Poisoning and Drug Overdose

Presented By:
• Sadiq Sabeel
• Ameer hamza
• Musavir
• Asim
• Sahib Ullah
Presented To:

MR. KHALIL KHAN

(AP INS)

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Objectives

At the end of this session, the learners will be able to :

• Define poisoning.
• Define drug overdose.
• Explain the causes of a drug overdose.
• Enlist some common drugs that can be overdosed.
• Explain the general management of drug overdose.
• Discuss the antidotes of some commonly used
overdosed drugs.
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What is Poisoning?

• A poison is any substance that is harmful to the

body.
• One might swallow it, inhale it, inject it, or absorb it
through the skin.
• Intentional or accidental.
• Any substance can be poisonous if too much is
taken.

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What is a Drug Overdose?

The term drug overdose (or simply overdose or OD)

describes the ingestion or application of a drug or
other substance in quantities greater than are
recommended or generally practiced.
An overdose may result in a toxic state or death.

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What are the causes of drug
overdose?

The cause of a drug overdose is either accidental

overuse or intentional misuse. Accidental overdoses
result from either a young child or an adult with
impaired mental abilities swallowing a medication
left within their grasp.

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What is the most common drug
used to overdose?

• The most frequent drugs that people overdose on are:

• Over-the-counter (OTC) drugs.
• Prescription pain relievers.
• Sedatives and antidepressants.
• Heroin.
• Methamphetamines.
• Cocaine.
• Drug combinations (i.e. heroin and alcohol)

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General- Management

• Provision of supportive care

• Prevention of poison absorption
• Enhancement of elimination of poison
• Administration of antidotes

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Supportive Care

• ABC
• Vital signs, mental status, and pupil size
• Pulse oximetry, cardiac monitoring, ECG
• Protect airway
• Intravenous access
• Cervical immobilization if suspect trauma
• Rule out hypoglycaemia
• Naloxone for suspected opiate poisoning
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Examination

• Physiologic excitation –
anticholinergic, sympathomimetic, or central
hallucinogenic agents, drug withdrawal
• Physiologic depression –
cholinergic (parasympathomimetic), sympatholytic,
opiate, or sedative-hypnotic agents, or alcohols
• Mixed state –
polydrugs, hypoglycemic agents, tricyclic
antidepressants, salicylates, cyanide
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 Preventing Absorption

Gastric lavage
• Not in an unconscious patient unless intubated (risk aspiration)
• Flexible tube is inserted through the nose into the stomach
• Stomach contents are then suctioned via the tube
• A solution of saline is injected into the tube
• Recommended for up to 2 hrs in TCA & up to 4hrs in Salicylate
OD
Induced Vomiting
• Not routinely recommended
• Risk of aspiration
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 Preventing Absorption

Activated charcoal
• Adsorbs toxic substances or irritants, thus inhibiting GI
absorption
• Addition of sorbitol →laxative effect
• Oral: 25-100 g as a single dose
• Repetitive doses useful to enhance the elimination of certain
drugs (eg, theophylline, phenobarbital, carbamazepine, aspirin,
sustained-release products)
• Not effective for cyanide, mineral acids, caustic alkalis, organic
solvents, iron, ethanol, methanol poisoning, lithium

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 Elimination of Poisons
Renal elimination
• Medication to stimulate urination or defecation may be given to try to flush the
excess drug out of the body faster.
Forced alkaline diuresis
• Infusion of a large amount of NS+NAHCO3
• Used to eliminate acidic drugs that are mainly excreted by the kidney eg
salicylates
• Serious fluid and electrolytes disturbance may occur
• Need expert monitoring
Hemodialysis:
• Reserved for severe poisoning
• Drug should be dialyzable i.e. protein bound with a low volume of distribution
• may also be used temporarily or as long term if the kidneys are damaged due to
the overdose.
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Antidotes
Antidotes are agents that negate the effect of a
poison or toxin. Antidotes mediate its effect either by
preventing the absorption of the toxin.

Thus, four basic mechanisms. This includes

1. Decreasing the active toxin level
2. Blocking the site of action of the toxin,
3. Decreasing the toxic metabolites, and
4. Counteracting the effects of the toxin.
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 Opiates
• Opioids include (Morphine, Heroin (Dia morphine),pethidine, codeine,
Buprenorphine)

• Commonly in the form of

• → analgesics→ Cough Suppressants→ anti- diarrheals.

Sign and symptoms (presentation)

• Depresses the medullary cough reflex → airway
obstruction.
• Causes histamine release → vasodilation → hypotension.
• Leads to miosis (pinpoint pupils), coma, and
bradycardia
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Cont….
• Other symptoms : Cyanosis, apnea,
Convulsions, Hypotension
• Non cardiogenic pulmonary edema →
injecting Heroin
• Delayed toxicity → methadone (long half
life: 15-60hr)
• Respiratory depression can cause death within 1hr
of overdose.
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 Treatments
• ABC approach, Clear airway
• Consider Ventilation if• Gcs ≤ 8, Respiratory
rate < 8/min
• PaO2 < 60 mmHg if breathing at 60% 02
• Supportive Measures
• Hypotension: Elevate foot end of trolley, if BP <
90 give 500ml Saline vasopressor, inotropes
• Treat Shocks
• 16/04/2025
If unconscious, Nurse Semi prone Position 16
Antidots >> naloxone
Specific Antidote

Reverses Sufficient respiratory depression & coma if given in

sufficient doses

Record Coma level, Pupil Size, R.R

Give naloxone in adults 0.4 mg IV

Followed by a further dose of 0.8mg after 60sec if no

response
Aim is to reverse respiratory depression
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In children
• Give 100 mcg/1kg

• Up to 2mg repeated as necessary ,Can give IV,

IM ,Intranasal

• Dripping or spraying in nose over 60 sec enables rapid

absorption

• Naloxone has short half life

• Coma & respiratory depression can recur when the effect

wears off

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 Cont.….

• More Naloxone may be needed

• Dose adjusted on response,

• If repeated doses required; consider IV Infusion

• Observe for 6 hours after last dose of Naloxone 24 hrs
if methadone overdose.

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Benzodiazepines

Clinical Features:-
• Drowsiness, Dizziness, Ataxia, Dysarthria

Late findings
• Respiratory depression, Coma

• High risk patients(elderly and COPD patients )

• Remembers they have coma with normal vital is one of the

indication of benzodiazepine overdoses
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Investigation and
treatments
• Urine toxicology Screen for benzodiazepines

• Remembered >Efavirenz, used in HIV treatment

cause false positive result

Treatments

• ABC approach

• Give O2 if sats <92

• Endotracheal intubation if needed

• Maintain iv Access ,Continuous Cardiac Monitoring

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Cont.….
• Activated Charcoal if pt presents with < 1 hr

Antidots >>>Flumazenil:

• Specific antagonist of BZD

• Reverses action of BZD within 1 minute

• Short duration of action (<1hr)

• Flumazenil 0.2 mg Iv over 30 seconds

• Repeat doses of 0.2mg to a maximum of 1mg can be given

for desired effect
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Relapse
• Relapse if Symptoms reappear flumazenil can be repeated at
interval of 20 min with max. Dose of 3 mg within 1 hour a

Caution
• Flumazenil causes (Seizures & Arrythmia) in pt with
Congestion of Tricyclic antidepressants + BZD

• Chronic BZD dependent pts

• Only Give flumazenil when acute BZD overdose is

confirmed with no co-ingestion

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Beta blocker
Mechanism
• Block Sympathetic Nervous System

• Drugs (Propranolol, Carvedilol, Labetalol, Atenolol,

Metoprolol)
• Uses
• CHF ,anxiety
• Arrythmias
• Esophageal varices

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Sign and symptoms

• Sinus Bradycardia, Hypotension

• Coma, Convulsions, Cardiac Arrest

• Propranolol (Bronchospasm in asthmatics,

Hypoglycemia in Children)

• Sotalol (Prolonged QTc and VT wave with

torsade's de point )

ECG changes

• QRS prolongation, ST & T wave abnormalities

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Treatments
• ABC approach

• Monitor (Heart rate, Blood pressure, ECG)

• Check Blood Glucose, Electrolytes, Ca2+, CBC
• Give Activated Charcoal if <1 hr
• If the pt have Bradycardia with hypotension
• Give atropine(Adult: 0.5-1.2 mg, Children: 0.02 mg/kg)

• Antidots >>glucagon (Adult: 5-10mg IV ,Children 50-100

mcg /1kg)

• Best treatments for cardiotoxicity

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What if glucagon is
unavailable?
• Consider Vasopressors

• Metaraminol (is basically sympathomimetics causes

vasoconstriction increase in HR )

• Adrenaline

• Insulin therapy for Severe hypotension

• Intralipid therapy for drug toxicity

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TCAD Overdose -Treatment

• ABC – many require intubation

• Consider gastric lavage if taken < 2hrs
• Activated charcoal
• Treatment of hypotension with isotonic saline
• Sodium bicarbonate for cardiovascular toxicity
• Alpha adrenergic vasopressors (norepinephrine) for
hypotension refractory to aggressive fluid resuscitation
and bicarbonate infusion
• Benzodiazepines for seizures

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How much does it take to
overdose on paracetamol?
Overdose levels:

• >150 mg/kg of paracetamol

• E.g. 70 kg man takes 10 grams of paracetamol = 20 tablets
(500mg) and this the toxic lovel of paracetamol overdose .
• Mechanism
• Glutathione is the protective layer of liver
• Paracetamol(NAPQ1) decrease the glutathione level causes
hepatic necrosis.

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Sign and symtoms

• Symptoms appear 6-12 hours post-

ingestion (nausea, vomiting, RUQ pain,
liver failure).
• 2-4 days jaundice occurs due to damage
of liver
• 3-5 day: Onset of Hepatic Encephalopathy

• Liver Failure presents with bleeding, metabolic acidosis

(hyper ventilation)

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Paracetamol investigations

• Paracetamol level
• 24 hrs overdose

• Increase Prothrombin time (most sensitive indicator of liver

damage)

• LFTs and bilirubin levels Slowly Lise (peak in 3-5 days)

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Paracetamol Overdose Treatment

• Activated charcoal within four hours of ingestion

• May reduce absorption by 50 to 90 percent
• Single oral dose of one gram per kilogram
• Inhibits absorption of oral methionine

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Antidots >>N-
acetylcysteine
• Is given in 5% glucose

• Initial dose 150mg/kg in 200ml of glucose over 1hr

• Then 50mg/kg in 500ml of glucose over 4hr and

• Then 100mg/kg in 1L of glucose over 16 hr

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Cont.….
• Children :-

• Lower Risk of hepatotoxicity

• <75 mg/kg paracetamol intake

• No investigation and the treatment is needed discharge pt.

• Treatment with N. Acetylcysteine rarely needed Doses are

same as adults but with smaller fluid volumes

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Organophosphate poisoning
• Insectides

• Organophosphate nerve gas agents e.g. Sarin (bioterrorism)

• Can be absorbed via accumulates in skin , gut, bronchial

mucosa neuromuscular junction
• Presynaptic neuron release acetylcholine cause stimulation
of parasympathetic at postsynaptic and an enzyme
(acetylcholine esterase ) prevent the over stimulation
• Organophosphate block this enzyme and can irreversible and
accumulation of acetylcholine increase parasympathetics
stimulation.
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Sign and symptoms
• Diarrhea

• Urination

• Moises

• Bradycardia

• Emesis

• Lacrimation

• Lethargy

• Salivation
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In sever poisoning
Paralysis & respiratory failure

Bronchos spasms and bronchial secretions, Convulsions &

Coma

Hyperglycemia & cardiac arrythmias

Delayed effects after 1-4 day

Cranial Nerve Palsies, Muscle Weakness, Respiratory failure

After 2 weeks: Peripheral neuropathy in legs

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Management
• Ensure all staff wear protective clothing

• ABC approach & Clear Airway Secretions ,Give O2

• IPPV if indicated () intermittent positive pressure ventilation

• Insert IV Cannula

• Take blood sample for Cholinesterase levels in EDTA tube

and put that tube in ice (4°c )when shifting.
• Give diazepam to treat agitation 8 convulsions

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 Conti..
• If there secretions are profuse bronchial or bronchospasm give
atropine

• Adult: 2 mg and Child : 0.02 mg 1kg

• Repeat every 5 minutes with dose doubled every 5 mins until Chest
Clear, Systolic BP > 80 mmHg, Pulse >80

• In moderate or Severe Case (GIVE PRALIDOXIME)

• Use Within 24 hours of exposure (Dose: 30 mg / kg IV over 30 mins),

• Followed by IV Infusion @ 8mg/kg/hr

• Improvement is apparent within 30 mins

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Salicylate poisoning
• Common forms:

• Aspirin (acetylsalicylic acid), Sulphasalazine and Diflunisal

• Effect and uses
• → Analgesic→ anti-inflammatory →Antipyretic

• Overdose level: ingestion > 125 mg/kg

• Symptoms:

• Vomiting, Gastric irritation, Tinnitus , deafness,

Sweating, Dehydration Hyperventilation
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In sever case
• Confusion , coma, Convulsion, pulmonary edema
• Children:-

• Hyperpyrexia and Hypoglycemia

• Acid Base Imbalance

• Initially :- Respiratory alkalosis

• Hyperventilation washes out CO2 in blood

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Metabolic acidosis

• In late stage the pt show metabolic acidosis

because of anaerobic metabolism of glucose.(by
blocking the kreb cycle of glucose )
• Investigations:-

• Salicylate Levels(Gold Standard0

• Electrolytes IMPORTANT = (HYPOKALEMIA )

• Glucose levels

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Cont.….
• ABG (Resp. Alkalosis & Metabolic acidosis)

• Clotting Profile
• Treatment
Give activated Charcoal if

Salicylate levels > 125 mg/kg

pt presents < 1hr of ingestion

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Treatment on the basis of overdose

• Mild poisoning(< 300 mg/L salicylate level in blood)

• After treatment observed the pt for 6hrs (Normal

ABG/VBG) then discharge the pt

• Moderate poisoning(300-700 salicylate level in blood)

• Replace potassium

• Give bicarbonate 50-100 mmol over 30 mins

• In sever case (sever acidosis & CNS failure) needs urgent

dialysis.
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 Summary
A poison is any substance that is harmful to the body. The
term drug overdose(greater than are recommended). The
cause of a drug overdose is either accidental overuse or
intentional misuse. The most frequent drugs that people
overdose on are: Over-the-counter (OTC) drugs,
Prescription pain relievers, Sedatives and antidepressants,
Heroin, Methamphetamines.
General- Management, Supportive Care, Examination,
(Physiologic excitation , Physiologic depression ,
Physiologic depression). Preventing Absorption, Gastric
lavage, Induced Vomiting, Activated charcoal. Elimination
of Poisons, Renal elimination , Forced alkaline diuresis,
Hemodialysis. Antidote – naloxone, flumazenil, TCAD
Overdose –Treatment(Sodium bicarbonate)
Paracetamol and alcohol(treatments)
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How we can avoid Drug overdose?

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