Problems Solving In Toxicology

Grades of toxic coma :

grade :0 Conscious
grade :1 Drowsy patient - responds to verbal
commands
grade :2 Unconscious : responds to minimal painful Sreflexes intact
grade:3 Unconscious : responds to maximal painful SAbsent superficial reflexes and sluggish deep R
grade 4: Unconscious - NO response
All of the following are Characteristics of dialyzable
poisons EXCEPT:
1. Low molecular weight
2. Low plasma protein binding
3. Low lipid solubility.
4. Low water solubility.

Gut dialysis is indicated in Salicylate toxicity due to:

1. Its anticholenergic effect
2. Pylorospasm
3. Enterohepatic circulation
4. Re excretion in gut.

All of the following are toxicological Screening tests

EXCEPT :
1-Colour tests.
2-Gas chromatography (GC)
3-Spectrophotometry.
4-Radioimmunoassay (RIA),

All of the following are Chemical local antidotes

EXCEPT
a. Copper sulphate
b. Sodium formaldehyde sulphoxylate
c. N acetyl cystaine
d. Sodium thiosulphate

Respiratory

PaCO2

Resp. Alkalosis

35-40

35-45

mmHg

Resp. Acidosis.

less

More

WHILE
Metabolic HCO3
M. Acidosis

24-28

24 -28

Meq/liter

M .Alkalosis

less

more

- Respiratory alkalosis means :

A. PaCO2 less than 35 mmHg
B. PaCO2 more than 45mmHg
C. Bicarbonate less than 24 mEq/liter
D. Bicarbonate more than 28 mEq/liter
Systemic hypocalcaemia is a main Pathophysiology of :
A. Carbolic acid
B. Oxalic acid
C. Sulphoric acid
D. Salicylic acid

PPP
Hypotension
Hypothermia
Arrhythmia
Torticollis
restlessness,
upward deviation of the eyes,

phenpthiazine

PPP
Hypotension
Hypothermia
Deep coma
Multiple needle marks

Morphine

PPP
Hypotension
Hypothermia
vomiting diarrhea
Sweating
muscle fasciculation
Pulmonary oedema

Hypotension

organo Ph

Hypothermia
Shock patient
Sweating
Deep coma.
pulse 70/minute.
large

barbiturate

bullae

Agitated
Dilated pupils
hypertension
Temp was 38C
Flushed face ,
dry

Atropine

Agitated ,paranoid
dilated reactive pupil
conjuctival injection; hypotension

ataxia Dysarthria,
Dilated pupils
flushed face,
wet , Hypothermia
Hypotension.

Alcohol

cannabis

Dilated reactive pupil

Hypotension,
pulse 110/min,
Cardiac arrhythmias
history of psych

TCA

Cases
1- A child 8 years was admitted to the hospital after
eating some plant in a garden.
On examination the child was agitated with flushed face
and dilated fixed pupils and temperature was 38C, pulse
was 90 / minute.
What is the possible diagnosis and how could you treat
this child?
Possible diagnosis :

Atropine in plant poisoning

Treatment :
1. Support respiration.
2. Circulation :
3. Control convulsion if present with diazepam.
4. Decontamination:
Emesis
Gastric lavage .
Activated charcoal

 Cathartics
5. Physiological antidotes
physostigmine salicyalte (Antilirium ) or Pilocarpine.
It cross the blood brain barrier for central and
peripheral actions.
Dose : 1-2 mg Im or IV (over 5 minutes ) after half-one
hour with maximum
dose 4 mg .
Pilocarpine It is used for peripheral action only.
6. Symptomatic :
Treat hyperthermia by ice packs.
IV fluids to maintain urine output.
Catheterization is indicated

2- A 30 years old male found comatosed in the street and

the people transferred him to the poison center.
Examination showed a comatosed with blood pressure
90/60 mmHg , rectal temp 35 C pulse 50/min, cool ,
cyanotic . Multiple needle marks were present along the
course of the veins, pupils are
pinpoint and rectal examination relieved hard stool.
What is the possible diagnosis and how could you treat
this case ?
Morphine toxicity
Treatment
1. Support respiration.

2. Decontamination:
Emesis NO
Gastric lavage .
Activated charcoal
Cathartics
3. Circulation :
4. Physiological antidotes:
Naloxone (Narcan)
Dose : 0.4 - 0.8 mg

iv

Naltrexone
Dose: Oral dose 50 mg / day , or 350 mg / week in 2-3
divided doses.

3 - A 20-year-old female was discharged from a

psychiatric hospital on the request of her family, Two days
later, she was brought to hospital with restlessness,
upward deviation of the eyes, torticollis and abnormal
movements of the tongue.
What is your diagnosis and how can you treat such a
case ?
Diagnosis : Acute phenothiazine poisoning
Treatment :
1.

Care of respiration ( A B) :

2.

Care of circulation (C) :

3. Decontamination:
Emesis

NO

gastric lavage .
Activated charcoal
Cathartics
4. Physiological antidotes
Treat extra pyramidal manifestations
By the use of antiparkinsonian drugs e.g.
Benztropine Mesylate (cogentin)1-2 mg IV
5. Elimination ( E ): NO

4- An adult 25 years old was admitted to the hospital by

his friends, he was delirious, agitated and paranoid. He
had reactive mydriasis with conjuctival injection; pulse
was rapid with palpitation, orthostatic hypotension.
What is the possible diagnosis and how could you treat
this case ?
The possible diagnosis is cannabis
Its active principle is delta-9-tetrahydro-cannabinol
Discuss the mode of action?
It is hallucinogenic drug causing mixture of stimulation
and depression of the CNS.
Treatment of acute cannabis poisoning
AB -C
Decontamination

Diazepam for agitation and excitement

5.A 22-year old male with history of bronchial asthma was

brought to PC . He was confused and agitated, with
vomiting and diarrhea. Blood pressure was 70/50 mmHg;
pulse was 120/minute, respiration 30/minute. Temperature
37C. Suddenly he developed tremors and (convulsions)
and ECG showed regular supraventricular tachycardia.
What is diagnosis and treatment of such a case ?
1. Care of respiration ( A_B).
2. Care of circulation (C) :
hypotension
tachycardia :Esmolol ,Beta-blockers as propanol
1. Decontamination (D) :
Syrup of Ipecac is best avoided
Gastric lavage is a preferred method .
Multiple dose oral activated charcoal .
Charcoal with cathartic more effective
4. Convulsion by diazpam (5-10 mg IV)
5. Elimination through the kidney (E):
Hemoperfusion is the definitive treatment and if
unavailable haemodialysis should be considered
Treat metabolic acidosis by IV sodium bicarbonate .

 Correct

hypokalemia .

6- - A 30-year old female was admitted to emergency

department after ingestion of tablets for suicidal attempt.
On examination, the patient was
in grade III coma.
pulse was 70/minute.
blood pressure was 80/50 mm Hg.
temperature was 36 C.
large bullae were found on the dorsum of the hand.
What is diagnosis and treatment of such a case ?
Barbiturate poisoning
Treatment
Care of respiration
Maintain a clear patent airway
Endotracheal tube
Artificial ventilation and oxygen inhalation
Care of circulation
Treat hypotension and shock
Decontamination
Emesis NO
Gastric lavage in comatosed patients
Repeated doses of activated charcoal

 Excretion ??????
Alkalinization of urine long only
Haemodialysis in severe cases long only
Haemoperfusion with short acting barbiturates
Treat hypothermia and acidosis
Treat complications as pneumonia by giving proper
antibiotic

7- A 35 year-old female with history of death of her

husband presented to Poison Center with dilated
reactive pupil, BP 80/60 mmHg pulse 110/min, ECG
was done and revealed cardiac arrhythmias.
What is the diagnosis?

TCA

Care of respiration
Maintain a clear patent airway
Endotracheal tube
Artificial ventilation and oxygen inhalation
Care of circulation
Treat hypotension and shock
Treat arrhythmia

IV NaHco3

- Lidocaine

Decontamination
Emesis NO
Gastric lavage in comatosed patients

Repeated doses of activated charcoal

cathartics
Excretion
Haemodialys

No

Haemoperfusion
8- A 30-year-old cardiac patient was presenting to
Alexandria poison center after attempting suicide by
her medication. She was complaining of abdominal
pain, blurring of vision and headache. On
examination: the patient was drowsy and disoriented.
Blood pressure was 90/60mmHg, pulse was 60/min.
and full followed by arrhythmia . Pupils were normal,
lower limbs showed bilateral edema.
What is the possible diagnosis? How can you treat
this patient? Digitalis
Treatment

Stop drug administration & ICU Monitor

Establishment of respiration
Decontamination
Lavage

Charcoal enterohepatic circulation

Repeated administration of charcoal (MADC)is of

value
Excretion of digitalis :

by Cholestyramine

Correct :

o Hypokalemia: give KCL 5g in fruit juice every hour until

ECG improve

o Hyperkalemia: give 20 units of insulin with 5% dextrose

o Hypomagnesaemia: replete magnesium
o Hypocalcaemia: avoid replacement
Treatment of arrhythmia:
Bradycardia :

Atropine sulphate 1-2 mg IM

Tachyarrhythmia:

Antidotal therapy:

phenytoin .

(Digibind) or Fab fragment .

they bind to the free digoxin

increase the excretion of digoxin bound to Fab
fragments
Indications for DIGIBIND Life threatening

Hyperkalemia (K+ >5mEql/L)

Bradyarrythmias unresponsive to atropine
ventricular tachycardia
High degree AV block

9- A 28 years old woman brought to the emergency

center department by her father complaining of
severe vomiting, restlessness and severe noise heard
by ear. On examination the patient was diaphoretic,
tachypnaic & hyperthermia. Her father stated his
daughter complained severe headache 2 weeks ago &
and doctor prescribed a medication to relieve her
pain. Her father found the bottle empty; he stated
that she had a history of suicidal attempts.

Salicylate toxicity
Management :
Respiration :air way ventilation if pulmonary

edema.

Decontamination : Gastric lavage and activated

charcoal.
Circulation:

Correct haemorrhagic tendency

Correct electrolyte and fluid balance

Vit K

Elemination :
Alkaline diuresis using sodium bicarbonate IV.
Dialysis in Severe cases

Supportive Therapy :

Cold blanket for hyperthermia .

Anticonvulsant for convulsion.
Antihistamines for allergy.
Antibiotic to prevent secondary infection.

10, A 40 years old man presented the Emergency

Department with vomiting and diarrhea. His vital signs
were: pulse 65/min., B.P 100/50mmHg, temperature
normal, pupils were constricted. He was lethargic and
diaphoretic, then he developed pulmonary edema.
What is the possible diagnosis, investigations and
management of such case?

OP
Treatment:
1-Respiration
2- Circulation
2- Decontamination:
Dermal decontamination: by removal of contaminated
clothes. Then the skin is washed first with soap and
water and finally with ethyl alcohol and water to
prevent further absorption.
GIT decontamination: Gastric lavage is done in
indicated cases after endotracheal intubation to avoid
aspiration
Antidotal therapy:
A- Atropine:
It is given initially as 2 mg I.V and repeated every 10 -15
minutes until atropinization known by drying of
tracheobronchiol secretions.
B-Oximes:
Pralidoxime : PAM
Dose :1 gm IV in normal saline.
Toxogonine : one ampoule (250 mg) IV to be repeated
within 1-2 hours up to three ampoules
Mechanism of Oximes:

Ch E reactivator

Detoxify

OP

Anti cholinergic

With My Best wishes

Prof..Wafaa .M. EL- Sehly
Department Of Forensic Medicine and Clinical Toxicology
Director of quality Assurance Unit
Faculty of Medicine
Alexandria University
email:wafaaelsehly@gmail.com
tel:01005669190