Ethyl Alcohol Poisoning

Clinical picture:

Stage of Excitement: Flushed face - hiccup - increased appetite - sense of well being, violence and warmth.

Stage of Confusion: Delirium - unstable gait - blurred vision - tremors - difficult problem solving - positive

Rhombergism.

Stage of Stupor-dead drunk: Marked impairment of consciousness (no complete loss) - constricted pupil

(dilated on pinching the face).

Treatment: 

1- Care of coma and hypotension.

2- Support respiration.

3- Gastric lavage with activated charcoal.

4- IV glucose.

5- Vitamin B complex: help alcohol oxidation.

* Vitamin B complex as Tri B -trivarol - neurorubine - neurobion - neuroton - Vit. B Complex.   

Kerosine Poisoning

NB:

Gastric lavage is contraindicated unless with the use of cuffed endotracheal tube due to aspiration pneumonia.

Treatment:

1- Emergency treatment: 

- Ask those present with the patient to buy milk and eggs then add 2 eggs to 1 cup of milk then ask the

patient to drink egg-milk cups continuously all day and if vomiting occurs ask him to continue to drink after

vomiting stops.

- Or gastric lavage with cuffed endotracheal tube.

2- Supportive treatment:

- Do X-ray to exclude aspiration pneumonia.

- Antibiotics to guard against secondary infection.

- Course of corticosteroids may be used as (Orazone - Deltazone - Dexamethasone).

Corrosive Poisoning

KOH - NaOH - Amonia - .................

Clinical picture: 

1- Local burns around mouth and lips.

2- Excess mucous.

3- Puffy swelling of tissues.

4- Whitish vomiting and containing blood.

Treatment: 

1- First aid. 2- Antidote. 3- Supportive treatment. 4- Surgery.

1- First aid: 

Washing with water current.

Removing of all clothes containing corrosives.

Give milk or water.

2- Antidote: Milk is the best.

3- Supportive treatment: 

Corticosteroids to decrease fibrosis.

Demulcents: continue to give milk, egg white and olive oil.

Soft diet + more fluids for dehydration.

Pain relieving by morphine ampoule.

No gastric lavage (no intubation).

No induction of vomiting.

4- Surgery:

If perforation occurs.

Esophageal dilatation started from 6th day

Organophosphorus poisoning

Poisoning happens by eating or smelling the insecticide.

Clinical picture:

1- Pin point pupil (important sign).

2- Blurring of vision.

3- Incontinence of urine and stool.

4- nausea, vomiting and diarrhea.

5- Difficult respiration (bronchospasm - increased bronchial secretions - pulmonary edema).

6- Decreased heart rate - decreased blood pressure - pallor - increased salivation.

7- May be convulsions - coma - death.

8- History (child eat insecticide).

Treatment:

1- Antidote = Atropine.

At first : cannula insertion.

Then : give 2 ml Atropine IV.

Continue to give Atropine IV till pupil is dilated (Atropine till mydriasis).

* If heart rate reaches 120, wait till heart rate decrease then give atropine till mydriasis as before.

* In children: atropine is diluted in 9 ml saline  then give atropine as before.

* Sometimes we may use up to 50 ampoule atropine.

* To save patient life we should reach mydriasis in 24 hours.

2- Stomach wash using NaHCO3 5%.

3- Oxygen with 5% CO2.

4- Bronchodilators for bronchial spasm.
R/ Minophylline ampoule very slow IV.

5- Morphine is avoided as it may lead to respiratory depression.

6- Prophylactic antibiotics.

7- Diazepam if convulsions.
R/ Valpam ampoule.
R/ Farcozepam ampoule.

 

Food poisoning

Diagnosis:

Usually many cases sharing the same food.

* Botulism: Often with eating canned food (salmon - jam - ..............and others).

With incubation period 12 - 36 hours.

Clinical picture: ptosis - dilated pupil - diplopia - dysphagia and respiratory paralysis.

No GIT manifestations.

Treatment:

1- Gastric lavage.

2- Polyvalent antitoxic serum.

3- Care of respiratory failure.

4- Symptomatic Treatment.

NB: Treatment is of no value if clinical picture is well seen.

* Salmonellosis: Food contaminated with Salmonella typhimurium or salmonella enteritidis (incubation period 12 - 24 hours).

Clinical picture: GIT manifestations (nausea - vomiting - diarrhea - ..............)

Widal test is important after 1 week.

Treatment:

1- Gastric lavage (Not effective enough).

2- Symptomatic treatment.

* Staphylococcus poisoning:

Contaminated food (takeaway).

Clinical picture: GIT manifestation (nausea - vomiting - diarrhea - .........) - rapid onset - no fever - rapid recovery.

Treatment: 

1- Gastric lavage may be needed in severe cases.
 
2- Symptomatic cases.

Hyperglycemic Coma

There are 2 types: Diabetic ketoacidosis and Nonketotic hyperosmolar coma.

Diagnosis of Diabetic ketoacidosis (DKA):

D → dehydration
K → ketosis
A → acidosis

Dehydration: Sweeting or dry skin - woody tongue - hypotension - shock.

Ketosis: Epigastric pain - acetone odour in breathing - nausea & vomiting.

Acidosis: deep rapid breathing.

Clinically → random glucose more than 200.

Hyperosmolar nonketotic coma differs from Diabetic ketoacidosis in:

* very very severe dehydration.

* very high blood sodium so when you give saline give 0.45% not 0.9%.

Treatment: 

Insulin - Fluids - Electrolytes - Heparin - Treatment of precipitating factors - Symptomatic

treatment.

1- Fluids to treat and prevent dehydration to prevent renal failure.

Give saline 0.9% (in Diabetic ketoacidosis) in the following way:

* 2 liters in first 2 hours
- 500 ml in first 15 minutes.
- 500 ml in second 15 minutes.
- 500 ml in next 30 minutes.
- 500 ml in the remaining 1 hour.
- after that 500 ml every 2 hours.
* The patient takes about 5 & 1/2 to 7 & 1/2  liters of saline a day.

2- Insulin:

R/ Actrapid insulin using 100 unit syringes by one of the following methods.

A- IM method.

- Calculating the dose according to blood sugar:

* (150   Mg/dl - 200 Mg/dl → 5 units) - (200 Mg/dl - 250 Mg/dl → 10 units) - (250 Mg/dl - 300 Mg/dl → 15 units) - (300 Mg/dl - 350 Mg/dl → 20 units) and so on.......

e.g. If blood sugar of the patient is 400 Mg/dl give him 30 units insulin IM and so on. 

Then: 
- Give the patient 10 insulin units IM every hour and urinary acetone  follow up every 1/2 hour till glucose

reaches 250 Mg/dl then give the patient 10 units subcutaneous and then the patient may go home.

- But the best is:

Through 48 hours → measure blood sugar every 6 hours, calculate the dose according to blood sugar and

give it to the patient then calculate the average dose of insulin per day.

e.g. If the patient received 150 units during 48 hour so the average dose per day is 75 units then give the patient:

R/ Insulin Mixtard 75 units
 
→ 2/3 the dose in the morning.
→ 1/3 the dose in the evening.

B- Infusion method:

500 ml saline + 50 insulin units in the saline solution + 3 ml of the patient blood.

* The advantage of patient blood in the solution is to prevent precipitation or deposition of insulin on the wall of the bag of the solution.

* Infusion rate: 15 - 20 drops per minute.
 If faster → may lead to hypoglycemia.

C- IV method:

Start with 10 - 20 units IV actrapid insulin then continue as in IM or infusion method.

NB: If blood sugar reaches 250 mg/dl and still there is acetone in urine, stop saline and give only 100 ml

glucose 25% instead while insulin is in the other hand as before.

3- Electrolytes:

Take blood sample as soon as the patient comes and measure blood Na & K (normal K level = 3.5 -5.5).

* If normal K, give K ampoule in the solution every 2 hours.

* If low K, give K ampoule in the solution every 2 hours.

* If K is below 2.5, give 2 K ampoules in the solution every 2 hours.

4- Heparin:

If old patient, give heparin subcutaneous.

R/ heparin ampoule SC (5000 units) as dehydration may cause cerebral thrombosis.

Treatment of Hyperosmolar coma: as treatment of diabetic ketoacidosis but there is no acetone in urine.

Hypoglycemic Coma

Diagnosis:

Clinical picture: Sweeting - tremors - hunger - cold - irritable (up to convulsions) - salivation from the mouth in

severe cases as decreased glucose leads to increased osmolar pressure.

History: History of recent large insulin or hypoglycemic drug dose or history of taking normal daily dose but

without eating.

Clinical glucose (random) measuring: usually < 50.

Treatment: 

Start with 100 ml glucose 25% or till recovery.

If you want to measure blood glucose it should be at least 2 hours later.
 

Hepatic and Prehepatic Coma

Manifestation of precoma:

- History of liver disease.

- Drowsiness, irritability or slurred speech.

- Flapping tremors.

- Behavioural changes.

Manifestation of coma:

- Coma with liver patient.

Treatment: Hepatic and prehepatic coma → the same treatment.

A- Give glucose 5% solution by IV infusion and add the following drugs to the solution.

1- Nootropil ampoule.

2- Oxybral ampoule.
1 & 2 to improve consciousness.

3- Antibiotic: Cefotax 1 gm vial to protect from infection.

4- Zantac ampoule to protect from sress ulcer.

5- 2 Hepa merz ampoules in the solution in case of coma and hepa merz sachets (1/2 sachet in 1/2 glass of water every 8 hours) in case of precoma to wash out amonia.

B- deal with haematemesis if present:

if haematemesis → red (fresh) blood in case of precoma or coma → Sengstaken-Blakemore tube (life saving) + enema.

if haematemesis → brown (not fresh blood) and the patient is conscious → Ryle tube (gastric lavage) + enema every 2, 4 or 8 hours.

C- Enema to wash out amonia:

R/ Enemax.

Precoma  → perform enema every 4 or 8 hours.

Coma → perform enema every 2 hours. 

D- Flagyl infusion to prevent anaerobic infection.

R/   Flagyl infusion 500 mg.

May be given in the other arm every 12 hours.

E- Drugs for liver support → continued at home.

R/ Lactulose syrup ( tablespoonful /8 hours).

R/ Inderal tablets (1 tablet 3 times a day) to decrease portal hypertension.

R/ Legalon (Silymarin) (1 tablet 3 times a day) to support liver.

R/ Neomycin 500 tablets  (1 tablet 2 times a day) to protect from GIT infection.

R/ Adenoplex ampoule intramuscular every 3 days.  

Dangers with blood transfusion

1- Disseminated intravascular coagulation (DIC) → cyanosis and massive

bleeding.

2- Major miss match → skin rash, dyspnea, restlessness, headache, vomiting, bleeding due to

DIC and renal failure (tubal necrosis).


Treatment of 1 and 2:

1- Stop blood transfusion.

2- Immediate IV Solu cortef vial + Avil (antihistaminic) ampoule.

3- IV fluids to maintain blood volume.

4- Lasix ampoule → repeated if the urine output does not increase.

5- Sodium bicarbonate 8.4% 50 ml IV to alkalinize the urine.

NB: Excess glucose 5% is harmful to red cells.

3- Hypersensitivity to donor plasma proteins (early or may be delayed) →

urticaria, rigors and pyrexia.

Treatment:

R/ IV solu cortef vial.

R/ IV avil ampoule.

4- Hyperkalemia → increased myocardial excitability.

- ECG is important → high T wave.

Treatment: R/ Calcium Chloride 10 ml ampoule IV very slowly and IV Calcium Chloride is considered a routine after transfusion of 4 units (bags) of blood.

5- Hypocalcemia → citrate toxicity.

Treatment: routine infusion of Calcium Chloride or Calcium Gluconate 10% ampoule IV slowly.

6- Diseases transmission: diseases may be discovered late.

7- Air embolism: rare.

Prophylaxis: good observation of IV route.

8- Acidosis → increased myocardial excitability (due to lactic acid production in stored blood (glycolysis) ).

Treatment: R/ Sodium bicarbonate 8.4% 100 - 200 ml for each unit (bag) of stored blood after the forth unit.

Acute Abdomen

* May be acute appendicitis, acute cholecystitis, acute pancreatitis ....................

Diagnosis:

* Acute pain all over abdomen.

* Tenderness all over abdomen.

* Rebound tenderness.

* Guarding.

* X ray in erect position → if air under diaphragm → perforated peptic ulcer.

Treatment:

* Refer the patient to a Surgeon or a hospital with surgery department. 

Intestinal Obstruction

Diagnosis:

1- Absolute constipation (no fluid - no flatus).

2- Abdominal distension.

3- Colic.

4- Vomiting.

* It is important to do per rectum examination.

* X ray in erect position → multiple air fluid levels

Treatment:

* Refer the patient to a Surgeon or a hospital with surgery department. 

Heat Syncope

It is fainting due to vigorous physical activity in hot environment .

There is hypotension < 100 mm Hg systolic blood pressure, cold skin and severe sweeting

Treatment:

1- Cooling the patient: take the patient to a cool place and remove his clothes.

2- Cold water to drink.

3- Give saline 0.9% by slow IV drip.  
   

Heat Strock

Severe high temperature resulting in failure of the thermoregulatory mechanism.

Diagnosis:

Positive history - Rising temperature to 41°c or more - Flushed hot dry skin - Early constricted then dilated

pupil - Hyporeflexia - Convulsions and projectile vomiting (danger sign) - Increased pulse more than 160

beats / minute - Increased blood pressure early then hypotension later.

Treatment:

1- Specific treatment (cooling procedure).

Remove the patient clothes - Put ice or cold blanket on patient body - Follow-up temperature.

2- Symptomatic treatment as:

R/ Neurazine (Chlorpromazine = major tranquilizers) ampoule to control muscular activity as shivering.

R/ Ringer solution IV for hypovolemia.

R/ Valpam ampoule only for convulsions.

- Fresh blood transfusion for bleeding.

- Respiratory care if respiratory failure.

Atrial Flutter & Fibrillation

Atrial flutter → regular tachycardia ( HR: 125 - 175 beats / minute does not vary according to rest or exertion ) 

Atrial fibrillation → irregular tachycardia ( HR: 100 - 150 beats / minute )

Treatment:

1- Immediate Lanoxin (Digoxin) ampoule IV slowly.

2- Refer the patient to a cardiologist or a hospital with a cardiology department. 

Exertional Cyanotic Attack

Is cyanotic attack precipitated by effort.

- More common in pediatric due to Tetralogy of Fallot.

Treatment:

1- Morphine ampoule 2 mg / kg IM.

2- Inderal (Propranolol) ampoule IV given by specialist.

3- Oxygen 100% by face mask.

Pulmonary Embolism

Diagnosis:

Sudden chest compression and dyspnea - cyanosis - may be shock - weak pulse.

Signs of pulmonary hypertension and right ventricular failure.

Treatment:

1- Insert an IV cannula.

2- Give:

R/ Heparin ampoule IV.

R/ Morphine or pethidine ampoule IV.

R/ Solu cortef ampoule IV.

R/ Avil ampoule IV.

R/ Atropine ampoule IV or IM.

3- Refer the patient to a cardiologist or a hospital with a cardiology department.

 ICCU = Intensive Cardiac Care Unit is needed.

Myocardial Infarction

Myocardial infarction pain is similar to anginal pain but differ in:

- Being more severe and prolonged and there may be sweeting, nausea and vomiting.

- Not relieved by rest or sublingual nitrates.

Treatment:

R/ Morphine ampoule diluted in 10 ml saline → give 2 ml intravenous slowly immediately

Then refer the patient to a cardiologist or a hospital with a cardiology department for thrombolytic and anticoagulant therapy.

ICCU = Intensive Cardiac Care Unit is needed.  

NB: 

- There are some bad things about MI.

1- It may be silent myocardial infarction and the patient complains only of dyspnea and or vomiting that is why cardiac assessment is important in any patient with dyspnea → ECG.

2- Myocardial infarction may present with epigastric pain → the doctor may think it is a gastric problem so it is important to differentiate.

If gastric cause → there may be tenderness in epigastric area and the pain improves with zantac.

If cardiac cause → there is no tenderness in epigastric area  as the pain is referred and the pain does not improve with zantac → ECG.
         
- Nubain or Nalufin (Nalbuphine) has similar efficacy to morphine but with fewer side effects and less abuse potential.

Angina Pectoris

- You must be able to diagnose anginal pain.

Anginal pain:

- May be dull aching, compression, squeezing or burning but never throbbing or stitching.

- Substernal radiating to left arm or both arms and shoulder (may radiate to epigastrium or back or neck root)

- Never under left breast.


- Increased by exertion and decreased by rest .

- ECG is normal at rest.

Treatment:

R/ Angised (Glycerine nitrate) tablets = Tridil tablets

1- Give one tablet sublingual. 

2- Refer the patient to a cardiologist or a hospital with a cardiology department.

Anaphylactic Shock

- Is a shock due to severe allergic reaction (e.g. wrong injection of an ampoule for a hypersensitive patient)

Diagnosis:

Immediate wrong injection →

- Sudden fall of blood pressure

- Tachycardia

- Cutaneous manifestations (itching,  urticaria ............. )

Treatment:

1- Stop harmful injection

2- Immediate:
R/ Adrenaline ampoule intravenous or subcutaneous
R/ Solu cortef ampoule intravenous

- Dose of adrenaline:

 Adult → 1 ml of adrenaline is diluted in 9 ml saline and give by direct intravenous injection slowly (ml by ml till resolution of blood pressure &        (tachycardia ↓

Pediatric  → (0.01 mg / kg) = (0.1 ml adrenaline is diluted in 9 ml saline and give 0.1 ml for each kg by direct intravenous injection slowly)

- Dose of solu cortef (hydrocortisone)
Adult  → whole ampoule
Pediatric  → 0.1 ml / kg  

3- Ringer lactate or normal saline 0.9% to restore blood volume and pressure.

4- Oxygen therapy.

5- Mechanical ventilation may be required.  
  

Bronchial Asthma

Diagnosis:

- History of bronchial asthma

- Difficult breathing

- Wheezy chest

                                                   
respiratory rate ↑-

 Treatment:

- Give 500 ml saline or glucose solution by intravenous infusion + bronchial asthma cocktail.

Bronchial asthma cocktail consists of:

R/ Dexamethasone ampoule = Fortecortin ampoule.

R/ Minophylline, Ventolin or Atrovent ampoule = Theophylline ampoule.

R/ Bisolvon ampoule.

R/ Avil ampoule.

- If no improvement, give 1 or 2 Solu cortef ampoules

- It is possible to give these 4 drugs (cocktail) together in single injection directly intravenous but very slowly (over 15 minutes).

NB:

- If hypertensive patient → use glucose 5% (no saline)

- If diabetic patient → use saline 0.9% (no glucose)

- If hypertensive + diabetic → use glucose 5% + 10 units Insulin

-If cardiac patient → do not use Minophylline or Theophylline but use Atrovent (Ipratropium bromide) or Ventolin (Salbutamol).

- Never inject minophylline rapidly or non diluted as it may lead to convulsions and cardiac arrest.
 
- It is possible to give oxygen inhalation with these drugs especially in severe cases.

- It is possible to give 1 ml Farcolin + 2 ml saline through Nebulizer (in children give 1/2 ml Farcolin + 2 ml saline).

- It is very important to determine heart rate or diagnose heart problems before prescribing farcolin or giving farcolin intravenous because some cases may die due to negligence in such points.
 
Examples of drugs:

R/ Minophylline 

R/ Ventolin (salbutamol)

R/ Salbovent (salbutamol)

R/ Atrovent (Ipratropium bromide)

R/ Bisolvon (Bromhexine)

R/ Mucosolvan (Ambroxol) 
 

   

Convulsions

- The patient needs Oxygen.

- Blood glucose should be measured as it may be the cause of convulsions.

Treatment:

1- Diazepam ampule intravenous very slowly.

- If it can not be taken intravenous, you may give it rectally with the same dose 1/2 mg/kg.

2- Phenytoin Na

- Loading dose: 10-20 mg/kg in 100 ml saline over 2 hours.

- Maintenance dose: 5-7 mg/kg/day divided in 3 doses intravenous very slowly.

  Examples of drugs:

- Phenytoin

- Epanutin

- Phenytin

- Valpam

- Farcozepam

- Neuril = Valpam = Farcozepam → in 10 ml saline and given  intravenous very slowly. 

Haematemsis

Diagnosis:

-First make sure that it is vomiting of blood not coughing up of blood (Haemoptysis).

-Ask about melena.

-Esophageal varices: old patient- history of liver disease- lax abdomen.

-Perforated peptic ulcer: young patient- history of gastric troubles- rigid abdomen.

Differential Diagnosis:

-Esophageal Varices

-Perforated Peptic Ulcer

-Acute Erosive Gastritis 

-Mallory Weiss Syndrome 

-Hiatus Hernia

Treatment: 

Give: Glucose 5% solution, Ringer or saline solution + haematemesis cocktail  

Haematemesis cocktail consists of :

1-Dicynone ampule

2-Haemostop ampule

3-kapron ampule 

1&2&3 in the solution

4-vitamin k ampule intramuscular (Konakion ampule)

NB:

-Slow haematemesis (bleeding) : coffee ground.

-It is very important to differentiate between haematemesis and haemoptysis.

Hypotension

Diagnosis:

If blood pressure is below 90/60

headache, drowsiness or fainting 

Treatment:

Give: 0.9% saline 500 ml intravenous infusion + Dexamethasone ampule +/- Solu cortef ampule

NB:

-Dexamethasone do not raise blood pressure but improves peripheral circulation 

-Hydrocortisone raises blood pressure as it causes Na retention

-There is Dexamethasone syrup and ampule form

-Dexamethasone and Fortecortin give the same result

-Solu cortef (Hydrocortisone) ampule may be given alone without intravenous saline 
                                                                                                                   

Cerebrovascular Stroke

Diagnosis:

hypertension- hemiplegia- slurred speech- altered consciousness or coma

CT scan: brain edema

Management:

you must: 1-lower blood pressure 2- lower brain edema 3- increase brain stimulation 4- inhibit stress ulcer

1-Lower blood pressure: by Lasix ampule 40 mg /12 hour intravenous until blood pressure is about 100/70 not less

                                                 
Or Epilat capsule sublingual after puncture of the capsule by a pin

2-Lower brain edema: by

1- Manitol 20% solution over one hour for first 2 days

2- By Dexamethazone ampule intravenous/12 hour for first 2 days then once daily for 2 days then stop

3-Brain stimulation: by 2 ampule Nootropil intravenous /8 hours

4-Inhibit stress ulcer: by Zantac ampule /12 hours

Or Zantac tablet /12 hours

 NB
      - Manitol is osmotic diuretic.

      - If hypertension + renal colic: use Epilat from the start.

      - If hypertension + DM (dehydration) : use Epilat instead of Lasix.

      - Lasix = Furosemide = Salex.

      -Nootropil = Stimulan = Piracetam : is a brain stimulant and protect cerebral cortex from hypoxia.