Indian Journal of Critical Care Medicine

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2019 | December | Volume 23 | Issue S4

EDITORIAL

Poisoning—The Road Less Travelled

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

PDF  |  DOI: 10.5005/jp-journals-10071-23315  |  Open Access |  How to cite  | 

INVITED ARTICLE

Jagadish Chandran

Initial Management of Poisoned Patient

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Accidental poisoning, Charcoal hemoperfusion, Resuscitation

PDF  |  DOI: 10.5005/jp-journals-10071-23307  |  Open Access |  How to cite  | 

INVITED ARTICLE

Antidotes in Poisoning

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Antidote, Binding, Poison, Toxin

PDF  |  DOI: 10.5005/jp-journals-10071-23310  |  Open Access |  How to cite  | 

Abstract

Introduction: Antidotes are agents that negate the effect of a poison or toxin. Antidotes mediate its effect either by preventing the absorption of the toxin, by binding and neutralizing the poison, antagonizing its end-organ effect, or by inhibition of conversion of the toxin to more toxic metabolites. Antidote administration may not only result in the reduction of free or active toxin level, but also in the mitigation of end-organ effects of the toxin by mechanisms that include competitive inhibition, receptor blockade or direct antagonism of the toxin. Mechanism of action of antidotes: Reduction in free toxin level can be achieved by specific and non-specific agents that bind to the toxin. The most commonly used non-specific binding agent is activated charcoal. Specific binders include chelating agents, bioscavenger therapy and immunotherapy. In some situations, enhanced elimination can be achieved by urinary alkalization or hemadsorption. Competitive inhibition of enzymes (e.g. ethanol for methanol poisoning), enhancement of enzyme function (e.g. oximes for organophosphorus poisoning) and competitive receptor blockade (e.g. naloxone, flumazenil) are other mechanisms by which antidotes act. Drugs such as N-acetyl cysteine and sodium thiocyanate reduce the formation of toxic metabolites in paracetamol and cyanide poisoning respectively. Drugs such as atropine and magnesium are used to counteract the end-organ effects in organophosphorus poisoning. Vitamins such as vitamin K, folic acid and pyridoxine are used to antagonise the effects of warfarin, methotrexate and INH respectively in the setting of toxicity or overdose. This review provides an overview of the role of antidotes in poisoning.

INVITED ARTICLE

Vijay V Pillay, Anu Sasidharan

Oleander and Datura Poisoning: An Update

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Cerbera, Datura, Nerium, Oleander, Plant poison, Thevetia

PDF  |  DOI: 10.5005/jp-journals-10071-23302  |  Open Access |  How to cite  | 

Abstract

India has a very high incidence of poisoning. While most cases are due to chemicals or drugs or envenomation by venomous creatures, a significant proportion also results from consumption or exposure to toxic plants or plant parts or products. The exact nature of plant poisoning varies from region to region, but certain plants are almost ubiquitous in distribution, and among these, Oleander and Datura are the prime examples. These plants are commonly encountered in almost all parts of India. While one is a wild shrub (Datura) that proliferates in the countryside and by roadsides, and the other (Oleander) is a garden plant that features in many homes. Incidents of poisoning from these plants are therefore not uncommon and may be the result of accidental exposure or deliberate, suicidal ingestion of the toxic parts. An attempt has been made to review the management principles with regard to toxicity of these plants and survey the literature in order to highlight current concepts in the treatment of poisoning resulting from both plants.

INVITED ARTICLE

Alladi Mohan, Janjam Harikrishna

Cleistanthus collinus Poisoning

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Cleistanthus collinus, Clinical presentation, Outcome, Poisoning, Treatment

PDF  |  DOI: 10.5005/jp-journals-10071-23317  |  Open Access |  How to cite  | 

INVITED ARTICLE

Neonicotinoid Poisoning and Management

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Acute poisoning, Insecticide, Neonicotinoid

PDF  |  DOI: 10.5005/jp-journals-10071-23308  |  Open Access |  How to cite  | 

Abstract

Neonicotinoids are a newer class of insecticides, which act on postsynaptic nicotinic acetylcholine esterase receptors. Its use is gradually increasing over recent years due to its better safety profile compared to other commonly used pesticides like organophosphates, organochlorides, carbamates, and pyrethroids. The better toxicological profile is attributed to more selectivity for insects compared to mammals and decreased penetration through the blood–brain barrier. Common symptoms of self-poisoning described are dizziness, hypertension, tachycardia, nausea, vomiting, eye irritation, dermatitis, and oral mucosal lesions. Mortality due to poisoning is less than 3%. Till date, there is no specific antidote for neonicotinoid poisoning and management of poisoning is symptomatic and supportive.

INVITED ARTICLE

Cynthia A Sukumar, Ananthakrishna B Shastry

Paraquat: The Poison Potion

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Clinical toxicology, Edavarone, Paraquat, Pesticide poisoning, Poisoning, Pulmonary fibrosis

PDF  |  DOI: 10.5005/jp-journals-10071-23306  |  Open Access |  How to cite  | 

Abstract

Paraquat is a commonly used herbicide in India that has lethal consequences even on minimal consumption. The case fatality rate for this poisoning is high and there is dearth of evidence-based recommendation for the treatment of this poison. This review article explores the diagnosis and management of paraquat poisoning with an emphasis on recent advances in treatment. Though immunosuppressants and antioxidants are conventionally used, there is a gap in evidence to prove survival benefit of these treatment regimens. There are also some data showing the use of hemoperfusion (with toxin-specific cartridges) as an early intervention, i.e., within 4 hours of exposure to the poison. The recent drug, Edaravone, has also shown promise in the prevention of renal and hepatic injury in paraquat poisoning. Though it did not reduce pulmonary fibrosis in patients with paraquat poisoning, it delays the generation and development of pulmonary fibrosis. However, there is a need for more clinical and experimental studies to validate its use in paraquat poisoning.

INVITED ARTICLE

Atul M Ramchandra, Peter J Victor

Pyrethroid Poisoning

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Insecticides, Poisoning, Pyrethroid

PDF  |  DOI: 10.5005/jp-journals-10071-23304  |  Open Access |  How to cite  | 

Abstract

Introduction: Pyrethroid compounds are widely used as insecticides. These compounds not only have a versatile application, but also have favourable toxicological profiles with high selectivity and toxicity to insects and low toxicity to humans. Despite this, there have been several reports of toxicity to humans in both occupational exposure and deliberate ingestional poisoning. Classical presentation and treatment: Two classical syndromic presentations are described. Type I syndrome is characterised predominantly by tremors and is seen with exposure to type I pyrethroids. Type II pyrethroids, which are structurally modified type I pyrethroids with the addition of a cyano group, can result in type II syndrome characterized by choreo-athetosis and salivation. Mega-dose poisoning and mixed poisoning, particularly with organophosphorus compounds, is associated with significant toxicity and death. Treatment is supportive and symptomatic. A favourable outcome can be expected in most patients.

INVITED ARTICLE

Rodenticide Poisoning

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Aluminium/zinc phosphide, Hydroxycoumarins, Rodenticide, Yellow phosphorous

PDF  |  DOI: 10.5005/jp-journals-10071-23318  |  Open Access |  How to cite  | 

INVITED ARTICLE

Surjeet Kumar, TK Kavitha

Kerosene, Camphor, and Naphthalene Poisoning in Children

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Aspiration pneumonitis, Hemoglobinuria, Hemolysis, Seizures

PDF  |  DOI: 10.5005/jp-journals-10071-23316  |  Open Access |  How to cite  | 

Abstract

Kerosene poisoning is one of the most common accidental poisoning in children in developing countries due common use of kerosene in house-hold and unsafe storage practices. Aspiration pneumonitis is the most common manifestation of kerosene ingestion due to its low viscosity, high volatility, and low surface tension. The treatment of aspiration pneumonitis due to kerosene poisoning is symptomatic including oxygen support, respiratory monitoring, and careful monitoring of fluid balance. Children with severe respiratory distress and hypoxemia unresponsive to supplemental oxygen and/or severe central nervous system involvement require early intubation and mechanical ventilation. Transfer to the pediatric intensive care unit (PICU) is required at this stage. Emesis, gastric lavage, and administration of activated charcoal are contraindicated due to risk of aspiration. There is no clear benefit of using corticosteroids or prophylactic antibiotics. Asymptomatic children should be kept under observation for atleast 6 hours after exposure. The mortality rate is low and death occurs due to pneumonitis. Camphor is used in house-hold items including vaporized or topical cold preparations, liniments, moth repellents, for performing rituals in religious ceremonies, and in antimicrobial preparations. Camphor poisoning is not very common in childhood. Even small doses of camphor can cause serious toxicity and is potentially fatal. The onset of action is very rapid (5–15 minutes). The common manifestations are confusion, restlessness, delirium, and hallucinations, muscle twitching, myoclonus, ataxia, hyperreflexia, fasciculations, and seizures. Seizures are common and serious complication in camphor toxicity. The treatment is supportive including decontamination, gastric lavage, activated charcoal, and seizure control. Naphthalene is a major constituent of mothballs which are commonly used in household to protect clothes from moths. Though the poisoning with naphthalene is uncommon in children, most of the cases with naphthalene poisoning occur in developing countries where mothballs are still commonly used. The manifestations of naphthalene toxicity are predominantly due to acute intravascular hemolysis leading to anemia, hemoglobinuria, methemoglobinemia, and acute kidney injury (AKI). The treatment of naphthalene toxicity is supportive in form of transfusion of the packed red blood cells, monitoring of fluid and electrolyte balance, administration of alkalis in presence of hemoglobinuria, and renal replacement therapy. Prevention is better than cure. The strategies should be adopted to prevent children being exposed to these toxic compounds in the house-hold. Safe storage of toxic compounds away from the reach of children, avoiding storing kerosene in cold drink and beverage bottles, community education, provision of electricity in rural areas, safe cooking practices, and parental supervision are important interventions to prevent accidental poisoning among children.

INVITED ARTICLE

Raja Kalayarasan, Nilakantan Ananthakrishnan, Vikram Kate

Corrosive Ingestion

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Caustic injury, Corrosive, Esophageal stricture, Gastric stricture, Poisoning

PDF  |  DOI: 10.5005/jp-journals-10071-23305  |  Open Access |  How to cite  | 

Abstract

Corrosive ingestion remains a common problem in developing countries, such as India due to the lack of strict laws that regulate the sale of caustics. While appropriate treatment of the acute phase can mitigate tissue damage improper management of the acute corrosive injury is widely prevalent due to the limited experience of the individual physicians in managing this condition. The aim of this review is to summarize the epidemiology and pathophysiology of corrosive ingestion, principles in the management of acute phase injury, long-term effects of caustic ingestion, and prevention of corrosive ingestion.

INVITED ARTICLE

Narendra N Jena

Super Vasmol Poisoning: Dangers of Darker Shade

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

PDF  |  DOI: 10.5005/jp-journals-10071-23303  |  Open Access |  How to cite  | 

INVITED ARTICLE

Shakuntala Murty

Antiepileptic Overdose

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Antiepileptics, Extracorporeal removal, Poisoning, Toxicology

PDF  |  DOI: 10.5005/jp-journals-10071-23301  |  Open Access |  How to cite  | 

Abstract

Antiepileptics include various groups of drugs that have different mechanisms of actions and adverse effects. They are often also used to treat other disorders such as psychosis, chronic pain, and migraine. The most common drugs implicated in overdose include phenytoin, sodium valproate, carbamazepine, and phenobarbital. Common signs of toxicity of these drugs are central nervous system manifestations such as altered sensorium, lethargy, ataxia, and nystagmus. Some ingestions can paradoxically precipitate seizures and even status epilepticus. Sodium valproate can cause hyperammonemic encephalopathy and cerebral edema. Carbamazepine is implicated in cardiac arrhythmias and hyponatremia. Phenobarbital causes sedation, respiratory depression, and hypotension. In suspected overdose, apart from the routine laboratory tests, serum levels of the drug should be sent. Serial levels should be measured, as drug toxicity can be prolonged. Treatment of all these overdoses begins with stabilization of airway, breathing, and circulation, and endotracheal intubation being performed to protect the airway in patients with altered mental status. For decontamination, a single dose of activated charcoal should be given. Multidose of activated charcoal may be useful in phenytoin, carbamazepine, and phenobarbital overdose. Naloxone and carnitine are indicated in valproate overdose. Carbamazepine overdose can cause a widened QRS complex and arrhythmias, which can be treated with sodium bicarbonate. Forced alkaline diuresis is no longer advocated for phenobarbital poisoning. The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup have formulated guidelines for extracorporeal removal of all these drugs. In most cases, hemodialysis is preferred. Other modalities include charcoal hemoperfusion (especially for carbamazepine) or continuous venovenous hemodialysis. Patients who ingest long-acting preparations should be monitored for longer periods.

INVITED ARTICLE

Lekhansh Shukla, Deepak S Ghadigaonkar, Pratima Murthy

Poisoning with Drugs of Abuse: Identification and Management

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Accidental poisoning, Benzodiazepine, Cocaine, Flumazenil, Malignant hyperthermia, Methanol, Naloxone, Opioids, Overdose, Stimulant

PDF  |  DOI: 10.5005/jp-journals-10071-23309  |  Open Access |  How to cite  | 

Abstract

Substances of abuse include alcohol, nicotine, cannabinoids, opioids, sedatives, volatile solvents, stimulants, and hallucinogens. With the increasing prevalence of drug abuse in India, intensivists are likely to encounter more cases of intentional and accidental poisoning due to drugs of abuse. We aim to sensitize the intensivists to challenges involved in diagnosing and treating poisoning with drugs of abuse. We also aim to provide a hands-on primer that can augment the usual protocols of “approach to life-threatening poisoning”. A toxidrome approach along with urine drug testing can help in speedily arriving at a diagnosis and instituting definitive treatment. In this article, we discuss spurious alcohol poisoning (methanol poisoning), benzodiazepine, opioid, and stimulant poisoning in detail and poisoning due to other substances including newer psychoactive substances is discussed briefly.

INVITED ARTICLE

Priya Ranganathan

Understanding Research Study Designs

[Year:2019] [Month:December] [Volume:23] [Number:S4] [Pages:1] [Pages No:0 - 0]

Keywords: Clinical trials as topic, Observational studies as topic, Research designs

PDF  |  DOI: 10.5005/jp-journals-10071-23314  |  Open Access |  How to cite  | 

Abstract

In this article, we will look at the important features of various types of research study designs used commonly in biomedical research.

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