WELCOME

1. WELCOME

2. NURSING MANAGEMENT OF POISONED PATIENTS Presented by: Reviewed by: Mr. Santhosh Thomas Prof. Shashkumar Lecturer, HOD,MSN Department, YNC YNC Updated Date: 19-03-2019.

3. Learning objectives. • The students will be able to: • Define Poisoning. • Narrate Etiologyof Poisoning. • Explain the Pathophysiology of Poisoning. • Enumerate the clinical manifestations of Poisoning. • Explain the diagnosis and management of Poisoning.

5. THE POISONED OR OVERDOSED PATIENT • Poisonings and drug overdoses can cause quick physical and mental changes in a person. Bystanders usually are the ones who must initiate care and call a poison control center or emergency number. • The most common routes of exposure in poisoning are inhalation, ingestion, and injection. • Toxic chemical reactions compromise cardiovascular, respiratory, central nervous system, hepatic, gastrointestinal (GI), and renal systems.

6. Incidence. • Poisoning is a significant global public health problem. • According to WHO data, in 2012 an estimated 193,460 people died worldwide from unintentional poisoning. • Of these deaths, 84% occurred in low- and middle-income countries.

7. Etiology. • Chemical agents that cause toxicity include: • Drugs • Insecticides/herbicides • Plant toxins, Animal toxins • Chemical weapons, • Radioactive elements • Household cleaning products • Toxic fumes • Substance Abuse and Overdose.

8. Pathophysiology.

9. Symptoms. • Wheezing • Rapid respirations are typicalmetabolic acidosis or cellular asphyxia. • Hypertension and tachycardia • Hyperthermia may be associated with sympathomimetics, anticholinergic, salicylates • Seizures or muscular rigidity. • Miosis is typical of opioids, cholinesterase inhibitors. • Exam skin for hot, and dry, flushing, bruising, cyanosis, • Hyperactive bowel sounds, tenderness abdominal cramping and diarrhea.

10. Laboratory Studies • Tests that provide clues to the agent(s) taken by the patient include • arterial blood gases (ABGs), electrolytes, • serum osmolality tests, • urinalysis, • complete blood count, • electrocardiography , • imaging findings and hepatic function, • Toxicology screens

11. Approach to the poisened patient • Many toxins depress the Central Nervous System(CNS), resulting in coma. • Comatose patients frequently lose their airway protective reflexes and their respiratory drive.

12. ASSESSMENT • A health care facility’s systematic approach to the assessment of the poisoned or overdosed patient includes performing triage, • A) Obtaining the patient’s history, • B) Performing a physical examination, and • C) Conducting laboratory studies.

13. Triage • Triage is always the first step performed in the emergency department. • Two essential questions to be considered in the triage evaluation are: 1. Is the patient’s life in immediate danger? 2. Is the patient’s life in potential danger?

14. Initial management of the poisoned patient • If the patient’s life is in immediate danger, the goals of immediate treatment are patient stabilization and evaluation and management of airway, breathing, circulation and dextrose (ABCDs). • Stabilization;First the airway should be cleared of vomitus or any other obstruction and an oral airway or nasotracheal or endotracheal intubation may be necessary to adequately maintain and protec the patient’s airway.For many patients is sufficient to move the flaccid tongue out of the airway.

15. Breathing Breathing should be assesed by measuring arterial blood gases. Mechanical ventilation may be necessary to support the patient. Many drugs and toxins, such as heroin, depress the respiratory drive. Patients therefore may require ventilator assistance until the drugs or toxins are eliminated from the body.

16. Circulation • should be assesed by continious monitoring of pulse rate, blood pressure, urinary output and evaluation of peripheral perfusion • Some toxic drug ingestions impair myocardial contractility, cause cardiac conduction delays and arrhythmiasand fluid overload may result because of the heart’s inability to pump effectively.

17. Dextrose. • Every patients with altered mental status should receive a concentrated Dextrose. Adults are given 25g (50ml of 50% dextrose solution) i.v. Children 0.5g/kg(2ml/kg of 25% dextrose). • Hypoglycemic patients may appear to be intoxicated , and there is no rapid and reliable way to distinguish them from poisened patients.

18. History and Physical examination • Once the essantial initial ABCD interventions have been instituted , • one can begin a more detailed evaluation to make a spesific diagnosis.This includes gathering any available history and performing a toxicologically oriented physical examination.

19. A.History • A history of the patient’s exposure provides a framework for managing the poisoning or overdose.Need to obtain as much info as possible about exposure • Key points include identifying the drug(s) or toxin(s), type of exposure, the time and duration of the exposure, amount or dose, empty bottles or containers, houshold products, over the counter drug (OCD), smells or suicide not.

20. B. Physical Examination • Check clothing for objects or substances • A quick but thorough physical examination is essential.These include vital signsand temperature, eyes and mouth, skin, abdomen and nervous system.

21. MANAGEMENT • Management of the poisoned or overdosed patient seeks to prevent absorption of and further exposure to the agent. • Treatment begins with first aid at the scene and continues in the emergency department and often the intensive care unit (ICU). • Advanced general management involves further steps to prevent absorption and enhance elimination of the agent. For instance, antidotes, antivenins(the treatment of venomous bites or stings) or antitoxins may be administered.

22. General- management • I.provision of supportive care • II.prevention of poison absorption • III.enhancement of elimination of poison • IV.administration of antidotes

23. I. Supportive care • Vital signs, mental status, and pupil size • cardiac monitoring, ECG • Protect airway • Intravenous access • cervical immobilization if suspect trauma • Rule out hypoglycaemia

24. II.Preventing absorption • Decontamination; • A) dermal, • B) ocular, • C) inhalation, and • D) ingestion exposures follow.

25. Gastrointestinal Decontamination • 1. Vomiting, • 2. Gastric lavage, • 3. adsorbents(is the adhesion of molecules of gas, liquid, or dissolved solids to a surface), • 4. cathartics, and • 5. whole-bowel irrigation are used to prevent absorption toxins.

26. III. Enhanced elimination. III.There are six methods of enhanced elimination: 1. Multiple-dose activated charcoal 2. Alteration of urine pH 3. Chelation 4. Hemodialysis 5. Hemoperfusion 6. Hyperbaric oxygenation (HBO) therapy

27. ■ Acetaminophen ■ Amphetamines ■ Antihistamines ■ Aspirin ■ Barbiturates ■ Benzodiazepines ■ Beta blockers ■ Calcium channel blockers ■ Cocaine ■ Opioids ■ Phenytoin ■ Theophylline ■ Valproic acid Drugs/Toxins Not Well Adsorbed by Activated Charcoal ■ Acids ■ causticalkalis ■ Alcohols ■ Iron ■ Lithium ■ Metals cyanide mineral acids, organic solvents, Drugs/Toxins Well Adsorbedby Activated Charcoal

28. IV. Antidotes (Antitoxins) and Antagonists), • In pharmacology, an antagonist is a substance that counteracts the action of another drug. • Although the general public often believes there is an antidote for every drug or toxin, the opposite is closer to the truth. • There are, in fact, very few antidotes.

29. Continuous Patient Monitoring • Seriously poisoned or overdosed patients may require continued monitoring for hours or days after exposure. • Physical examination, the use of diagnostic tools, and careful assessment of clinical signs and symptoms provide information about the patient’s

34. Recapitulation. • What is Poisoning, Explain. • What are the clinical manifestations of poisoning. • Write its pathophysiologyand management.

35. Refrences. • Brewer M. Five keys to successful nursing management. Philadelphia: Williams & Wilkins, 2003. • Lee RI, Jone LW. The fundamentals of good medical care. Chicago: University of Chicago Press, 1983.