Department of Forensic Med. & Toxicology

1. Department of Forensic Med. & Toxicology Tehran University Faculty of Medicine A. Aghabiklooie M.D.

2. Dermal (skin) Oral (mouth) Inhalation (lungs) Eyes Methods of Exposure

8. Toxicity or Poisoning • Drug Toxicity • Non- Drug Toxicity

9. 50 %مراجعات به مطبهادربيمارانتحتدرمان دارويي 20 %موارد كوما 3 تا 28 %بستري دربخش هايداخلی جنرال 90 % بيمارانمسموم بهاورژانسبيمارستان مراجعهميكنند. 15 درصدكودكانيكهبهاورژانس هاآوردهميشوند

10. Mode of Toxicity: • Intentional Suicidal Murder • Accidental • Medication, Overdose

11. Timming: • Acute • Chronic • Acute on Chronic

12. Poisoning almost have no specific presentation

13. How can we diagnose the Toxicity?

14. Think about poisoning

15. When we must think about poisoning ?

16. Presentation ?

17. Presentation of poisoned pt. • ASYMPTOMATIC • Non- Specific • TOXIDROM: • Cholinergic, Anticholinergic • Sympathomimetic • serotonergic • opioid • N.M.S

18. ASYMPTOMATIC Pt. • NO POTENT POISON • LOW AMOUNT POISON • PT. TOLERANCE • NO ABSORPTION • NO METABOLIZATION • PSEUDOSUICIDE • PREHOSPITAL CARE

19. Non specific presentation • Psychiatric • Neurologic • Fluid & electrolyte disturb. & unexplained metabolic Acidosis • A.R.F, Multi organ failure • Infectious • G.I. upset • Cardiovascular

20. Neurologic • Loss of consciousness, Coma • Convulsion • Agitation • Fever & Coma • Movement disorder (Wrist & Foot drop, Guilen-barre)

21. A few person with same presentation • Suddenly L.O.C in a child , young woman & psychiatric pt. • Acute G.I upset in a few worker • Previous Hx. Of Suicide & Self-Inflicted injury • Pt. With new complaint Who is on medication • Sudden Foot & Wrist Drop • Unexplained high A.G Metabolic Acidosis • Hallocination, Delirium, Agitation • Unexplained Dysrrhythmia, Syncope, Shock

22. General approach to poisoned Pts • EMERGENCY MANAGEMENT • CLINICAL EVALUATION • PREVENTION OF ABSORBTION • SPECIFIC THERAPY (Antidote) • ELIMINATION ENHANCEMENT • SUPPORTIVE THERAPY • OBSERVATION & DISPOSITON

23. EMERGENCY MANAGEMENT • B.L.S & A.L.S ( A, B, C, D ) • Air way Management • Breathing • Circulatory Support • Treatment of Shock & Hypotension • Fluid & Electrolyte Correction • Acid - Base disturbances • Antidotal therapy

24. Pre-Hospital Management • ABC • Decontamination • Antidote • Transfer to Medical facility

25. Severe Poisoning • Suction • Endotracheal Intubation • ICU admission • Pulse Oximetry • Mechanical Ventilation • Cardiac Monitoring • Pressor agents

26. Decontamination • Gastric lavage • Activated charcoal • Sorbitol • Washing • Soap & water • Ethyl alcohol

27. CLINICAL EVALUATION • HX. TAKING • PHYSICAL EXAMINATION • ASSESMENT OF TOXIC MAJOR SIGNS • EVALUATION OF LAB. DATA • OTHERS : X-Ray, E.C.G , . . .

28. MAJOR SIGNS • Pupil size • Mental status & Neurologic signs • Cardiac Dysrrhythmia • Acid - Base Disturbance specially unexplained high Anion - Gap Metabolic Acidosis

29. PREVENTION OF ABSORBTION • GASTRIC DECONTAMINATION : • Emesis: Ipecac, Salt water, Mustard • G. Lavage: N/S , Na bicarb. , K permangnate • ACTIVATED CHARCOAL • DILUTION • CATHARSIS :Sorbitol, Na sulfate, ... • W.B.I • OTHERS : Endoscopy, surgery

30. CONTRAINDICTION FOR EMESIS & G. LAVAGE • Comatose Pt. & Seizure State • Lake of Gag Reflex • When Stomach is Empty • Acute M.I • Corrosive Ingestion : Acids, Alkali ,... • Carbohydrate Ingestion • Active G.I.B or Coagulopathy

31. ACTIVATED CHARCOAL • Broad Absorption Surface • Make a reversible Complex • No Body Absorption • Safe in Child & Pregnant woman • Many Drugs & Chemical Sub. Absorb. • Low - Water Soluble & Non-Ionized Sub. Better Absorb.

32. M.D.A.C (G.I. DIALYSIS ) • Drugs with E.H. Circulation : Phenobarb. , Theophyllin, . . . • Bezoar Formation : Salicylates, Fe, . . . • Enhanced Elimination : Dig. , C.M.Z.P, V.P.A, Quinine, Meprobamate, Salicylate, Dopson, Phnylebutasone, . . . • Sustained - Release Formulation

33. ELIMINATION ENHANCEMENT • Urinary Alkalization & Forced Diuresis • G.I. Dialysis (M.D.A.C) • Hemodialysis • Hemoperfusion & Filtration • Blood Exchange • Alter Metabolism

35. If the poisoning happened ; Severity ?

36. Severity: • HX. (Dosing) • Clinical status • Lab. data

37. Magic Words What ?How much ?When ?

38. NON - TOXIC INGESTION • Not be Suicidal • Listed as a Non-Toxic Substance • Be a Known Substance • Only one Product is Involved • Pt. Be free of Signs & Symptoms • Amount of Ingested Product be clear (low amount )

39. Household items : Baby Product Candle Clay & Caulk Cosmetic & Lipstic Eraser Shampoo & Soap Toothpaste Water color paints Termometer Mercury Medication Antacids Calamin Lotion Birth control Pill (single ingestion) Mineral Oil Some Oral Antibiotics Water Soluble Vitamins Zinc Oxid NON-TOXIC SUBSTANCE

40. MANAGEMENT OF NON-TOXIC INGESTION • Need no Lab. Test • NEED No Treatment • Only Observation For 6 h • Follow-up must be available & reliable • If any of these aren’t met, pt. should be managed as an unknown ingestion

41. UNKNOWN INGESTION • Suicidal Cases • Amount of Ingested isn’t Clear • Kind of Ingested Drug or poison isn’t Clear

42. APPROACH TO UNKNOWNINGESTION

43. Gastric Decontamination Vomiting G. Lavage O.G.T N.G.T

44. Prevention of Absorption Charcoal Cathartics W.B.I

45. Laxative Enema W.B.I

46. Noting

47. Prevention of Absorption Gastric washing W.B.I Charcoal Cathartics