2013Toxicology Klinik

8/9/2019 2013Toxicology Klinik

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TOTOKSIKOLOGI KLINIKKSIKOLOGI KLINIK

Noor WijayahadiNoor Wijayahadi


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DefinitionsDefinitions

ToxicologyToxicology

IlmuIlmu pelajari bahan toksik:pelajari bahan toksik: detection,detection,properties, effects and regulation ofproperties, effects and regulation oftoxic substances, including poisonstoxic substances, including poisons..

Racun (Racun (PoisonPoison))

Semua bahan yang menimbulkan efek merugikanSemua bahan yang menimbulkan efek merugikan((harmful effectharmful effect)) igunakan senga!a atau"unigunakan senga!a atau"untiak senga!atiak senga!a

Poisoning isPoisoning is #uantitati$e conce"t#uantitati$e conce"t


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Dose esponse !ur"e related toDose esponse !ur"e related to

ToxicityToxicity


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Dose#Time $rincipleDose#Time $rinciple

Toksisitas i"engaruhi oleh%

&esar 'osis

Lama Pa"aran


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%lood $lasma &e"el Toxicity%lood $lasma &e"el Toxicity


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Toxicological TermsToxicological Terms

'.'. &D&D()()* dose at +hich () die* dose at +hich () die

-nly animals-nly animals

TDTD()()* dose at +hich () ha"e toxicity* dose at +hich () ha"e toxicity

easure of harmfulnesseasure of harmfulness

/./. T.I.T.I.* Therapeutic Index* Therapeutic Index

TDTD()() # 0D# 0D()()

The larger the number, the safer the drugThe larger the number, the safer the drug

easure of safetyeasure of safety

1.1.2cute Toxicity2cute Toxicity

3ingle dose +ithin /4 hrs3ingle dose +ithin /4 hrs

Defines intrinsic toxicityDefines intrinsic toxicity


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Toxicological Terms 5con6t7Toxicological Terms 5con6t7

4.4. !hronic Toxicity!hronic ToxicityDaily exposure for up to a lifetimeDaily exposure for up to a lifetime

(.(. T&8T&8* Threshold &imit 8alue* Threshold &imit 8alue

!oncentration belo+ +hich there is no expected unto+ard!oncentration belo+ +hich there is no expected unto+ardeffect o"er a period of 9hrs#day ( days#+eekeffect o"er a period of 9hrs#day ( days#+eek

N-0&N-0&* no obser"able effect le"el* no obser"able effect le"el

2DI2DI* allo+able daily intake* allo+able daily intake

2DI 5N-0&7 # x2DI 5N-0&7 # x

x is some safety factor (i.e., 100)x is some safety factor (i.e., 100)


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Toxicological Terms 5con6t7Toxicological Terms 5con6t7

;.;.

3T0&3T0&

* 3hort term exposure le"el* 3hort term exposure le"el

4x a day, +ith the a"erage being e


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3electi"e "s. Nonselecti"e Toxicity3electi"e "s. Nonselecti"e Toxicity

Nonselecti"eNonselecti"eNearly all chemical are nonselecti"e in theirNearly all chemical are nonselecti"e in theiractionsactions

?e+ chemicals are sufficiently selecti"e to harm?e+ chemicals are sufficiently selecti"e to harmcertain cellscertain cells

3electi"e3electi"e

-ne man6s poison is another man6s pill.-ne man6s poison is another man6s pill.What may be harmful to one specimen may beWhat may be harmful to one specimen may berelati"ely harmless to another.relati"ely harmless to another.

@arden spray@arden spray


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Cou can. . .Cou can. . .

Start ith the basicsStart ith the basics *iray+*iray+ &&reathing+reathing+ ,,irculationirculation

Get a better historyGet a better history Get -.S to get "ill bottles+ tell you hatGet -.S to get "ill bottles+ tell you hat

they o kno (foun outsie+ insie+they o kno (foun outsie+ insie+garage/)garage/) ,all friens+ family+ neighbors,all friens+ family+ neighbors ,all "sych or "rimary .' to see hat he is,all "sych or "rimary .' to see hat he is

on regularlyon regularlyGet him to tell youGet him to tell you *lays remember that suicial "atients*lays remember that suicial "atients

(!ust like e$eryone else) can lie so(!ust like e$eryone else) can lie so bebeske"tical of their historyske"tical of their history


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ToxidromesToxidromes

Not e"ery drug fits into a broad basedNot e"ery drug fits into a broad basedcategorycategory &ots of meds ha"e uni


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!ommon !auses of Death in the!ommon !auses of Death in the

2cutely $oisoned $atient2cutely $oisoned $atient

,omatose,omatosepatient:patient: &oss of protecti"e reflexes&oss of protecti"e reflexes 2ir+ay obstruction by flaccid tongue2ir+ay obstruction by flaccid tongue 2spiration of gastric contents into2spiration of gastric contents into

tracheobronchial treetracheobronchial tree &oss of respiratory dri"e&oss of respiratory dri"e

espiratory arrestespiratory arrest3y"otension3y"otension* due to depression of* due to depression of

cardiac contractilitycardiac contractility


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Sei4uresSei4ures* may result in pulmonary* may result in pulmonaryaspirationEasphyxiaaspirationEasphyxia

.uscular hy"eracti$ity.uscular hy"eracti$ity resulting inresulting in

hyperthermia, muscle breakdo+n,hyperthermia, muscle breakdo+n,myoglobinemia, renal failure, lacticmyoglobinemia, renal failure, lacticacidosis and hyperkalemiaacidosis and hyperkalemia

&eha$ioral effects&eha$ioral effects**traumatic in!urytraumatic in!uryferom fights, accidents, fall from hiferom fights, accidents, fall from higghhplaces. 3uicides, etcplaces. 3uicides, etc


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.assi$e amage to a s"ecific organ.assi$e amage to a s"ecific organ

system%system% &i"er 5acetaminophenE amanita phylloides&i"er 5acetaminophenE amanita phylloides

Fpoison mushroomGFpoison mushroomG

&ungs 5para


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II. anagement of a $oisoningII. anagement of a $oisoning

Segera Lakukan%Segera Lakukan%

55 Su""ort 6ital 7unctionsSu""ort 6ital 7unctions

8585 Ientifikasi racunIentifikasi racun

9595 :"aya "engeluaran racun ari tubuh:"aya "engeluaran racun ari tubuh


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3upport "ital life functions 52%!6s73upport "ital life functions 52%!6s7

**irayiray* endotracheal tube if needed, +atch for fluid* endotracheal tube if needed, +atch for fluid

accumulation in air+ay 5i.e.. 2spiration of "omit7accumulation in air+ay 5i.e.. 2spiration of "omit7

&&reathingreathing* 3upplemental -xygen, bag "al"e mask* 3upplemental -xygen, bag "al"e mask5%87 and respirator.5%87 and respirator.

,,irculationirculation* onitor 0!@, +atch for arrhythmias, cardiac* onitor 0!@, +atch for arrhythmias, cardiacarrest and shockarrest and shock

8asogenic 3hock8asogenic 3hock* faulty "asomotor tone, increase capillary* faulty "asomotor tone, increase capillarypermeability.permeability.

!ardiogenic 3hock!ardiogenic 3hock* inade


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@eneral Treatment of a@eneral Treatment of a!omatose $atient!omatose $atient


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3upporti"e Drug Therapy3upporti"e Drug Therapy

Treat all patients +ho come into theTreat all patients +ho come into the

hospital in a coma +ithhospital in a coma +ith glucose, insulinglucose, insulin

and naloxoneand naloxone..

Ase drugs to treat emergent conditions, ie:Ase drugs to treat emergent conditions, ie:SeizuresSeizures* anticon"ulsants 5"alium7* anticon"ulsants 5"alium7

Cardiac DysrhythmiasCardiac Dysrhythmias* antiarrhythmias 5lidocaine,* antiarrhythmias 5lidocaine,

digoxin7digoxin7

Severe AgitationSevere Agitation* anxiolytics 5benJo7* anxiolytics 5benJo7


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Ientifikasi RacunIentifikasi Racun;;

'. $atient history'. $atient history

/. &aboratory testing/. &aboratory testing

1. !omparison of drugs or chemicals +ith1. !omparison of drugs or chemicals +ith

kno+n toxicology standards.kno+n toxicology standards.


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Identification of the $oisonIdentification of the $oison

553ample Types3ample Types77

:rine:rine ' 'ststchoice * easier to detect presence ofchoice * easier to detect presence ofthe drug due to the accumulation of drug in thethe drug due to the accumulation of drug in theurine.urine.

&loo


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Identify $oison 5Identify $oison 5TestsTests77

:rine tests:rine tests

Immunoassay (Immunoassay (-.IT-.IT+ -LIS*) = semi#uantitati$e tests+ -LIS*) = semi#uantitati$e testsusually ith automate instrumentation5 ,an etectusually ith automate instrumentation5 ,an etectcannabinois+ am"hetamines+ cocaine+ barbs etc5cannabinois+ am"hetamines+ cocaine+ barbs etc5

Thin Layer ,hromatogra"hy (TL,Thin Layer ,hromatogra"hy (TL,) = To2iLab+ > stage) = To2iLab+ > stagesol$ents+ #ualitati$e testsol$ents+ #ualitati$e test

:rine


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!ontraindications of 0mesis!ontraindications of 0mesis

0mesis is contraindicated in cases of:0mesis is contraindicated in cases of:

$etroleum hydrocarbon sol"ent * chemical$etroleum hydrocarbon sol"ent * chemical

pneumonitispneumonitis

!austic acid or alkali agent 5rupture7!austic acid or alkali agent 5rupture7

3eiJing $atient3eiJing $atient

!omatose $atient!omatose $atient


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emo"al of the Drugemo"al of the Drug

55@astric &a"age@astric &a"age77@astric &a"age * +ashing of@astric &a"age * +ashing ofthe stomach. 5the stomach. 5early tx.7early tx.7

22 tube is insertedtube is insertedthrough thethrough the

nose or mouth, do+n thenose or mouth, do+n theesophagus, andesophagus, and into theinto thestomach.stomach.3ometimes a topical3ometimes a topicalanesthetic may be applied toanesthetic may be applied tominimiJe irritation and gaggingminimiJe irritation and gaggingas the tube is being placed.as the tube is being placed.

3tomach contents can be3tomach contents can beremo"ed usingremo"ed using suctionsuctionimmediately or afterimmediately or after irrigatingirrigating +#+#fluids through the tube.fluids through the tube.


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2cti"ated !harcoal2cti"ated !harcoal##!athartics!athartics

*cti$ate ,harcoal*cti$ate ,harcoal52!752!7

Ased to bind compounds and to pre"ent absorption in theAsed to bind compounds and to pre"ent absorption in the

@I tracts. 5@I tracts. 5many drugsmany drugs77

!ontraindicated +ith caustic agents and petroleum!ontraindicated +ith caustic agents and petroleum

distillates due to the lack of absorption of these agents bydistillates due to the lack of absorption of these agents by

the charcoal and risk of "omiting associated +ith thethe charcoal and risk of "omiting associated +ith thecharcoalcharcoal

-rder of use of charcoal and ipecac-rder of use of charcoal and ipecac

,athartics,athartics

$romotes rapid passage of poison through the @I tract$romotes rapid passage of poison through the @I tract

!ounteracts the constipati"e effects of 2!!ounteracts the constipati"e effects of 2!

I.0. sorbitol, g !itrate,I.0. sorbitol, g !itrate, g 3ulfateg 3ulfate


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%% 2 tid t l T t t 52 tid t l T t t 5' ! l ti 7' ! l ti 7


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%.%.2ntidotal Treatments 52ntidotal Treatments 5'. !omplexation7'. !omplexation7

2. ea"y etals2. ea"y etals

!helators 5!helators 5%2&, 0DT2%2&, 0DT27 complexes +ith the metals7 complexes +ith the metalsmaking them inertmaking them inert

%. eparin%. eparin

$rotamine$rotamine5base7 binds to acidic heparin to terminate its5base7 binds to acidic heparin to terminate itsaction and is excreted by glomerular filtration.action and is excreted by glomerular filtration.

!. Toxins!. Toxins

%otulinum Toxin 2&D K ).(mcg &D%otulinum Toxin 2&D K ).(mcg &D()()')ng#kg')ng#kgost potent poison kno+n, rapidly absorbed andost potent poison kno+n, rapidly absorbed andpre"ents 2! release from ner"e terminalspre"ents 2! release from ner"e terminals

Tx: 2%!s, la"age, emesis, charcoal,Tri"alent antitoxinTx: 2%!s, la"age, emesis, charcoal,Tri"alent antitoxin

ortality of =) to ') +ith treatmentortality of =) to ') +ith treatment


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!omplexation 5con6t7!omplexation 5con6t7

D. -rganophosphatesD. -rganophosphates$ralidoxime$ralidoximeis a nucleophillic reagent that ties upis a nucleophillic reagent that ties upthe organophosphates and permits its excretion.the organophosphates and permits its excretion.

0. !yanide0. !yanide%inds to cytochrome oxidase, &D%inds to cytochrome oxidase, &D()() /mg#kg /mg#kg

!auses death in ' to '( minutes at high doses.!auses death in ' to '( minutes at high doses.

!helator is made in the body,!helator is made in the body, methemoglobinmethemoglobin

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@i"e@i"e2myl Nitrites2myl Nitritesandand Na NitriteNa Nitrite+ith -+ith -//and +holeand +hole

blood to con"ert hemoglobin toblood to con"ert hemoglobin to methemoglobinmethemoglobin

5&D5&D()()

increases ( fold7increases ( fold7

..


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2ntidotal Treatments 5con6t72ntidotal Treatments 5con6t7

/./.0nhancement of metabolic con"ersion to a0nhancement of metabolic con"ersion to asafer formsafer form

0xample: !yanide $oisoning and thiosulfate0xample: !yanide $oisoning and thiosulfate

treatment 5&Dtreatment 5&D()() increases 1 fold7increases 1 fold7

!N!NII 3!N3!N

hodanese

SulfurTreatment: @i"e

Thiosulfate

53ulfur source7


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2ntidotal Treatments 5con6t72ntidotal Treatments 5con6t7

1. Inhibition of metabolic con"ersion to1. Inhibition of metabolic con"ersion totoxic forms.toxic forms.

2.2. 0thylene glycol # ethanol0thylene glycol # ethanol* ethanol* ethanoladministration pre"ents 2lcohol dehydrogenaseadministration pre"ents 2lcohol dehydrogenase52D7 from con"erting these substances into toxic52D7 from con"erting these substances into toxicforms. 5forms. 5HHmm* echanism of Toxicity* echanism of Toxicity77

4. 2ccelerating rate of excretion4. 2ccelerating rate of excretion!ompete +ith reabsorption 5!ompete +ith reabsorption 5enal Tubulesenal Tubules7.7.

I.e. ?or 3rI.e. ?or 3r/L/L or aor a/L/L radiation gi"eradiation gi"e !a!a/L/LEE?or %r?or %r'I'I

poisoning gi"epoisoning gi"e !l!l'I'Ito aid in excretion.to aid in excretion.

! i i f 0 i l( ! titi f 0 ti l t


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(. !ompetition for 0ssential receptors(. !ompetition for 0ssential receptors

2. !arbon onoxide2. !arbon onoxide!- is found in cigarette smoke 5(7 and auto!- is found in cigarette smoke 5(7 and autoexhaust 5>7.exhaust 5>7. Not in natural gas itself.Not in natural gas itself.

!ommonly used as a means of suicideE o"er ()))!ommonly used as a means of suicideE o"er ()))

fatalities a year from !- poisoning.fatalities a year from !- poisoning.

!arboxyhemoglobin is found in "ery small amounts!arboxyhemoglobin is found in "ery small amountsin nonsmokers M/.( of the body6s hemoglobin andin nonsmokers M/.( of the body6s hemoglobin and=') for smoker=') for smoker

T&8 * 1(ppm 3T0& * /))ppm 5'(min7T&8 * 1(ppm 3T0& * /))ppm 5'(min7

2&D ).'2&D ).'

!- has a /')x greater affinity for b than -!- has a /')x greater affinity for b than -//doesdoes


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! titi f 0 ti l t! titi f 0 ti l t


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!ompetition for 0ssential receptors!ompetition for 0ssential receptors

5con6t75con6t7

%. Turbocurare#pancuronium%. Turbocurare#pancuronium!ause a competition bet+een the poison and 2ch at the!ause a competition bet+een the poison and 2ch at theskeletal muscle endplate.skeletal muscle endplate.

Treatment:Treatment: !holinesterase Inhibitors!holinesterase Inhibitors 5i.e. Neostigmine and5i.e. Neostigmine andphysostigmine7physostigmine7

2dministration of 2! alone ineffecti"e2dministration of 2! alone ineffecti"e

!. !oumarin!. !oumarin

2nticoagulant that interferes +ith synthesis of coagulation2nticoagulant that interferes +ith synthesis of coagulationfactors II, 8II, IO and O.factors II, 8II, IO and O.

Treatment:Treatment: 8itamin H8itamin H

D. -piatesD. -piates!ompetition at opiate receptors +ith antagonists like!ompetition at opiate receptors +ith antagonists like

naloxone and naltrexone.naloxone and naltrexone.


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;. epair or %ypass effect of poison;. epair or %ypass effect of poison

2. Nitrites#sulfa drugs2. Nitrites#sulfa drugs!on"erts hemoglobin into methemoglobin, +hich reduces!on"erts hemoglobin into methemoglobin, +hich reducesthe ability of the blood to carry -the ability of the blood to carry -//..

ethylene blueethylene bluecauses a direct reduction ofcauses a direct reduction ofmethhemoglobin back to hemoglobin.methhemoglobin back to hemoglobin.

%. Digitalis%. DigitalisToxic effects include @I disturbances, neurologic, disordersToxic effects include @I disturbances, neurologic, disordersand cardiac arrhythmias.and cardiac arrhythmias.

@i"e antidote of@i"e antidote of DigibindDigibind

!. (?luorouracil and (fluodeoxyuridine!. (?luorouracil and (fluodeoxyuridine2ntitumor agents used to decrease DN2 synthesis.2ntitumor agents used to decrease DN2 synthesis.

ThymidineThymidineis a specific and effecti"e antidote.is a specific and effecti"e antidote.


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=. %lockade of receptors=. %lockade of receptors

responsible for Toxic 0ffectsresponsible for Toxic 0ffects

The toxic action and the therapeutic actionThe toxic action and the therapeutic action

are mediate by different receptors.are mediate by different receptors.

2. 2nticholinesterases2. 2nticholinesterases?ound in pesticides and chemical +arfare agents.?ound in pesticides and chemical +arfare agents.

increases le"el of acetylcholine resulting inincreases le"el of acetylcholine resulting in!holinomimetic effects!holinomimetic effects

2tropine2tropine blocks muscarinic receptors to block theblocks muscarinic receptors to block the

effect of the 2!e inhibitors. 5anticholinesterases7effect of the 2!e inhibitors. 5anticholinesterases7


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3$0!I?I! 2NTID-T033$0!I?I! 2NTID-T03

PoisonPoison*cetamino"hen*cetamino"hen

*cetylcholinesterases+*cetylcholinesterases+OP?s+ "hysostigmineOP?s+ "hysostigmine

Iron saltsIron salts

.ethanol+ -thylene glycol.ethanol+ -thylene glycol

.ercury+ lea.ercury+ lea

Narcotic rugsNarcotic rugs

*nti


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T idT id


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ToxidromesToxidromes

Toxidromes are clinical syndromes that areToxidromes are clinical syndromes that are

essential for the successful recognition ofessential for the successful recognition of

poisoning patternspoisoning patterns sindroma toksik.sindroma toksik.

The most important toxidromes, clinically,The most important toxidromes, clinically,

are:are:

3ympathomimetics3ympathomimetics

3edati"e ypnotics3edati"e ypnotics

-piates-piates

2nticholinergics2nticholinergics

!holinergics!holinergics

Tricyclics 5T!2s7Tricyclics 5T!2s7

3alicylates3alicylates


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3ympathomimetic Toxidrome3ympathomimetic Toxidrome

!N3 2gitation, hallucinations, paranoia2gitation, hallucinations, paranoia

espiration

$upils ydriasisydriasis

-ther 3eiJure, hypertension, tremor,3eiJure, hypertension, tremor,hyperreflexia, hyperthermiahyperreflexia, hyperthermia

Drugs !ocaine, amphetamines, $!$!ocaine, amphetamines, $!$


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3edati"e#ypnotic Toxidrome3edati"e#ypnotic Toxidrome

!N3 !oma!oma

espiration DecreasedDecreased


-ther ypothermia, decrease reflexes,ypothermia, decrease reflexes,hypotensionhypotension

Drugs 2lcohol, barbiturates,2lcohol, barbiturates,benJodiaJepinesbenJodiaJepines


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-pioid#-piate-pioid#-piate

!N3 !oma!oma

espiration DepressionDepression

$upils $inpoint$inpoint

-ther ypothermia, hypotension, triad,ypothermia, hypotension, triad,histamine releasehistamine release

Drugs -piates, morphine, codeine,-piates, morphine, codeine,propoxyphene, oxycodone,propoxyphene, oxycodone,hydrocodonehydrocodone


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2nticholinergic Toxidrome2nticholinergic Toxidrome

!N3 2gitation2gitation

espiration


-ther ?e"er, dry skin, flushing, urinary?e"er, dry skin, flushing, urinaryretention 52!37retention 52!37 Fot, dry, mad, red,Fot, dry, mad, red,

blindGblindGDrugs 2nticholinergics, antidepressants2nticholinergics, antidepressants


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!holinergic Toxidrome!holinergic Toxidrome

!N3 !oma 5not


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Tricyclic 2ntidepressant ToxidromeTricyclic 2ntidepressant Toxidrome

!N3 !oma agitation!oma agitation

espiration


-ther 2rrythmias, con"ulsions,2rrythmias, con"ulsions,hypotension, mycoclonus,hypotension, mycoclonus,

hyperthermiashyperthermiasDrugs T!26s, amipramine, imipramine,T!26s, amipramine, imipramine,

desipraminedesipramine


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3alicylate Toxidrome3alicylate Toxidrome

!N3 8ariable up or do+n8ariable up or do+n

espiration !an increase or normal!an increase or normal

$upils

-ther Diaphoresis, tinnitis, agitation,Diaphoresis, tinnitis, agitation,alkalosis 5early7, acidosis 5late7,alkalosis 5early7, acidosis 5late7,

fe"erfe"erDrugs 232, aspirin, 5salicylates7232, aspirin, 5salicylates7


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3pecific $oisons ?re


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SourceSource &ye, li


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SourceSource eroin, morphine, oxycodone,eroin, morphine, oxycodone,hydrocodonehydrocodone

SignsSigns %ilateral miosis 5%ilateral miosis 5$$$$$$7, !N37, !N3depression, apnea, decrease in bodydepression, apnea, decrease in bodytemperature, heart rate andtemperature, heart rate andrespiratory depression#arrestrespiratory depression#arrest..

TreatmentTreatment 2%!6s, Naloxone, gastric la"age and2%!6s, Naloxone, gastric la"age andsupporti"e care.supporti"e care.

1. -piates



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SourceSource DemerolDemerol

SignsSigns Dilated pupilsDilated pupilsdue to antimuscarinicdue to antimuscariniceffects,effects, increase in increase in , con"ulsions, con"ulsions

due to metabolite 5normeperidine7,due to metabolite 5normeperidine7,respiratory depression#arrest, coma.respiratory depression#arrest, coma.?e+ fatalities +ith meperidine?e+ fatalities +ith meperidine5tolerance7.5tolerance7.

TreatmentTreatment 2%!6s, @astric la"age 5if oral7,2%!6s, @astric la"age 5if oral7,diaJepam for seiJures and naloxonediaJepam for seiJures and naloxonefor depressi"e effects 5not for tremors7for depressi"e effects 5not for tremors7

4. eperidine



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SourceSource 2tropine, Deadly Nightshade2tropine, Deadly Nightshadeplantplant

SignsSigns Dry mucous membranes, burning inDry mucous membranes, burning inthroat, intense thirst, dilation of pupils,throat, intense thirst, dilation of pupils,hot dry skin, hyperpyrexia, tachycardia,hot dry skin, hyperpyrexia, tachycardia,mania and deliriumE death frommania and deliriumE death fromrespiratory failurerespiratory failure

ot, dry, mad, red and blind.ot, dry, mad, red and blind.TreatmentTreatment 2%!6s, &a"age +ith 4 tannic acid,2%!6s, &a"age +ith 4 tannic acid,

pilocarpine or physostigmine, aspirinpilocarpine or physostigmine, aspirin5antipyretic7 and alcohol sponges.5antipyretic7 and alcohol sponges.

(. 2tropine



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SourceSource 3uicide,3uicide, automatismautomatism5forget you5forget youalready took your dose7already took your dose7

SignsSigns !N3 depression 5progressi"e7,!N3 depression 5progressi"e7,dro+siness, shallo+ rapid respiration,dro+siness, shallo+ rapid respiration,!8 collapse, lo+ body temp and death!8 collapse, lo+ body temp and deathdue to respiratory depressiondue to respiratory depression

TreatmentTreatment 2%!6s, &a"age +ith HmN-2%!6s, &a"age +ith HmN-44, charcoal,, charcoal,

alkaline diuresis 5Na!-alkaline diuresis 5Na!-117,7,

hemodialysis 5long acting barbs7hemodialysis 5long acting barbs7

;. %arbiturates



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SourceSource DiaJepam 5long acting7, alpraJolamDiaJepam 5long acting7, alpraJolam5short acting7, triaJolam 5ultra short75short acting7, triaJolam 5ultra short7

SignsSigns 3ame as barbiturates,3ame as barbiturates, rarely fatalrarely fatalunless taken +ith 0T- or other !N3unless taken +ith 0T- or other !N3depressant due to synergistic !N3depressant due to synergistic !N3depressiondepression

TreatmentTreatment 2%!6s, emesis, gastric la"age,2%!6s, emesis, gastric la"age,antidote:antidote:flumazenilflumazenil short Tshort T'#/'#/maymay

re


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SourceSource Whisky, +ine, beer etc.Whisky, +ine, beer etc.

SignsSigns -dor on breath, impaired motor-dor on breath, impaired motor

coordination, slurred speech,coordination, slurred speech,dehydration, gastritis, hypothermia,dehydration, gastritis, hypothermia,coma and death due to respiratorycoma and death due to respiratorydepressiondepression

TreatmentTreatment 2%!6s, gastric la"age +ith bicarb,2%!6s, gastric la"age +ith bicarb,caffeine, hemodialysis 5if ())mg7caffeine, hemodialysis 5if ())mg7

9. 0thanol



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SourceSource ajor tran


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SourceSource Illuminating fuels, paint thinnersIlluminating fuels, paint thinners

SignsSigns 0uphoria0uphoria, burning in the chest,, burning in the chest,

headache, +eakness, dro+siness,headache, +eakness, dro+siness,con"ulsions, death due to respiratorycon"ulsions, death due to respiratoryarrest orarrest or "entricular fibrillation"entricular fibrillation

TreatmentTreatment 2%!6s, large amounts of +ater, oli"e2%!6s, large amounts of +ater, oli"eoil and saline cathartic, antibiotics,oil and saline cathartic, antibiotics,corticosteroids to reduce kerosenecorticosteroids to reduce kerosenepneumonitis, no emetics or la"age.pneumonitis, no emetics or la"age.

'). Herosene

p < yp < y0ncountered0ncountered



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SourceSource -rganophosphate insecticide-rganophosphate insecticide

SignsSigns 3&AD03&AD0, fixed pin point pupils, loss of, fixed pin point pupils, loss of

muscle coordination, muscle t+itching,muscle coordination, muscle t+itching,mental confusion, death due tomental confusion, death due torespiratory arrest.respiratory arrest.

TreatmentTreatment

2%!6s, atropine, pralidoxine, la"age2%!6s, atropine, pralidoxine, la"age+ith ( Na!-+ith ( Na!-11, +ash affected, +ash affected

areas, a"oid morphine, barbituatesareas, a"oid morphine, barbituatesand phenothiaJines.and phenothiaJines.

''. $arathion



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SourceSource 2spirin, percodan2spirin, percodan

SignsSigns Deep and rapid breathingDeep and rapid breathing,, tinnitistinnitis,,hallucinations, con"ulsions, resp.hallucinations, con"ulsions, resp.

alkalosis 5adult7, metabolic acidosisalkalosis 5adult7, metabolic acidosis5child7, respiratory and !8 collapse5child7, respiratory and !8 collapse

3erum le"el 4))mcg#ml3erum le"el 4))mcg#ml

TreatmentTreatment 2%!6s, emetics, gastric la"age (2%!6s, emetics, gastric la"age (Na!-Na!-11, monitor p, barbituates or, monitor p, barbituates or

benJo6s for seiJures, hemodialysis ifbenJo6s for seiJures, hemodialysis ifneeded.needed.

'/. 3alicylates



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SourceSource Tylenol, 8icodin, $ercocetTylenol, 8icodin, $ercocet

SignsSigns 2fter depletion of glutathione, nausea,2fter depletion of glutathione, nausea,

"omiting, ele"ated li"er enJymes"omiting, ele"ated li"er enJymes53@-T, 3@$T, bilirubin7, hepatic53@-T, 3@$T, bilirubin7, hepaticnecrosis and death due to hepaticnecrosis and death due to hepaticfailure.failure.

TreatmentTreatment 2%!s, emetics, la"age, charcoal, N2%!s, emetics, la"age, charcoal, Nacetylcysteine to restore glutathioneacetylcysteine to restore glutathioneearlier the better 5grapefruit juice7,earlier the better 5grapefruit juice7,monitor li"er enJymes.monitor li"er enJymes.

'1. 2cetaminophen



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2cetaminophen %lood le"el2cetaminophen %lood le"el

0ffects0ffects

$lasma le"els of /()mcg#ml at 1($lasma le"els of /()mcg#ml at 1(

hours post ingestion.hours post ingestion.

umack atthe+ nomogram * $robableumack atthe+ nomogram * $robable

toxicitytoxicity

!hildren 5>')yrs7 are less susceptible to!hildren 5>')yrs7 are less susceptible to

the toxic effect of acetaminophen.the toxic effect of acetaminophen.



67/76

SourceSource !oca plant, cocaine, crack!oca plant, cocaine, crack

SignsSigns !N3 stimulation, euphoria, Qcocaine!N3 stimulation, euphoria, Qcocaine

bugsR,halo lights, seiJures, hallucinations,bugsR,halo lights, seiJures, hallucinations,cardiac arrhythmias lead to cardiaccardiac arrhythmias lead to cardiac

arrestarrest

TreatmentTreatment 2%!6s, charcoal, diaJepam 5seiJures7,2%!6s, charcoal, diaJepam 5seiJures7,

lidocaine 5arrhythmias7, no dialysis orlidocaine 5arrhythmias7, no dialysis orla"age.la"age.

'4. !ocaine



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SourceSource 2ngel dust, 3ernyl 5old "eterinary2ngel dust, 3ernyl 5old "eterinarygeneral anesthetic7general anesthetic7

SignsSigns $sychosis, sensory analgesia,$sychosis, sensory analgesia, rotaryrotarynystagmusnystagmus, hypertension, hyperacti"e, hypertension, hyperacti"ereflexes, seiJures.reflexes, seiJures.

TreatmentTreatment &ock in padded room, diaJepam,&ock in padded room, diaJepam,antipsychotic agent 5aloperidol7,antipsychotic agent 5aloperidol7,cranberry juice 5'))x increase incranberry juice 5'))x increase inexcretion7excretion7

'(. $hencyclidine 5$!$7



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SourceSource 2mitryptyline, imipramine, doxepin2mitryptyline, imipramine, doxepin

SignsSigns 2nticholinergic 3yndrome 52!372nticholinergic 3yndrome 52!37 FdryFdry

mouth, mydriasis, hyperpyrexia, increasemouth, mydriasis, hyperpyrexia, increase, decreased @I motilityG, decreased @I motilityGhallucinations,hallucinations,seiJures, respiratory depression, cardiacseiJures, respiratory depression, cardiacarrhythmias 5


71/76

SourceSource Suaalude, ludes 5sedati"e#hypnotic7Suaalude, ludes 5sedati"e#hypnotic7

SignsSigns DepersonaliJation, tongueDepersonaliJation, tongue

discoloration, diJJiness, nausea,discoloration, diJJiness, nausea,hemorrhage, abstinence syndromehemorrhage, abstinence syndrome

TreatmentTreatment 2%!6s, emesis, la"age, hemodialysis2%!6s, emesis, la"age, hemodialysis

'=. etha


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SourceSource Digitalis, digoxinDigitalis, digoxin

SignsSigns eadache, nausea, "omiting, blurredeadache, nausea, "omiting, blurred"ision, delirium, slo+ed pulse, cardiac"ision, delirium, slo+ed pulse, cardiac

irregularities, hypokalemia,irregularities, hypokalemia,arrhythmias, "entricular fibrillationParrhythmias, "entricular fibrillationPlo+ TIlo+ TI

TreatmentTreatment 2%!6s Dose adjustment, drug2%!6s Dose adjustment, drug

+ithdra+al, la"age, charcoal, emesis,+ithdra+al, la"age, charcoal, emesis,Digibind, HDigibind, HLLsupplement, treatsupplement, treatarrhythmias 5lidocaine, phenytoin,arrhythmias 5lidocaine, phenytoin,propranolol7propranolol7

'9. Digoxin



73/76

SourceSource DilantinDilantin

SignsSigns Nystagmus, ataxia, dro+siness,Nystagmus, ataxia, dro+siness,

seiJuresPdeath is rare but is usuallyseiJuresPdeath is rare but is usuallydue to "entricular fibrillation anddue to "entricular fibrillation andcardiac arrest. Toxicity /(mcg#mlcardiac arrest. Toxicity /(mcg#ml

TreatmentTreatment 2%!6s, emesis 5if conscious7, la"age,2%!6s, emesis 5if conscious7, la"age,

charcoal, cathartics, discontinuecharcoal, cathartics, discontinuephenytoinphenytoin

'>. $henytoin

p < yp < y

0ncountered0ncountered


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/' Dioxin 5/ 1 = 9 T!DD7


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SourceSource erbicides, cigarette smoke, smokeerbicides, cigarette smoke, smoke

from burning trash and debrisfrom burning trash and debris

SignsSigns !hloracne!hloracne5small yello+ comedones75small yello+ comedones7mainly on the face can last 1) years,mainly on the face can last 1) years,

hepatomegaly, fatigue, irritability,hepatomegaly, fatigue, irritability,blurred "ision, porphyria cutanea tardablurred "ision, porphyria cutanea tarda5slate gray skin pigmentation7,5slate gray skin pigmentation7, limitedlimitedsystemic effects, DeathBBsystemic effects, DeathBB

TreatmentTreatment 2%!6s, alkaline diuresis, If recent2%!6s, alkaline diuresis, If recentingestion: Femesis, la"age, charcoal,ingestion: Femesis, la"age, charcoal,catharticG, mainly supporti"e carecatharticG, mainly supporti"e care

/'. Dioxin 5/,1,=,9 T!DD7

Dioxin $oisoningDioxin $oisoning


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Dioxin $oisoningDioxin $oisoning

6iktor Aushchenko% :kraine Presient

2013Toxicology Klinik

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Transcript of 2013Toxicology Klinik