General principles of drug poisoning therapy. Symptomatic therapy of acute poisoning Basic principles of poisoning treatment
REANIMATION ANDINTENSE
THERAPY FOR ACUTE
POISONING
ACUTE POISONING
1. General principles of renderingemergency care for acute
poisoning:
Install at the scene:
A). cause of poisoning;
b). type of toxic substance;
V). quantity;
G). route of entry;
e). time of poisoning.
ACUTE POISONING
2. Routes of entry of toxicsubstances:
A). by mouth (oral poisoning);
b). through the respiratory tract
(inhalation);
V). through the integument (percutaneous);
G). after injections of toxic doses
medicines;
e). when injected into body cavities
(rectum, vagina, urinary
bladder, ear canal).
ACUTE POISONING
3. Periods of clinical manifestations:A). hidden (until the first signs
poisoning);
b). toxicogenic (specific action
poison);
V). somatogenic (secondary complication
internal organs).
4. Principles of emergency care:
A). removal of poison;
b). antidote (specific) therapy;
V). symptomatic therapy.
ACUTE POISONING
5. Removal of poison that has not entered the blood:A). if poison is ingested: gastric lavage through
thick probe 12-15 liters of room water
temperature in portions of 300-500 ml. Then through the probe
inject 100-150 ml of 30% sodium sulfate solution or
vaseline oil depending on the solubility of the poison
in water or fats. To adsorb toxic substances
1 tablespoon of activated charcoal is administered before and after
gastric lavage (or 5-10 tablets of carbolen,
polyphepan).
Patients in a coma, the stomach is washed
after tracheal intubation;
b). from the skin: rinse with running water;
V). from the conjunctiva: rinse with a gentle stream of warm water,
enter 1% solution of novocaine or 0.5% solution of dicaine;
ACUTE POISONING
G). from the mucous membranes of the mouth and nasopharynx: multiplerinsing the mouth and rinsing the nose with warm water,
inhalation with a mixture of novocaine, suprastin,
hydrocortisone 1:1:1.
e). from the cavities: washed with an enema or
douching, give a laxative;
e). in case of inhalation poisoning: remove from
the affected atmosphere, ensure patency
respiratory tract, oxygen inhalation;
and). with snake bites, i / m or s / c administration
toxic doses of drugs: an introduction to
injection site 0.3 ml of 1% adrenaline solution, cold on
6-8 hours and circulation novocaine blockade
above the point of entry of the toxin.
ACUTE POISONING
6. Removing the poison that entered theblood:
A). forced diuresis;
b). hemodialysis;
V). peritoneal dialysis;
G). hemosorption;
e). replacement blood transfusion;
e). physiotherapy: magnetic,
ultraviolet, laser,
chemotherapy, HBO.
7. Antidote therapy:
Activated carbonnonspecific sorbent
medications
Ethyl alcohol
methyl alcohol, ethylene glycol
Atropine 0.1% solution
fly agaric, FOS, cardiac glycosides,
prozerin, clonidine
Acetylcysteine 10%
paracetamol, pale grebe
Vikasol 1% solution
indirect anticoagulants
Vitamin "B6" 5% solution
tubazid, ftivazid
Vitamin "C" 5% solution
aniline, potassium permanganate
Heparin
snake bites
sodium bicarbonate
4%
acids
Methylene blue 1%
rr
aniline, hydrocyanic acid, permanganate
potassium.
7. Antidote therapy:
Naloxone 0.5% solutionmorphine, heroin, promedol
Prozerin 0.5% solution
atropine, pachycarpine
Protamine sulfate 1%
rr
heparin
Magnesium sulfate 30% barium solution, its salts
Sodium thiosulfate 30%
rr
iodine, copper, mercury, benzene, sublimate, aniline
Unithiol 5% solution
copper, arsenic, phenols
Sodium chloride 2%
silver nitrate.
Calcium chloride 10% solution
ethylene glycol, oxalic acid
Potassium chloride 0.5% solution
cardiac glycosides
Ammonium chloride 3% solution
formalin (gastric lavage)
ACUTE POISONING
8. Symptomatictherapy:
breathing correction,
cardiovascular
insufficiency,
toxic nephropathy,
hepatopathy, neurological
disorders.
Poisoning by alcohol and its surrogates (cologne, lotion, BF glue)
Symptoms: (history, smell) lossconsciousness, cold clammy skin, hyperemia
faces, transient anisocoria,
horizontal nystagmus, decrease
body temperature, vomiting, involuntary
urination and defecation, breathing
slow, pulse is frequent, weak,
hypotension, sometimes convulsions, hypertonicity
flexors. Possible aspiration of vomit
masses, laryngospasm, respiratory arrest.
Treatment:
Gastric lavage through a tube, salinelaxative, forced diuresis.
Infusion therapy
1)
2000 ml of Ringer's solution, rheopolyglucin, polyglucin, before stabilization
hemodynamics.
2)
Sodium bicarbonate 4% solution up to 1000 ml to alkalinize urine IV
drip.
3)
Sodium hypochlorite 0.06% solution 400 ml IV drip.
4)
Glucose 40% - 20 ml IV.
5)
Caffeine 2 ml, Cordiamin 2 ml IV.
6)
Vitamin "B6" - 5 ml, "B1" - 5 ml IV.
7)
Nicotinic acid 5% solution 1 ml / m, repeatedly.
With aspiration - intubation, mechanical ventilation, sanitation of the TBD.
The lethal dose is 300 ml of 96% alcohol (in chronic
much more alcoholics).
Botulism
Symptoms: history - canned foodhome cooking. Incubation
period of 2 hours - 10 days. The onset is acute
headache, nausea, vomiting, pain in
epigastric, thirst, loose stools, then
flatulence, normal temperature, consciousness
clear, blurred vision, diplopia, anisocoria,
ptosis, limited mobility of the eyeballs,
swallowing disorder, slurred speech, aphonia,
dyspnea, bradycardia, blood pressure normal or
increased. ECG shows conduction disturbance.
Death from paralysis of the respiratory muscles.
Treatment:
1.Rinse the stomach with potassium permanganate or 2%
solution of sodium bicarbonate.
2.
Cleansing, then siphon enema 1-2% solution
soda.
3.
Laxative - 20-30 g of magnesium sulfate.
4.
Antibotulinum serum. Before
establishing the type of toxin, 10,000 IU of the type are administered
A, C, E, and 5,000 IU type B on day 1 IV, then IV.
5.
Prozerin 0.05% solution 1 ml, repeatedly.
6.
Antibiotics (levomycetin, penicillin series).
7.
Infusion therapy, IVL, HBO.
Complications: pneumonia, sepsis, endocarditis.
Lethality -50%.
Methyl alcohol (methanol, wood alcohol)
Symptoms: nausea, vomiting, fliesbefore the eyes, for 2-3 days blindness.
Pain in the legs, head, thirst. Hyperemia
bluish, pupils
dilated, sweating, tachycardia,
abdominal pain, paresis of the oculomotor
muscles, darkening of consciousness,
respiratory failure, circulatory disorders,
convulsions, death.
Treatment:
1.Gastric lavage with water, then 2% solution of soda.
2.
Salt laxative - magnesium sulfate 0.5 g / kg.
3.
Forced diuresis with alkalization.
4.
early hemodialysis.
5.
Antidote - ethyl alcohol 5% solution in / in cap. 1 ml/kg/day Or
30% alcohol 100 ml orally, then 50 ml every 2 hours
4-5 times a day.
6.
Prednisolone 30 mg IV.
7.
Glucose 40% - 200 ml and novocaine 0.25% - 200 ml IV
drip.
8.
Vitamins "B1" - 5 ml and "C" -20 ml IV
9.
infusion therapy.
A lethal dose of about 100 ml without prior administration
alcohol.
Morphine (opium, heroin, codeine)
Symptoms: comaconstriction of the pupils with weakening
reactions to light, hyperemia of the skin.
Increased muscle tone, sometimes
tonic or clonic convulsions,
vomiting, shortness of breath. In heavy
cases of asphyxia, cyanosis of mucous membranes,
dilated pupils, bradycardia,
collapse, hypothermia.
Treatment:
1.Repeated gastric lavage, regardless of
routes of administration.
2.
activated charcoal, saline
laxative.
3.
Antidote - naloxone 3-5 ml 0.5% solution IV,
again.
4.
Sodium hypochlorite 0.06% solution - 400 ml IV drip
5.
Atropine 0.1% solution 1-2 ml i.v., s.c.
6.
Caffeine 10% solution 2 ml IV, cordiamine 2 ml IV.
7.
Vitamin "B1" 5% solution 3 ml IV, repeatedly.
8.
Oxygen inhalation, artificial respiration,
intubation and IVL.
Indian hemp (plan, marijuana, marijuana, hashish)
Symptoms: Poisoning is possible withsmoke inhalation, tobacco smoking along with
these substances, when taken orally
or introduction into the nasal cavity, ear, as well as
with the introduction of a vein of their aqueous solution.
At first, psychomotor
agitation, dilated pupils, noise in
ears, vivid visual hallucinations,
then - general weakness, lethargy, thirst and
long deep sleep with slow heart rate,
drop in temperature.
Treatment:
1.2.
3.
4.
Gastric lavage with
ingestion of poison
Activated carbon.
Forced diuresis.
Hemosorption.
On sudden arousal
chlorpromazine 2.5% solution -4-5 ml i / m
or haloperidol 2.5% solution 2-3 ml
in / m.
Atropine (henbane, dope, belladonna)
Symptoms: dry mouth and throat,speech and swallowing disorder
near vision, diplopia, photophobia,
palpitations, shortness of breath, headache. Leather
red, dry. Pulse is fast, pupils are dilated,
do not respond to light. Mental and motor
agitation, visual hallucinations, delusions,
epileptiform seizures followed by
loss of consciousness and development of coma
states. uncontrolled hyperthermia,
respiratory distress, cyanosis, drop in blood pressure,
increased CVP, swelling. Poisoning is harder
runs in children.
Treatment:
1.Gastric lavage through a tube, plentifully
lubricated with vaseline oil until clean
water.
2.
forced diuresis
3.
Hemosorption.
4.
Sodium hypochlorite 0.06% solution - 400 ml IV drip.
5.
Prozerin 0.05% solution, 1 ml IV or s / c,
again.
6.
When excited - chlorpromazine 2.5% solution 2 ml,
diazepam 1-2 ml IV, IM.
7.
With hyperthermia - amidopyrine 4% solution 10-20 ml,
physical cooling.
Lethal dose for adults over 100 mg
FOS (dichlorvos, karbofos, chlorophos, sarin, soman)
Symptoms: poisoning develops wheningestion, through the respiratory tract and
skin.
Stage 1: arousal, miosis, salivation,
sweating, chest tightness, shortness of breath,
bronchorrhoea, diarrhea, increased blood pressure.
Stage 2: convulsions join,
hyperthermia, chills, cyanosis. Violation
breathing, coma
Stage 3: paresis, bradycardia, drop in blood pressure,
hypothermia, death from respiratory arrest.
Treatment:
1.The poison is removed from the skin with a dry swab, then treated
ammonia, the body is washed with warm water and soap or soda.
2.
Eyes in case of damage are washed with water, then atropine 1% is dripped.
3.
Repeated gastric lavages with 2% soda, then inside - sodium sulfate 0.25 - 1.5 g / kg.
4.
Fatty laxative (vaseline oil, etc.), high
siphon enemas after 6-8 hours.
5.
Forced diuresis, early hemodialysis, hemosorption.
6.
Symptomatic therapy.
7.
Antidote therapy:
1 tbsp. - 0.1% atropine 2-3 ml s / c until dry mouth during the day, repeatedly.
2 tbsp. - 0.1% atropine 3 ml IV in 5% glucose solution repeatedly until dry
mucous membranes (25-30 ml). For convulsions - Relanium 2 ml IV. Atropinization in
within 3-4 days.
3 art. - mechanical ventilation, hydrocortisone, antibiotics, treatment are added
toxic shock. Atropinization 5-6 days.
The lethal dose when ingested is about 5 g.
Carbon monoxide
Symptoms: dizziness, chest pain,lacrimation, vomiting, agitation, skin hyperemia,
tachycardia, increased blood pressure. Further coma, convulsions,
respiratory failure and cerebral circulation.
Treatment:
1.
Remove victim to fresh air
Airways.
2.
Oxygen inhalation, HBO.
3.
With bronchospasm - Eufillin 2.4% solution - 10 ml, prednisolone
30 mg IV.
4.
Vitamin "C" 5% solution - 10-20 ml IV.
5.
For convulsions - Relanium 2 ml IV, IM.
6.
Glucose-novocaine mixture in/in cap.
7.
With convulsions, impaired breathing, consciousness - IVL.
Hydrocyanic acid and other cyanides
Symptoms: vomiting, abdominal pain, shortness of breath, convulsions,loss of consciousness, cyanosis of mucous membranes, hyperemia of the skin,
acute cardiovascular failure, stop
breathing.
Treatment:
1.
Gastric lavage through a tube with 0.1% solution of permanganate
potassium or 0.5% solution of sodium thiosulfate.
2.
Activated charcoal inside.
3.
Antidote: sodium nitrite 1% solution - 10 ml IV slowly every 10
minutes (2-3 times). Sodium thiosulfate 30% solution 50 ml,
methylene blue 1% solution 50 ml IV.
4.
Glucose 40% solution - 20-40 ml IV repeatedly.
5.
Vitamin "B12" - 1000 mcg IV, IM.
6.
Vitamin "C" 5% solution - 20 ml IV.
The lethal dose is 0.05 g.
Barbiturates
Symptoms:1 st. - prolonged sleep, pupils are narrow, hypersalivation,
unrelated speech
2 tbsp. - superficial coma, cyanosis of mucous membranes, blood pressure is reduced,
shallow breathing, pain sensitivity is preserved.
Grade 3 - coma, breathing is rare, shallow, pulse is weak, pupils
do not react to light, cyanosis.
4 tbsp. - deep coma, asphyxia, pupils are wide, pulmonary edema.
Treatment:
1.
Rinse the stomach again if the victim is in a coma, after
intubation.
2.
Activated carbon.
3.
Forced diuresis.
4.
Antidote - Bemegride 0.5% solution - 10 ml IV, repeatedly 5-7 times a day.
5.
Sodium hypochlorite 0.06% solution - 400 ml IV drip.
6.
IVL, symptomatic therapy.
Mushrooms are poisonous
Pale grebe (hepato-, nephro-,enterotoxicity).
Symptoms: develop after 5-24
hours. Sudden sharp pains
in the abdomen, vomiting, profuse diarrhea with
blood, convulsions, hypotension,
hypothermia. On the 2nd day
dehydration, jaundice,
anuria, collapse. Then builds up
renal liver failure,
coma.
Treatment:
1.Gastric lavage through a thick tube with warm water 10-12
liters.
2.
Activated charcoal inside.
3.
Forced diuresis.
4.
Plasmapheresis, hemosorption on the 1st day.
5.
Penicillin 40 million units per day of continuous infusion (as a competitor for the transport protein).
6.
Prednisolone 30 mg IV 4 times a day.
7.
Lipoic acid 2 g/day IV.
8.
Kontrykal 10-20 thousand units 2-3 r / day in / in.
9.
Acetylcysteine 1% solution 100 ml orally.
10.
Infusion of saline solutions 2-4 l / day.
11.
Symptomatic therapy.
Lethality up to 90%, 1 mushroom per family.
Mushrooms are poisonous
Fly agaric (neurotoxic effect).Symptoms develop in 0.5-5 hours. Vomiting, pain in
stomach, diarrhea, sweating, hypersalivation, bronchorrhea, narrow
pupils, shortness of breath, hallucinations, delirium, convulsions, bradycardia,
hypotension.
Treatment:
1.
Gastric lavage, activated charcoal, saline
laxative.
2.
Atropine 0.1% solution repeatedly 1-2 ml until reduction
salivation.
3.
Relanium 2 ml i / m.
4.
Prednisolone 30 mg 3 times a day IV.
5.
Infusion therapy 2-4 l / day.
Mushrooms are poisonous
Morels, lines (hemolytic,enterotoxicity).
Symptoms develop after 6-10 hours. Pain occurs in
stomach, vomiting. Jaundice, red urine appears quickly
(hemoglobinuria), convulsions, diarrhea, renal and hepatic
failure.
Treatment:
1.
Rinse the stomach, intestines, give a saline laxative, polyphepam, activated charcoal.
2.
Forced diuresis.
3.
Penicillin 40 million units per day. IV continuous infusion.
Lipoic acid 2 g IV, bolus.
4.
Sodium bicarbonate 4% solution - 1000 ml IV drip.
5.
Vitamin "B6" - 5 ml IV.
6.
Prednisolone 30 mg 4 times / in.
7.
Infusion therapy 2-4 l / day.
Acute poisoning with chemicals, including drugs, is quite common. Poisonings can be accidental, deliberate (suicidal) and related to the peculiarities of the profession. The most common are acute poisonings with ethyl alcohol, hypnotics, psychotropic drugs, opioid and non-opioid analgesics, organophosphate insecticides and other compounds.
A) DELAY OF ABSORPTION OF A TOXIC SUBSTANCE INTO THE BLOOD
The most common acute poisonings are caused by ingestion of substances. Therefore, one of the important methods of detoxification is the cleansing of the stomach. To do this, induce vomiting or wash the stomach. Vomiting is caused mechanically (by irritation of the posterior pharyngeal wall), by taking concentrated solutions of sodium chloride or sodium sulfate, by administering an 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 esophageal mucosa will occur. In addition, aspiration of substances and burns of the respiratory tract are possible. More effective and safe gastric lavage with a probe. 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, if necessary, activated charcoal and other antidotes are added. The stomach is washed several times (after 3-4 hours) until it is completely cleared of the substance.
To delay the absorption of substances from the intestines, adsorbents (activated charcoal) and laxatives (salt laxatives, liquid paraffin) are given. In addition, bowel lavage is carried out.
If the substance that caused intoxication is applied to the skin or mucous membranes, it is necessary to rinse them thoroughly (preferably with running water).
If toxic substances enter through the lungs, their inhalation should be stopped (remove the victim from the poisoned atmosphere or put on a gas mask).
When a toxic substance is administered subcutaneously, its absorption from the injection site can be slowed down by injections of an adrenaline solution around the injection site, as well as cooling this area (an ice pack is placed on the skin surface). If possible, a tourniquet is applied to obstruct the outflow of blood and create venous congestion in the area of injection of the substance. All these activities reduce the systemic toxic effect of the substance.
B) REMOVING THE TOXIC SUBSTANCE FROM THE BODY
If the substance has been absorbed and has a resorptive effect, the main efforts should be aimed at removing it from the body as soon as possible. For this purpose, forced diuresis, peritoneal dialysis, hemodialysis, hemosorption, blood replacement, etc. are used.
The method of forced diuresis consists in a combination of water load with the use of active diuretics (furosemide, mannitol). In some cases, alkalization or acidification of urine (depending on the properties of the substance) contributes to a more rapid excretion of the substance (by reducing its reabsorption in the renal tubules). The forced diuresis method can only remove free substances that are not associated with blood proteins and lipids. When using this method, electrolyte balance should be maintained, which can be disturbed due to the removal of a significant amount of ions from the body. In acute cardiovascular insufficiency, severe renal dysfunction and the risk of developing cerebral or pulmonary edema, forced diuresis is contraindicated.
In addition to forced diuresis, hemodialysis or peritoneal dialysis is used. In hemodialysis (artificial kidney), the blood passes through a dialyzer with a semi-permeable membrane and is largely freed from non-protein-bound toxic substances (such as barbiturates). Hemodialysis is contraindicated with a sharp decrease in blood pressure.
Peritoneal dialysis consists in washing the peritoneal cavity with an electrolyte solution. Depending on the nature of the poisoning, certain dialysis fluids are used, which contribute to the most rapid excretion of substances into the peritoneal cavity. Antibiotics are given along with dialysis fluid to prevent infection. Despite the high efficiency of these methods, they are not universal, since not all chemical compounds are well dialyzed (ie, do not pass through the semi-permeable membrane of the dialyzer in hemodialysis or through the peritoneum in peritoneal dialysis).
One of the methods of detoxification is hemosorption. In this case, toxic substances in the blood are adsorbed on special sorbents (for example, on granular activated carbon coated with blood proteins). This method makes it possible to successfully detoxify the body in case of poisoning with antipsychotics, anxiolytics, organophosphorus compounds, etc. It is important that the method is also effective in cases where drugs are poorly dialyzed (including substances bound to plasma proteins) and hemodialysis does not give a positive result. .
In the treatment of acute poisoning, blood replacement is also used. In such cases, bloodletting is combined with a transfusion of donor blood. The use of this method is most shown in case of poisoning with substances that act directly on the blood, for example, causing methemoglobin formation (this is how nitrites, nitrobenzenes, etc. act). In addition, the method is very effective in case of poisoning by high-molecular compounds that bind strongly to plasma proteins. The operation of blood replacement is contraindicated in severe circulatory disorders, thrombophlebitis.
In recent years, in the treatment of poisoning with certain substances, plasmapheresis (withdrawal, removal) has become widespread, in which plasma is removed without loss of blood cells, followed by its replacement with donor plasma or an electrolyte solution with albumin.
Sometimes, for the purpose of detoxification, lymph is removed through the thoracic lymphatic duct (lymphorrhea). Lymphatic dialysis, lymphosorption are possible. These methods are not of great importance in the treatment of acute drug poisoning.
If the poisoning has occurred by substances released by the lungs, then forced breathing is one of the important ways to treat such intoxication (for example, by means of inhalation anesthesia). Hyperventilation can be induced by the respiratory stimulant carbogen, as well as artificial respiration.
Strengthening the biotransformation of toxic substances in the body in the treatment of acute poisoning does not play a significant role.
C) ELIMINATION OF THE ACTION OF THE ABSORBED TOXIC SUBSTANCE
If it is established which substance caused the poisoning, then they resort to detoxifying the body with the help of antidotes.
Antidotes (antidote) name the means used for the specific treatment of chemical poisoning. These include substances that inactivate poisons through chemical or physical interaction or through pharmacological antagonism (at the level of physiological systems, receptors, etc.). So, in case of heavy metal poisoning, compounds are used that form non-toxic complexes with them (for example, unithiol, D-penicillamine, CaNa2EDTA). Antidotes are known that react with the substance and release the substrate (for example, oximes - cholinesterase reactivators; antidotes used in case of poisoning with methemoglobin-forming substances act in a similar way). Pharmacological antagonists are widely used in acute poisoning (atropine in case of poisoning with anticholinesterase agents, naloxone in case of morphine poisoning, etc.). Usually, pharmacological antagonists interact competitively with the same receptors as the substances that caused the poisoning. It is promising to create specific antibodies against substances that are especially often the cause of acute poisoning.
The earlier treatment of acute poisoning with antidotes is started, the more effective it is. With developed lesions of tissues, organs and body systems and in the terminal stages of poisoning, the effectiveness of antidote therapy is low.
More precisely, antidotes are called only those antidotes that interact with poisons according to the physicochemical principle (adsorption, formation of precipitates or inactive complexes). Antidotes whose action is based on physiological mechanisms (for example, antagonistic interaction at the level of the "target" substrate) are referred to in this nomenclature as antagonists. However, in practical application, all antidotes, regardless of the principle of their action, are usually called antidotes.
D) 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 respiration. For this purpose, cardiotonic drugs are used, substances that regulate the level of blood pressure, agents that improve microcirculation in peripheral tissues, oxygen therapy is often used, sometimes respiratory stimulants, etc. If unwanted symptoms appear that aggravate the patient's condition, they are eliminated with the help of appropriate drugs. So, convulsions can be stopped with the anxiolytic diazepam, which has a pronounced anticonvulsant activity. With cerebral edema, dehydration therapy is carried out (using mannitol, glycerin). Pain is eliminated by analgesics (morphine, etc.). Much attention should be paid to the acid-base state and, in case of violations, the necessary correction should be carried out. In the treatment of acidosis, sodium bicarbonate solutions, trisamine are used, and in alkalosis, ammonium chloride is used. It is equally important to maintain fluid and electrolyte balance.
Thus, the treatment of acute drug poisoning includes a complex of detoxification measures combined with symptomatic and, if necessary, resuscitation therapy.
E) PREVENTION OF ACUTE POISONING
The main task is to prevent acute poisoning. To do this, it is necessary to reasonably prescribe medicines and properly store them in medical institutions and at home. So, you should not keep medicines in cabinets, a refrigerator where food is located. Storage areas for medicines should be out of the reach of children. It is not advisable to keep medicines at home that are not needed. Do not use medicines that have expired. Used drugs must have appropriate labels with names. Naturally, most medicines should be taken only on the recommendation of a doctor, strictly observing their dosage. This is especially important for poisonous and potent drugs. Self-medication, as a rule, is unacceptable, as it often causes acute poisoning and other adverse effects. It is important to comply with the rules for storing chemicals and working with them at chemical-pharmaceutical enterprises and in laboratories involved in the manufacture of medicines. Meeting all of these requirements can significantly reduce the incidence of acute drug poisoning.
Similar information.
Types of poisoning 1. Unintentional: 1. Medicinal - from 20 to 63% 2. Food (alcoholic, PTI)% 3. Non-drug: caustic liquids (5 - 22%, of which 60-70% - acetic acid), carbon monoxide ( 1-6%), others (8-16%). 2. Deliberate: 1. Suicidal 2. Criminal 3. Combat OV
Drug poisoning Benzodiazepines - up to 35% Tricyclic antidepressants - 19.6%. NSAIDs - up to 1.4% Causes of death from acute poisoning (in the Russian Federation) Alcohol - 62.2% (mainly men), Carbon monoxide - up to 15.4% (mainly in winter), Drugs - 12.1% ( heroin: Moscow, Moscow Region, St. Petersburg; Khanka: Ural, Far East) Acetic essence - 6.3% (mainly women), Medicines - 4%. Mortality in Moscow from acute poisoning ~ person/day
Typical causes, clinic and treatment 1. Cauterizing liquids - acids, alkalis. 2. Alcohol, alcohol surrogates, other alcohols - methyl, ethylene glycol, isopropyl, etc. 3. Psychotropic drugs - tranquilizers, neuroleptics, anticonvulsants, tricyclic blood pressure, drugs. 4. Cardiotoxic drugs - blockers, CCB, SG, antiarrhythmic, hypotensive, tricyclic blood pressure. 5. Convulsive poisons - tubazid, tricyclic AD, etc. 6. Anticholinergic (anticholinergic) drugs - antihistamine, antiparkinsonian, belladonna derivatives, tricyclic AD. 7. Anticholinesterase drugs - FOS insecticides, etc. (carbamates, pyrethroids, physostigmine). 8. Methemoglobin formers - aniline, nitrates 9. Heavy metals - compounds of copper, mercury, etc. 10. Toxic gases - irritating, suffocating, etc.
TYPICAL ERRORS IN THE TREATMENT OF ACUTE POISONING 1. Insufficient therapy (necessary treatment is not used or is not used effectively enough); 2. Over-treatment (treatment in excess); 3. Wrong therapy (treatment in the absence of indications, or in the presence of contraindications).
Principles of treatment of poisoning (pre-hospital and pre-hospital stages) 1. Establishment of the fact of poisoning (receiving agents). 2.Personal safety 3.Organizational measures 4.Maintenance of body functions (ABC) 5.Identification of a poisonous substance 6.Stopping the intake of OM into the body 7.Removal of OM from the body - detoxification. 8. Neutralization of agents 9. Symptomatic help
3. Organizational measures - from any mobile phone, if there are no signs of explosiveness. Acute poisoning - immediate provision of staged medical care - pre-hospital, and then inpatient (toxicological or resuscitation profile). Chronic poisoning - outpatient or inpatient care in occupational pathological institutions. Stages of assistance - 1. Self- and mutual assistance 2. First aid 3. Medical assistance 4. Specialized assistance
Mild poisoning 1. It happened recently, 2. The victim is conscious, 3. There is no pronounced pain syndrome. Actions: The pharmacist is obliged to provide first aid: 1. Stop further entry of the poison into the body. 2. To speed up the removal from the body of the substance that caused intoxication.
Severe poisoning 1. Disturbance of consciousness, pain syndrome 2. Severe organ failure. Actions The pharmacist is obliged to provide first aid: 1. Stop further intake of the poison into the body. 2. Accelerate the removal from the body of the substance that caused intoxication Eliminate the most painful manifestations of poisoning. 4. Contribute to the restoration and maintenance of the functions of vital organs and systems of the body. Poisoning with sleeping pills and sedatives is very common (there is in almost every family). Characterized by drowsiness, lethargy, lethargy, impaired coordination of movements, unsteady gait. With a mild overdose, these symptoms disappear after a few hours or 1-2 days. In cases of severe poisoning, accompanied by loss of consciousness, treatment is carried out only in a hospital.
4. Maintenance of vital functions ASSESSMENT OF CONSCIOUSNESS Shake your shoulder and ask the question: What happened? A. If he cannot answer, check the reaction to pain. b. If there is no reaction to speech and pain (a slap on the cheek) - go to the ABC system. V. If he can answer, evaluate the level of consciousness on the “normal-stupor-sopor-coma” scale: A person in consciousness (normal) is able to name: 1. Your name, 2. Your location, 3. Day of the week. If he understands speech, is able to correctly answer the four questions above, it is necessary to clarify the cause of poisoning and provide antidote assistance.
ABC system A. Air way - airway patency. Cleaning the oral cavity Fixation of the tongue Triple Safar maneuver Heimlich maneuver B. Breathing – breathing movements. Ambu bag, S-shaped tube, "Mouth to nose" C. Circulation of blood - blood circulation. Indirect massage (4-8 to 1) - see pupils.
Conditions that can lead to death in a few minutes: 1. Cardiac arrest (clinical death): - In a sudden loss of consciousness, - Absence of heart contractions and pulsation of blood vessels on the lateral surface of the neck, - Wheezing, - Earthy shade of skin and mucous membranes, - Involuntary urination. It is necessary to immediately apply a strong blow with a fist to the sternum (mechanical defibrillation).
If there is no effect (there are no heartbeats), immediately begin an indirect heart massage: put the resuscitated back on a hard surface, kneel on the side, place the base of your palm on the lower third of the sternum (middle finger on the nipple), with two straightened hands through the base of the other palm laid crosswise rhythmically (clicks per minute) press the body weight with a force of about 20 kg. With the crunch of the ribs, slightly weaken the pressure by increasing the frequency. In the absence of breathing, it is necessary to alternate pressing on the sternum with vigorous exhalations into the respiratory tract (in a ratio of 4-8 to 1).
Monitoring the effectiveness of cardiopulmonary resuscitation - by the size of the pupils, which should not be dilated. The pharmacist is obliged to carry out resuscitation until the restoration of effective heart contractions or until the onset of signs of death: 1. With a cat's pupil symptom, 2. Rigor rigor, 3. Large spots. The doctor conducts resuscitation until the fact of brain death is ascertained.
2. With tridor (swelling of the tissues of the larynx) - - painful suffocation with difficulty in breathing, - fading of consciousness, - skin of a bluish-graphite hue. Help - conicotomy: dissection of the conical ligament of the larynx - a small depression just under the top of the thyroid cartilage ("Adam's apple"). The head is thrown back, the tissues are cut without moving the skin - in the transverse direction, the incision is up to 1 cm wide (before the air passes).
3. Collapse (drop in blood pressure, cessation of blood supply to the brain and heart). Help - lay the patient horizontally, raise his arms and legs. It is desirable to centralize blood circulation - apply tourniquets to the limbs. In case of inefficiency, slowly inject intravenously - catecholamines (epinephrine 0.25 mg), - glucocorticosteroids (prednisolone 60 mg) - volemic plasma substitutes (rheopolyglucin 500 ml).
6. Removing the poison and delaying its absorption into the blood. In case of local action of RH, remove it by repeated washing under running cold water. If the agent enters the esophagus and stomach, induce vomiting or rinse the stomach. In an unconscious state - take measures to prevent the ingress of vomit into the respiratory tract (turn your head to one side), ensure their patency.
To delay the absorption of OB from the stomach and intestines, give adsorbents (starch suspension, activated charcoal). To stop the inhalation intake of agents (gases and volatile liquids), remove the victim from the poisoned atmosphere and ensure the supply of fresh clean air. In case of subcutaneous or intramuscular injection of OS, a tourniquet is applied above the injection site, and an ice pack is placed on the injection site.
7. Reducing the concentration of absorbed poison in the blood and removing it from the body. Reducing the concentration - is achieved by introducing large amounts of water into the body: 1. Abundant drinking (up to 3-5 liters), Further - medical assistance: 2. In / in the introduction of physical. solution (up to 3 l).
Algorithm for help in case of drug poisoning Personal safety + ABC + call an ambulance. What is important to know: Do not pour water, milk or other liquid into the mouth if the patient is unconscious, as this can lead to respiratory failure, sometimes with serious consequences. Rinse the affected stomach - give 3-4 glasses of water to drink and press the root of the tongue with the handle of the spoon so that vomiting occurs sooner, gastric lavage should be repeated 2-3 times; In case of impaired coordination of movements, unsteady gait, immediately put the patient to bed; If the victim has lost consciousness, turn his head to the side so that the vomit does not enter the respiratory tract; Do not forget to hand over to the medical workers the packaging from the drugs taken by the victim and, if possible, tell the time of taking the drug, its dose.
Algorithm for assistance with IPT Personal safety + ABC + SMP call! What's important to know: If you're vomiting while unconscious, turn your head to the side. If conscious: Give the victim to drink 4-5 glasses of warm water (children - 100 ml for each year of life). Induce vomiting by pressing on the root of the tongue. Rinse the stomach again until completely cleansed. Give the victim 5 tablets of crushed activated charcoal (drank with water). Give plenty of fluids: alkaline mineral water, 2% baking soda solution.
Removal of poison from the body A) Forced diuresis - 1. Detoxification plasma substitute that removes toxins from tissues into the vascular bed (400 ml of hemodez intravenously slowly), 2. In one load (up to 3 liters of crystalloid solutions intravenously quickly ) 3. Active diuretic (20-80 mg furosemide bolus). Only free OB molecules (not associated with blood proteins and lipids) are excreted. Contraindications: HF, obstruction of the urinary tract, cerebral and pulmonary edema.
B) Peritoneal dialysis - washing the abdominal cavity with a solution of crystalloids (R-rum Ringer-Locke). Fluid is injected through a needle or a thin catheter into the upper sections of the abdominal cavity, drainage (outflow) is carried out from the lower section. c) Plasmapheresis (gravitational blood surgery) - repeated centrifugation of ml of the patient's blood with the rejection of plasma (containing proteins that bind OB) and the dilution of blood cells with plasma substitutes.
D) Hemodialysis and hemosorption (artificial kidney) - blood filtration: - through a dialyzer (semipermeable membrane), where non-protein-bound OB is retained, - through columns with activated carbon, + through columns with ion exchange resins, on which they are adsorbed OV. e) Blood substitution - bloodletting with transfusion of donor blood.
A) Antidotes that bind agents and promote their excretion from the body. - heavy metals (mercury, bismuth, copper, lead, iron, arsenic, etc. - cardiac glycosides. These include: Nitiol, tetacin-calcium, pentacin, disodium salt of ethylenediamine - tetraacetic acid (EDTA), penicillamine (Cu), deferroxamine (Fe) Form complexes that are excreted in the urine.
Plasma-substituting solutions are drugs that compensate for the deficiency of blood plasma or its individual components. Infusion solutions are plasma-substituting solutions for intravenous administration. Detoxification agents are drugs that promote the release of toxins from tissues into the blood plasma and their excretion by the kidneys.
Plasma substitutes 1. Blood, or whole frozen plasma, or individual components (erythrocyte mass, etc.) 2. Hemodynamic drugs (rheological, volemic) Crystalloids (low molecular weight, mass up to D) Salt solutions (NaCl, K, Mg ...) - since 1831 (with cholera). Sugar solutions (glucose 5%) Colloids (detoxification, antishock) - Dextrans, Gelatins, Starches (best of all): - low molecular weight, m.mass D - medium molecular weight, m.mass D - high molecular weight, m.mass more than D 3. Gas regulators , water-salt metabolism, and CBSS Oxygen carriers (Hb solutions, fluorodecalins) Parenpits (lipid, amino acid, carbohydrate) Complex agents (Reogluman, Polifer)
HETEROGENEOUS COLLOIDAL PLASMA SUBSTITUTE SOLUTIONS 1. DEXTRANS (dextran is a polymer of glucose): low molecular weight, mass D medium molecular mass, mass D Syncol - the first drug of this class - in the Leningrad Research Institute of Hematology and Blood Transfusion in 1952. Poliglukin - in 1954, at the Central Research Institute of Hematology and Blood Transfusion (MM - - D).
Polyglusol - dextran with MM D, containing Na +, K +, Ca +2, Mg +2 salts. Anti-shock effect + correction of electrolyte imbalance. Polyoxidine is a colloidal hemodynamic blood substitute based on polyethylene glycol. The drug improves the rheological properties of blood to a greater extent. Rondeferrin is a radiation-modified dextran with MM ± D. This is a rheological agent with the ability to stimulate hematopoiesis - it contains iron in an easily digestible form, as well as copper and cobalt. The drug restores blood pressure, normalizes systemic hemodynamics and microcirculation.
Rondex - 6% solution of radialized dextran with MM ± 5.000 D in 0.9% sodium chloride solution. Complies with international standards for plasma substitutes such as dextran-70, however, it has advantages in the form of a viscosity reduced by almost 1.5 times and a reduced size of macromolecules. It has a detoxifying property, as well as the effect of protecting the genetic apparatus of bone marrow cells after irradiation. Rondex-M - "Rondex" with carboxyl groups. Additionally, it has immunomodulatory and interferon-inducing activity. The anti-adhesive effect is 5 times higher than Polyglukin and 2.5 times Rondex. In terms of severity of hemodynamic action, Rondex-M corresponds to Polyglukin, and in terms of its effect on microcirculation and tissue blood flow - Reopoliglyukin.
Polyfer - a modification of polyglucin, consists of a complex of dextran with iron. It has a hemodynamic effect, and is also able to accelerate erythropoiesis in posthemorrhagic anemia. Reogluman - reopoliglyukin + mannitol + sodium bicarbonate. It eliminates tissue acidosis, and the rheological and diuretic effects are enhanced compared to rheopolyglucin. A promising direction in the creation of CRC is the creation of blood substitutes based on pullulan, a polysaccharide consisting of malto-triazone units connected by alpha-1-6 bonds.
2. PREPARATIONS BASED ON GELATIN. Gelatin is a denatured protein from collagen-containing tissues of cattle (including from the nervous tissue of a bull - infection with prions!) As a result of stepwise thermal and chemical processing. MM: 5 thousand D (usually - thousand D) Used to replace blood in case of blood loss since 1915 (J. Hogan). Currently, more than 50 different gelatin preparations of 3 main types are used in the world: 1 - solutions based on oxypolygelatin (OPG); 2 - solutions based on succinated gelatin (modified liquid gelatin) - (MLG); 3 - solutions based on gelatin prepared from urea Features of gelatin preparations compared to dextrans - the strength of water binding by gelatin is much less (substitution volume%) and the effect is less long-lasting (no more than 2 hours).
Features of individual gelatin preparations Imported preparations (average MM in most D) - Zhemakcel, Zhelifundol, Zhelofusin, Physiogel, Plasmion, Zheloplasma, Zhelofuzal:. In comparison with them, the weight MM of the domestic drug "Gelatinol" is D (range of molecular weight distribution from to D) - developed at the Leningrad Research Institute of Hematology and Blood Transfusion in 1961.
3. STARCH (solutions of hydroxyethyl starch - HES) Solutions have been produced since the beginning of the 60s. Over the past decade, HES solutions have overshadowed dextrans and gelatin derivatives. Preparations: Volekam (Russia) - MM - HAES-steril - 6%, HAES-steril - 10%, Refortan, Refortan - plus, Stabizol (Berlin-Chemie products), Plazmasteril (Fresenius products) - MM The less MM, the shorter the circulation time of the drug in plasma. Application: Hemorrhagic, traumatic, septic and burn shock, as well as in extreme situations, when there is a pronounced deficiency of BCC, a decrease in cardiac output and a violation of oxygen transport.
1. Stopping the flow of poison into the patient's body.
2. Accelerated removal of poison from the body, the use of antidote therapy, methods of detoxification therapy.
3. Symptomatic therapy aimed at correcting the vital functions of the body.
Treatment is etiotropic.
Methods of detoxification therapy (according to E.A. Luzhnikov)
I. Methods for stimulating the natural processes of cleansing the body. A. Stimulation of excretion
Cleansing the gastrointestinal tract:
emetics (apomorphine, ipecac),
gastric lavage (simple, probe),
bowel lavage (probe lavage 500 ml / kg - 30 l, enema),
laxatives (salt, oil, vegetable), pharmacological stimulation of intestinal motility (KCI + pituitrin, serotonin adipate).
Forced diuresis:
water and electrolyte loading (oral, parenteral), osmotic diuresis (urea, mannitol, sorbitol), saluretic diuresis (lasix).
Therapeutic hyperventilation of the lungs.
B. Stimulation of biotransformation
Regulation of the enzymatic function of hepatocytes:
enzymatic induction (zixorin, phenobarbital),
enzymatic inhibition (levomycetin, cimetidine).
Therapeutic hyper- or hypothermia (pyrogenal).
Hyperbaric oxygenation.
B. Stimulation of the activity of the immune system of the blood, Ultraviolet physiohemotherapy.
Pharmacological correction (tactivin, myelopid).
II. Antidote (pharmacological) detoxification. Chemical antidotes (toxicotropic): contact action,
parenteral action.
Biochemical antidotes (toxicokinetic). Pharmacological antagonists (symptomatic). Antitoxic immunotherapy.
III. Methods of artificial physical and chemical detoxification. Apheretic:
plasma-substituting drugs (hemodez),
hemapheresis (blood replacement),
plasmapheresis,
lymphapheresis, perfusion of the lymphatic system.
Dialysis and filtration.
Extracorporeal methods:
hemo- (plasma-, lympho-) dialysis,
ultrafiltration,
hemofiltration,
hemodiafiltration.
Intracorporeal methods:
peritoneal dialysis,
intestinal dialysis.
Sorption.
Extracorporeal methods:
hemo- (plasma-, lympho-) sorption,
application sorption,
biosorption (spleen), allogeneic liver cells.
Intracorporeal methods: enterosorption. Physio-and chemo-hemotherapy: ultraviolet irradiation of blood, laser irradiation of blood,
magnetic blood treatment,
electrochemical blood oxidation (sodium hypochlorite), ozone hemotherapy.
In case of oral poisoning, mandatory and emergency measures
Tie is gastric lavage through a probe, regardless of the time elapsed since the moment of intoxication. Patients with impaired consciousness/inappropriate behavior must be securely fixed; in patients with impaired pharyngeal reflexes and in a coma, tracheal intubation is preliminarily performed.
In case of poisoning with caustic liquids, washing the stomach through a tube is mandatory in the first hours after taking the poison. The presence of blood in the wash water is not a contraindication for this procedure. In these cases, the probe is abundantly lubricated with vaseline oil before administration, 1 ml of a 1% solution of promedol or omnopon is injected subcutaneously. Neutralization of acid in the stomach with an alkali solution is ineffective, and the use of sodium bicarbonate for this significantly worsens the patient's condition due to a significant expansion of the stomach with carbon dioxide formed. Laxatives in case of poisoning with cauterizing poison are not administered, vegetable oil is given orally 4-5 times a day.
In case of poisoning with KMnO 4 crystals, gastric lavage is carried out according to the same scheme. To cleanse the mucous membrane of the lips, oral cavity, tongue, use a 1% solution of ascorbic acid.
In case of poisoning with gasoline, kerosene and other oil products, 100-150 ml of vaseline oil must be injected into the stomach before washing, and then washed in the usual way.
In severe forms of poisoning in patients who are unconscious (poisoning with organophosphorus insecticides, hypnotics, etc.), gastric lavage is repeated, 2-3 times on the first day after poisoning, since due to a sharp slowdown in resorption in a coma in the stomach - the intestinal tract can deposit a significant amount of a toxic substance with its repeated absorption.
At the end of the lavage, magnesium sulphate can be introduced into the stomach as a laxative, or in case of poisoning with fat-soluble substances, 100 ml of vaseline oil. It is also necessary to cleanse the intestines with siphon enemas. In case of poisoning with cauterizing poisons, these measures are contraindicated.
The appointment of emetics and the induction of vomiting by irritation of the posterior pharyngeal wall in patients in a soporous and unconscious state, as well as in case of poisoning with cauterizing poisons, is contraindicated. For the adsorption of toxic substances in the gastrointestinal tract, before and after gastric lavage, activated charcoal with water in the form of a slurry is used (enterosorption).
With snake bites, subcutaneous or intramuscular administration of toxic doses of drugs, cold is used locally for 6-8 hours. Also shown is the introduction of a 0.1% solution of adrenaline into the injection site and a circular novocaine blockade above the site of entry of toxins.
In case of poisoning through the skin, the patient should be freed from clothing, the skin should be thoroughly washed with warm water and soap.
In case of poisoning through the conjunctiva, the eyes are washed with a light stream of warm water using a 20-gram syringe. Then, a 1% solution of novocaine or a 0.5% solution of dicaine with adrenaline hydrochloride (1:1000) is injected into the conjunctival sac.
In case of inhalation poisoning, first of all, the victim should be taken out of the zone of the affected atmosphere, laid down, ensured airway patency, freed from restrictive clothing, given oxygen inhalation. Treatment is carried out depending on the substance that caused the poisoning.
Personnel working in the affected area must wear personal protective equipment.
When toxic substances enter the rectum, it is washed with a cleansing enema.
To remove toxic substances from the bloodstream, the most commonly used method is forced diuresis, which consists in carrying out a water load followed by the introduction of osmotic diuretics or saluretics. The method is indicated for most poisonings with water-soluble poisons, when their excretion is carried out mainly by the kidneys.
The first stage of forced diuresis is hemodilution (blood dilution), designed to reduce the concentration of a toxic substance, and alkalization, under which the rate of transition of toxic substances from tissues into the blood increases. For this purpose, a puncture and catheterization of the vein according to Seldinger is performed. Short-term hemodilutants are used (0.9% isotonic sodium chloride solution; Ringer's solution, as well as other electrolyte solutions or electrolyte mixtures, glucose solutions 5.10%). The second stage is the introduction of diuretics to stimulate diuresis. In the classical version, osmotic diuretics such as urea and mannitol are used as diuretics. However, lasix has now become the leading drug. It is administered at a dose of 40 mg after the introduction of 150-200 ml of infusion solutions. When using lasix, there is a significant loss of electrolytes, so treatment must be carried out under strict control of water and electrolyte balance. When carrying out forced diuresis, a constant accounting of the volume of injected solutions and excreted urine is necessary. When choosing infusion solutions
creations should be REMEMBERED. that for some poisons (in particular for organophosphorus compounds), alkalization is undesirable, because in an alkaline environment the process of "lethal synthesis" occurs more intensively, i.e., the formation of products that are more toxic than the starting substance.
The method of forced diuresis is contraindicated in case of intoxication complicated by acute and chronic cardiovascular insufficiency (persistent collapse), as well as in violation of kidney function.
Hemodialysis using an "artificial kidney" apparatus is an effective method for the treatment of acute poisoning with dialyzing substances (barbiturates, salicylates, methyl alcohol, etc.), especially in the early period of intoxication in order to accelerate the removal of toxic substances from the body.
Hemodialysis in case of poisoning with salts of heavy metals and arsenic should be carried out in combination with specific therapy (intravenous administration at the time of dialysis of a 5% unithiol solution), which makes it possible to prevent the development of acute renal failure.
Hemodialysis (hemofiltration, hemodiafiltration) is widely used in the treatment of acute renal failure caused by the action of nephrotoxic poisons.
A contraindication to the use of hemodialysis is cardiovascular failure (collapse, toxic shock).
Peritoneal dialysis is used to accelerate the removal from the body of toxic substances that have the ability to be deposited in adipose tissues or bind tightly to plasma proteins.
The operation of peritoneal dialysis is possible in any surgical hospital. Peritoneal dialysis is carried out by an intermittent method after a special fistula is sewn into the abdominal wall. Dialysis fluid is introduced into the abdominal cavity through a fistula using a polyethylene catheter. The amount of fluid required for a single abdominal lavage depends on the age of the child.
The peculiarity of this method lies in the possibility of its use even in cases of acute cardiovascular insufficiency, which compares favorably with other methods of accelerated elimination of toxic substances from the body.
Hemosorption detoxification by perfusion of the patient's blood through a special column with a sorbent is the most effective method for removing a number of toxic substances from the body. The method is used in a specialized hospital.
The operation of replacing the recipient's blood with the donor's blood is indicated for acute poisoning with certain chemicals that cause toxic blood damage - the formation of methemoglobin (aniline), a long-term decrease in cholinesterase activity (organophosphorus insecticides), massive hemolysis (arsenic hydrogen), as well as severe drug poisoning (amitriptyline, belloid, ferrociron) and plant poisons (pale toadstool), etc.
For blood replacement, one-group Rh-compatible individually selected donor blood is used. A positive effect is observed after replacing 25% of the BCC. Optimal is the replacement of 100% BCC.
On average, BCC = 70-75 ml / kg of body weight.
To remove blood from the victim, a puncture and catheterization of the jugular or subclavian vein is performed. A certain portion of blood is removed (no more than 3% of the BCC once) and the same amount of donor blood is injected instead. The replacement rate is not more than 25 - 30% of the BCC per hour. Heparin is administered intravenously. When using donor blood containing sodium citrate, 10 ml of sodium bicarbonate solution and 1 ml of 10% calcium gluconate solution are administered intravenously for every 100 ml of transfused blood. After the operation, it is necessary to control the electrolyte balance of the blood, and the next day - a study of a general urine test and a general blood test.
The operation is contraindicated in cardiovascular insufficiency.
Detoxification plasmapheresis is designed to remove toxic substances from blood plasma and involves extracting the patient's blood plasma and replacing it with appropriate solutions (albumin, polyamine, hemodez, electrolyte solutions, etc.) or returning it to the body after purification by various methods (filtration, sorption). The advantages of plasmapheresis include the absence of a harmful effect on hemodynamics.
10. GENERAL PRINCIPLES FOR THE TREATMENT OF ACUTE DRUG POISONING1
10. GENERAL PRINCIPLES FOR THE TREATMENT OF ACUTE DRUG POISONING1
Acute poisoning with chemicals, including drugs, is quite common. Poisonings can be accidental, deliberate (suicidal 2) and related to the characteristics of the profession. The most common are acute poisonings with ethyl alcohol, hypnotics, psychotropic drugs, opioid and non-opioid analgesics, organophosphate insecticides and other compounds.
For the treatment of chemical poisoning, special toxicological centers and departments have been established. The main task in the treatment of acute poisoning is to remove from the body the substance that caused intoxication. In a serious condition of patients, this should be preceded by general therapeutic and resuscitation measures aimed at ensuring the functioning of vital systems - respiration and blood circulation.
The principles of detoxification are as follows. First of all, it is necessary to delay the absorption of the substance along the routes of administration. If the substance has been partially or completely absorbed, its elimination from the body should be accelerated, and antidotes should be used to neutralize it and eliminate adverse effects.
A) DELAY OF ABSORPTION OF A TOXIC SUBSTANCE INTO THE BLOOD
The most common acute poisonings are caused by ingestion of substances. Therefore, one of the important methods of detoxification is the cleansing of the stomach. To do this, induce vomiting or wash the stomach. Vomiting is caused mechanically (by irritation of the posterior pharyngeal wall), by taking concentrated solutions of sodium chloride or sodium sulfate, 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 esophageal mucosa will occur. In addition, aspiration of substances and burns of the respiratory tract are possible. More effective and safe gastric lavage with a probe. 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, if necessary, activated charcoal and other antidotes are added. The stomach is washed several times (after 3-4 hours) until it is completely cleared of the substance.
To delay the absorption of substances from the intestines, adsorbents (activated charcoal) and laxatives (salt laxatives, liquid paraffin) are given. In addition, bowel lavage is carried out.
If the substance that caused intoxication is applied to the skin or mucous membranes, it is necessary to rinse them thoroughly (preferably with running water).
If toxic substances enter through the lungs, their inhalation should be stopped (remove the victim from the poisoned atmosphere or put on a gas mask).
When a toxic substance is administered subcutaneously, its absorption from the injection site can be slowed down by injections of adrenaline solution around the injection site.
1 This section refers to general toxicology.
2 From lat. suicide- suicide (sui - oneself, Caedo- kill).
substances, as well as cooling this area (an ice pack is placed on the skin surface). If possible, a tourniquet is applied to obstruct the outflow of blood and create venous congestion in the area of injection of the substance. All these activities reduce the systemic toxic effect of the substance.
B) REMOVING THE TOXIC SUBSTANCE FROM THE BODY
If the substance has been absorbed and has a resorptive effect, the main efforts should be aimed at removing it from the body as soon as possible. For this purpose, forced diuresis, peritoneal dialysis, hemodialysis, hemosorption, blood replacement, etc. are used.
Method forced diuresis consists in a combination of water load with the use of active diuretics (furosemide, mannitol). In some cases, alkalization or acidification of urine (depending on the properties of the substance) contributes to a more rapid excretion of the substance (by reducing its reabsorption in the renal tubules). The forced diuresis method can only remove free substances that are not associated with blood proteins and lipids. When using this method, electrolyte balance should be maintained, which can be disturbed due to the removal of a significant amount of ions from the body. In acute cardiovascular insufficiency, severe renal dysfunction and the risk of developing cerebral or pulmonary edema, forced diuresis is contraindicated.
In addition to forced diuresis, hemodialysis or peritoneal dialysis is used 1 . At hemodialysis(artificial kidney) blood passes through a dialyzer with a semi-permeable membrane and is largely freed from non-protein-bound toxic substances (eg barbiturates). Hemodialysis is contraindicated with a sharp decrease in blood pressure.
Peritoneal dialysis consists in washing the peritoneal cavity with an electrolyte solution. Depending on the nature of the poisoning, certain dialysis fluids are used, which contribute to the most rapid excretion of substances into the peritoneal cavity. Antibiotics are given along with dialysis fluid to prevent infection. Despite the high efficiency of these methods, they are not universal, since not all chemical compounds are well dialyzed (ie, do not pass through the semi-permeable membrane of the dialyzer in hemodialysis or through the peritoneum in peritoneal dialysis).
One of the methods of detoxification is hemosorption. In this case, toxic substances in the blood are adsorbed on special sorbents (for example, on granular activated carbon coated with blood proteins). This method makes it possible to successfully detoxify the body in case of poisoning with antipsychotics, anxiolytics, organophosphorus compounds, etc. It is important that the method is also effective in cases where drugs are poorly dialyzed (including substances bound to plasma proteins) and hemodialysis does not give a positive result. .
Also used in the treatment of acute poisoning blood replacement. In such cases, bloodletting is combined with a transfusion of donor blood. The use of this method is most indicated for poisoning with substances that act directly on the blood, for example, causing methemoglobin formation.
1 Dialysis (from the Greek. dialysis- separation) - the separation of colloidal particles from the solute.
ing (this is how nitrites, nitrobenzenes, etc. act). In addition, the method is very effective in case of poisoning by high-molecular compounds that bind strongly to plasma proteins. The operation of blood replacement is contraindicated in severe circulatory disorders, thrombophlebitis.
In recent years, in the treatment of poisoning with certain substances, it has become widespread plasmapheresis 1, in which plasma is removed without loss of blood cells, followed by its replacement with donor plasma or an electrolyte solution with albumin.
Sometimes, for the purpose of detoxification, lymph is removed through the thoracic lymphatic duct. (lymphorrhea). Possible lymphodilysis, lymphosorption. These methods are not of great importance in the treatment of acute drug poisoning.
If the poisoning has occurred by substances released by the lungs, then forced breathing is one of the important ways to treat such intoxication (for example, by means of inhalation anesthesia). Hyperventilation can be induced by the respiratory stimulant carbogen, as well as artificial respiration.
Strengthening the biotransformation of toxic substances in the body in the treatment of acute poisoning does not play a significant role.
C) ELIMINATION OF THE ACTION OF THE ABSORBED TOXIC SUBSTANCE
If it is established which substance caused the poisoning, then resort to detoxification of the body with the help of antidotes 2 .
Antidotes are drugs used for the specific treatment of chemical poisoning. These include substances that inactivate poisons through chemical or physical interaction or through pharmacological antagonism (at the level of physiological systems, receptors, etc.) 3 . So, in case of heavy metal poisoning, compounds are used that form non-toxic complexes with them (for example, unithiol, D-penicillamine, CaNa 2 EDTA). Antidotes are known that react with the substance and release the substrate (for example, oximes - cholinesterase reactivators; antidotes used in case of poisoning with methemoglobin-forming substances act in a similar way). Pharmacological antagonists are widely used in acute poisoning (atropine in case of poisoning with anticholinesterase agents, naloxone in case of morphine poisoning, etc.). Usually, pharmacological antagonists interact competitively with the same receptors as the substances that caused the poisoning. It is promising to create specific antibodies against substances that are especially often the cause of acute poisoning.
The earlier treatment of acute poisoning with antidotes is started, the more effective it is. With developed lesions of tissues, organs and body systems and in the terminal stages of poisoning, the effectiveness of antidote therapy is low.
1 From Greek. plasma- plasma, aphairesis- taking away, taking.
2 From Greek. antidoton- antidote.
3 More precisely, antidotes are called only those antidotes that interact with poisons according to the physicochemical principle (adsorption, formation of precipitates or inactive complexes). Antidotes whose action is based on physiological mechanisms (eg, antagonistic interaction at the level of the "target" substrate) are referred to in this nomenclature as antagonists. However, in practical application, all antidotes, regardless of the principle of their action, are usually called antidotes.
D) 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 respiration. For this purpose, cardiotonic drugs are used, substances that regulate the level of blood pressure, agents that improve microcirculation in peripheral tissues, oxygen therapy is often used, sometimes respiratory stimulants, etc. If unwanted symptoms appear that aggravate the patient's condition, they are eliminated with the help of appropriate drugs. So, convulsions can be stopped with the anxiolytic diazepam, which has a pronounced anticonvulsant activity. With cerebral edema, dehydration therapy is carried out (using mannitol, glycerin). Pain is eliminated by analgesics (morphine, etc.). Much attention should be paid to the acid-base state and, in case of violations, the necessary correction should be carried out. In the treatment of acidosis, sodium bicarbonate solutions, trisamine are used, and in alkalosis, ammonium chloride is used. It is equally important to maintain fluid and electrolyte balance.
Thus, the treatment of acute drug poisoning includes a complex of detoxification measures combined with symptomatic and, if necessary, resuscitation therapy.
E) PREVENTION OF ACUTE POISONING
The main task is to prevent acute poisoning. To do this, it is necessary to reasonably prescribe medicines and properly store them in medical institutions and at home. So, you should not keep medicines in cabinets, a refrigerator where food is located. Storage areas for medicines should be out of the reach of children. It is not advisable to keep medicines at home that are not needed. Do not use medicines that have expired. Used drugs must have appropriate labels with names. Naturally, most medicines should be taken only on the recommendation of a doctor, strictly observing their dosage. This is especially important for poisonous and potent drugs. Self-medication, as a rule, is unacceptable, as it often causes acute poisoning and other adverse effects. It is important to comply with the rules for storing chemicals and working with them at chemical-pharmaceutical enterprises and in laboratories involved in the manufacture of medicines. Meeting all of these requirements can significantly reduce the incidence of acute drug poisoning.
Pharmacology: textbook. - 10th ed., corrected, revised. and additional - Kharkevich D. A. 2010. - 752 p.
