MILITARY PHARMACY AND MEDICINE

© Military Pharmacy and Medicine • 2012 • 4 • 68 – 76of death. Suicidal poisonings are often associatedwith excessive alcohol consumption.After clearing the airway and restoring airwaypatency, the presence of respiration and pulseis checked. Mouth-to-mouth ventilation shouldnot be performed when dealing with poisoningsdue to agents such as cyanides, hydrogen sulfide,corrosives or organophosphorous substances.Patient’s lungs are ventilated through a pocketmask or a facemask set using the highest possibleoxygen concentrations. Precautions shouldbe taken in paraquat poisoning, as high oxygenconcentrations can exacerbate lung damage.Aspiration of stomach content to the lungsoccurs in a considerable proportion of poisonings.Therefore, unconscious patients withoutpharyngeal reflexes should be intubated early.So-called fast induction with cricoid cartilagecompression is performed in order to reduce therisk of aspiration. Preferentially, it should be performedby a trained anesthesiologist or a personwith appropriate experience.BLS and ALS should be commenced during cardiacarrest. Pulseless electrical activity (PEA)usually results from use of medicines exertingnegative inotropic effect, but is associated withbetter prognosis than PEA from primary cardiaccauses. Cardioversion is indicated in life-threateningtachyarrhythmias with the exception ofTorsades de Pointes (look below).Drug hypotension is a frequent phenomenon insuicidal poisoning. It usually responds to fillingof vascular bed with fluids, although it sometimesrequires use of inotropic drugs.During resuscitation, we must undertake actionsto identify the poison (or poisons). Patient’s relatives,friends and the ambulance team can usuallyprovide important information. Physicalexamination can reveal diagnostic clues (smell,puncture marks, tablets left in the oral cavity).Specific therapeutic actionsIn poisoning management, we can formulatefew specific therapeutic guidelines usefulin emergency situations. Particular emphasisshould be put on maintenance of vital functions,Review articleoxygenation, compensating acid-base and electrolyteimbalances.Gastric lavage with addition of activated carbonis justified up to 1 hour after poison ingestion. Itis usually performed following intubation. Lategastric lavage exerts little influence on poisonabsorption and can even induce its movementfurther along the gastrointestinal tract. Eliminationof poison from the system can be acceleratedthrough hemodialysis or hemoperfusion.Effective specific antidotes include:1) N-acetylcysteine in paracetamol poisoning;2) high doses of atropine in organophosphorousinsecticide poisoning;3) sodium nitrate, sodium thiosulfate or EDTAin cyanide poisoning, digoxin-specific antibodiesin digoxin poisoning;4) flumazenil in benzodiazepine poisoning,naloxone in opioid overdose.Tricyclic antidepressantsSuicidal tricyclic antidepressant overdosesare frequent and may lead to convulsions andarrhythmias. Threat to patient’s life exists withinthe first 6 hours following ingestion. Widening ofQRS complexes (over 0.16 seconds) indicates elevatedrisk of arrhythmias. Sodium bicarbonatecan provide some cardiac protection and preventarrhythmias in high-risk patients.OpiatesOpiate overdose causes respiratory depression,pinpoint constriction of pupils and coma.Pethidine overdose may result in convulsions.Naloxone is a specific opiate antagonist. Therecommended dose is 0.4-0.8 mg i.v. (drug isadministered slowly in the amount that is neededto obtained an effect) or 0.8 to 1.2 mg in anintramuscular or subcutaneous injection (whichis easier in drug abusers with difficult venousaccess). Time of action of naloxone is shorter (45-70 minutes) than opiates (up to several hours),necessitating administration of additional dosesat times.CocaineThe following may occur in cocaine poisoningdue to excessive sympathetic stimulation:68 http://military.isl-journals.com