General Principles Poisoning

Poisoning is defined as contact with a substance which leads to an effect. Symptoms may vary, but some specific syndromes can be assigned to specific toxic classes. The diagnosis must be made primarily clinically, in some poisoning but blood and urine tests may be helpful in diagnosis. Most poisoning require only supportive treatment; specific antidotes are only required for a few poisoning. The prevention of poisoning includes the clear labeling of drugs (packaging) and storage of poisons out of reach of children one with.

Most poisonings are dose dependent. The dose depends on the concentration over time. Toxicity can show even with large amounts of non-toxic substances. Some poisonings but are triggered by substances that are toxic over the entire dose range. Poisoning must be distinguished from hypersensitivity and idiosyncratic reactions are unpredictable and dose-independent, as well as any incompatibilities which are a toxic response to normally non-toxic doses of a substance in general.

Poisoning is defined as contact with a substance which leads to an effect. Symptoms may vary, but some specific syndromes can be assigned to specific toxic classes. The diagnosis must be made primarily clinically, in some poisoning but blood and urine tests may be helpful in diagnosis. Most poisoning require only supportive treatment; specific antidotes are only required for a few poisoning. The prevention of poisoning includes the clear labeling of drugs (packaging) and storage of poisons out of reach of children one with. Most poisonings are dose dependent. The dose depends on the concentration over time. Toxicity can show even with large amounts of non-toxic substances. Some poisonings but are triggered by substances that are toxic over the entire dose range. Poisoning must be distinguished from hypersensitivity and idiosyncratic reactions are unpredictable and dose-independent, as well as any incompatibilities which are a toxic response to normally non-toxic doses of a substance in general. Poisoning caused mostly by oral ingestion, but may also be caused by injection, inhalation or contact with the body surface (eg., Skin, eye, mucous membranes). Many of the substances ingested with food are generally non-toxic (see table: substances whose income usually is not dangerous *); in large amounts, however, but almost any substance can be toxic. Substances whose income usually is not dangerous * Adhesives antibiotics, topical antifungals, topical barium sulfate bath toy (floating) chalk (calcium carbonate) bleach, hypochlorite (sodium hypochlorite <6% and sodium concentration <0.5%) Candles (with insect repellents can be toxic ) PEG (polyethylene glycol) carboxymethyl (dehydrating material in conjunction with medication, and other product packaging) castor oil, cetyl alcohol cigarettes swallowed (small amounts of Child) Ton (arts and crafts) contraceptives, corticosteroids, topical crayons (children; labeled with AP, CP , CS or 130-46) detergents, dishwashing detergents, liquid dicloran (herbicide) diaper rash creams and ointments dry (anode) battery (alka lisch) softener, solid sheets of lamps (eg. B. light sticks, luminous necklaces) glycerol monostearate glycerol graphite rubber resins (e.g., as acacia, agar, ghatti) ink (the amount that is included in a ballpoint pen) iodide salts kaolin lanolin linoleic acid linseed oil (non-cooked) Lipstick lotion, zinc ointment (except for products containing antihistamines or local anesthetics) lozenges, throat lozenges (without anesthetics) magnesium silicate (antacid) makeup matches methylcellulose mineral oil (if not inhaled) newspaper ink, water colors or water-based paraffin, chlorinated pencil lead (graphite) petrolatum food plants (household) polyethylene glycols polyethylene glycol stearate, polysorbate Lute shaving silica (silicon dioxide) soap (bath soap or dishwashing detergent) spermaceti laundry starch and sizing stearic acid talc (not inhaled) titanium dioxide toothpaste (With or without fluoride) triacetin (glyceryl triacetate) vitamins, children's multivitamins with or without iron vitamins, multivitamin without iron oxide zirconia * This table is intended only as a guide. The substances can be combined with phenol, petroleum distillate carriers or other toxic chemicals. Poison Control Centers should be consulted to update inforamtion. Almost any substance is potentially toxic when taken in sufficient quantity Grosserer. Unintentional poisonings are common in young children who are curious and take substances despite their unpleasant taste or smell to it. But poisonings are common in older children, young adults and adults in the context of suicide attempts; various substances, including alcohol, acetaminophen and other over the counter medicines, can play a role. but unintentional poisonings occur in the elderly before due of confusion, poor eyesight, mental disorders or multiple prescriptions of the same substance by different doctors. Occasionally poisons also be used with intent to murder or to incapacitate to certain persons (eg. As in rape or robbery). Substances used for such purposes (scopolamine, benzodiazepine, Gammahydroxybuttersäure) sedate usually can lead to amnesia, or do both. In rare cases, parents poison with medical background knowledge their children either unclear psychiatric reasons, or they add their children harm to thereby gain medical attention (a condition called "one other added factitious disorder" [formerly Munich Hausen -Stellvertreter syndrome called]). Most toxins are after exposure or ingestion and absorption, metabolized, excreted through the intestines or otherwise. Occasionally, after taking tablets (such as acetylsalicylic acid, iron, acid-proof products) to form larger concretions in the gastrointestinal tract that linger long periods of time in most cases. This leads to a delayed continuously absorption and thus a delayed but sustained Vergiftungssymtomatik. Symptoms and signs Symptoms and signs of poisoning vary depending on the underlying substance (see Table: Symptoms and treatment of specific toxins). Even patients who are poisoned by the same substance can develop very different symptoms. Nevertheless (toxic syndromes or Toxidrome) usually occur six symptom types, which can be characteristic of specific classes of compounds (see Table: Common Toxic Syndromes (Toxidrome)). Be included more substances from the patient, it is unlikely that the characteristic of a single substance symptoms. Common toxic syndromes (Toxidrome) Syndrome symptoms Common causes anticholinergic tachycardia, hyperthermia, mydriasis, hot and dry skin, urinary retention, ileus, delirium ( "mad as a hatter, blind as a bat, red as a beet, hot as a hare, and dry as a bone "*) antihistamines atropine Belladonna alkaloids Datura (angel trumpet) Datura fungi (some) Psychoactive drugs (some) scopolamine Tricyclic antidepressants cholinergic, muskarinartig salivation, Lacrimation, urination, defecation, abdominal cramps, vomiting or Durchfalliarrhö; urination; miosis; bronchorrhea, bradycardia and bronchoconstriction; vomiting; lacrimation and salivation wheezing carbamates fungi (some) organophosphates physostigmine pilocarpine pyridostigmine cholinergic, nicotinic acid mydriasis, tachycardia, weakness, hypertension and hyperglycemia, Fasciculationen, sweating abdominal pain, paralysis spider bite (Black Widow) carbamates nicotine organophosphates (some) opioid hypoventilation, hypotension, miosis, sedation, hypothermia may opioids (eg. as diphenoxylate, fentanyl, heroin, methadone, morphine, pentazocine, propoxyphene) sympathomimetic Tachycardia, hypertension, mydriasis, restlessness, seizures, sweating, hyperthermia, psychosis (after chronic use) amphetamines (stimulants) caffeine cocaine ephedrine organic and synthetic marijuana and frequent substitutes MDMA (Ecstasy) phenylpropanolamine theophylline withdrawal tachycardia, hypertension, mydriasis, sweating, restlessness , restlessness, anxiety, hyperreflexia, Chilling, yawning, abdominal cramps, lacrimation, flu-like symptoms, insomnia, vomiting and diarrhea task of following sedating or recreational drugs: barbiturates marijuana opioids agitat ion, hallucinations, confusion, disorientation, seizures, hyperreflexia, hypertension, tachycardia, arrhythmias, dehydration, autonomic instability, death Baclofen: severe muscle spasms object of the following medications with sedative-hypnotic effects: alcohol Baclofen benzodiazepines GHB decreased mental alertness, lethargy, coma, drop in blood pressure, decreased heart rate task of the following drugs with sympathomimetic effects: amphetamines cocaine Phencyclidine Synthetic cathinones (bath salts) Mild flu-like symptoms, insomnia, restlessness and anxiety The object of the following drugs with antidepressant activity: MAOI SSRI Tricyclic antidepressants * From Carroll L: Alice's Adventures in Wonderland. London, MacMillan & Co. 1865. GHB = Gammahydroxybutyrat; MDMA = methylenedioxymethamphetamine usually begins the symptoms soon after exposure, but in certain poisons can occur also delayed. The delay may be due to the metabolite that only the actual toxicity triggers (eg., Methanol, ethylene glycol or various liver poisons). The intake of Lebergiftten (z. B. paracetamol, iron, Amanita mushrooms) can lead to acute liver failure, which occurs only after a latency of one or more days. For metals or solvents from the class of hydrocarbons symptoms typically occur only after chronic exposure. Orally ingested and absorbed poisons usually result in systemic poisoning signs. Caustic or corrosive fluids mainly damaging the mucous membranes of the gastrointestinal tract and cause stomatitis, enteritis or lead to perforation. Some toxins such as alcohol and hydrocarbons produce a distinctive breath odor. The contact a poison with the skin can lead to various acute lesions such as rashes, pain or blistering; chronic exposure may lead to dermatitis. Inhaled toxins lead, provided they are water soluble (eg. Chlorine, ammonia), typically to a damage of the upper respiratory tract. Little water-soluble substances such. As phosgene, damage the lower respiratory tract and cause nichtkardial induced pulmonary edema (toxic lung edema). Inhalation of carbon monoxide, hydrogen cyanide or hydrogen sulfide gas can cause ischemia of organs or cause a cardiac or respiratory arrest. The contact of the eye with poisons (solid, liquid or vapor) can damage the cornea, sclera and lens and cause eye pain, redness, and at worst, the loss of vision. Some substances such as cocaine, phencyclidine and amphetamines can cause severe agitation, which might lead to hyperthermia, acidosis, and rhabdomyolysis. Diagnosis of poisoning should be considered in patients with alterations of consciousness or unexplained symptoms into consideration. Information from all available sources selective, direct testing The first step in the diagnosis of poisoning is the imposition of a whole-body status of the patient. Severe poisoning require immediate intervention to treat the threatening / manifest cardiovascular or respiratory arrest. Poisons may already be known at admission, they should be considered at least when patients have unexplained symptoms, esp. With altered mental status, states of agitation, somnolence to coma states. In suicidal motivated poisoning should be considered in adults of taking several different substances. The history is often groundbreaking. If many patients (eg. As toddlers, suicidal or psychotic adults, patients with altered mental status) can not provide reliable information, friends, acquaintances and rescue personnel should be consulted. Even at first glance appears reliable patient can make untrue statements about the amount or timing of ingestion. Where possible, should be included further evidence of the direct living environment of the patient (eg. As part emptied medication boxes, evidence of habitual drug use, one suicide note). Pharmacies and health record (prescriptions, medical reports, etc.) can also provide useful information. With potential poisoning in the workplace employees and supervisors should be interviewed. For all industrially used chemicals a safety data must be available in the workplace, which contains detailed information on the toxicity and, where appropriate, specific treatment. In many countries of the world information on household and industrial chemicals can be collected via Poison Control Centers. The contact with these devices is recommended because the exact composition of the substances, first aid procedures, antidotes that are specified on the packaging, are sometimes wrong or outdated. Also, the vessel in question may have been replaced or the attached substance not gwhört to the container. Poison Control Centers can thereby help to identify unknown pills based on their appearance, and they have direct access to toxicologists. The number can be obtained through the telephone inquiry. The telephone number of the nearest Poison Control Center can be found, often together with other emergency numbers on the front pages of local telephone books. In Germany Poison Control Centers are 19 240 to reach using the emergency telephone number (area code) (Berlin 030, Bonn 0228, Erfurt 0361; Freiburg 0761; Goettingen 0551, Homburg / Saar 06841; Mainz 06131; München 089). More information is available at the website of the American Association of Poison Control Centers. The physical examination may in some cases direct references to the substance used to give (for example by the presence of so-called Toxidrome.. [See Table: Common Toxic Syndromes (Toxidrome)], the smell of the air we breathe, the presence of tropical drugs, injection sites or tracks which suggest an iV drug abuse, signs of chronic alcohol abuse, etc.). Even if intoxication is secured in a patient, an altered consciousness can have other causes (eg. As CNS infection, head injury, hypoglycemia, stroke, hepatic encephalopathy, Wernicke's encephalopathy), which must also be considered , A suicide attempt should be considered, especially in older children, young adults and adults who have taken a medication in larger amounts. After such patients are stabilized, a psychiatric follow-up must be ensured. Tests In most cases, the sole laboratory analysis of limited help. (Often called drug screening) quickly available standard tests that identify the most common drugs or abuse substances are only qualitatively but not quantitatively. These tests can give false-negative or false-positive results and prove only a limited number of substances. The detection of a substance abuse does not necessarily have to be responsible for the patient presented symptoms or signs. Urine tests on substances are used most frequently, but have limited value because they can only identify classes of drugs or metabolites, however, no specific medications. For example, an opioid urine immunoassay fentanyl or methadone may not realize it but react to very small amounts of morphine or codeine analogs. The test is used to identify cocaine, but can only detect a metabolite, not the actual cocaine. For most substances blood levels can not be readily determined or not help in deciding on the type of treatment. For a few substances such. As paracetamol, acetylsalicylic acid, carbon monoxide, digoxin, ethylene glycol, iron, lithium, methanol, phenobarbital, phenytoin and theophylline may be useful quantitative blood levels for further treatment. A variety of experts recommends the measurement of Paracetamolspiegeln in all patients with multiple poisonings because the Paracetamoleinnahme is often asymptomatic and often in the early stages; However, acetaminophen can cause a delayed onset of serious damage which can be prevented by the administration of antidote. For some substances other laboratory parameters may further treatment control (z. B. PPT / INR determination for warfarin or Phenprocoumonüberdosierung, for certain substances and methemoglobin). In patients who have an altered level of consciousness or disturbances of vital functions, or certain substances have taken, and the biochemical values ??of serum electrolytes, urea, creatinine, serum osmolality, glucose, coagulation and arterial blood gas values ??should be determined. Other tests (eg. As methemoglobin levels, carbon monoxide content, cranial computed tomography) may be indicated for suspected certain toxins or certain clinical conditions. Common specific antidotes toxin antidote N-acetylcysteine ??paracetamol anticholinergics physostigmine * * benzodiazepine flumazenil spider bite (Black Widow) Lactrodectus antivenom botulism botulinum antitoxin ?-blockers glucagons lipid emulsion i.v. Calcium channel blockers Calcium iv Insulin in high doses with i.v. Glucose lipid emulsion i.v. Carbamates atropine pralidoxime chloride snake bites (pitvipers, USA) Crotalinae-polyvalent immune Fab (ovine) cyanide hydroxocobalamin cyanide antidote putty (from amyl nitrate, sodium nitrite, and sodium thiosulfate) Digitalis glycosides (eg. Digoxin, digitoxin, oleander, thimble) digoxin-specific Fab fragments ethylene glycol fomepizole ethanol Schwermet Chelants all (see Table: Guidelines for chelation therapy) Ionizing radiation potassium iodide iron deferoxamine isoniazid pyridoxine (vitamin B6) methanol fomepizole ethanol Methämoglobinbildende agents (eg. As aniline dyes, some local anesthetics, nitrates, nitrites, sulfonamides) methylene blue methotrexate Leucovorin (folic acid) glucarpidase (carboxypeptidase G2) opioids naloxone organophosphates atropine pralidoxime Scorpio poisoning (Centruroides sp) Centruroides immune F (ab ') 2 sulfonylureas octreotide Thallium Prussian blue Tricyclic antidepressants NaHCO3 sodium bicarbonate unfractionated heparin protamine folic acid L-carnitine warfarin Vitamin K Fresh frozen plasma ( "fresh frozen plasma") prothrombin complex concentrate (PCC) * D ie use is controversial. Fab = Fab fragments of antibodies. In some poisoning (for. Example, by iron, lead, arsenic, other metals or packets of cocaine or other illicit drugs that are ingested by the so-called. Body packers) can display a plain abdominal detection and localization of the total-price substance. In cases of poisoning with drugs that cause cardiovascular symptoms or poisoning with an unknown substance ECG and cardiac monitoring should be standard. be if the blood levels of a poison or toxic symptoms after the initial drop or an improvement to rise again or persist the symptoms for an unusually long time, should of tablets conglomerates, taking sustained-release or a re-exposure intended (eg. as repeated secret intake a freely accessible substance). Therapy Supportive treatment activated carbon for severe oral poisoning Uncommon only very rarely of specific antidotes or dialysis: gastric emptying in severely poisoned patients had ventilator or treatment of heart and circulatory arrest may be necessary. Patients with impaired consciousness able to be provided a continuous monitor monitoring. The discussion of the treatment of specific poisonings (see Table: Common specific antidotes, see table: Guidelines for chelation therapy and refer to Table: Symptoms and treatment of specific toxins) is general and does not deal with specific problems and details. is generally for all poisonings unless they are lightweight and are treated standardized, contact a Poison Control Center recommended. Guidelines for chelation therapy chelating substance * Metal dosage † Deferoxamine iron See treatment of iron poisoning dimercaprol, 10% in oil Antimony Arsenic Bismuth copper salts Gold Lead Mercury Thallium * 3-4 mg / kg by deep i.m. Injection every 4 h on the first day 1, 2 mg / kg i.m. every 4 h at zweitenTag, 2, 3 mg / kg i.m. every 6 h on the third day, then 3 mg / kg i.m. every 12 h over 7-10 days to recovery EDTA-Ca-Disodium (Ca disodium edathamil) diluted ? 3% cobalt zinc lead zinc salts 25-35 mg / kg by deep i.m. Injection or iv slowly (over 1 h) every 12 h for 5-7 days, followed by 7 days without the drug, then repeated penicillamine arsenic copper salts gold lead p.o. 5-7.5 mg / kg 4 times a day (the usual starting dose is 250 mg 4 times daily) up to a maximum adult dose of 2 g per day Succimer arsenic (occupational exposure in adults) cadmium salts, lead in children with blood lead levels> 45 ug / dL (> 2 15 .mu.mol / L) lead (occupational exposure in adults) mercury (occupational exposure in adults) 10 mg / kg po every 8 h for 5 days, then 10 mg / kg p.o. every 12 h for 14 days * thallium salts form in a different extent by this drug chelates (s thallium salts see table. symptoms and treatment of specific poisons). † The dosage depends on the type and severity of the poisoning. Initial stabilization maintaining the airway, breathing and circulation i.v. Naloxone iv Dextrose and thiamine infusions, sometimes vasopressors airway, breathing, and circulation need for patients for whom a systemic poisoning is believed to be maintained. Patients with no pulse or blood pressure requiring emergency resuscitation. In all patients with respiratory failure or impaired respiratory tract (eg. As foreign bodies in the oropharynx, weakened cough and gag reflex) should be endotracheal intubation (see Tracheal intubation). In patients with respiratory insufficiency or hypoxemia, administration of additional O2 by inhalation or mechanical ventilation should be done as needed. Naloxone iv (2 mg in adults, 0.1 mg / kg in children) should be tried in patients with apnea or severe respiratory depression, while the support of the respiratory tract is maintained. Bei Opiatabhängigen kann Naloxon ein Entzugssyndrom auslösen, wobei das Entzugssyndrom im Vergleich zur ernsten Atemwegsdepression das geringere Übel darstellt. Sofern eine Atemdepression trotz Einsatz von Naloxon persistiert, sind die endotracheale Intubation und kontinuierliche mechanische Ventilation erforderlich. Sofern Naloxon die Atemdepression aufhebt, müssen die Patienten sorgfältig überwacht werden; sobald die Atemdepression wieder auftritt, sollten die Patienten durch eine erneute Bolusinjektion von Naloxon oder durch eine endotracheale I

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