Toxicology is the branch of science which deals with the study of poisons, including their

mechanism of action, adverse effects on the body and treatment of the various conditions
produced by the poisons. These poisons can be from environment, industry, home or
pharmacological substances.
Branch of Toxicology is further divided into following branches:
1. Experimental Toxicology - It is the branch of Toxicology which studies the toxic effects of
various chemicals on the biological systems.
2. Clinical Toxicology - Clinical Toxicology involves the diagnosis and treatment of poisoning in
human beings.
3. Environmental Toxicology - This is a new branch of Toxicology and deals with the
identification and elimination of environmental poisons.
Poisons are unwanted substances which produce harmful effects on the body and
sometimes can be fatal. Antidotes are the substances used to reverse the harmful effects of the
poison. Antidotes act by either by preventing absorption or by inactivating or antagonizing the
actions of poisons.
General principles employed for the management of poisoning
Toxicology provides the basic guidelines to treat both acute and severe poisoning.
1) Identify the cause poisons
- The first step of the treatment is to identify the poisons
- Cause of poison can be known from the relative of the patient or by the parent himself if
he is conscious
- This step helps in deciding the specific treatment to the poisoning
2) Preventing the further absorption of the poison
- This is an important step in controlling the further spread of the poison in the body
- General rules include:
a) Induction of vomiting
o Syrup of Ipecac is the preferred emetic for inducing vomiting
o Dose of Ipecac syrup is 15 ml for children less than 6 months and 30 ml for adult
o Emesis is contraindicated in the following cases:
Vomiting should not be induced in comatose patients
Emesis is contraindicated in caustic poisoning and in Petroleum distillates
poisoning
Emetics should also be not given to those where is a risk of convulsions in the
patient

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b) Gastric lavage
o Gastric lavage is an important measure to control poisoning when it occurs due to
some aromatic substances such as perfumes
o It is also helpful when emesis is contraindicated
c) Use of activated charcoal
o Activated charcoal adsorbs the poisons and delays the gastrointestinal absorption
of the poison
o It is helpful in the treatment of poisoning from aromatic and alkaloid compounds.
Activated charcoal is used in the emergency treatment of certain kinds of poisoning. It
helps prevent the poison from being absorbed from the stomach into the body. Sometimes,
several doses of activated charcoal are needed to treat severe poisoning. Ordinarily, this medicine
is not effective and should not be used in poisoning if corrosive agents such as alkalis (lye) and
strong acids, iron, boric acid, lithium, petroleum products (e.g., cleaning fluid, coal oil, fuel oil,
gasoline, kerosene, paint thinner), or alcohols have been swallowed, since it will not prevent
these poisons from being absorbed into the body.
Some activated charcoal products contain sorbitol. Sorbitol is a sweetener. It also works as a
laxative, for the elimination of the poison from the body. Products that contain sorbitol should be
given only under the direct supervision of a doctor because severe diarrhea and vomiting may
result.
Activated charcoal has not been shown to be effective in relieving diarrhea and intestinal
gas.
Activated charcoal may be available without a doctor's prescription; however, before
using this medicine, call a poison control center, your doctor, or an emergency room for advice.
This product is available in the following dosage forms:

Liquid

Suspension

Tablet

Tablet, Chewable

Kit

Powder for Suspension

Hastening the elimination of poison
This is also an important aspect in treating the poisoning. Following general rules are
applied for increasing the elimination of poison from the body.
1) Altering the pH of urine
- In poisoning from basic substances such as amphetamine or quinine urine of the
patient should be made acidic to hasten the elimination of these substances

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- In case of acidic substances poisoning such as salicylates or phenobarbitone,

urine should be made alkaline to speed the elimination of the poison.
Eat citrus fruits, such as oranges, grapefruits, clementines, lemons or limes,
which cause the urine to become more alkaline. If your urine is too acidic, you
are at risk for uric acid-based kidney stones, MedlinePlus notes
Opt for dark green leafy vegetables, such as kale, spinach, chard, arugula,
romaine lettuce and collard greens. These foods are alkaline in nature and help
raise urine pH, according to the Cornell Institute for Biology teachers.
However, you should moderate your intake of these veggies, especially if you
have a specific illness causing a low pH, because these varieties contain
oxalates -- a compound responsible for kidney stones.
Dissolve sodium bicarbonate, also known as baking soda, in a 4 oz. glass of
water. Drugs.com states that you can safely consume 325 to 2,000 mg of
baking soda 1 to 3 times daily.
Take a combination of magnesium and calcium citrate oral supplements,
which aid in the alkalization of the urine. A study published in the March 2008
issue of the Journal of the American Society of Nephrology found that
magnesium and calcium effectively regulate the urine pH by either raising or
lowering levels, depending on the individual.
Drink milk, yogurt or eat dairy foods, which are high in calcium and act to
increase urine pH. Choose low-fat or nonfat varieties, as these items tend to be
high in saturated fat. Also, select plain yogurt, as flavored items may be high
in processed sugar, which can irritate the urinary tract.
2. Dialysis
o Peritoneal dialysis is very popular nowadays and used in the treatment of
methanol poisoning and in Snake bite.
o Hemodialysis is more superior technique but requires highly sophisticated unit for
care
o Peritoneal dialysis and hemodialysis have limited use in the treatment of
intoxication with chemicals.
3. Cathartics
o Cathartics are used to hasten the removal of a toxic substance and are useful in
ingestion of hydrocarbons and enteric coated tablets
o Sodium Sulfate is a frequently used cathartic

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4. Uses of Antidotes
o There are certain specific antidotes for treating the specific cases of poisoning

General supportive measures for improving the condition of patient

General supportive measures are meant to ensure the wellbeing of the patient and for the fast
recovery from the poisoning. General measures include the following steps:
Use of Oxygen therapy when there is hypoxia or probability of the same in the patient
Correction of the Blood Pressure of the patient by fluid therapy; Dopamine may be
required for correcting the BP
If there is cardiac arrhythmia in the patient, then safety measures should be taken under
the supervision of the expert
Correction of plasma biochemistry like, acidosis or alkalosis in the blood
Airways should be cleared with the help of suction apparatus
Toxicological emergencies
Exposures can be occupational, environmental, recreational, or therapeutic.
Exposures occur through inhalation, ingestion, injection, or contact with skin and mucous
membranes.
Antidotes are available for a variety of substances. An antidote is physiological
antagonist that reverses the signs and symptoms of poisoning (Badillo, Hovseth, &
Schaffer, 2013).
SPECIFIC TOXICOLOGICAL EMERGENCIES
Alcohol Use
Opiate Use
Cocaine
Amphetamines
Inhalants
Carbon Monoxide Poisoning
Salicylate Poisoning
Acetaminophen Poisoning
Sedative, Hypnotic & Barbiturate Poisoning
Acid and Alkali Burns
Cyanide Poisoning
Digoxin Toxicity
Assessment

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 Begin with primary assessment: airway, breathing, circulation, disability (A, B,C, Ds).
Resuscitation if necessary.
History of Present Illness- information regarding use/abuse/ingestion. Route of exposure,
reason for exposure,
Past Medical History- current meds, hospitalizations.
Psychological/social/environmental factors suicide, addictions
Objective Data: General appearance, level of consciousness, vital signs, odors,
auscultation of heart/breath/abdominal sounds.
Diagnostics: Drug levels, glucose, serum/urine
toxicology, CBC, CMP, ABG, Chest X-ray
Analysis: differential diagnoses
Anxiety/fear
Ineffective coping
Risk for injury/falls
Risk for poisoning
Risk for self/other-directed violence
Disturbed sensory/perception: visual, auditory, kinesthetic
Risk for impaired gas exchange
Risk for ineffective airway clearance
Risk for seizures
Planning, implementation and interventions
Priorities of Care: Maintain airway, breathing, circulation, disability
Provide supplemental oxygen as needed
Obtain intravenous access
Administer pharmacological therapy as ordered
Allow loved ones to remain with patient if supportive
Educate patients and significant others
Notify Poison Control for reporting and treatment recommendations.
Poison control center experts help clinicians to assess patients and can suggest
management practices.
The center uses POISINDEX and other toxicological databases, which are updated
regularly.
Notifications help them to track patients and gather demographic and statistical
information
(02) 524 1078

Age-related considerations
Pediatrics
Decreased renal clearance of children <6months old effects half-life of drugs
Most poisoning occur in children <6years old and usually in the home

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Poison Prevention Packaging Act of 1970 reduced the number of pediatric exposure
related deaths by mandating child-resistant caps on toxic substances (Badillo et al., 2013)
Geriatrics
Poly-pharmacy puts this population at high risk for therapeutic medication errors
Slowed metabolism leads to greater chance of toxicity
Cognitively impaired adults may accidentally take extra medications

SPECIFIC TOXICOLOGICAL EMERGENCIES

Alcohol intoxication
Symptoms
Altered mental status, nystagmus, flushed skin, bradypnea, vomiting, Impaired judgment,
impaired gait/coordination, coma
Treatment
Thiamine and multivitamins to prevent Wernicke-Korsakoff syndrome
Dextrose 50%(D50W) if hypoglycemic
IV access for crystalloid fluids
100% oxygen
Benzodiazepines: Librium, Lorazepam, Diazepam
Opiate use
Symptoms
Drowsiness, apathy, seizures, apnea/respiratory arrest, hypotension, bradycardia, and
miosis.
Treatment
Maintain A, B ,C, Ds
Provide supplemental oxygen
Establish IV access
Administer Naloxone (short acting narcotic antagonist)- may need to repeat doses
Activated charcoal if indicated
Cocaine use
Symptoms
Irritability, anxiety, hallucinations such as bugs crawling under skin, mydriasis,
tachycardia, hypertension, hyperthermia or heart attacks. You may also find perforated
nasal septum from snorting.
Treatment
Maintain A, B, Cs and provide supplemental oxygen
Establish IV access
Haldol for delirium/psychosis
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NGT and Whole bowel irrigation

ECG and Continuous cardiac monitoring

Amphetamines
Symptoms
Changed level of consciousness and bizarre behavior, paranoia, delusions, seizure
activity, hypertension, mydriasis, tachycardia, tremors. Thin, appears emaciated and
unkempt
Treatment
Maintain A, B, Cs and provide supplemental oxygen
Establish IV access for medications and/or crystalloids
Activated charcoal (if indicated) prevents systemic absorption
Benzodiazepines provides sedation; Haldol for psychotic symptoms
Inhalant
Symptoms
Behavior ranges from euphoria to depression, suicidal ideations (Perron & Howard,
2009), ataxia or wide-based gait, bloodshot eyes. Respiratory wheezing, circumoral red
spots on mouth and nose if using spray paint, decreased peripheral reflexes.
Treatment
Maintain A, B, Cs and provide supplemental oxygen
Establish IV access
Sodium bicarbonate for metabolic acidosis
Electrolyte replacements (especially potassium)
Carbon monoxide poisoning
Symptoms
Headache (most common), dizziness, weakness, nausea, vomiting, confusion. Cherry
red skin and mucus membranes.
Treatment
Maintain A, B, Cs
High flow100% oxygen (decreases half-life of COHb)
Establish IV access
Hyperbaric oxygen therapy for severe cases
Salicylate (aspirin) poisoning
Symptoms
Respiratory alkalosis, electrolyte imbalances, nausea, vomiting, tinnitus, tachypnea,
tachycardia, diaphoresis, respiratory crackles.
Treatment
Maintain A, B, Cs and provide supplemental oxygen
Establish IV access for meds and fluids
activated charcoal
IV crystalloids for renal clearance and hydration
Sodium bicarbonate to correct acidosis or alkalinize urine
Replace electrolytes

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Acetaminophen poisoning
Symptoms
3 stages: Initial (0-24 hrs), Dormant (24-48 hrs after), Hepatic (48-96 hrs).
Malaise, nausea/vomiting, Palpitations, syncope, bradycardia, hypotension, metabolic
acidosis, hepatic failure, Jaundice and electrolyte imbalances
Treatment
Maintain A, B, Cs and provide supplemental oxygen
Establish IV access
Activated charcoal within one hour of ingestion, IV Fluids (NS)
N-acetylcysteine (Mucomyst) orally, by NGT or intravenous (Acetadote)
IV Calcium Gluconate, Glucagon or vasopressors,
Acid and alkali burns
Symptoms
Stridor, drooling, burn blister in oral cavity or skin, corneal erosion, pale conjunctiva,
respiratory crackles
Treatment
Maintain A, B, Cs and provide supplemental oxygen as indicated
Establish IV access
Alkali exposure: diluted with small amounts of water if ingested. For Ocular injuries,
Irrigate with NS for one hour
Acid exposure: Do not use water for ingestions as it will create heat. For ocular injuries,
irrigate with NS for 15 minutes.
Pain medications/analgesics
Steroids for alkali burns
Activated charcoal if indicated
Calcium Chloride for hydrofluoric acid burns
Digoxin toxicity
Symptoms
Unusual visual changes (seeing spots, blurred vision), nausea, vomiting, diarrhea,
irregular pulse, confusion, loss of appetite, fatigue. Pupil mydriasis and photophobia.
Exams and Tests
ECG, serum digoxin level (0.5-2.0 ng/L), chemistries, renal function studies
Treatment
Maintain A, B, Cs and establish intravenous access
Discontinuation of drug
Possible external cardiac pacing or pacemaker insertion
hydration with IV crystalloid fluids
Digoxin Immune Fab (intravenous)
Activated charcoal for acute ingestions
Dialysis for severe cases
CONCLUSION

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Toxicological poisonings are increasing in the number of emergency room visits each
year. With the rise and evolution of new illicit drugs, the poly-pharmacy of geriatric medications
and increased access of home medications to young children, nurses must be adequately
educated to handle these type of situations. This presentation involved only a small number of
substances in existence and included the major symptoms and treatments related to each one. It is
the professional responsibility of every medical and nursing provider in emergency care to
familiarize themselves with various toxicological agents, symptoms and treatment interventions.

References

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319-332). St. Louis, Missouri: Elsevier Mosby.
Felicilda-Reynaldo, R. F. (2013). Cardiac glycosides, digoxin toxicity and the
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Olson, K. R. (Ed.). (2012). Poisoning and Drug Overdose (6th ed.). San Franciso,
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http://www.indiastudychannel.com/resources/146416-General-principles-of-toxicologyin-the-treatment-of-poisoning.aspx
http://www.mayoclinic.org/drugs-supplements/charcoal-activated-oralroute/description/drg-20070087
https://en.wikipedia.org/wiki/Alkaloid

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