POISONING AND SNAKE BITE Rx GUIDE

TABLE OF CONTENTS

ORGANOPHOSPHATE POISONING Rx

BENZODIAZEPINES POISONING Rx

OPIOIDS POISONINGS Rx

ACIDS/CAUSTIC INGESTION Rx

KEROSENE POISONING Rx

PARAPHENYLENEDIAMINE (PPP) POISONING Rx

SNAKE BITES ER/WARD Rx

ORGANOPHOSPHATE POISONING Rx

C/C:

DUMBBELLS-F are Positive

Diarrhea

Urination

Miosis (Pinpoint pupil)

Pathophysiology of OP Poisoning

Absorbed through the skin, respiratory system, or gastrointestinal tract

Irreversible inhibition of acetylcholinesterase →

Increase acetylcholine levels

activation of muscarinic and nicotinic acetylcholine receptors

Result: life-threatening activation of parasympathetic nervous system

Cholinergic excess → cholinergic syndrome with muscarinic effects (DUMBBELLS), nicotinic effects (flaccid paralysis, respiratory arrest), and CNS effects (seizure, coma)

The greatest danger in organophosphate poisoning is respiratory failure.

1. Airway:

Ensure patient is maintaining own airway

Assess and secure stable airway

2. Breathing: Check SpO, & Give high flow 02 as appropriate

3. Circulation:

Pass IV line (IV cannula)

Start 0.9% Normal Saline (N/S) x IV x Stat

> Vitals monitoring: Check BP, PR, RR, Temperature, SpO,

Send labs: CBC, U/C/E, LFTS, RBS, PT INR, ABGS and anticholinesterase level.

Inj R/L 1L x IV x BD

Inj Omeprazole 40 mg (Risek, Ruling) x IV x OD

> Inj Ceftriaxone 1g (Titan, Rocephin) x IV x BD

Inj Atropine 2-4mg x IV x Stat then double the dose every 10th minute till atropinization. Alternative is Pralidoxime

Protocol in Our Ward/Hospital:

✓ Atropine 2-4mg x IV x Stat dose

✓ Then 1mg/ml for 2 days every 15 min

✓ Then 1mg/ml for 1 day every 30 min

✓ Then 1mg/ml for 1 day every 1 hourly

✓ Then 1mg/ml for 1 day every 2 hourly

✓ Then 1mg/ml for 1 day every 4 hourly

« Pralidoxime usually is not given because of high S.E profile WHO Dose: 30 mg/kg x IV x Stat over 20-30 minutes then 8 mg/kg/hr. continues infusion until recovery of patients OR Inj Pralidoxime 2g in 100ml 0.9% N/S x slow IV x Stat, then followed by 500mg/hr. for 7 days

If OP induced Seizures Or Agitation: Inj Diazepam (Valium) 10mg/2ml x diluted in 8ml N/S OR D/W5 % x IV x SOS

4. Disability & Exposure

Remove from exposure and remove contaminated cloths

Gastric lavage

>> Consider early HDU/ICU Admission

Pass Nasogastric tube and foley's catheter

Monitor pupillary reflexes and GCS level

Correct underlying cause

« Consider IV Multivitamins: Inj Neurobion/Multibionta

Radiology: CXR, ECG

BENZODIAZEPINES POISONING Rx

Respiratory depression

Mild hypotension

Hypotonia and hyporeflexia

Ataxia

Slurred speech

Differential diagnosis

Other substances that lead to a sedative-hypnotic toxidrome after an overdose (e.g., alcohol, barbiturates, and anticonvulsants such as phenytoin)

Nystagmus, which typically accompanies alcohol and phenytoin overdose, is absent in the case of benzodiazepine overdose

1. Airway:

Ensure patient is maintaining own airway

Assess and secure stable airway

2. Breathing: Check SpO, & Give high flow 02 as appropriate

3. Circulation:

Pass IV line (IV cannula)

Start 0.9% Normal Saline (N/S) x IV x Stat

Vitals monitoring: Check BP. PR, RR, Temperature, SpO

Send labs: CBC, U/C/F, LFTS, RBS, PT, INR, ABGS and urine

drug toxicology

Crystalloid fluid: Inj R/L & 0.9% N/S 1L x IV x BD/TDS

Inj Omeprazole 40 mg (Risek, Ruling) x IV x OD

Inj Ceftriaxone 1g (Titan, Rocephin) x IV x BD (2g x OD)

Inj. Haemaccel 500ml x IV x SOS (hypotension/shock)

" Inj Flumazenil 1mg/10ml

Routine use of flumazenil for benzodiazepine overdose is not recommended

Should be used in caution because it causes seizures

The recommended initial dose of Flumazenil is 0.3 mg IV If

The required level of consciousness is not obtained within 60 seconds, a further dose of 0.1 mg can be injected and repeated at 60-second intervals, up to a total dose of 2 mg or until the patient awakes.

If drowsiness recurs, an intravenous infusion of 0.1-0.4 mg/h may be useful

4. Disability & Exposure

Consider early HDU/ICU Admission

Pass Nasogastric tube and foley's catheter

Monitor pupillary reflexes and GCS level

Observe patient for 12-24 hours

Radiology: CXR, CT brain

OPIOIDS POISONINGS Rx

C/C

Altered mental status

Bilateral miosis (pinpoint pupils)

Respiratory depression

decreased respiratory rate

and tidal volume) and hemorrhagic lung edema

Seizures

Decreased bowel sounds

Decreased heart rate and blood pressure, hypothermia

Rhabdomyolysis

Altered mental status, respiratory depression, and miosis are the classic triad of opioid intoxication! However, the absence of meiosis does not rule out opioid intoxication!

1. Airway:

Ensure patient is maintaining own airway

« Assess and secure stable airway

2. Breathing: Check SpO, & Give high flow 02 as appropriate

3. Circulation:

Pass IV line (IV cannula)

Vitals monitoring: Check BP, PR, RR, Temperature, SpO

Send labs: CBC, U/C/E, LFTS, Blood sugar, urine

drug/toxicology screening and ABGs.

Inj Naloxone 0.4-2 mg IV x Stat, titrated to response.

Start N/S 0.9% Or R/L 1L and put 4-6 AMP Naloxone (2-3mg) in R/L x IV x Stat

As naloxone has a shorter half-life than opiates, it may need to be given often or as an intravenous infusion to prevent re- occurrence of signs and symptoms. If the patient is threatening to self-discharge, it can be given IM.

Naloxone may precipitate severe withdrawal in high-dose opiate misusers, who may be very angry at you for ruining their 'trip'

If Vomiting: Inj. Dimenhydrinate 50mg (Gravinate) x IV x TDS If not controlled/severe than Inj Ondansetron 8 mg (Onset) Diluted in 50-100 ml 0.9% N/S over 15 minutes.

Complication - If seizures: Give Inj Diazepam (Valium) 10mg/2ml x diluted in 8ml 0.9% N/S x (2mg up to 10 mg) x IV

4. Disability & Exposure

Monitor pupillary reflexes and GCS level

1) Correct underlying cause

Consider IV thiamine: Inj Neurobion

Observe patient for 6-8 hours, once the patient is medically stable, he should be referred for a psychiatric assessment

Radiology: CT scan, CXR

ACIDS/CAUSTIC INGESTION Rx

EXAMPLES OF CAUSTICS/ACIDS: ACIDS:

Sulphuric Acid: Car Batteries

Nitric Acid: Metal Cleaners

Hydrochloric Acid And Acetic Acid

Phenol And Boric Acid

Hydrofluoric And Oxalic Acid (Rust Removers)

Alkalis

Ammonia: Household Cleaners & Laundry Detergents

Bleach (Disinfectant)

Sodium Hydroxide: Drain Cleaners

WHY NOT TO DO:

>>> GASTRIC LAVAGE: Risk of perforation (Immediate lavage within 1 hrs. after large volume of ingestion is maybe beneficial)

» EMESIS: Leads to new exposure and risk of aspiration.

>>> NEUTRALIZATION: Leads to heat production more injury.

>>> ACTIVATED CHARCOAL: Obscures endoscopic view.

NO GASTRIC LAVAGE (CONTRA-INDICATED)

1. Airway:

Ensure patient is maintaining own airway

Assess and secure stable airway

2. Breathing:

Check SpO, & Give high flow 02 as appropriate

>>> Syp Aluminium Hydroxide (Mucain/Gaviscon) full stat then repeat half every 15-20 min

Syp Sucralfate (Ulsanic) 2 TSP TDS

3. Circulation:

Pass IV line (IV cannula)

Start 0.9% Normal Saline (0.9% N/S) x IV x Stat

Vitals monitoring: Check BP, PR, RR, Temperature, SpO2

Send labs: CBC, U/C/E, LFTs, blood sugar & ABGS.

Inj Ringer Lactate 1L (R/L) 1L x IV x BD

Inj Co-Amoxiclav 1.2g (Augmentin) Or Inj Ceftriaxone 1g (Titan/Rocephin) x IV x BD

Inj Omeprazole 40 mg (Risek) x IV x OD

Pain: Inj Ketorolac 30mg (Toradol) in 4ml 0.9% N/S x IV

If not respond give Inj Nalbuphine 10mg/ml (Kinz) PLUS with Inj dimenhydrinate 50mg (Gravinate) dilute in 8ml 0.9% N/S or D/W x give slow IV

For Laryngeal edema: Inj Hydrocortisone 100 OR 250mg x IV x TDS/BD; Alternative Inj Dexamethasone (Decadron 4mg/1ml)

4. Disability & Exposure

NO Gastric lavage - May induced retching and vomiting which

can cause compound injury

Monitor pupillary reflexes and GCS level

Correct underlying cause

Radiology: Chest X-Ray, Neck X-Ray, OGD

Reassure and DC on

Cap. Omeprazole 40mg x OD

Syp. Sucralfate x 2 TSP BD

Tab. Moxifloxacin 400mg x OD

KEROSENE POISONING Rx

C/C:

Mostly patient are asymptomatic with history of exposure

Symptoms soon after ingestion → typically progress to respiratory failure

Characteristic odor

Respiratory system: symptoms usually occur within 30 minutes of exposure Immediate signs are coughing, choking, gagging. Signs of pulmonary injury are dyspnea, cyanosis wheezing, rales, nasal flaring, grunting and fever. Fever >48

hours indicates bacterial superinfection.

CVS: Dysrhythmias, hypotension, and shock.

>> CNS: Headache, LOC, dizziness, ataxia, seizures, tremors and coma

>>> GIT: Burning sensation, nausea, vomiting, hematemesis & abdominal pain

>>> Skin and mucous membrane: mucosal irritation and chemical burns

Diagnosis:

>>> Petroleum distillate odor may emanate from the mouth/cloths

>> Arterial Blood Gas (ABG) will show hypoxemia and hypercarbia.

>> Bedside pulse oximetry: SpO2 (Hypoxia)

>> CBC may reveal raised WBCS

>> Chest X-ray: may be normal up to 6- 12 hours post aspiration following which pneumonitis may be seen.

>> ECG may reveal arrhythmia if the poisoning is severe.

Observe patient in ER for 6-8 hours

Do not induce vomiting

Do not attempt gastric lavage

Risk of aspiration outweighs any benefit from removal of substance

There is no role for steroids

Pneumatoceles usually resolve spontaneously

NO GASTRIC LAVAGE (CONTRA-INDICATED)

Treatment is mainly supportive, as there is no specific antidote

1. Airway:

Ensure patient is maintaining own airway

" Assess and secure stable airway

2. Breathing:

Check SpO2 & Give high flow 02 as appropriate

Keep patient NPO

3. Circulation:

Maintain intravenous line (IV cannula)

Vitals monitoring: Check BP, PR, RR, Temperature, SpO2

Send labs: CBC, U/C/E, LFTS, Blood sugar, ABGs.

IV hydration: Inj. Ringer Lactate 1L x IV x Stat

IV Antibiotics: Inj. Ceftriaxone 1-2g, diluted in 100 ml 0.9% NS x IV x stat

Indication of antibiotics: Fever more than 48 hours, increasing infiltrates on chest x-ray, Sputum/tracheal aspirate yield culture positive

If vomiting: Inj. Dimenhydrinate

If seizures: Give Inj. Diazepam 10mg/2ml (Valium) x diluted in 8ml 0.9% NS or Dextrose 5% x (2mg up to 10 mg) x IV slow over 5 minutes.

If recurrent seizures: Inj. Levetiracetam 500mg - 1g in 100ml 0.9% N/S x IV slow over 15-20 minutes

4. Disability & Exposure

Cutaneous decontamination: Remove contaminated clothing. Irrigate affected skin, eyes and hair. Wash with soap and water.

Gastric decontamination is not recommended. The risk of aspiration due to emesis and gastric lavage outweigh the benefits. Activated charcoal does not bind well to hydrocarbons while it increases the risk of spontaneous vomiting and further aspiration.

Monitor pupillary reflexes and GCS level

Consider early HDU/ICU Admission

Correct underlying cause

PARAPHENYLENEDIAMINE (PPP) POISONING Rx

▲ PPD/Kala-Pathar Poisoning

Swelling of lips, tongue, neck and eyelids

Tongue swollen & protruded

Cervicofacial edema

Dysphagia

>> Difficulty in opening of mouth

Muscle aches/rigidity

Chocolate-brown-colored urine (Dark urine)

In the event of life threatening reaction involving urticaria with laryngeal edema or angioedema: EPINEPHRINE may be tried to stabilize patient

Management of PPD poisoning is MAINLY SUPPORTIVE and NO SPECIFIC ANTIDOTE is available

1. Airway:

১১ Ensure patient is maintaining own airway

Assess and secure stable airway

Endotracheal intubation, tracheostomy, and assisted ventilation were crucial and lifesaving measures.

Perform urgent tracheostomy if laryngeal edema

2. Breathing: Check SpO, & Give high flow 02 as appropriate and assisted ventilation (if required).

3. Circulation:

Pass IV line (IV cannula)

Vitals monitoring: Check BP, PR, RR, Temperature, SpO,

33 Send labs: CBC, BUN, RFTS, LFTS, RBS, LDH, CPK, PT, APTT INR, phosphorus, bicarbonate level & ABGs On daily basis

IV fluid: Inj R/L, Inj. 0.9% N/S & Inj Dextrose 5%

33 Forced diuresis with diuretics + IV fluid 5-6L is used to enhance the excretion of toxins via urine.

Give Inj. Furosemide 40mg/2ml (Lasix) 20mg every 8 hours

Give Inj. Mannitol 250ml (If the patient is still oliguric)

Inj. Omeprazole 40 mg (Risek, Ruling) x IV x OD

Inj. Ceftriaxone 2g (Titan, Rocephin) x IV x OD

For Laryngeal edema: Give Inj. Methylprednisolone at dosage of 1mg/kg/day for 5 days Or Inj. Hydrocortisone sodium (Solu- Cortef) 250mg x IV stat then 100mg for 7 days x TDS PLUS Inj. Pheniramine maleate 50mg/2ml (Avil) every 8 hours for 3-5 days for Cervicofacial edema

IV Sodium bicarbonate to be administered to prevent myoglobin precipitation in kidney at average dosage 1 ampule (22.5 mEq) in 500ml Dextrose 5% or Normal saline

If develops Hyperkalemia: Give inj. calcium gluconate 10%/10ml 8 hourly and salbutamol (Ventoline) nebulization every 3 hours. Or Give Cocktail for hyperkalemia (See Hyperkalemia ER Rx)

Cardiac Support: If hypotension persists despite adequate fluid resuscitation, give Inj. Dopamine infusion at the rate of 6-8 mcg/kg body weight per minute in order to maintain systolic BP above 90 mmHg

- Disability & Exposure Gastric lavage: Perform gastric lavage with 2 grams of activated charcoal every 6 hours, useful within 1 hour after ingestion

Consider early HDU/ICU Admission

Pass Nasogastric tube and foley's catheter

Monitor urine output, pupillary reflexes and GCS level

Correct underlying cause

Plasmapheresis or Dialysis is required for patients with ARF Radiology: Chest- X-Ray, ECG, USG whole abdomen

SNAKE BITES ER/WARD Rx

C/C:

Most venomous snake bites occur in developing countries

Not necessarily result in envenomation- even if snake is poisonous (up to 30% of bitten patients are not envenomated)

Poisonous snake bites are indicated by one or two fang marks on the skin, whereas multiple teeth mark suggests that the snake is not poisonous.

Severe local pain, swelling, discoloration developing within 30 mins of bite

Effects of venom

Bleeding due to coagulopathy

Increase in capillary permeability, which leads to: Local edema & Accumulation of interstitial fluid in the lungs

Neuromuscular blockade

Cardiac failure can result from hypotension and acidosis.

Conventional dosage schedule of polyvalent anti-snake venom:

A. Only local swelling, no systemic symptoms-2-5 units.

B. Systemic symptoms/ haemorrhagic abnormalities -5-9 units.

C. Severe systemic manifestations/shock-10- 15 units.

1. Airway:

Ensure patient is maintaining own airway

Assess and secure stable airway

2. Breathing: Check SpO, & Give high flow 02 as appropriate

3. Circulation:

Pass IV line (IV cannula)

Avoid IM injection - Risk of hematoma formation

Vitals monitoring: Check BP, PR, RR, Temperature, SpO

IV Fluid: Ringer Lactate/0.9% N/S x 1L x IV x stat

>> Give Inj hydrocortisone 200 mg (Solu-cortef) + Pheniramine

maleate 25 mg (Avil) x IV x Stat

3) Send labs: CBC, U/C/E, LFTS, PT, APTT & INR, Markers of hemolysis (Severe intravascular haemolysis)

Consider 'O' Negative blood (universal donor) in emergency

Cross matching with Arrange 2 units/Pint of PCVs

FFPs if PT/INR is increased OR active bleeding

Inj Imitate 0.5ml x IM x stat, repeat after 4 weeks

Inj Adrenaline 0.5ml (1:1000) x SC, before injection of

antivenom to prevent severe acute reactions.

Analgesia: Paracetamol, oral/IV for pain/fever

Inj polyvalent anti-snake venom (ASV) 5 vial in 500ml 0.9% N/S x IV x TDS (each vial containing 1 unit of antivenin is made into 10 ml solution).

Inj Co-Amoxiclav 1.2g (Augmentin) x IV x BD

Deeper or more serious wound infections Inj piperacillin- tazobactam 2.25mg/vial OR 4.5g/vial (Tanzo) x IV x OD/BD

Inj Omeprazole 40 mg (Risek) x IV x OD

>> For Swelling: Tab Danzen DS/ Tab Danzen forte x PO x TDS

For muscle spasms: Diazepam 10mg (Valium) x IV x SOS

For severe Pain: NSAIDs or opioids and in severe cases

Acute renal Failure: Try to correct the electrolyte imbalance and give sufficient fluid parenterally. Inj. mannitol (20%) 300 ml is infused over 3 hours or a large dose of furosemide (100- 200 mg) I.V is given. If not corrected by above measures, the patient may require peritoneal or haemodialysis.

In Elapidae (cobra) group of snake bites: Inj. neostigmine 0-5 mg (1 ml) is given, I.V every half an hour for 4-6 injections until the ptosis or neuro deficit is corrected (here, the toxin blocks neuromuscular junction). Then injection neostigmine is given every one hourly and ultimately to be given at 2-3 hours intervals till all signs of paralysis have disappeared.

Every injection of I.V neostigmine should be preceded by 0-6 mg (1 amp) of inj atropine given by I.V route.

Respiratory failure: In respiratory muscle paralysis (by Elapidae group), ventilation by a respirator and proper control of blood gasses should be employed.

4. Disability & Exposure

Try to identify the snake and refer the victim to nearby hospital

Only valid first aid-splint extremity; do not cruciate cuts, suck out venom, wrap with ice, or apply tourniquet

Local wound care, cleaning and immobilization of extremity

Elevating the affected limb to prevent pooling of the venom

Lately surgical debridement, fasciotomy or skin grafting may be needed.

Obtained ECG for cardiac arrhythmia i.s. Atrial Fibrillation

As the outcome of snake bite is unpredictable in the initial stage, all cases should be carefully monitored for at least the first 12 hours. Dose of antivenom serum (AVS) in children is either equal or a bit more than the adult dose. Antibiotics covering gram-negative organisms and anaerobes are advocated in local infection.

>> Reassure the patient Counsel the patient and discharge

1 Tab Augmentin/ Tab Moxiget 400mg/ Cap Cefiget 400mg

2. Tab Danzen DS/ Tab Danzen forte x PO x TDS

3. Tab Paracetamol (Panadol/Calpol) x PO x TDS

4. Cap Risek 40mg x PO x OD (stress ulcer)

5. Tab Multivitamins

DISCHARGE RX OF SNAKE BITE

1. Tab. Moxifloxacin 400mg (Moxiget) OR Cap Cefixime 400mg (Cefspan/Cefiget) 0-0-1(OD)

2. Tab Panadol/Tab Nuberol forte (Voren, Voltral) 1-1-1(TDS), 1-0-1 (BD)

3. Tab Danzen DS Or Fort / Tab Chymoral Forte (For Swelling) 1-1-1(TDS), 1-0-1 (BD)

4. Tab Becefol / Tab Vitrum 0-0-1(OD)

POISONING AND SNAKE BITE Rx GUIDE

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