What Is Acute Intoxication?

Acute intoxication means that the poison enters the body through the skin, mucous membranes, respiratory tract, digestive tract, etc. within a short period of time, causing damage to the body and organ dysfunction. Acute poisoning has a rapid onset, severe symptoms, and rapid changes in condition. Failure to treat it in time is often life-threatening. Diagnosis and emergency treatment must be made as soon as possible.

Lu Yiming	(Chief physician)	Department of Emergency Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
Wei Bohua	(Resident)	Department of Emergency Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Acute intoxication means that the poison enters the body through the skin, mucous membranes, respiratory tract, digestive tract, etc. within a short time, causing damage to the body and organ dysfunction. Acute poisoning has a rapid onset, severe symptoms, and rapid changes in condition. Failure to treat it in time is often life-threatening. Diagnosis and emergency treatment must be made as soon as possible.

Western Medicine Name

Acute poisoning

English name

acute intoxication

Introduction to Acute Poisoning Disease

Poisons refer to substances that act on the human body in various forms and doses under certain conditions, produce biological reactions and pathological changes that are harmful to the human body, cause serious damage to the body's functions and even endanger life, including chemicals, drugs, plants and gases. After the poison enters the body, it can cause a series of symptoms of poisoning after interacting with body fluids and tissues in the body. Those with severe tissue metabolism and organ dysfunction can cause death or lifelong disability. A series of life-threatening pathophysiological changes and corresponding symptoms caused by ingestion of poisons are called poisoning. Acute poisoning is manifested within hours to days after ingestion of poison.

The range of poisons is very wide. Some poisons are severely toxic to the human body, such as cyanide and organic phosphorus. Other poisons are only toxic under certain conditions, such as food, drugs, vitamins, oxygen, etc. do not have the characteristics of poisons in normal times, but only after excessive application or interaction with other substances.

Acute poisoning is one of the common emergencies in pediatrics. Toxic poisoning is most common in children, and it is more common in children aged 1 to 5 years. The reason is that young children have a certain ability to move, but lack of cognitive ability and life experience, and lack of awareness of the harm of certain poisons and drugs. In the literature, although the incidence of poisoning groups younger than 5 years old is high, most of them are unintentional poisoning. The dose of poisoning substances they consume is not large, and the types of poisons are single. A considerable part of the latter takes self-harm poisoning in the presence of mental depression or mental disorders, and the dose is usually large, and the mortality rate is relatively high. When children are taken to the hospital after being poisoned, they often encounter medical records where the parents of the sick child cannot accurately provide the type of poison and the intake of the poison. Due to the lack of targeted detoxification measures, the sick child can die in a short time. Therefore, parents should provide poisons as much as possible when facing acute poisoning. In addition, even for suspected poisoning, treatment should be given as soon as possible to save time, avoid further aggravation of poisoning, reduce and reduce mortality and sequelae.

Acute poisoning is also an integral part of emergency medicine. In western developed countries, acute poisoning and clinical toxicology have become an independent medical specialty, with specialized courses and specialized clinical toxicologists. In the United States, there is also a Poison Control and Information Advisory Center, which is an advisory body that mainly provides guidance on identifying toxicants and clinical prevention and treatment. In China, although the poisoning control and information consultation center is not popular, the acute poisoning prevention and treatment group of the Chinese Medical Association Emergency Medical Association was also established in Zhengzhou in 1995. Its main task is to identify and improve rare and new types of acute diseases. Prevention and treatment of poisoning, create conditions to carry out the detection technology of poisons, and improve the prevention and treatment of acute poisoning and the success rate of rescue.

Classification of acute poisoning diseases

There are many kinds of poisons, which can be divided into the following types according to their scope of use and purpose:

1. Industrial poisons: including industrial raw materials, such as chemical solvents, paints, heavy metal gasoline, chlorine cyanide, methanol hydrogen sulfide, etc.

2. Agricultural poisons: organic phosphorus pesticides, chemical herbicides, rodenticides, chemical fertilizers, etc.

3. Poisoning overdose: Many drugs (including traditional Chinese medicine) can cause poisoning, such as digoxin, antiepileptic drugs, antipyretic drugs, sedative drugs, antiarrhythmic drugs, and so on.

4. Animal poisons: poisonous snakes, slugs, bee scorpions, spiders, puffer fish, fresh jellyfish, etc.

5. Food poisons: expired or moldy foods, spoiled foods, toxic food additives

6, plant poisons: wild mushrooms, aconite, ginkgo and so on.

7. Others: strong acid and alkali, carbon monoxide, cosmetics, detergents, insecticides, etc.

Pathogenesis of acute poisoning

1. Poison absorption:

(1) Respiratory tract: smoke, fog, vapor, gas, carbon monoxide, etc.

(2) Digestive tract: various poisons are ingested orally

(3) Skin and mucous membrane: aniline, nitrobenzene, tetraethyl lead, organophosphorus pesticides, etc.

2. Toxic metabolism: Most poisons enter the body and are reduced or disappeared after being transformed by the liver. They are excreted by the kidneys, and some of the poisons can also be excreted by the kidneys. Minor toxicants can be excreted by skin sweat glands, breasts, tears, respiratory tract, biliary tract, or intestines. The speed of excretion varies greatly between poisons, mainly depending on the characteristics of the poison itself and the function of the patient's kidneys. The excretion time of the poison can be up to several weeks or even months. The distribution of toxic drugs in toxicological kinetics is of great significance in guiding the treatment of poisoning. The method of promoting toxin excretion during treatment is better for patients with most of the poison accumulated in the bloodstream in the early stages of poisoning. When the distribution of the poison reaches equilibrium in the body, most of the poison is only about 5% in the blood. Use of excretion therapy is less effective. In addition, poisons have high fat solubility or high plasma protein binding rate, poisoning doses are large when poisoning, and shock and other factors will also lead to slower excretion of poisons ^[1] .

Mechanism of acute poisoning

1. Local irritation and corrosion

Hypoxia of tissue cells

3. Anesthetic effect

4.Inhibition of enzyme activity

5. Interfering with the physiological functions of cell membranes or organelles

Competitive binding of receptors

Clinical manifestations of acute poisoning

1. Skin and mucous membrane: burns (strong acid, strong alkali), cyanosis (nitrite), jaundice (fish gall)

2. Eyes: dilated pupils (atropine), dilated pupils (morphine), optic neuritis (see methanol poisoning)

3. Nervous system: coma, delirium (see atropine poisoning), muscle fibrillation (see organophosphorus), convulsions (see organochlorine, isoniazid), paralysis (see arsenic trioxide), mental disorders (see carbon monoxide, atropine)

4. Respiratory system: Respiratory odor: wine, bitter almond (cyanide), garlic, etc.

Breathing faster: salicylic acid, methanol

Slowed breathing: hypnotics, morphine

Pulmonary edema: zinc phosphide, organic phosphorus, etc.

5, the circulatory system: arrhythmia: such as digitalis, theophylline.

Cardiac arrest: like digitalis, theophylline directly affects the heart muscle; asphyxiating poisons cause hypoxia; barium salts and gossypol cause hypokalemia.

6. Urinary system: acute renal failure

7. Blood System: Hemolytic Anemia: Arsenide

Leukopenia and Aplastic Anemia: Chloramphenicol, Antitumor Drugs

Bleeding: aspirin, chloramphenicol

Blood clotting: enemy rat, snake venom

8. Serious complications

Fatal heart failure and shock can be accompanied by severe arrhythmias, pulmonary edema, respiratory muscle paralysis, and respiratory failure. Kidney damage, hematuria, proteinuria, acute renal failure, hypertension, azotemia, etc. Nervous system convulsions, paralysis, coma, and central respiratory failure. Causes anemia, hemolysis, DIC, and extensive bleeding. After the acute phase of acute poisoning, some patients may have sequelae, such as the deformation and narrowing of the digestive tract caused by corrosive poisoning, which affects the normal diet; brain poisoning damage or psychomotor dysfunction after severe hypoxia, etc. ^[2]

Criteria for diagnosis of acute poisoning

1. History of poison exposure: Corresponding to patients with acute symptoms of unknown cause, doctors should be alert to patients who may be poisoned, and need to carefully interrogate the medical history, do not let go of any clues, promptly diagnose patients with poisoning, and win time for patients in time.

(1) The type or name of the poison, the dose, route, and time of entry, the time when the symptoms of poisoning appeared or the time and time when the patient was found.

(2) On-site condition of the disease, whether there is any residual suspicious poison.

(3) Those who are likely to take drugs should understand the patient's living conditions, mental state, types of drugs that are often taken, whether there are medicine bottles nearby, whether there is a lack of drugs at home, and the estimated dose of medication.

(4) Those who are suspected of food poisoning should investigate whether the same symptoms occur with those who eat the same meal.

(5) Those who are suspected of carbon monoxide (CO) gas poisoning should understand the situation of indoor fires, chimneys and others in the same room.

Physical examination

(1) Consciousness: Is it sober, hazy, delirious, or unconscious, and whether the expression is painful or irritable.

(2) Blood pressure, pulse, heart rate and heart rhythm, breathing (frequency and rhythm, no rales in the lungs, and exhaled air with special odors, such as: organic phosphorus poisoning with garlic smell, ethanol poisoning with alcohol smell, hydrogen sulfide Class poisoning has egg smell, etc.).

(3) pupil size and reflection of light. Such as expansion: seen in atropine, amphetamine and other poisoning; reduction seen in organophosphorus, morphine, anesthetic and other poisoning.

(4) Skin, lip color (hair bun, fuchsia, pale or gray), whether there are signs of corrosion around the lips and in the mouth, whether there are medicinal stains and odors, whether there are inflammatory damage to the skin, wounds and injection marks, and body surface temperature And humidity, skin dryness and dehydration.

(5) Whether there are muscle twitches and cramps, and whether there is tenderness in the abdomen.

(6) The color of vomitus and feces (urine, feces) and whether there is a special smell.

3.Experimental inspection

(1) Poison identification: analyze vomit, gastric lavage, urine, feces, blood and so on.

(2) According to the needs of the disease: blood cholinesterase (CHE) measurement, blood biochemistry, blood gas analysis, liver and kidney function, cerebrospinal fluid, X-ray, electrocardiogram, electroencephalogram and other examinations ^[3] .

Differential diagnosis of acute poisoning

For example, if the diagnosis is unclear and accompanied by coma, it should be differentiated from hypoglycemia, ketoacidosis, intracranial hemorrhage, central infection, hepatic encephalopathy, uremia, and electrolyte disorders.

Acute poisoning first aid measures

Acute poisoning is accompanied by the following manifestations: suggesting a critical condition deep coma; shock or blood pressure instability; high fever or temperature not rising; respiratory failure; heart failure or severe arrhythmia; convulsive status; diffuse intravascular coagulation (DIC); serum sodium is higher than 150mmol / L or lower than 120mmol / L. For these patients, liver, kidney and other organ functions should be routinely monitored to provide evidence for disease judgment and supportive treatment.

Symptomatic supportive treatment for acute poisoning

Many acute poisonings do not have special detoxification treatments. Symptomatic supportive treatment is very important to help critically ill patients through difficult times. The important thing is to protect vital organs and restore their functions. Patients with acute poisoning should stay in bed and stay warm. Should pay close attention to the patient's consciousness, breathing, circulation and other conditions, and give appropriate treatment.

Acute poisoning treatment

1. Immediately remove the patient from the poisoning scene:

(1) For contact or inhalation poisoning, immediately remove the poisoned person from the poisoning place, remove contaminated clothes, and wash the skin surface with warm water.

(2) If there is a wound, wash the wound, apply medicine and bandage.

2.Remove poisons that have not been absorbed from the body

(1) Remove poisons that have not been absorbed from the gastrointestinal tract

, induce vomiting:

A. Indications: Clear-minded and collaborators.

B, contraindications: coma, convulsions, eating strong corrosive agents, kerosene, gasoline and other patients should not use; patients with elderly and frail, pregnancy, hypertension, heart disease, portal hypertension and other patients with caution.

C. Method:

Use your finger or tongue depressor or 500ml cold water with 60g of salt to administer, and take it 3 to 4 times, then stimulate the posterior wall of the pharynx to make the patient vomit repeatedly. You can also use emergency saliva powder (alum 10g, saponin 9g) decoction to 250ml, orally; or use 0.2% -0.5% copper sulfate 100ml-200ml orally to induce vomiting.

Gastric lavage:

A. Indications: Coma and uncooperatives should be carried out as soon as possible. Generally, gastric lavage is not effective 6 hours after taking the drug.

B. Contraindications: Those who are poisoned by corrosive poisons (such as strong acid or alkali) should not be used.

C. Method: gastric tube method, syringe method and gastric lavage method.

The gastric lavage solution can use mung beans (broken) 150g, licorice 60g, decoction to 1000ml, add cold water to 2000ml, or use warm water, 0.02-0.05% potassium permanganate solution (do not use for organophosphorus pesticide 1605 poisoning), Normal saline, tea water, 1% sodium bicarbonate (not suitable for trichlorfon poisoning). If the poison is unknown, wash the stomach with water. The gastric lavage solution should be washed out repeatedly until the liquid is clear and tasteless.

Catharsis:

A. Indications: It is suitable for taking poison for more than 4 hours after gastric lavage.

B. Method:

For catharsis, 6 grams of alum (fried first) and 250 grams of rhubarb (followed by the next) are used in 250ml, washed; 6 grams of weathered nitrate or 30 grams of senna leaves are washed in water. Can also use Glauber's salt or magnesium sulfate 20-30 grams, dissolved in warm boiled water, or into the stomach tube after gastric lavage. Oil diarrhea is generally banned to avoid promoting the absorption of fat-soluble poisons. Patients with coma with severely suppressed central nervous system should not use magnesium sulfate for catharsis, because magnesium ions can inhibit the central nervous system.

Enema

Indications: In addition to corrosive poisoning, it is suitable for those who have been poisoned orally for more than 6 hours, who have ineffective catharsis, and drugs that inhibit bowel movements (such as barbiturates, belladonna, opioids).

Methods: 5000ml of 1% soap water was used to enema for several times in a row.

(2) Remove poison from skin, eyes and wounds

Wash the skin and hair; splash poison into the eyes, and immediately rinse with water for more than 20 minutes; those bitten by poisonous snakes should quickly bind the proximal end of the wound, and thoroughly rinse the wound and surrounding skin, remove the possible fangs in the wound, and rinse repeatedly. Squeeze out the venom remaining in the wound.

3.Promote the excretion of absorbed poisons

(1) Diuretic:

A large amount of drinking water or intravenous infusion (using 5% glucose physiological saline and 5% glucose alternately, 200ml--400ml per hour) can dilute the concentration of toxicant, increase urine output, and accelerate the excretion of toxicant. At the same time, osmotic diuretics such as 125% -250ml of 20% mannitol can be used for rapid intravenous drip, or 20-40mg of fast urine, intravenous injection.

(2) oxygen inhalation

When carbon monoxide is poisoned, oxygen inhalation can promote the dissociation of carboxyhemoglobin and accelerate the discharge of carbon monoxide. Hyperbaric oxygen therapy is a special treatment for carbon monoxide poisoning.

(3) dialysis therapy

Hemodialysis: Can be used to remove salicylates, methanol, theophylline, ethylene glycol, lithium, etc.

Hemoperfusion: Blood flows through a perfusion column filled with activated carbon or resin. After the poison is absorbed, the blood is returned to the patient. This method can adsorb fat-soluble or protein-bound chemicals, and can remove barbiturates, paraquat (ultra-early), etc. in the blood ^[4] .

Application of Acute Poisoning Antidote

1.Traditional Chinese medicine antidote

15g raw licorice, 15g windproof, 30g mung bean.

15g of raw licorice and 10g of rhubarb

100-150g fresh grass root or 30-50g reed roots.

A fresh bowl of 100-150g pounding sauce.

2.General antidote

Activated carbon or 0.2-0.5% activated carbon suspension (as a strong adsorbent), combined with gastric lavage, can block the absorption of poisons and is suitable for many poisoning. Such as strong acid poisoning, take magnesium oxide, magnesium milk, aluminum hydroxide gel, etc .; strong alkali food poisoning, take 1% acetic acid, diluted vinegar, lemonade, orange water;

3.Special antidote

(1) Metal poisoning antidote:

Sodium edetate: used to treat lead poisoning. Usage: Add 1g daily to 250ml 5% glucose and dilute it after intravenous drip. 3 days of treatment is a course of treatment, and it can be reused after 3-4 days of rest. Dimercaptopropanol: used to treat arsenic and mercury poisoning. Usage: Acute arsenic poisoning, 2--3mg / kg on day 1-2, once every 4--6 hours, intramuscular injection, on day 3--10, twice daily.

Sodium dimercaptan: used to treat antimony, lead, arsenic, and mercury copper poisoning. Usage: Intravenous infusion or intramuscular injection of 1--2g daily for 3 days, and 4 days of withdrawal as a course of treatment.

(2) Antidote for methemoglobinemia:

Methylene blue (methylene blue): used to treat methemoglobinemia caused by nitrite, aniline, nitrobenzene and other poisoning. Methods: Intravenous injection of 5--10ml (1--2mg / kg) of 1% methylene blue, and repeated use if necessary. Note: Necrosis is easily caused by extravasation when the liquid injection is injected. The use of large doses (10mg / kg) has the opposite effect and can produce methaemoglobinemia.

(3) Cyanide poisoning and antidote:

Nitrite-sodium thiosulfate method: Mechanism: An appropriate amount of nitrite oxidizes hemoglobin to produce a certain amount of methemoglobin; the latter forms cyanated methemoglobin with cyanide in the blood, and methemoglobin can also capture the oxidized form Cyanochrome oxidase-bound cyanide ions; cyanide ions interact with sodium thiosulfate to transform into thiocyanate with low toxicity and excreted from the body. Usage: Immediately inhale isoamyl nitrite and slowly inject 10 ml of 3% sodium nitrite solution. Immediately intravenously with 50% 25% sodium thiosulfate.

(4) Organophosphorus pesticide poisoning and antidote:

Use atropine, clodoxine or phosphine. Changtuining (pentexaquine hydrochloride injection) is a new type of effective antidote for organophosphate poisoning. Changtuining combined with atropine rescues severe acute organophosphate poisoning.

(5) Central nerve inhibitor antidote:

Naloxone: Naloxone is a morphine receptor antagonist, an antidote for opioid anesthetics, and has specific antagonistic effects on respiratory depression caused by narcotic analgesics. Recently, it has been found to have a awakening effect on acute alcoholism. Some people have tried it for other sedative hypnotic drugs, such as diazepam, and have also achieved certain results.

Flumazenil: Flumazenil is an antagonist of benzodiazepine poisoning ^[5] .

Acute poisoning carbon monoxide poisoning

Carbon monoxide (CO) is a colorless, odorless, odorless, non-irritating gas that is difficult to identify from a sensory perspective. Carbon monoxide is mainly produced by incomplete combustion of carbon-containing compounds. Most people often inadvertently get poisoned without knowing it. Every year, when some cases are discovered, the poisoning is often too deep to be saved. Therefore, it should be taken seriously.

1 Common causes of acute carbon monoxide poisoning

Industrially, steelmaking, coking, kiln, etc. are not tightly closed during the production process, gas pipes leak, and automobile exhausts can emit a large amount of carbon monoxide. A large amount of carbon monoxide was generated when the gun smoke and mine gas explosion occurred in the mine. The chemical industry synthesizes ammonia, methanol, acetone, etc. to be exposed to carbon monoxide. Scattered cases of poisoning are mostly caused by incomplete combustion in the northern winter with coal stoves and fire heating. There were also city residents who were poisoned by gas pipeline leaks.

2 Main manifestations of acute carbon monoxide poisoning

The initial symptoms may appear dizziness, headache, nausea, vomiting, palpitations, fatigue, drowsiness, etc., which is medically called mild poisoning. At this time, if you can escape from the poisoning environment in time and inhale fresh air, the symptoms can be quickly relieved.

Unresponsiveness, except for dizziness, headache, nausea, vomiting, palpitations, fatigue, drowsiness, flushing complexion, cherry-red lips, rapid pulse, coma, dull pupils' light reflection, corneal reflection and tendon reflection, breathing, blood pressure That can change. Medically, it is called moderate poisoning. At this time, if you can rescue in time, you can recover.

Deep coma occurs, various reflexes weaken or disappear, muscle tone increases, and incontinence occurs. Severe poisoning is medically called. At this time, cerebral edema, pulmonary edema, shock, stress ulcers, and focal brain damage can occur. Reddened swellings, blisters, or even necrosis can occur in the area under pressure.

3 How to do home care

When someone finds or suspects carbon monoxide poisoning, the following measures should be taken immediately:

(1) Ventilate doors and windows immediately

Quickly move the person to a place with fresh air, rest in bed, keep quiet and keep warm.

(2) Ensure that the airway is unobstructed

For unconscious persons, the head should be tilted to one side to prevent the vomit from inhaling into the respiratory tract and choking.

(3) Quickly rush to the hospital with hyperbaric oxygen treatment conditions

Because hyperbaric oxygen can not only reduce the half-life of carboxyhemoglobin, increase the removal of carbon monoxide and remove residual carbon monoxide in tissues, but also increase the amount of dissolved oxygen, reduce brain edema and relieve the inhibition of cytochromenase ^[6] .

Prevention of acute poisoning diseases

1. Take good care of children to prevent accidental consumption of poisons and drugs.

Toxic drugs are placed in a way that children cannot get, to prevent children from accidentally ingesting poisoning. Toxic and harmful substances should be properly stored and kept in a safe place.

2. Adolescents can take self-harm drugs, and pay attention to their physical and mental health ^[7] .

Friends and relatives should avoid unnecessary stimuli, be considerate, and live in harmony, and avoid things like drug poisoning or poisoning caused by various emotional entanglements or contradictions in life.

3. Strengthen publicity and popularize anti-virus knowledge about plants and drugs.

Avoid CO poisoning: pay attention to ventilation and ventilation, check the equipment for leaks frequently, and always be vigilant.

Avoid pesticide poisoning: When farming, take protective measures, wear waterproof clothing, and wear a mask to prevent pesticides from being absorbed through the skin and respiratory tract.

Medical institutions should strengthen and improve the management of drugs and poisons, build a poison control center, improve the level of poisoning treatment and prevention in China, strengthen scientific research, explore the establishment of an integrated poisoning inspection platform, provide a scientific research platform for the diagnosis and treatment of poisoning, and strengthen scientific research and clinical practice. Combined with ^[8] .