⚕️ Principles of Treatment for Poison
The treatment of a poison patient can be divided into the following two main parts:
1. Specific Treatment (When the Poison is Known)
- If it is known which poison the patient has consumed, a specific treatment or antidote for that particular poison can be used to save the patient’s life.
2. General Measures (When the Poison is Unknown)
- If the nature of the poison cannot be determined, the following general measures should be adopted:
Step Measure Detail (a) Elimination of Unabsorbed Poison Removing the poison that has not yet entered the bloodstream (e.g., from the stomach/gut). (b) Use of an Antidote Administering a substance to counteract the effects of the poison. (c) Elimination of Absorbed Poison Removing the poison that has already been absorbed into the body (e.g., via dialysis or forced diuresis). (d) Treatment of General Symptoms Managing the symptoms caused by the poisoning (e.g., treating convulsions, respiratory failure, etc.). (e) Restoration of General Condition Stabilizing the patient’s overall vital functions and general physical state.
(A) Elimination of Unabsorbed Poison
The following immediate measures are taken based on the route of poison administration:
1. Inhaled Poisoning (Inhalational Toxins)
- Action: If the victim has suffered from carbon monoxide, car fumes, or subterranean sewer gas, they should be immediately brought into fresh air.
- Respiration: Artificial respiration should be given.
- Position: During artificial respiration, the victim should be laid face down (prone) so that mucosal secretions do not obstruct the airway, allowing them to breathe easily.
2. Poisoning via Injection
- Binding: A tight tourniquet should be tied near the injection site (e.g., for narcotics, insulin, or snakebite).
- Caution: The tourniquet should be loosened for one minute every 10 minutes to prevent gangrene due to the interruption of blood circulation.
- Extraction/Neutralization: After this, a small incision should be made at the injection site, and the poison should be sucked out with a pump or an attempt should be made to neutralize it with a chemical.
3. Contact Poisoning
- Washing: If the poison has been spilled on the skin, eyes, or a wound, or if it was introduced via spray into the vagina, anus, or urethra, the area should be thoroughly washed with plain, but lukewarm water.
- Antidote: A suitable antidote should be used, depending on the type of poison.
4. Ingested Poisoning
If the poisoned person has consumed the poison mixed in food and liquid, an attempt should be made to expel the maximum possible quantity of poison from the stomach.
For this purpose, the following methods are used:
- (a) Emetics
- (b) Stomach Wash (Gastric Lavage)
(a) 🤮 Emetics – Methods to Induce Vomiting
- The following two types of emetics are used to induce vomiting:
1. Household Emetics
Common household items can be used immediately to induce vomiting. This process should be repeated repeatedly.
- Water: Hot water, or
- Salt Solution: Give the patient 30 grams of common salt dissolved in 200 ml of water.
- Mustard Solution: Give the patient 15 grams of mustard powder dissolved in 200 ml of water.
- Ipecac: Give the poisoned person 1 to 2 grams of Ipecac with 30 ml of Soap berry solution.
- Other Medications:
- Ammonium Carbonate: Up to 2 grams mixed with water. 1.5 grams mixed with water.
- Sulphate of Zinc: 1.5 grams mixed with water.
Mechanical Method: If the patient is conscious and willing to cooperate, vomiting can be induced by putting a finger or some other object into the throat.
Important Warnings
- Emetics only manage to expel about 20% of the ingested poison from the stomach through vomiting.
- There is a risk that the poison may move further down into the intestines during this process.
- If the poisoned person has swallowed an acid or an alkali, emetics should never be used, as this can cause perforation (a hole) in the stomach.
2. Medical/Therapeutic Emetics
The following medications and treatment methods can be used for this purpose:
Drug Dosage and Method Effects Apomorphine 0.6 milligrams given as a subcutaneous injection. This may cause the poisoned person to become drowsy or sleepy. Naloxone Hydrochloride or Narcan 5 to 10 milligrams given via intramuscular or intravenous injection. Administered after the Apomorphine injection to prevent drowsiness/sleep (to counteract the effect of Apomorphine). Oral Medication (Tablet Form) A dose of 12 milligrams can be given in tablet form. Vomiting occurs approximately half an hour after administration.
2. 🩺 Gastric Lavage / Stomach Wash
Timing: If the poison was taken by the victim within 4 to 6 hours, this method can be adopted to save their life.
📝 Initial Preparation and Precautions
The following precautions should be taken before performing gastric lavage.
Convulsions: If the patient is suffering from convulsions due to nux vomica poisoning, they should be treated first.
Kerosene/Volatile Poison or Coma: In case of kerosene or any volatile poison, or if the patient is in a coma, a cuffed tube (inflatable) should be used so that the airway is sealed off, preventing the effects of the poison from entering the airway and lungs as vapors.
Body Temperature: If the victim’s body temperature is lower than normal, efforts should be made to raise it.
Artificial Teeth: If the patient has false teeth, they should be removed so that they do not fall or get stuck in the throat during gastric lavage, causing complications.
Unconscious Victim: A Mouth Gag should be used to keep the mouth open in an unconscious victim.
Stomach Tube and Gastric Lavage
🩺 Introduction to the Stomach Tube
The stomach tube is a soft rubber tube, approximately 1.5 meters long and 12.7 (mm) in diameter.
- Upper End: It is fitted with a funnel.
- Lower End: This end is rounded and has several openings so that the function is not affected even if one or two holes are blocked.
- Mark: A mark is made about 50 centimeters (cm) from this end. This mark is placed at 50 cm because the distance from the mouth to the stomach in an adult is approximately this length.
- Suction Bulb: A suction bulb is also attached in the middle of the tube. This is used to:
- Extract the stomach fluid if it cannot exit by the principle of siphonage.
- Remove any obstruction using air pressure.
Method of Use (Gastric Lavage)
Patient's Position (Positioning)
- For gastric lavage, the poisoned person is laid in a supine position such that their head is lower and hips are higher.
- Purpose: This facilitates breathing and prevents the contents expelled from the stomach from entering the trachea (windpipe).
Inserting the Tube
- The tube is lubricated with olive oil, wax, or groundnut oil.
- The tongue is depressed with a finger, and the tube is gradually maneuvered into the pharynx.
- It is then lowered until the 50 cm mark appears.
Precautionary Measures (Verification)
- After lowering the tube, and before washing, it must be confirmed that the tube has not entered the trachea but is properly in the stomach.
Verification Method Presence in Stomach Presence in Trachea Pumping Air Air is pumped into the tube, and the abdomen is auscultated with a stethoscope.
Bubbling sounds are heard at the location of the stomach.The poisoned person experiences a strong spasmodic cough. Listening at Funnel If the patient is unconscious, a hissing sound can be heard by placing the ear against the funnel.
Gastric Lavage Procedure (Lavaging Process)
1. First Wash:
- The funnel is held above the patient’s head, and approximately 250 (ml) of warm water 35 centigrade is introduced into the stomach via the funnel.
- The funnel is then lowered below the level of the patient’s stomach so that the stomach contents exit by the principle of siphonage.
- This expelled water is collected for chemical examination.
- Note: The quantity of water is not kept large initially, as a large amount might cause toxic substances to move from the stomach into the duodenum.
2. Subsequent Washes:
- The above process is repeated using half a liter of water.
3. End of Lavage:
The lavage is continued until the colour of the fluid exiting the stomach becomes clear, like the washing water used.
4. Using Fluids/Antidotes:
Only water is used in the first wash. However, in subsequent washes, other fluids or antidotes may be mixed with the water.
5. Before Tube Removal:
Before removing the tube after lavage, a small amount of water mixed with an antidote, or Sodium Sulphate (30 grams) dissolved in water, should be instilled.
This is to ensure that any remaining poison in the stomach or intestines is expelled via diarrhea.
- Examples: In Aspirin poisoning, Sodium Bicarbonate may be used, and in Alkali poisoning, Charcoal and Liquid Paraffin may be used.
Gastric Lavage in Children
- Tube Used: French rubber catheters of size 8 to 12 French are used.
- Insertion: They are inserted into the stomach via the nose or mouth.
- Fluid Removal: Gastric fluid is withdrawn using a 50 ml syringe.
🚫 Contraindications
Except for Carbolic Acid, the use of the stomach tube is contraindicated in all Alkali poisons.
- Reason: These poisons cause inflammation and ulcers in the oesophagus and stomach. Inserting the stomach tube could therefore cause a perforation (hole) in these organs.
- In cases of Corrosive Poisons, the stomach tube should be inserted with great caution.
(B) Use of Antidotes
- Antidotes, by their mechanism of action, neutralize the effects of the poison or produce opposite effects to the poison without causing harm to the body.
Indications
Antidotes can be used in the following situations:
- When Poison is not Completely Expelled: If the poison has not been completely expelled from the body through emetics or stomach wash (Gastric Lavage), or if there is no opportunity to use these methods.
- When the poison has been absorbed into the body.
- When the poison has entered the body through an alternative route: If the poison has entered the body through a route or pathway other than the mouth.
Types of Antidotes
Antidotes are classified into four groups based on their nature of action (mechanism):
- Physical or Mechanical Antidotes
- Chemical Antidotes
- Physiological or Pharmacological Antidotes
- Universal Antidotes
Mechanical or Physical Antidotes
These antidotes prevent the absorption of poison in the stomach. They can be divided into the following categories:
1. Demulcents
- Description: These substances are rich in fatty/oily content, or are mucilaginous.
- Examples: Fat, oil, milk, egg white, etc.
- Mechanism: They form a coating/layer on the walls of the stomach, thereby preventing the absorption of the poison.
- Usefulness: They are also beneficial in poisoning caused by corrosive and irritant poisons.
- Caution: They are not used in poisoning cases involving fat-soluble poisons, such as:
- Phosphorus
- Organophosphates
- DDT
2. Absorbents / Bulk Foods
- Description: These are viscous or bulky solid foods.
- Examples: Banana or Custard.
- Usefulness: They act as a mechanical antidote, commonly used in cases of poisoning by powdered glass.
- Mechanism: They envelop the powdered glass in the stomach, rendering it harmless by preventing its harmful effects and absorption.
3. Wood Charcoal / Activated Charcoal
- Description: This also acts as a mechanical antidote.
- Usefulness: It is primarily used to prevent the absorption of alkaloid-based poisons (like Strychnine) and certain mineral poisons.
- Dosage: It is administered mixed with five times its amount of water:
- In Children: 30 to 60 grams
- In Adults: 60 to 100 grams
Chemical Antidote
This type of antidote directly neutralizes the effects of poison through its chemical actions, or converts them into non-toxic or insoluble compounds through the process of Oxidation.
1. Direct Effects (Neutralization)
Antidotes that neutralize poisons through chemical reactions.
For Alkaline Poisons (Bases):
- Diluted or aerated Acetic Acid (Vinegar).
- Canned fruit juices (Fruity).
For Acidic Poisons (Acids):
- Diluted or aerated base like Milk of Magnesia.
- These neutralize the poisons.
2. Oxidizing Action (Detoxification)
These antidotes render poisons ineffective or non-toxic by subjecting them to the process of oxidation.
Potassium Permanganate:
- Usage: Used as a solution, prepared by mixing one gram of Potassium Permanganate in one liter of water.
- Effect: Through its oxidizing action, it neutralizes almost all Alkaloids, Barbiturates, Amidopyrine, Phosphoric compounds, and Cyanides.
Iodine:
- Alternative: Can be used if Potassium Permanganate is unavailable.
- Usage: Mix 15 drops of Iodine in 200 ml of water.
3. Insoluble Compounds (Binding)
These antidotes combine with the poisons to form compounds that are insoluble, preventing their absorption into the body.
Strong Tea or Tannin:
- Effect: It combines with most alkaline poisons, Glucosides, and mineral poisons, converting them into insoluble compounds.
Physiological or Medicinal Antidotes
This refers to medications that produce effects opposite to those of poisons. They are categorized into two main types:
1. Antagonists
These are drugs that produce effects contrary to those of poisons to counteract their toxicity. Examples:
- Atropine for Pilocarpine
- Diazepam for Strychnine (Kuchela)
- Naloxone for Morphine
Caution: Since these are potent opposing drugs themselves, they may produce adverse effects.
2. Chelating Agents
- These agents are used for certain metallic poisons. They bind the toxic particles of the poison into a “chelate” (case) structure, making them harmless and facilitating their removal from the body.
A. BAL (British Anti-Lewsite)
Also known as Dimercaprol.
Use: Used for poisoning by certain heavy metallic poisons like Arsenic (Sankhiya) and Mercury (Parah).
Method of Use:
- A 10% solution is prepared in Benzoyl Benzoate and Arachis oil and administered via Intramuscular (I.M.) injection.
Dosage in Severe Cases:
- First 2 Days: 3mg/kg body weight, every 4 hours.
- Third Day: Every 6 hours.
- Following Days (up to 10 days): Every 12 hours.
Important Precaution: It should not be used in cases of severe liver disease.
B. EDTA (Ethylene Diamine Tetra Acetate)
Efficacy: Found to be more effective than BAL in Arsenic and Mercury poisoning.
Method of Use (Adults):
- Dose: 1 gram, twice a day.
- Administration: Used as an Intravenous (I.V.) Infusion mixed in Glucose Saline.
- Duration: For 5 days, followed by a two-day rest, after which the process is repeated.
Important Precaution: Should not be used in kidney diseases (renal disorder).
C. Cuprimine (Penicillamine)
This is a milder form of penicillin. It is less effective than EDTA.
- Use: Found very useful in poisoning by Copper, Lead, and Mercury.
- Special Use: Highly effective in Wilson’s Disease (a liver condition caused by copper accumulation).
- Method of Use: Can be used Orally (by mouth).
- Dosage: 2 grams daily (which can be divided into four doses of 30mg/kg body weight).
D. Desferrioxamine (Deferoxamine)
- Specific Use: Used specially for Iron poisoning.
- Other Use: Also beneficial in certain chronic conditions like Haemochromatosis, where the amount of iron in the body is increased.
Method of Use in Acute Poisoning:
- After gastric lavage, a solution of 5 to10 grams} in 100ml of distilled water is given orally.
- In cases of severe iron absorption, 0.1 gram is mixed in 5% Laevulose and administered via the Intramuscular (I.M.) route.
Universal Antidote
This antidote is used when the nature of the poison is unknown or when the poisoned person has consumed a mixture of several poisons.
Component Quantity Purpose Powder of Burnt Toast 2 tablespoons Prevents the absorption of alkaline poisons (basic poisons). Magnesium Oxide or Milk of Magnesia 1 tablespoon Neutralizes acid poisons. Tannic Acid or Strong Tea 1 tablespoon Causes precipitation of alkalis, glucosides, and most minerals.
- Dosage: 3 tablespoons (15 grams) of this mixture are dissolved in 200 ml of water and administered once or twice.
Important Note: This antidote is not effective. It is considered useless even if administered immediately after poisoning.
Unani Antidotes
| Herb/Substance | Dosage/Application | Benefits/Uses |
|---|---|---|
| Gentian (Jantiana) | Administer a decoction of 5 grams or 3 grams of powder. | Especially beneficial in poisoning from snake, scorpion, and dog bites. |
| Soapberry (Reetha, Funduq Hindi) | Grind it in water and administer, and apply the paste to the affected area. | Useful in most types of poisoning. |
| Aristolochia (Zarawand) | Administer a decoction of 6 grams. | Found to be useful in most types of poisoning. |
| Sea Shell (Sadaf Halzun/Sankh) | Administer 250 to 500 mg of the calcined preparation (Kushta Sadaf). | An antidote that expels the poison through sweat. |
| Double Coconut (Naril Daryai) | Grind approximately 500 mg to 1 gram in Rose Water or plain water and lick/administer. | Useful in poisoning from snake, scorpion, Beesh (Aconite), and Opium. |
(C) Elimination of Absorbed Poison
If poison has been absorbed into the body, the following methods are adopted to stimulate its elimination:
1. Enhancing the Excretory Capacity of the Kidneys
- The excretory capacity of the kidneys is increased. For this purpose, the poisoned person is given a sufficient quantity of intravenous fluids.
- Caution: Care is taken to ensure that the poisoned person does not suffer from water overload, otherwise, it may lead to circulatory failure or pulmonary edema (fluid in the lungs).
- Use of Diuretics: To increase urine output, diuretics such as Mannitol or Furosemide are administered. A 500 mL amount is given as an Infusion at 12-hour intervals.
2. Changing the Urine's pH
The pH of the urine is altered, as certain poisons are excreted more easily depending on the acidity/alkalinity:
- Salicylates and Phenobarbitone are easily excreted in alkaline urine.
- Amphetamine and Quinine are easily excreted in acidic urine.
3. Advanced Methods for Elimination
- In case of kidney failure in children, Peritoneal Dialysis may be used.
- For infants, Exchange Transfusion is used for poisoning with carbon monoxide, iron, barbiturates, and salicylates, among others.
- The use of artificial kidneys (Haemodialysis) is effective for certain poisons.
- Currently, the method of Whole Bowel Irrigation (WBI) is being used in preference to methods like gastric lavage and dialysis.
(D) Treatment of General Symptoms
Specific treatment is administered according to the symptoms of the poisoning. For example:
Pain:
- Morphine can be used.
Respiratory Distress:
- Oxygen or Artificial Respiration is provided.
Cardiac Depression:
- Cardiac Stimulants are used.
Convulsions:
- To prevent them, a suitable Anaesthetic, and Barbiturates or Diazepam should be administered.
Supportive Management
Treating Dehydration:
- Saline is beneficial. It helps reverse dehydration and also aids in the excretion of the poison via urine.
Glycogen Deficiency in the Liver:
- The use of Glucose is recommended to correct the lack of glycogen in the liver.
(E) General Management and Recovery
- The focus of this management is to provide the poisoned patient (victim) with comfort and protection.
Key Management Steps:
- Warmth and Comfort: The victim should be kept warm and given as much rest as possible.
- Preventing Upper Airway Infection: Once the victim’s survival is ensured, efforts to prevent upper airway infection should begin.
Increased Risk of Infection:
- This risk of infection is higher in the following individuals:
Elderly individuals.
- Victims who have remained unconscious for up to one hour.
- Victims of poisoning where a small amount of vomitus entered the airway during an episode of vomiting.
Prevention of Infection:
- To prevent infection, the necessary course of antibiotics can be initiated.
Psychological Aspect:
- If it is known that the victim consumed the poison with the intent of suicide, it is better to have the victim undergo a psychological analysis by a Psychiatrist before discharge from the hospital.
- Purpose: This is to prevent any future attempts.