Name
(1)

Symptoms and Signs

(2)

Management and Treatment

(3)

Remarks

(4)

Acids and Alkalies.

1)      Intense pain during the act of swallowing.

2)      Burns and ulcers on mucous membrane.

3)      Dysphagia.

4)      Shock due to pain.

5)      Oedematous glottis and difficulty in breathing.

     Acids can be neutralized by dilute alkaline substances, for example, magnesium oxide or aluminium hydroxide.

     Alkalies can be neutralized by weak acids like 10% vinegar or lemon juice.

     Demulcents.

     Supportive symptomatic treatments like intravenous fluids, analgesics.

Acetaminophen (Paracetamol).

Nausea and vomiting.

1^st-2^nd day: Abdominal pain, tender liver (liver function tests, become abnormal, 12 to 36 hrs. after over dose).h Bilirubin, h spartate aminotransferase,h Prothrombin time.

2^nd-7^th day: Liver Failure (jaundice, hepatic encephalopathy). Acute renal failure, cardiac arrhythmias, hypotension, tachycardia.

Gastric lavage (useful if carried out within 4 hrs of ingestion).

Antidote (best given within 10 hrs after ingestion).

Methionine 2.5g orally, then 2.5g 4-hrly. For further 3 doses. Total dose: 10g Methionine over 12 hrs.

N.Acetylcysteine 150mg/kg intravenously, over 15 minutes in 200 ml of 5% dextrose, then 50mg/kg in 500 ml of 5% dextrose intravenously, over the ensuing 16 hrs Total dose: 300mg/kg over 20 hrs.

Supportive measures.

Vit K 10 mg intravenously, for 3 days (if prothrombin time is prolonged).

N-Acetycysteine or Methionine ore effective in the prevention of liver damage provide it is administered within 10 hrs of ingestion of the overdose.

Asprin (Accelysalicylic Acid)

Nomogram relating blood serum level and expected severity of intoxication at varying intervals following ingestion of a single dose of salicylate.

Nausea, vomiting, epigastric pain, hyperpyrexia, profuse sweating, irritability, tremors, roaring in the ears, deafness, blurring of vision, tachypnea, hyperpnea, pulmonary oedema.

Dehydration due to vomiting. Sweating and overbreathing.

Respiratory alkalosis followed by metabolic acidosis (except in children).

Hyper or Hypoglycemia.

Hypoprothrombinaemia (in an adult, moderate to severe toxicity will result from the ingestion of 50 or more standard 300 mg aspirin tablets, provided he has not vomited).

[Hepariansed blood should be withdrawn for immediate determination of the initial blood salicylate level (BSL)].

Gastric aspiration and lavage, forced ‘cocktail' diurestis.

(Saline. 0.9%--0.51

Dextrose 5%--11

Sodium bicarb 1.26%--0.51

Potassium Chloride 3g)

as a mixture @ 21/hr for 3 hrs and thereafter 11/hr until BSL is 35 mg/100 ml when the drip nay be stopped. The rate of infusion is most important. In the absence of accompanying sedative drug overdose, acidaemia should be suspected and corrected by prior infusion of ½1 of 5% sodium bicarbonate within 30 minutes prior to the start of Forced cocktail Diuresis.

Haemoperfusion or haemodialysi if BSL> 90mg/100ml.

BSL is the best guide to measure to severity of salicylate poisoning. They should be determined after 6 hrsof ingestion of an overdose and repeated several hrs later to make sure that the level is not rising. Generally BSLi 500 mg/1, 6 hrs after ingestion of an overdose indicates mild toxicity. BSL between 500 & 750 mg/1 is associated with moderate toxicity. BSLh 750 mg/1 at 6 hrs may be associated with severe toxicity.

Chart (a) T.P.R. ½ hrly (b)fluid intake/output.

Amphetamine

Restless tremors, irritability insomnia.

Dry ness of mouth, nausea, vomiting, diarrhoea, abdominal pain.

Sweating, hyperpyrexia, cardiac arrhythmias, thachycardia, hypertension or hypotension.

Delirium, hallucianations, coma, convulsions.

1.  Gastric lavage.

2.  Supportive treatment.

3.  Chlorpromazine 50-100 mg intravenous and intramuscular/intravenous for sedation (repeated ½ to 1 hr intervals needed).

Forced acid diuresis may help those severely poisoned (as about 50% of drug is excreted in the urine).

Confusion, aggressiveness hallucinations, delirium, pani attacks; eve suidal/homicidal tendencie may occur.

Bizarre and inexplicable behaviour, often undistinguishable from paranoid schizophrenia, has been associated with amphetamine abuse.

Ammonia

  (Gas is usually compressed into a liquid)—Ammonium hydroxide.

Inhalation causes severe inflammation of respiratory tract—laryngitis, tracheobronchitis, pulmonary oedema, substernal pain, severe coughing, spasm of glottis, terminal pneumonia.

Liquid ammonia causes dermatitis, necrosis, conjunctivitis, cataract, total loss of vision etc.

Neutralise with vinegar.

Demulcents.

Antibiotics.

Symptomatic treatments.

Maximum permissible concentration of ammonia is 100 ppm.

Strong odour  on opening the body.

The stomach contents feels slippery, when touched.

Accidental, suicidal, vitriolage.

Bleaching Solutions

   (3-6% solutions of sodium hypochlorite in water).

Severe irritation, corrosion of mucous membrane, pain and vomiting.

Pulmonary irritation with coughing, choking oedema of pharynx, lungs.

B.Pi delirium, coma.

Skin contact: wash with running water until ‘disappearance of soapiness'

Give milk, ice cream (melted), or beaten eggs. Give sodium thiosulphate orally.

Do not use emesis, lavage or acid antidotes.

Antacide e g milk of magnesia or aluminium hydroxide are also useful.

The strength of solution used for chlorinating swimming pools is 20%.

Hypochlorous acid—released when bleaching solution comes in contact with acid gastric juice or acid solution is extremely irritating to the mucous membrane and skin.

Barbiturate hypnotics (Amylobarbitone, Butobarbitone.)

Drowsiness ataxia and dysarthria soon followed by coma, hypotension, respiratory depression and hypothermia, limbs hypotonic with loss of tendon reflexes.

Planatar response, if present flexor but in deep coma may be absent. Barbiturate blisters over pressure area. Pupils—normal.

Injection marks in addicts.

1.  Hypostatic pneumonia and after apparent recovery hepato—cellular failure.

2.  person having pulmonary hepatic and renal diseases succumb to the bad effects soon.

(Phenobarbitone).

As above, but coma if present seldom deeper than grade 2 or 3. gross coarse nystgmus on slightest movement of  eyes. Disinhibited mental state (loquacious, argumentative).

Gastric aspiration and lavage  supportive theraphy.

Charcoal haemoperfusion in case of grade IV coma or if plasma concentration of following drug is above 150 mg/1 in phenobarbitone poisoning.

Or

50 mg/1 in barbiturate hypnotic poisoning.

Attend to ‘burst' blisters.

To a 5% glucose intravenous drip, add 15 mg of amiphenazol in saline every 5 minutes, till pharyngeal and laryngealreflexes return and a safe state is brought about.

Or

Nikethamide (5-10 ml) intravenous, at 15-30 mins interval can be used.

Gastric aspiration and lavage. Supportive therapy.

Forced alkaline diuresis: (5% dextrose (0.51), 09% Saline (0.51) and 1.26% sodium bicarbonate (0.51) in rotation at 0.51/hr.)

Frusemide 20mg intravenously, (if urinary output falls more thatn 2 litre behind fluid input). Antibiotics and good nursing.

Plasma concentrations frequently to rise in the first 48 hrs after ingestion, when the patient may be improving clinically.

Bladder catheterization.

Recovery within a week with supportive care and forced alkaline diuresis coma in severe poisoning lasts several days

Benzodiazepines (chloriazepoxide)

Diazepam

(Flurazepam, Lerazepam etc.)

Drowsiness apathy, ataxia, dysarthria, partial ptosis and nystagmus.

Coma (grade II usually). Hypotension.

Gastric aspiration and lavage. Supportive therapy.

Flumazenil.

Overdose of nitrazepam mayresult in bullous skin lesions. Many benzodiazepines have active metabolities with long plasma half-lives, so that performance is skilled task (e g, driving motor vehicles may be impaired for severa days or weeks after apparen recovery from overdose. Persons poisoned with benzodiazepine recove considerably within 24 hrs Benzodiazepines are taken with other psychotropic drug and potentiate CNS depressan effects of alcohol barbiturate and tricyclic antidepressants.

Beta Adrenergic blocking drugs.

(Atenol Metoprolol, Propranolol)

Pallor, Cold Clammycyanosed/limbs.

Ataxia bradycardia (Sinus in Origin)

Marked QRS prolongation and ST & T wave Changes in E.C.G.

Bronchospasm.

Gastric aspiration and lavage.

Atropine 3 mg intravenously (or 0.04 mg/kg)for bradycardia and hypotension; followed if required, by isoprenaline 2mg/500ml normal saline or 5% glucose 20/40 drops/min, depending upon response.

Glucagon 5-10 mg intravenously (a safe alternative to isoprenaline and is the treatment of choice).

Supportive terapy.

Severe bronchospasm respondsto salbutamol inhalations.

Cannabis (Marihuana)

If Smoked or ingested, mild anxiety, excitement followed by a feeling of calmness euphoria, uncontrollable laughter. Perception of colour and soun often enhanced. Purposeless muscular exercises, later drowsiness and sleep (Intoxication may result fron the rupture of ingested cannabes—filled  balloons (condoms)in which the drug is bsing smuggled).

Chronic use—results in increased desire and decreased sexual power, leading to sexual perversions.

Generally not required, if inhaled or ingested.

Symptomatic treatment if necessary.

Intravenous injection of cannabis-tea results in nausea, vomiting, abdominal pain, watery diarrhoea, fever, rigor, B.P.i, shock, later renal impairement, cholestatic jaundice, leathargy, hypoglycaemic E.C.G. may show ischaemic changes. The alterations in functions seen cannabis has been ingested or smoked.

Chlorine (Gas)

Lacrimation, conjunctivitis, cough followed by breathlessness, wheezing, hoarseness due to laryngeal oedema, tachypnoea, central cyanosis with rhonchi and crepitations in lungs.

Remove patients from the toxic atmosphere.

Symptomatic therapy.

O₂ inhalation.

Bronchodilators.

Prednisolene 60 mg/daily until symptoms disappear and on x-ray clear lungs, then withdraw over about 2 weeks.

Observe for 12 hrs, in case of those exposed minimally.

Inhalation of chlorine results in oedema of lungs, patchy necrosis of respiratory mucosa (Chlorine combines with maisture to form Hcl).

Dhatura

Fixed dilated pupils.

Diplopia.

Dysphagia.

Difficulty in speaking.

Drunken appearance gait.

Delirium (muttering type) mental confusion, excitement, hallucinations.

Pillrolling movements or drawing imageinary threads.

Hyperpyrexia.

Tachycardia.

Gastric aspiration, lavage if needed.

Carbachol 0.125 mg test dose, if no untoward effect give 0.5 mg subcutaneously or physostigmine salicylate 1-4 mg sub-cutaneously, intramuscularly or repeated 1-2 hrs later if necessary.

Ice bag.

Diazepam intravenously for seizures.

Catheterization.

It is used by road-side robbers to stupefy travelers to rob them of their belongings.

Avoid promethazine, phenothiazine and morphine.

Iodine

Nausea, vomiting (brown/blue), diarrhoea, Burning sensation in mouth, throat, epigastric pain, salivation. Albuminuria aliguria.

Gastriclavage with starch solution. Intravenous 10% sodium thisulphate 10ml/4-hrly.

Intravenous fluids and supportive therepy.

Iron Poisoning

Epigastric pain, nausea, vomiting, diarrhoea, heamatemesis, melena, circulatory collapse.

Later complications: acute encephalopathy (headache, confusion, coma conculsions) Cyanosis, pulmonary oedemia, metabolic acidosis, acute renal failure, circulatory collapse and death, hepatic failure, high gastrointestinal obstruction, Black line at the junction of gum and teeth.

Gastric aspiration and lavage with (a) 5% naHCO_{3 or} (b) Desferrioxamine solution 2g in 11 of warm water.

Following lavage, leave desferrioxamine solution (5g in/50-200ml of water) to chelate any free iron in gastro-intestinal tract. In addition, intravenous slow drip of desperrioxamine not exceeding 15mg/kg body weight (maximum 88mg/kg bodya weight in 24 hrs); or

Inject desperrioxamine (2 g in 10ml water in a child) intramuscularly every 12 hrly. According to clinical state and plasma concentration level.

If  oliguria/anuria develops peritoneal dialysis or haemodialysis.

Methyl alcohol (Methanol)

Latent period of 12-24 hrs or more, later headache, weakness, blurring of vision, breathlessness, nausea, vomiting, abdominal pain, rarely dairrhoea. Pupils dilated, not responding to light. Hyperaemia of optic disc in acute stage, later Peripapillary oedema (upto 8 weeks). Sweating, excitement, drowsiness, coma, convulsion, atrophy of optic nerve and blindness.

Gastric aspiration & lavage. In minor intoxication: Absolute alcohol (0.5 ml/kg) orally followed by 0.25 ml/kg 2 hourly. In severe poisoning absolute alcohol (5-10g/h) until the plasma methanol conc. Is less than about 200ml/1.

Haemodialysis to be considered if the plasma methanol conc. h500mg/1, if visual symptoms have developed and there is significant metabolic acidosis. Continue dialysis till plasma conc. Fall below 250mg/1.

Intravenous sodium bicarbonate to correct metabolic acidosis.

May cause optic atrophy, central scotma ect. Cerebral oedema necrosis in the putamen and haemorrhagic pancreatitis may be found on postmortem.

Methamoglobinemia due to:

Direct oxidants: Nitroglycerin Anylnitrite, AgNO₃ (burns) Quinones (Choloroquine, Primaquine), food rich in nitrates, Nitrous gases seen in arc welders) food abulterated with nitrites, well water (nitrates).

Indirect oxidants: Aniline dye derivatives (for example, wax crayons, moth ball) phenacetic, Benzocaine, Nitrobenzenes Sulphonamides limesulfamethizole etc.).

h30-40% concentration of methaemoglobin: Headache, giddiness, weakness, dysnea, cyanosis.

40-60% concentration: Stupor, respiratory depression. Chocolate coloured blood.

h60% concentration: Death.

Gastric aspiration or lavage—wash skin contact thoroughly with soap and water.

Give 100% O₂ by mask when Met Hb conc. Is h40% or in presence of symptoms give antidote.

Methylene 1 or 2 mg/kg of 1% solution intravenously, over a 10 minutes period of Vit C 1g. Slowly intravenous—supportive therapy.

Exchange transfusion

Methemoglobin is formed by oxidation of the ferrous iron of Hb to the ferric form by the action of a number of chemicals including nitrities, chlorates and amino and nitro-organic compounds.

Caution: Intravenous administration of therapeutic doses of methylene blue may cause nausea, giddiness, rise in B.P.

Spectrophotometric analysis gives the Met-Hb concentration in blood.

Narecotic Analgesis—opium, morphine, heroin (Dextropropoxyphene, Pentazocine, Pethidine, Codine).

Methadone, Lomotil tablet (diphenoxylate and atropine).

Exhiliration and physical case followed by depression coma, pinpoint pupils, marked reduction of the respiratory rate are the hallmarks.

BPi, Tempi, Sweating. Presence of injection marks.

Naloxone 1.2mg intravenously (0.4 mg for child) to be repeated every 15-30 min, till pupils begin to dilate (as much as 75 mg naloxone in 24 hrs has been given without obvious adverse effects). Once the patient is resuscitated from the CNS depression and lavage whether taken orally or parenterally.

Gastric lavage.

Alkanisation if urine (give sodium bicarbonate, 5g orally every 4 hr or as necessary).

Diuretics (gave upto 15ml/kg/hr or fluids with furosemide 1 mg/kg for maximum diuresis and to reduce injury to the kidney from Hb products).

Dialysis if necessary.

Avoid fats, milk and castor oil etc.

Oxalic acid (Binocalate o Potassium salts of sorrel or essential salts of lemon).

Local irritation and corrosion of mouth, oesophagus and stomach woth pain and greenish-broen or black vomiting. Muscular tremors, convulsions and collapse. Later acute renal failure from blocking of renal tubules by calcium oxalate crystals, RBC and albumin.

Precipitate oxalates by saccharated solution of lime water orally.

Inject calcium gluconate, 10% 10ml slowly intravenously.

Fluid orally 3-41/day to prevent precipitation of calcium oxalate in the renal tubules.

Organophorphorus, compounds & carbamates (Baygon).

Refer text for proprietary names and other details.

Kerosence like odour. Early: headache, nausea, giddiness, tightness of chest dimness of vision, miosis, twitching eye muscles, tremors of tongue, profuse frothing.

Late: vomiting, sweating salivation, oronasal froth, muscular fasciculations, bronchospasm, cyanosis pulmonary oedema, disorientation, drowsiness, coma, convulsions, incontinence. (CNS manifestations less in carbamate poisoning).

Remove soiled clothes, Thoroughly wash contaminated skin, gastric aspiration and lavage.

Atropine 2mg intravenous every 10-30 minutes till signs of atropine may be much as 30mg or more in first 24 hrs).

Pradoxine (P₂Am, 2-PAM, P₂S), 1 gm slow intravenous (to be given within 12-24 hrs of exposure/ingestion] (but/are/contra—indicated in carbamate poisoning.)

Intensive supportive therapy. Remove respiratory secretions

Artificial respiration and anticonvulsants. I/R paraldehyde.

                            O₂

OLEANDER

A. Nerium/Odorum (White Oleander),

kaner.

Due to

a) Gastro-intestinal irritation, nausea, vomiting, epigastric pain, diarrhoea:

b) digitals like action on heart, cardiac arrthythmias and heart block:

c) General: Profuse frothy salivation, difficulty in swallowing/talking, lock jaw, giddiness, muscular twitching, coma.

Gastric aspiration and lavage.

Phenytoin 100-200 mg, orally every 6 hrs until arrhythmia is reverted.

Proparnolol 1-3 mg intravenous, slowly.

Morphine sulphate 10-15 mg sub-cutaneously.

All parts of the plant poisonous.

Active principles (cardiac glycosides Nerin, Oleandrin).

B. Cerberal thevetia (Yellow Oleander) Pila Kaner.

Burning pain in mouth with dryness of troat, tingling and numbness of the tongue, nausea, vomiting, diarrhoea, headache, giddiness, loss of muscular power, varying decress of heart block, fainting collapse, tetanoid convulsions.

1) Gastric aspiration and lavage.

2) Molar sodium lactate intravenously.

3) Intravenous injection by drip method of 5% glucose solution with 1.2 mg of atopine, 2ml of adrenaline (1:1000) (and 2 mg of noradrenaline if blood pressure is low).

All parts of plant poisonous.

Active Principles glycosides:

A. From plant (I) Thevetin and (II) Cerberin. Peruvoside and ruvoside the other two glycosides are digitaloid in action.

B. From Kernel of Seeds (Glycosides) (I) Thevetin and (II) Thevetoxin; (III) Nerifoline; (IV) Cerberin.

Fruit resembles an unripe mango, and kernal contains glycosides, cerboris and cerebroside.

C. Cerebra odollain (Dabur).

Due to

(i) Gastro intestinal irritation and

(ii) like action on heart,

(iii) vomiting, diarrhoea respiration irregular, collapse, general paralysis.

ECG may show sinus bradycardia.

S-A block, combination of S.A. and A.V. block, other cardiac arrhythmias.

Treatment similar to that of Nerium odorum.

Fruit resembles an unriped Mango, and kernal contains glycosides, cerboris and cereborside.

Petroleum distillates and Turpentine Bezine, Diesel Fuel, Furniture Polish, Kerosene, Naphtha, Paraffin, Petrol.

Smell of hydrocarbon in breath.

Nausea, vomiting, diarrhoea rarely.

Excitation more often drowsiness coma in severe poisoning, convulsions rarely.

Cough, choking, cyanosis breathlessness breathlessness are the pulmonary complications.

X-rays: Hydrocarbon pneunmonitis (usually involves 2 or more lobes and occasionally perihilar).

Fever, ploymorph leukocytosis. (Diafnosis of hydrocarbon ingestion may be confirmed by finding a double fluid level in stomach taken in the erect posture.

Gastric lavage after insertion of a cuffed endotracheal tube in a case (a) showing serious poisoning or (b) when a solution contains another poison (c) if a 2 or 3 year old child has swallowed a mouthful (4-5ml).

Supportive therapy.

Antibiotics if necessary.

Petroleum dostillates are group of fuels solvents, containing a variety of aliphatic and aromatic hydrocarbons. While turpentine refers to a mixture of pinenes, camphenes and other terpenes.

Turpentine substitute (white spirit) is a mixture of long chain hydrocarbons and is used as paint tinner.

(Refer text).

Snake bite (poisonous) (ophitoxamia). (refer text for local names of snakes and other details).

Bite Marks.

Local Features: Severe local pain tingling, swelling spreading from bite, bleeding from the site, local echymosis, serum filled bullae, later extensive sloughing, unclearation. Necrosis with putrid smell.

i) Cramps in abdominal muscles

ii) Myalgia and myoglobinuria. Systemic features: Nausea, vomiting , headache, fever and allergic rash.

CNS: Muscular paralysis (ascending), can't talk, swallow or protrude the tongue. Paraesthesia, muscle spasm, convulsions, ptosis, squint, diplopia.

CVS: Tachycardia, BPi, Cardiac arrtythmias, nonspecific ECG changes. Hemopoetic system: Haemorrhagic tendencies, bleeding from site, echymosis, bleeding from gums, haematemesis, hemoptysis, hematuria, intra-abdominal/retroperitoneal haemorrhage.

First aid measure: To transport the victim to the nearest hospital. Do not use tourniquet. Do not apply ice. Do not incise or apply suction to the punctured wounds, keep bitten limb immobilized at the level of the heart. The victim should avoid exertion. Reassurance of the victim is important aspect of first aid.

Specific treatment: perform skin test for sensitivity to anti-snake venom serum. If no reaction or urticaria, inject slowly intravenous 20ml reconstituted, anti-snake venom serum; repeat 2hrs later, further dose 6 hrly till symptoms disappear.

In presence of sensitivity, reactions to serum, desensitization or the administration of serum under cortisone cover may be undertaken.

Neostigmine 5mg, intravenous (in elapid snake bite case). Repeat ½ hrly, after 5 such injections at an interval of 2-12 hrs depending on response.

Skin or conjuctival tests for sensitivety to anti-snake venom serom is mandatory before its administration. Andrenaline should be available for immediate use, should allergic a negative sensitivity test. (Inject promptly Adrenaline 0.5 ml of 1:1000, which must be drawn into the syringe before giving antivenom).

Admit under observation for 24 hrs. a patient with minimal or no local reaction and who is given first aid treatment only.

Monitor vital signs.

Records pulse and B.P hrly for proximal and distal parts of the bitten limb (measured about the mid point).

Blood grouping should be done at the earliest, since venom may interfere with blood grouping.

Solvent abuse (Acetone, Butane, ether, florinated, hydrocarbons petrol, Tolune, Trichlorethylene etc).

Other names:

Solvent inhalation, glue sniffing.

Skin irritation (Excitation, followed by depression, hypoxia).

Diziness, disorientation, hallucination, convulsions, coma.

Later complications: Jaundice, renal damage (toluene,carbon tetrachloride).

Acute and chronic encephalopathy (Petrol with its tetraethy1 lead content). Cerebellar degeneration (toluene). Predominantly (hexane).

Stop solvent inhalation (considerable I,provement by the time brought to hospital).

Supportive therapy.

Abstinence from further solvent abuse is vitally important.

Halogenated hydrocarbons sensitise the heart to endogenous catholamines leading to fatal cardiac dysarrhythmias.