General principles of treatment of acute drug poisoning. Basic principles and methods of treatment of acute poisoning
Regardless of the toxic substance, treatment of all acute poisonings is carried out according to the following principles:
1. Assessment of vital functions and correction of identified disorders.
2. Stopping the entry of poison into the body.
3. Removal of unabsorbed poison.
4. Use of antidotes.
5. Removal of absorbed poison.
6. Symptomatic therapy.
1. The condition is assessed using the ABCDE algorithm.
“A” - restoration of airway patency.
“B” – effective ventilation. If necessary, providing auxiliary ventilation or, if necessary, artificial ventilation (ALV) through an endotracheal tube.
“C” – assessment of blood circulation. Skin coloration, blood pressure (BP), heart rate (HR), saturation (SpO2), electrocardiography (ECG) data, and diuresis are assessed. Vein catheterization is carried out and a urinary catheter is placed, and, if necessary, appropriate medication correction is performed.
“D” – assessment of the level of consciousness. Depression of consciousness is the most common complication of poisoning. In case of depression of consciousness, it is necessary to perform tracheal intubation, since this is often combined with respiratory depression. In addition, suppression of the cough and gag reflexes can lead to the development of aspiration.
The presence of severe agitation and convulsions also require drug treatment.
In the presence of disturbances of consciousness, it is necessary to carry out a differential diagnosis with injuries to the central nervous system, hypoglycemia, hypoxemia, hypothermia, and infections of the central nervous system, even if the diagnosis is obvious.
“E” – re-assessment of the patient’s condition and the adequacy of the actions performed. It is carried out systematically after each manipulation.
2. Preventing poison from entering the body carried out at the first aid stage. Necessary:
Remove the victim from the atmosphere that caused the poisoning;
If poison enters the skin (gasoline, FOS), wash the skin with running water and soap. (In case of FOS poisoning, you can treat the skin with a 2-3% solution of ammonia or a 5% solution of baking soda (sodium bicarbonate); then 70% ethyl alcohol and again running water and soap). Rubbing the skin should be avoided.
If poison gets on the mucous membrane of the eyes, it is recommended to rinse the eyes with an isotonic solution of sodium chloride.
3. Removal of unabsorbed poison. The main way to remove poison from the gastrointestinal tract is gastric lavage. However, in case of poisoning with mushrooms, berries, or drugs in the form of large tablets, initially (before gastric lavage) it is advisable to induce vomiting (if there was none) by pressing on the root of the tongue to remove large fragments. Contraindications to reflex induction of vomiting: poisoning with substances that damage the mucous membrane, convulsive readiness and convulsions, disturbances of consciousness and coma.
Gastric lavage is a mandatory part of medical care; the stomach is washed, regardless of the period of exposure to the poison. There are no absolute contraindications for this method. In case of poisoning with certain poisons, the washing procedure has some limitations. So, in case of poisoning with cauterizing poisons, rinsing is possible only in the first hour, because In the future, this procedure can lead to perforation of the gastrointestinal tract. In case of barbiturate poisoning, gastric lavage is carried out in the first 2-3 hours, then the smooth muscle tone decreases, the cardiac sphincter may open and regurgitation, so in the future only the gastric contents are suctioned.
In unconscious patients, gastric lavage is performed after tracheal intubation, because aspiration is possible. Rinsing is carried out through a probe, which is inserted orally, which allows the use of a thicker probe. The depth of standing is determined by the distance from the edge of the teeth to the xiphoid process. For rinsing, cool tap water is used, a single volume of liquid in adults is not > 600 ml, in children under 1 year - 10 ml/kg, after 1 year - 10 ml/kg + 50 ml for each subsequent year. The stomach contents are drained and sent for toxicological testing. The total volume of liquid is not< 7 л (до 10-15 л), промывают до чистых промывных вод. При отравлении липофильными ядами (ФОС, анальгин, морфин, кодеин) желательны повторные промывания через 2-3 часа, т.к. возможна печеночно-кишечная рециркуляция. Повторение процедуры также необходимо при отравлении таблетированными формами, поскольку их остатки могут находиться в складках желудка 24-48 часов.
After gastric lavage, it is necessary to enter into the stomach with orbents: activated carbon – 0.5-1.0/kg in powder form. Repeated administration of activated carbon is carried out with the aim of interrupting enterohepatic circulation.
Along with coal, they are usually recommended laxatives– petroleum jelly 0.5-1 ml/kg, it is possible to use a 10-20% magnesium solution at a dose of 250 mg/kg. Their necessity is due to the fact that the sorbent binds the toxin only for 2-2.5 hours, and then splits off again, therefore It is necessary to remove this complex as quickly as possible. Contraindications to the use of laxatives: poisoning with iron supplements, alcohol, lack of peristalsis, recent intestinal surgery.
To remove unabsorbed poison from the intestines, it is possible to carry out intestinal lavage, high siphon enemas.
4. Specific (pharmacological) antidotal therapy.
Radical neutralization of the poison and elimination of the consequences of its action in many cases can be achieved with the help of antidotes. An antidote is a drug that can eliminate or weaken the specific effect of a xenobiotic due to its immobilization (for example, chelating agents), reducing the penetration of the poison to effector receptors by reducing its concentration (for example, adsorbents) or counteraction at the receptor level (for example, pharmacological antagonists). There is no universal antidote (the exception is activated carbon - a nonspecific sorbent).
Specific antidotes exist for a small number of toxicants. the use of antidotes is far from a safe measure, some of them cause serious adverse reactions, so the risk of prescribing antidotes should be comparable to the effect of its use.
When prescribing an antidote, one should be guided by the basic principle - it is used only if there are clinical signs of poisoning by the substance for which the antidote is intended.
Classification of antidotes:
1) Chemical (toxicotropic) antidotes affect the physicochemical state of the substance in the gastrointestinal tract (activated carbon) and the humoral environment of the body (unithiol).
2) Biochemical (toxicokinetic) antidote s provide a beneficial change in the metabolism of toxic substances in the body or the direction of the biochemical reactions in which they participate, without affecting the physicochemical state of the toxic substance itself (cholinesterase reactivators in case of FOS poisoning, methylene blue in case of poisoning with methemoglobin formers, ethanol in case of methanol poisoning).
3) Pharmacological (symptomatic) antidotes have a therapeutic effect due to pharmacological antagonism with the effect of the toxin on the same functional systems of the body (atropine for poisoning with organophosphorus compounds (OPC), proserine for poisoning with atropine).
4) Antitoxic immunotherapy has become most widespread for the treatment of poisoning by animal venoms due to snake and insect bites in the form of antitoxic serum (anti-snake - “anti-gurza”, “anti-cobra”, polyvalent anti-snake serum; anti-karakurt; immune serum against digitalis preparations (digitalis-antidote)).
Antidote therapy remains effective only in the early, toxicogenic phase of acute poisoning, the duration of which varies and depends on the toxicokinetic characteristics of the toxic substance. Antidote therapy plays a significant role in the prevention of irreversible states in acute poisoning, but does not have a therapeutic effect during their development, especially in the somatogenic phase of these diseases. Antidote therapy is highly specific, and therefore can be used only if there is a reliable clinical and laboratory diagnosis of this type of acute intoxication.
5. Removing absorbed poison is carried out by enhancing natural and using artificial detoxification of the body, as well as using antidote detoxification.
Stimulates natural detoxification achieved by stimulating excretion, biotransformation and immune system activity.
Assistance for acute poisoning consists of the following measures:
1 - prevention of absorption of poison into the blood;
2 - acceleration of the removal of poison from the body;
3 - antidote therapy (neutralization of poison);
4 - symptomatic therapy.
Preventing the absorption of poison into the blood. The poison should be washed off from the surface of the skin and mucous membranes with plenty of cold water or isotonic sodium chloride solution.
If poison gets inside, induce vomiting (if there is no damaging effect on the gastric mucosa) or wash the stomach. Vomiting is caused by mechanical irritation of the root of the tongue or by ingestion of 2-3 glasses of warm solution of table salt (2-3 teaspoons per glass of water). Gastric lavage is carried out using a thick probe with water at room temperature until the lavage water is clear. In case of poisoning with certain poisons (for example, morphine), which, after absorption into the blood, are released through the mucous membranes of the stomach, rinsing must be done every 4-6 hours. Then a saline laxative (sodium sulfate or magnesium sulfate) is administered through a probe - 20-30g per dose, washed down with two glasses of water. Laxatives are not used for poisoning with acids and alkalis, because they promote the movement of these substances through the digestive tract, which can result in damage to the mucous membranes
To reduce the absorption of poison from the gastrointestinal tract, adsorbents are also used: 30-40 g of activated carbon in 1-2 glasses of water. For gastric lavage, a 0.5% solution of tannin or a 0.05%-0.1% solution of potassium permanganate is also used.
To speed up the removal of poisons from the body After they are absorbed into the blood, different methods are used.
1- Forced diuresis method consists in the fact that a significant amount (up to 2.5 liters) of isotonic sodium chloride solution is injected into the victim’s vein, and then an active diuretic - furosemide or mannitol. At the same time, diuresis is significantly increased and the excretion of poison in the urine is stimulated.
2-Hemodialysis carried out by connecting an “artificial kidney” device.
3-Peritoneal dialysis– washing the abdominal cavity with special dialysate solutions. They are inserted through a catheter inserted using a fistula into the anterior abdominal wall.
4-Hemosorption– a method of removing poison from the blood using sorption columns filled with special types of activated carbon. When blood is passed through these columns, the poisons are adsorbed on activated carbon, and the purified blood is returned to the vein.
5-Plasmapheresis– removal of blood plasma with toxic substances contained in it, followed by its replacement with donor blood or plasma-substituting solutions.
Antidote therapy consists of neutralizing or weakening the effect of the poison with the help of antidotes (antidotes) or functional antagonists. Activated carbon is a universal antidote. It has the ability to inactivate substances of various chemical structures.
Main antidotes and antagonists
Salts of heavy metals – unithiol, tetacin-calcium
Alkaloids – potassium permanganate
Morphine – naloxone
M-cholinomimetics – atropine
M-anticholinergics – neostigmine
FOS – isonitrosine, dipyroxime
Cyanides – methylene blue
Symptomatic And pathogenetic therapy acute poisoning is carried out depending on the mechanisms of toxic action of the drug and the main symptoms of intoxication. So, in case of respiratory depression, analeptics are administered or oxygen therapy is resorted to. In case of acute heart failure, strophanthin or korglykon is used, in case of vascular collapse - adrenaline or mesaton. For severe pain, narcotic analgesics are prescribed, for convulsions - antipsychotics or tranquilizers, for anaphylactic shock - adrenaline, glucocorticoids or antihistamines, etc.
Acute poisoning with chemicals, including drugs, is quite common. Poisonings can be accidental, deliberate (suicidal) and related to the characteristics of the profession. The most common acute poisonings are ethyl alcohol, hypnotics, psychotropic drugs, opioid and non-opioid analgesics, organophosphate insecticides and other compounds. Special toxicology centers and departments have been created for the treatment of poisoning by chemical substances. The main task in the treatment of acute poisoning is to remove the substance that caused intoxication from the body. In case of serious condition of patients, this should be preceded by general therapeutic and resuscitation measures aimed at ensuring the functioning of vital systems - breathing and blood circulation. DELAY IN THE ABSORPTION OF A TOXIC SUBSTANCE INTO THE BLOOD Most often, acute poisoning is caused by ingestion of substances. Therefore, one of the important methods of detoxification is cleansing the stomach. To do this, induce vomiting or wash out the stomach. Vomiting is caused mechanically (by irritation of the posterior wall of the pharynx), by taking concentrated solutions of sodium chloride or sodium sulfate, or by administering the emetic apomorphine. In case of poisoning with substances that damage the mucous membranes (acids and alkalis), vomiting should not be induced, as additional damage to the mucous membrane of the esophagus will occur. In addition, aspiration of substances and burns of the respiratory tract are possible. Gastric lavage using a tube is more effective and safe. First, the contents of the stomach are removed, and then the stomach is washed with warm water, isotonic sodium chloride solution, potassium permanganate solution, to which activated carbon and other antidotes are added, if necessary. To delay the absorption of substances from the intestine, adsorbents (activated carbon) and laxatives (salt laxatives, petroleum jelly) are given. In addition, intestinal lavage is performed. If the substance that causes intoxication is applied to the skin or mucous membranes, it is necessary to rinse them thoroughly (preferably with running water). If toxic substances enter the lungs, you should stop inhaling them (remove the victim from the poisoned atmosphere or put a gas mask on him). When a toxic substance is administered subcutaneously, its absorption from the injection site can be slowed by injecting an epinephrine solution around the injection site, as well as cooling the area (an ice pack is placed on the skin surface). If possible, apply a tourniquet, which impedes the outflow of blood and creates venous stagnation in the area where the substance is administered. All these measures reduce the systemic toxic effect of the substance. REMOVAL OF TOXIC SUBSTANCE FROM THE BODY
If the substance is absorbed and has a resorptive effect, the main efforts should be aimed at removing it from the body as quickly as possible. For this purpose, forced diuresis, peritoneal dialysis, hemodialysis, hemosorption, blood replacement, etc. are used.
ELIMINATING THE EFFECT OF AN ABSORBED TOXIC SUBSTANCE
If it is established what substance caused the poisoning, then they resort to detoxification of the body with the help of antidotes.
Antidotes are drugs used for the specific treatment of poisoning by chemical substances. These include substances that inactivate poisons through chemical or physical interaction or through pharmacological antagonism (at the level of physiological systems, receptors, etc.)
SYMPTOMATIC THERAPY OF ACUTE POISONING
Symptomatic therapy plays an important role in the treatment of acute poisoning. It becomes especially important in case of poisoning with substances that do not have specific antidotes.
First of all, it is necessary to support vital functions - blood circulation and breathing. For this purpose, cardiotonics, substances that regulate blood pressure, agents that improve microcirculation in peripheral tissues are used, oxygen therapy is often used, sometimes respiratory stimulants, etc.
Drugs that reduce the sensitivity of afferent nerves, classification. Local anesthetics, classification, mechanism of action, comparative characteristics of individual drugs, main effects and indications for use, undesirable effects.
Agents that reduce the sensitivity of the endings of afferent fibers include local anesthetics, and agents that prevent the action of irritating substances on them include astringents and adsorbents. Local anesthetics are substances that can temporarily, reversibly block sensory receptors. First of all, pain receptors are blocked, and then temperature and tactile ones. In addition, local anesthetics disrupt the conduction of excitation along nerve fibers. First of all, the conduction along sensory nerve fibers is disrupted; however, at higher concentrations, local anesthetics can also block motor fibers. The mechanism of action of local anesthetics is due to the blockade of Na+ channels in the membranes of nerve endings and fibers. Due to the blockade of Na+ channels, the processes of depolarization of the membrane of nerve endings and fibers, the occurrence and propagation of action potentials are disrupted. Local anesthetics are weak bases. The non-ionized (non-protonated) part of the substance molecules penetrates into the nerve fibers, where an ionized form of the anesthetic is formed, which acts on the cytoplasmic (intracellular) part of the Na+ channels. In an acidic environment, local anesthetics are significantly ionized and do not penetrate the nerve fibers. Therefore, in an acidic environment, in particular, with tissue inflammation, the effect of local anesthetics is weakened. With the resorptive effect of local anesthetics, their effect on the central nervous system may occur. In this case, local anesthetics can cause anxiety, tremor, convulsions (suppression of inhibitory neurons), and in higher doses have a depressing effect on the respiratory and vasomotor centers. Local anesthetics inhibit myocardial contractility, dilate blood vessels (direct action associated with blockade of N+ channels, as well as a depressant effect on sympathetic innervation), and reduce blood pressure. The exception is cocaine, which strengthens and increases heart rate, constricts blood vessels, and increases blood pressure. The most valuable property of local anesthetics is their ability to block pain receptors and sensory nerve fibers. In this regard, they are used for local anesthesia (local anesthesia), in particular during surgical operations.
Local anesthetics are classified into esters (ANESTHESIN, DICAINE, NOVOCAINE) and substituted amides (LIDOCAINE, TRIMECAINE, BUPIVACAINE).
Tetracaine (dicaine) is an active and toxic anesthetic. Due to its high toxicity, tetracaine is used mainly for superficial anesthesia: anesthesia of the mucous membranes of the eye (0.3%), nose and nasopharynx (1-2%). The highest single dose of tetracaine for anesthesia of the upper respiratory tract is 3 ml of a 3% solution. In case of overdose, even when applied topically, tetracaine can be absorbed through the mucous membranes and have a resorptive toxic effect. In this case, excitation of the central nervous system develops, which in severe cases is replaced by its paralysis; death occurs from paralysis of the respiratory center. To reduce the absorption of tetracaine, adrenaline is added to its solutions.
Benzocaine (anesthesin), unlike other local anesthetics, is slightly soluble in water; soluble in alcohol and fatty oils. In this regard, benzocaine is used exclusively for surface anesthesia in ointments, pastes, powders (for example, for skin diseases accompanied by severe itching), in rectal suppositories (for lesions of the rectum), as well as orally in powders for stomach pain and vomiting.
Procaine (Novocaine) is an active anesthetic whose effect lasts 30-45 minutes. The drug is highly soluble in water and can be sterilized using conventional methods. With certain precautions (adding a solution of adrenaline, observing the dosage), the toxicity of procaine is low. Procaine solutions are used for infiltration (0.25-0.5%), conduction and epidural (1-2%) anesthesia. To prevent the absorption of procaine, a 0.1% solution of adrenaline is added to its solutions. Procaine is sometimes used for spinal anesthesia, and in high concentrations (5-10%) for superficial anesthesia. Bupivacaine is one of the most active and long-acting local anesthetics. For infiltration anesthesia, a 0.25% solution is used, for conduction anesthesia - 0.25-0.35% solutions, for epidural anesthesia - 0.5-0.75% solutions, and for subarachnoid anesthesia - a 0.5% solution. The resorptive effect of bupivacaine can be manifested by symptoms such as headache, dizziness, blurred vision, nausea, vomiting, ventricular arrhythmias, and atrioventricular block.
Lidocaine (xycaine, xylocaine). For superficial anesthesia, 2-4% solutions are used, for infiltration anesthesia - 0.25-0.5% solutions, for conduction and epidural anesthesia - 1-2% solutions. The toxicity of lidocaine is slightly higher than that of procaine, especially when used in high concentrations (1-2%). Lidocaine solutions are compatible with adrenaline (1 drop of 0.1% adrenaline solution per 10 ml of lidocaine solution, but not more than 5 drops for the entire amount of anesthetic solution). Lidocaine is also used as an antiarrhythmic agent.
Drugs that reduce the sensitivity of afferent nerves, classification. Astringents, enveloping and adsorbing agents, main drugs and indications for use, undesirable effects.
Astringents when applied to inflamed mucous membranes, they cause compaction (coagulation) of mucus proteins. The resulting protein film protects the cells of the mucous membrane and sensitive nerve endings from the action of various irritants. This reduces pain, swelling and hyperemia of the mucous membrane. Thus, astringents act as local anti-inflammatory agents. Organic - tannin, tanalbin, oak bark, blueberries, sage leaf, St. John's wort. Inorganic - lead acetate, basic bismuth nitrate, alum, zinc oxide, zinc sulfate, silver nitrate, xeroform. MD: coagulation of proteins of the superficial mucous membranes with the formation of a film. E: local narrowing of blood vessels, decreased permeability, decreased exudation, inhibition of enzymes. Adsorbent- talc, activated carbon, white clay. MD: adsorb substances on their surface. E: protect the endings of the senses. nerves, prevent the absorption of poisons. P: inflammation of the gastrointestinal tract, flatulence, diarrhea. PE: constipation, drowsiness. Annoying- mustard plasters, purified turpentine oil, menthol, ammonia solution. MD: irritate sensitive nerve endings of the skin and mucous membranes. E: suppress pain, improve trophism of internal organs. P: neuralgia, myalgia, arthralgia, fainting, intoxication. PE: skin redness, swelling.
31. Drugs affecting efferent innervation, classification.
Therapeutic measures aimed at stopping the effects of toxic substances and their removal from the body in the toxicogenic phase of acute poisoning are divided into the following groups: methods of enhancing natural cleansing processes, methods of artificial detoxification and methods of antidote detoxification
Basic methods of detoxifying the body.
Methods to enhance the body's natural detoxification:
gastric lavage;
bowel cleansing;
forced diuresis;
therapeutic hyperventilation.
Methods of artificial detoxification of the body
intracorporeal:
extracorporeal:
peritoneal dialysis;
intestinal dialysis;
gastrointestinal sorption.
hemodialysis;
hemosorption;
plasmasorption;
lymphorrhea and lymphosorption;
blood replacement;
plasmapheresis.
Antidote detoxification methods:
contact action;
parenteral action;
chemical antidotes:
biochemical:
pharmacological antagonists.
Methods to enhance the body's natural detoxification.
Cleansing the gastrointestinal tract. The occurrence of vomiting in some types of acute poisoning can be considered as a protective reaction of the body aimed at eliminating a toxic substance. This process of natural detoxification of the body can be artificially enhanced by the use of emetics, as well as gastric lavage through a tube. None of these methods has encountered serious objections in cases of oral poisoning since ancient times. However, there are situations that present known limitations in methods of emergency gastric cleansing.
In case of poisoning with cauterizing liquids, spontaneous or artificially induced vomiting is undesirable, since repeated passage of acid or alkali through the esophagus can increase the degree of its burn. There is another danger, which is the increased likelihood of aspiration of the cauterizing fluid and the development of a severe burn to the respiratory tract. In a coma state, the possibility of aspiration of gastric contents during vomiting also increases significantly.
These complications can be avoided by gastric lavage. In comatose states, gastric lavage should be performed after tracheal intubation, which completely prevents aspiration of vomit. The danger of inserting a gastric lavage tube in case of poisoning with cauterizing liquids has been greatly exaggerated.
In some cases, gastric lavage is abandoned if a lot of time has passed since the poison was taken. However, if the stomach was not washed, then at autopsy, even a long time after poisoning (2-3 days), a significant amount of poison is found in the intestines. In case of severe poisoning with narcotic poisons, when patients are unconscious for several days, it is recommended to rinse the stomach every 4-6 hours. The need for this procedure is explained by the repeated entry of the toxic substance into the stomach from the intestines as a result of reverse peristalsis and paresis of the pylorus.
The value of the method is very great, especially in the treatment of acute oral poisoning with highly toxic compounds such as chlorinated hydrocarbons (CHCs). In case of severe poisoning with these drugs, there are practically no contraindications for emergency gastric lavage using the tube method, and it should be repeated every 3-4 hours until the stomach is completely cleared of poisons. The latter can be established using sequential laboratory chemical analysis of the washing liquid. In case of poisoning with hypnotics, if tracheal intubation at the prehospital stage is impossible for any reason, gastric lavage should be postponed until the hospital, where both measures can be performed.
After gastric lavage, it is recommended to administer various adsorbents or laxatives orally to speed up the passage of the toxic substance through the gastrointestinal tract. There are no fundamental objections to the use of sorbents; activated carbon (50-80 g) is usually used along with water (100-150 ml) in the form of a liquid suspension. Any other drugs should not be used together with charcoal, as they will be sorbed and inactivate each other. The use of laxatives is often questionable because they do not act quickly enough to prevent the absorption of much of the poison. In addition, in case of poisoning with narcotic drugs, due to a significant decrease in intestinal motility, laxatives do not give the desired result. It is more favorable to use Vaseline oil (100-150 ml) as a laxative, which is not absorbed in the intestine and actively binds fat-soluble toxic substances, such as dichloroethane.
Thus, the use of laxatives has no independent value as a method of accelerated detoxification of the body.
A more reliable way to cleanse the intestines of toxic substances is to rinse them using direct probing and administer special solutions (intestinal lavage). This procedure can be used as an initial step for subsequent intestinal dialysis. With this method of detoxification, the intestinal mucosa plays the role of a natural dialysing membrane. Many methods of dialysis through the digestive tract have been proposed, including gastric dialysis (continuous gastric lavage through a double-lumen tube), dialysis through the rectum, etc.
Forced diuresis method . In 1948, the Danish physician Olsson proposed a method of treating acute poisoning with hypnotics by administering large amounts of isotonic solutions intravenously simultaneously with mercury diuretics. There was an increase in diuresis to 5 liters per day and a decrease in the duration of the coma. The method has become widespread in clinical practice since the late 50s. Alkalinization of the blood also increases the release of barbiturates from the body. A slight shift in arterial blood pH to the alkaline side increases the content of barbiturates in plasma and slightly reduces their concentration in tissues. These phenomena are caused by the ionization of barbiturate molecules, which causes a decrease in their permeability through cell membranes according to the law of “nonionic diffusion.” In clinical practice, urine alkalinization is created by intravenous administration of sodium bicarbonate, sodium lactate, or trisamine.
The therapeutic effect of water load and alkalinization of urine in severe poisoning is significantly reduced due to insufficient diuresis due to increased secretion of antidiuretic hormone, hypovolemia and hypotension. Additional administration of diuretics, more active and safe than mercury, is required to reduce reabsorption, i.e., promote faster passage of the filtrate through the nephron and thereby increase diuresis and elimination of toxic substances from the body. These goals are best served by osmotic diuretics.
The effectiveness of the diuretic effect of the drug furosemide (Lasix), which belongs to the group of saluretics and used in a dose of 100-150 mg, is comparable to the effect of osmotic diuretics, however, with its repeated administration, more significant losses of electrolytes, especially potassium, are possible.
The method of forced diuresis is a fairly universal way to accelerate the elimination of various toxic substances excreted from the body in the urine. However, the effectiveness of diuretic therapy is reduced due to the strong connection of many chemicals with proteins and blood lipids.
Any method of forced diuresis involves three main stages:
preliminary water load,
rapid administration of a diuretic,
replacement infusion of electrolyte solutions.
The peculiarity of the method is that when using the same dose of diuretics, a higher rate of diuresis is achieved (up to 20-30 ml/min) due to more intensive administration of fluid during the period of the highest concentration of diuretics in the blood.
The high speed and large volume of forced diuresis, reaching 10-20 liters of urine per day, pose the potential danger of rapid “washing out” of plasma electrolytes from the body.
It should be noted that strict accounting of the injected and excreted fluid, determination of hematocrit and central venous pressure make it possible to easily control the body’s water balance during treatment, despite the high rate of diuresis. Complications of the forced diuresis method (overhydration, hypokalemia, hypochloremia) are associated only with violation of the technique of its use. With long-term use (more than 2 days), in order to avoid thrombophlebitis of a punctured or catheterized vessel, it is recommended to use the subclavian vein.
The method of forced diuresis is contraindicated in cases of intoxication complicated by acute cardiovascular failure (persistent collapse, circulatory disorders of II-III degree), as well as in cases of impaired renal function (oliguria, azotemia, increased blood creatinine), which is associated with a low filtration volume. In patients over 50 years of age, the effectiveness of the forced diuresis method is noticeably reduced for the same reason.
Methods of enhancing the body's natural detoxification processes include therapeutic hyperventilation, which can be caused by inhalation of carbogen or by connecting the patient to an artificial respiration apparatus. The method is considered effective for acute poisoning with toxic substances, which are largely removed from the body through the lungs.
In clinical conditions, the effectiveness of this detoxification method has been proven for acute poisoning with carbon disulfide (up to 70% of which is released through the lungs), chlorinated hydrocarbons, and carbon monoxide. However, its use is significantly limited by the fact that long-term hyperventilation is impossible due to the development of disturbances in the gas composition of the blood (hypocapnia) and acid-base balance (respiratory alkalosis).
General principles of emergency treatment for acute poisoning
Emergency therapy for acute poisoning is carried out consistently and comprehensively in three areas:
1. Stopping further intake of poison into the body and removing it from the body - active detoxification;
2. The use of specific antidotes (antidotes) that reduce or eliminate the toxic effect of poison on the body - antidote therapy;
3. Symptomatic therapy aimed at combating the main pathological syndromes:
Restoration and maintenance of vital functions of the body (cardiovascular, respiratory systems);
Restoration and maintenance of the constancy of the internal environment of the body (CBS, water-salt balance, vitamin, hormonal);
Elimination of certain syndromes caused by poison (convulsive, pain, psychomotor agitation, etc.).
1) Relief of signs of ARF if present.
2) Relief of signs of OSHF, if present.
3) Removal of unabsorbed poison.
4) Removal of absorbed poison.
5) Introduction of antidotes, if available, for a given toxic substance.
6) Nonspecific detoxification.
7) Symptomatic therapy.
ALGORITHM FOR PROVIDING EMERGENCY CARE IN CASE OF POISONING at the prehospital stage:
1) Ensure normalization of breathing (patency of the upper respiratory tract) and hemodynamics (if necessary, carry out basic pulmonary-cardiac and cerebral resuscitation).
2) Stop further entry of poison into the body:
a) In case of inhalation poisoning, remove the victim from the contaminated atmosphere.
b) In case of oral poisoning, rinse the stomach and administer enterosorbents.
c) For cutaneous application: wash the affected area of skin with water (T not higher than 18*C).
3) Carry out antidote therapy.
When washing the stomach or washing off poisons from the skin, use water with a temperature no higher than 18*C; do not carry out a reaction to neutralize the poison in the stomach. The presence of blood during gastric lavage is not a contraindication for lavage. In the absence of contraindications, it is advisable to induce vomiting. As an emetic, use a warm solution of table salt 1-2 tbsp. spoons per 1 glass of water. Spontaneous or induced vomiting does not exclude subsequent gastric lavage through a tube.
Inducing vomiting is contraindicated when:
Unconscious state of the victim;
Poisoning with strong acids, alkalis, gasoline, turpentine;
Poisoning with cardiotoxic poisons (danger of bradycardia);
Arrhythmias.
In case of poisoning with gasoline, kerosene, phenol, introduce Vaseline or castor oil into the stomach before washing.
In case of poisoning with cauterizing poisons, before washing the stomach, give vegetable oil to drink, lubricate the probe with oil along the entire length and administer anesthesia.
After gastric lavage is completed, introduce a suspension of activated carbon through the tube (contraindicated in case of poisoning with acids and alkalis).
Contraindications to tube gastric lavage:
Convulsive syndrome, decompensation of breathing and blood circulation (gastric lavage should be temporarily postponed until the condition stabilizes);
Poisoning with poisons that cauterize or damage the mucous membrane of the esophagus and stomach, if more than 2 hours have passed - there is a danger of perforation).
4) the position of the patient - depending on the level of consciousness.
5) carrying out infusion therapy with saline solution 250-500 ml, pulse oximetry.
6) oxygen therapy 4-6 l/min.
7) symptomatic therapy.
8) Hospitalize the patient in the ICU.
