

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 General Principles of Management
for Poisoning
Specific antidotes Poison Antidote
Benzodiazepines Flumazenil

Carbon monoxide Oxygen

Digoxin Digoxin antibodies

Iron Desferrioxamine

Lithium Na replacement

Methanol Ethanol

Opiates Naloxone

Organophosphates Atropine,
pralidoxime
Paracetamol N-acetylcysteine

Note: Some antidotes may be used diagnostically Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
General Principles of Management
for Poisoning
General laboratory investigations
– Biochemistry, electrolytes, etc..
Special laboratory investigations
– e.g. X-ray of abdomen (iron ingestion)
– e.g. plasma paracetamol

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Management of corrosive injury (e.g.
acids, alkalis, dish washer detergents)
– As with other poisons, seek advice of Poisons
Information Centre

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
Supportive management
– A, B, C
– Other (fluids, acid-base, blood sugar level,
renal and hepatic function, management of
arrhythmias, etc..)

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
If poison is in contact with the skin
– Remove contaminated clothing
– Wash the affected area thoroughly with soap and cold
or tepid water (not warm or hot)
– Transport to hospital if skin is badly damaged or if the
poison is absorbed through intact skin (e.g. many
insecticides)
– Do not attempt to neutralize with another chemical
– Do not apply lotions, ointments or creams unless
instructed to do so

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
General Principles of Management
for Poisoning
If poison is in the eyes
– Irrigate with water (e.g. under a slow running
tap) for 10-15 minutes
– Do not instil drops or apply ointments
– If irritation persists, or the agent is corrosive,
or if advised by Poisons Information Centre,
cover the eye and send the patient to hospital
or medical practitioner

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Specific examples:
Acetaminophen toxicity:
APAP undergoes 2 pathways of metabolism which are
glucorinidation secreting it unchanged in the urine and
sulfation pathway leading to sulfate conjugates excreting
it unchanged in urine as well. If these pathways are
saturated, 5 % gets metabolized via cyp450 enzymes
CYP2E1 to form NAPQI that gets detoxified with
glutathione to form mercapturic acid.

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Acetaminophen toxicity:

N-acetylcysteine given in antidote

replenishes the hepatic stores of
glutathione. It should be started within 10
hours of the ingestion to be effective.
Symptoms of overdose:
-first 1 to 3 days: asymptomatic rise in AST,
ALT, plus bilirubin
-after 3 to 5 days: symptoms of liver injury
like jaundice, hypoglycemia, increase PT,
increase in INR Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
 Acetaminophen toxicity:

Lab tests: toxic serum APAP

concentrations, no earlier than 4 hours after
ingestion to compare to nommogram.
 No levels should be drawn before 4 hours
of ingestion, because it peaks after 4 hours.
 If patient is unresponsive to Acetylcysteine,
transplantation is last option.

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Acetaminophen toxicity:

Monitoring and prevention:

AST, ALT, bilirirubin, PT, serum creatinine,
plus urinalysis on admission and repeated
at 24 hours intervals until 96 hours have
elapsed.

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
Anticholinesterase insecticides
toxicity:
No breakdown of ACTH leading to
increase levels.
Clinical manifestation: pinpoint pupils,
excessive lacrimation, increase salivation,
bradycardia, diarrhea.
Clinical presentation: within 6 hours pts
are symptomatic, death within 24 hours.
Anticholinesterase insecticides:
organophophates and carbamates (less
potent). Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
 Anticholinesterase insecticides
toxicity
Risk assessment: triad of miosis, bronchial
secretion, and muscle fasciculations
should suggest an anticholinesterase
toxicity and warrants a dose of atropine.
Management of toxicity:
-people handling patients should wear
gloves.

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
Anticholinesterase insecticides
toxicity
If poison within 1 hour give gastric lavage
and activated charcoal.
Patients with skin contamination: clothes
removed plus washed with soap plus water
plus alcohol.
Supportive therapy with ABC plus
ventilation plus IV line.
Antidote: atropine plus pralidoxime should
be given together because they have
complementary actions. Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
Anticholinesterase insecticides
toxicity
Atropine as anticholinergic reverses
symptoms of bronchospasm plus
decrease bronchial secretions. It should
be given every 5 to 10 minutes until
pulmonary rales resolve.

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
Anticholinesterase insecticides
toxicity
Pralidoxime breaks the covalent bond
between organophosphates plus
cholinesterase and regenerates enzyme
activity. Organophosphates-cholinesterase
binding is reversible initially then becomes
irreversible thus pralidoxime should be
given within 36 to 72 hours of exposure.
Long term follow up for severe cases of
poisoning to detect presence of
neuropsychiatric effects. Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
 Calcium Channel blockers
toxicity:
Metabolic toxicity: cardiovascular, GI
toxicity, hyperglycemia, bradycardia,
appear early within 1 to 3 hours of
ingestion.
Management of toxicity:
-gastric lavage plus single dose activated
charcoal should be given if poisoning within
1 to 2 hours.
-WBI with PEG will enhance rectal
elimination of CCB. Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
 CCB toxicity:
Treat hypotension with NS infusion, if
persists give CaCl2 bolus dose if response
is positive start a continuous infusion.
Treat bradycardia with dopamine and
epinephrine.
If hypotension plus bradycardia persist,
glucagon can be given because it has an
inotropic and chronotropic activity by
increasing entry of Ca through Ca
channels.
Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
 Iron toxicity:
Clinical presentation: the first few hours
symptoms of GI irritation appear. (N,V,D).
Within 24 to 36 hours, coagulopathy
(decrease in thrombin formation), lactic
acidosis (iron inhibits aerobic glycolysis).
Coagulopathy which is decrease in thrombin
formation is one of the direct effects of
excessive iron concentrations.
Bacterial infection plus septicimia occur from
high iron concentrations.
Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
 Iron toxicity:
Lab tests:
Toxic serum iron concentrations above 500
mcg/dl
INR is increased within 1 to 2 days
Guaiac test of stools indicate presence of
blood
Local GI plus systemic symptoms

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Fe toxicity:
If symptoms present: treat with deferoxamine for the first
24 hours because more than 24 hours: ARDS
If Fe concentrations more than 500 mcg/dl then treat
with deferoxamine
If Fe concentrations is between 350 and 500: less
evidence for treatment
Rapid deferoxamine infusion causes tachycardia,
urticaria, erythema. Deferoxamine produces an orange
red colored urine within 3 to 6 hours.

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Iron toxicity:
Deferoxamine therapy should be
continued only for 12 hours after the
patient is asymptomatic and the urine
returns to normal color or until serum iron
concentrations fall below 350 mcg/dl and
approach 150 mcg/dl.

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 TCA toxicity:
Clinical presentation: cardiotoxicity, CNS, seizures within
1 hour. Major toxicity symptoms are within 6 hours of
ingestion.
Anticholinergic symptoms: mydriasis, constipation, dry
mouth, urinary retention.
QRS prolongation on EKG is the most common sign of
TCA overdose.
Mechanism of toxicity: TCA cause alpha blocking
activity: hypotension plus AV block, ventricular
tachycardia, decreasing heart contractility.

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 TCA toxicity:
Management of toxicity:
IV fluids for hypotension plus multiple dose activated
charcoal is useful during the first 12 hours of ingestion.
-single dose activated charcoal within first hour because of
decrease in GI motility from toxicity.
-gastric lavage if beyond 1 hour.
-IV Na HCO3 is first line treatment for QRS prolongation,
hypotension, plus arrythmias. Sodium plays a good role
in stabilizing the sodium channel to the myocardium.
-monitoring of EKG during first 24 hours.

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Role of pharmacist
Point of contact regarding poisonings
– Have handy the contact details for PIC
– Questions to ask if approached about
poisoning

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB
 Role of pharmacist
Advice on storage of medicines and household
poisons
– Store out of reach of children
– Put away as soon as used
– No hoarding of medicines
– Discard out-of-date medicines
– Reinforce that OTC medicines can cause serious
poisoning
– Just because a medicine does not have a child
resistant closure (CRC) does not mean it is safe
– Advice on CRCs
– Pamphlets on safe storage of medicines
– Talks to school and community groups
Sharjah Unit Code 1104412 –
Pharmacy Practice IVB
RUM – Returning Unwanted Medicine

Sharjah Unit Code 1104412 –

Pharmacy Practice IVB