Definition

The ingestion of a noxious substance in such volume as to result in interference with normal biologic function.

History

Symptoms: Depending on the offending agent, symptoms may involve any organ system. Nausea, vomiting, diarrhea, headache, dizziness, blurred vision, stupor, paresthesias, seizures, respiratory distress, diaphoresis, anhidrosis, and rash are common.

General: Though often difficult, it is important to identify the substance involved. Question the patient, family, or friends as to the access to potential poisons. Have someone (police, fire, rescue, social worker, family member) search the scene for empty drug or alcohol containers.

It is essential to know as accurately as possible the quantity and time of the ingestion.

Age: Approximately 50 percent involve children younger than five years old; 5 percent involve children 6 to 12 years old; 5 percent involve teenagers, and 40 percent involve adults.

Onset: Depends on substance.

Duration: Depends on substance.

Intensity: Depends on substance.

Aggravating Factors: Intentional poisoning has a higher morbidity than accidental poisoning. Pre-existing health problems (e.g., those affecting the liver and kidneys) can interfere with the elimination rate of the poison and the toxic effects.

Alleviating Factors: Early intervention.

Associated Factors: Mental illness, traumatic injury with altered mental status.

Physical Examination

Physical Signs Associated With Specific Drug Intoxication General/Vital Signs

• Hyperthermia: Belladonna, antihistamines, boric acid, dinitrophenal, phenolphthalein, quinine, zinc fumes, monamine oxidase inhibitors, amphetamines, tri cyclic antidepressants.
• Hypothermia: Alcohol, opiates, chloral hydrate, barbiturates, phenothiazines, tetracycline.
• Hypertension: Amphetamines, cocaine, ephedrine, phencyclidine, methylphenidate, monamine oxidase inhibitors, tricyclic antidepressants.
• Hypotension: Alcohol, barbiturates, opiates, phenothiazines, antihistamines.

Cardiovascular

• Arrythmia: Digitalis, quinidine, tricyclic antidepressants.
• Bradycardia: Barbiturates, chloral hydrate, opiates.
• Tachycardia: Amphetamines, belladonna, cocaine, ephedrine, xanthines, monamine oxidase inhibitors.

Gastrointestinal

• Vomiting, Pain, Diarrhea, Gastrointestinal Bleeding: Metals, alcohol, caustics, phosphorous, muscarine, digitalis, salicylates, xanthines, fluoride, bromide, insecticides, mushrooms (Amanita muscaria, Amanita phalloides). Jaundice: Metals, nitrobenzene, benzene, mushrooms (Amanita muscaria), quinidine, phosphorous, carbon tetrachloride, phenothiazines, thiazide diuretics, acetaminophen.

Neurologic

• Paresthesias, Weakness: Alcohol, organophosphate insecticides, chlorinated hydrocarbons, chloramphenicol, gold salts, isoniazide, nitrofurantoin, arsenic, lead, thallium.
• Fasiculations: Organophosphate insecticides. Increased Deep Tendon Reftexes, Muscle Tension: Phencyclidine,amphetamines, cocaine, ephedrine, monamine oxidase inhibitors.
• Depression/Coma: Ethanol, isopropyl alcohol, barbiturates, tricyclic antidepressants, antihistamines, chloral hydrate, carbon monoxide, cyanide, hydrogen sulfide, petroleum distillate, hydrocarbons, xylene opiates, metals, insecticides, salicylates, benzodiazapines, bromides.
• Convulsions: Insecticides, metals, cyanide, tri cyclic antidepressants, strychnine, amphetamines, camphor, mushrooms (Amanita muscaria, Amanita phalloides), propoxyphene, phenytoin, xanthines, monamine oxidase inhibitors.
• Hallucinations, Delirium: Phencyclidine, lysergic acid diethylamide, mescaline, psilocybin, amphetamines, cocaine, belladonna, tricyclic antidepressants, alcohol, mushrooms (peyote).

Ophthalmologic

• Pupillary Dilation: Amphetamines, belladona, chloroform, cocaine, ephedrine, epinephrine, ether, hallucinogens (LSD), isoproterenol, nicotine, pyribenzamine, opiates.
• Pupillary Constriction: Barbiturates, ethanol, opiates, organophosphate insecticides, phencyclidine, phenothiazines, physostigmine, pilocarpine.
• Strabismus: Botulism.
• Nystagmus: Phenytoin, phencyclidine, barbiturates, benzodiazepines.

Oral

• Salivation: Caustics, insecticides, metals, mushrooms (Amanita mus­caria).
• Dry Mouth: Antihistamines, belladonna, phenothiazines.
• Breath Odors: Alcohol (phenols, chloral hydrate, ethanol); acetone (salicylates, lacquer, thanol, isopropanol); wintergreen (methyl salicylate); garlic (phosphorus, arsenic, organophosphate insecticide); bitter almond (cyanide).

Pulmonary

• Bradypnea: Alcohol, barbiturates, opiates.
• Tachypnea: Aromatic oils, carbon monoxide, cyanide, dinitrophenol, nicotine, salicylates.

Renal

• Oliguria: Ethylene glycol, metals.
• Urinary Retention: Antihistamines, belladona, phenothiazines, tricyclic antidepressants.

Skin

• Hyperemia: Cyanide, alcohol, thallium.
• Cherry Red: Carbon monoxide.
• Cyanosis: Nitrobenzene, nitrates, nitrites, nitrophenol, benzocaine, phenacetin.
• Pallor: Benzenes.
• Blue Gum Line: Lead.
• Black Gum Line: Mercury.
• Rashes: Bromides, chlorides, iodides, gold salts, salicylates, chromium, phenothiazines.

Pathophysiology

Depending on drug, can interrupt the normal physiologic mechanisms of any organ.

Diagnostic Studies

Laboratory

• Toxicology screens: On gastric fluid, serum, and urine to identify the substance.
• Electrolytes: To look for abnormality.
• Liver function tests: To assess baseline function and potential damage.
• Arterial blood gas: To assess adequacy of ventilation.
• Radiology: Not applicable.
• Other: Not applicable.

Differential Diagnosis

Traumatic

Head injury: Differentiated by history.

Infectious

Meningitis: May see nuchal rigidity, positive Brudzinski and/or Kemig signs, leukocytosis with a shift, positive cerebral spinal fluid. Gastrointestinal infections: No history of toxic ingestion; Ilegative toxicology screen.

Metabolic

Epilepsy: History of seizure; negative toxicology screen. Schizophrenia: At risk patient; negative toxicology screen. Depression, mania: At risk patient; negative toxicology screen.

Neoplastic: Not applicable.

Vascular: Not applicable.

Congenital: Not applicable.

Acquired: Depression.

Treatment

Immediately support cardiovascular and respiratory systems Whenever possible have course directed by the regional poison control center.;

Pediatric Considerations

Children may have different tolerances and reactions to various medications. Treatment should be held pending consultation with the Poison Control Center (PCC). Prevention is the key to management.

Obstetrical Considerations

Initial management of poisoning should remain the same as in the non pregnant patient. Naloxone (Narc an) has been proven to be safe and effective in the management of narcotic overdoses in the pregnant patient. Elevated alcohol intake (”alcohol poisoning”) throughout a pregnancy can lead to fetal alcohol syndrome. This is usually seen in infants whose mother drinks more than six alcoholic beverages per day during the first trimester. Cocaine use in a pregnant mother, particularly in large amounts, can cause sudden fetal death, premature delivery, infants who are small for gestational age, asymmetric fetal growth, retardation, premature rupture of membranes, and many other organ and organ system defects.The following chemical compounds have been implicated as having profound effects on fetal well-being. Organic mercury Compounds can cross the placenta. The fetus then may develop congenital cerebral palsy, mental retardation, and other defects secondary to mercury concentration in the fetal central nervous system. Lead has also been found to cause growth retardation and central nervous system abnormalities in the fetus as well as increased chance of spontaneous abortion and still birth. Ethylene oxide, formaldehyde, methylene chloride, and CO may pose potential reproductive hazards.

Tagged under:alcohol amphetamines anhidrosis barbiturates chloral hydrate drug intoxication Health Flash monamine oxidase inhibitors noxious substance poisoning poisoning treatment

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