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Sarin and VX were released on an unprotected civilian population in Japan on six occasions in 1994−5. Clinicians must be prepared, therefore, to treat casualties from nerve agent exposure. This requires an understanding of the mechanisms of nerve agent toxicity and the factors which influence their clinical impact. Clinicians need to be able to make a rapid and accurate diagnosis and use atropine,...
Although the diagnosis of poisoning is usually evident (e.g. in a patient presenting with drug overdose), it may occasionally be obscure. This article describes some clinical presentations where poisoning should be considered in the differential diagnosis. Examples are unexplained coma or confusion, hypoglycaemia, abnormal liver function, unexplained convulsions or acidosis or abnormal bleeding. Poisoning...
Assessment of an acutely poisoned patient involves the taking of an appropriate history, assessment of the level of consciousness, ventilation and circulation, a physical examination, and requesting appropriate toxicological and non-toxicological investigations. Diagnosis is based on the history, circumstantial evidence (if available), a cluster of common features (if present) and, occasionally, on...
Accidental ingestion of products found in the environment is common. It particularly affects young children aged 1–4 years, especially boys. Fortunately, many substances that are taken by accident have low toxicity and further observation or treatment is unnecessary. This article includes information on substances found in the house or garden that are of low toxicity when taken by ingestion. Medicines...
Initial management involves the treatment of any potentially life-threatening conditions, such as airway compromise, breathing difficulties, haemodynamic instability and serious dysrhythmias. Thereafter, convulsions should be treated, fluid, acid–base and electrolyte abnormalities corrected and hypothermia managed by using a space blanket. Children under 5 years old who have ingested aspirin, salicylate,...
Sulphur mustard is a powerful vesicant (blistering agent) which was used extensively in World War I and in the Iran–Iraq conflict (1984–1987). In addition to causing characteristic blistering burns to the skin, exposure may also result in severe conjuctivitis, ulcerative necrosis throughout the respiratory tract and systemic toxicity including bone marrow suppression. There is no specific therapy...
Non-traumatic rhabdomyolysis may be caused by a direct insult to the cell membrane, affecting its ability to maintain ion gradients, or be secondary to local muscle compression as a result of coma or seizures. Acute renal failure and peripheral nerve damage are the two most common and important complications observed, though hyperkalaemia leading to a dysrhythmia is the main cause of death.
Biochemical abnormalities due to disturbed metabolic processes are common in severely poisoned patients. These may be of diagnostic value, but most importantly their recognition and treatment are important in the management of these patients. Acid–base abnormalites, particularly respiratory and metabolic acidoses, are common. Respiratory acidoses due to central nervous system depression or pulmomary...
The serotonin syndrome is the clinical manifestation of serotonin toxicity in patients taking one or more serotonergic agents. It is characterized by features of neuromuscular hyperactivity, autonomic instability and alteration of mental status. Management consists of discontinuation of the offending drug and supportive care. Cyproheptadine and chlorpromazine which have 5-HT 2A antagonistic...
Methaemoglobin is formed when ferrous haemoglobin iron (II) is oxidized to ferric iron (III), which cannot participate in oxygen transport. Methaemoglobin-forming chemical groups of particular importance in poisoning are organic nitrites (e.g. amyl and isobutyl nitrite) and amino- or nitro-derivatives of benzene (e.g. aniline, dapsone and lidocaine). An asymptomatic, apparent ‘cyanosis’ is the earliest...
Ricin is derived from the beans of the castor oil plant Ricinus communis. Many of the features seen in poisoning can be explained by ricin-induced endothelial cell damage, which leads to fluid and protein leakage and tissue oedema, causing so-called ‘vascular leak syndrome’. Immunization against ricin exposure using inactivated ricin toxoid or genetically engineered ricin A chain are realistic future...
The epidemiology of poisoning can be studied from different perspectives. These include overall mortality, hospital admission rates, and enquiries to Poisons Information Services. Accidental poisoning is most common in children, but deliberate self-harm becomes predominant in teenage years and early adulthood. Understanding the patterns of poisoning assists in developing suicide prevention strategies...
Antidotes exert their beneficial effects by a variety of mechanisms, including forming an inert complex with the poison, accelerating detoxification of the poison, reducing the rate of conversion of the poison to a more toxic compound, competing with the poison for essential receptor sites, blocking essential receptors through which the toxic effects are mediated and bypassing the effect of the poison...
Substances taken to alter the mental state may be ingested, inhaled, absorbed through mucous membranes or injected. Accidental overdose is common. Complications result either from the presence of contaminants or from the pharmacological actions of the substance(s) involved; these include respiratory, neurological, renal and metabolic complications. Body packers often swallow large numbers of packages...
Deliberate self-poisoning is one of the most common for general hospital presentation. The majority of the individuals involved are young, with females outnumbering males. Self-poisoning occurs in people from a variety of social backgrounds, but is associated with socio-economic deprivation and social fragmentation. Common precipitants include relationship problems, often in the context of depression...
There is no evidence that the use of activated charcoal, gastric lavage, syrup of ipecacuanha, cathartics or whole-bowel irrigation improves the clinical outcome in poisoned patients. However, activated charcoal and gastric lavage may be considered in patients who have ingested life-threatening amounts of a toxic agent up to 1 hour previously. To increase elimination, treatment with multiple-dose...
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