Regardless of the toxic substance, treatment of all acute poisonings is carried out according to the following principles:
1. Assessment of vital functions and correction of identified disorders.
2. Stopping the entry of poison into the body.
3. Removal of unabsorbed poison.
4. Use of antidotes.
5. Removal of absorbed poison.
6. Symptomatic therapy.
1. The condition is assessed using the ABCDE algorithm.
“A” - restoration of patency respiratory tract.
“B” – effective ventilation. If necessary, providing auxiliary ventilation or, if necessary, artificial ventilation (ALV) through an endotracheal tube.
“C” – assessment of blood circulation. Assess the color of the skin, arterial pressure(BP), heart rate (HR), saturation (SpO 2), electrocardiography (ECG) data, diuresis. Vein catheterization is carried out and a urinary catheter is placed, and, if necessary, appropriate medication correction is performed.
“D” – assessment of the level of consciousness. Depression of consciousness is the most common complication of poisoning. In case of depression of consciousness, it is necessary to perform tracheal intubation, since this is often combined with respiratory depression. In addition, suppression of the cough and gag reflexes can lead to the development of aspiration.
The presence of severe agitation and convulsions also require drug treatment.
In the presence of disturbances of consciousness, it is necessary to carry out a differential diagnosis with injuries to the central nervous system, hypoglycemia, hypoxemia, hypothermia, and infections of the central nervous system, even if the diagnosis is obvious.
“E” – re-assessment of the patient’s condition and the adequacy of the actions performed. It is carried out systematically after each manipulation.
2. Preventing poison from entering the body carried out at the first aid stage. Necessary:
Remove the victim from the atmosphere that caused the poisoning;
When poison enters through skin(gasoline, FOS) wash the skin with running water and soap. (In case of FOS poisoning, you can treat the skin with a 2-3% solution of ammonia or a 5% solution of baking soda (sodium bicarbonate); then 70% ethyl alcohol and again with running water and soap). Rubbing the skin should be avoided.
If poison gets on the mucous membrane of the eyes, it is recommended to rinse the eyes with an isotonic solution of sodium chloride.
3. Removal of unabsorbed poison. The main way to remove poison from the gastrointestinal tract is gastric lavage. However, in case of poisoning with mushrooms, berries, or drugs in the form of large tablets, initially (before gastric lavage) it is advisable to induce vomiting (if there was none) by pressing on the root of the tongue to remove large fragments. Contraindications to reflex induction of vomiting: poisoning with substances that damage the mucous membrane, convulsive readiness and convulsions, disturbances of consciousness and coma.
Gastric lavage is a mandatory component medical care, wash the stomach regardless of the period of exposure to the poison. There are no absolute contraindications for this method. In case of poisoning with certain poisons, the washing procedure has some limitations. So, in case of poisoning with cauterizing poisons, rinsing is possible only in the first hour, because In the future, this procedure can lead to perforation of the gastrointestinal tract. In case of barbiturate poisoning, gastric lavage is carried out in the first 2-3 hours, then the smooth muscle tone decreases, the cardiac sphincter may open and regurgitation, so in the future only the gastric contents are suctioned.
In unconscious patients, gastric lavage is performed after tracheal intubation, because aspiration is possible. Rinsing is carried out through a probe, which is inserted orally, which allows the use of a thicker probe. The depth of standing is determined by the distance from the edge of the teeth to the xiphoid process. Use cool water for rinsing tap water, a single volume of liquid in adults is not > 600 ml, in children under 1 year – 10 ml/kg, after 1 year – 10 ml/kg + 50 ml for each subsequent year. The stomach contents are drained and sent for toxicological testing. The total volume of liquid is not< 7 л (до 10-15 л), промывают до чистых промывных вод. При отравлении липофильными ядами (ФОС, анальгин, морфин, кодеин) желательны повторные промывания через 2-3 часа, т.к. возможна печеночно-кишечная рециркуляция. Повторение процедуры также необходимо при отравлении таблетированными формами, поскольку их остатки могут находиться в складках желудка 24-48 часов.
After gastric lavage, it is necessary to enter into the stomach with orbents: activated carbon – 0.5-1.0/kg in powder form. Repeated administration of activated carbon is carried out with the aim of interrupting enterohepatic circulation.
Along with coal, they are usually recommended laxatives– petroleum jelly 0.5-1 ml/kg, it is possible to use a 10-20% magnesium solution at a dose of 250 mg/kg. Their necessity is due to the fact that the sorbent binds the toxin only for 2-2.5 hours, and then splits off again, therefore It is necessary to remove this complex as quickly as possible. Contraindications to the use of laxatives: poisoning with iron supplements, alcohol, lack of peristalsis, recent intestinal surgery.
To remove unabsorbed poison from the intestines, it is possible to carry out intestinal lavage, high siphon enemas.
4. Specific (pharmacological) antidotal therapy.
Radical neutralization of the poison and elimination of the consequences of its action in many cases can be achieved with the help of antidotes. An antidote is a drug that can eliminate or weaken the specific effect of a xenobiotic due to its immobilization (for example, chelating agents), reducing the penetration of the poison to effector receptors by reducing its concentration (for example, adsorbents) or counteraction at the receptor level (for example, pharmacological antagonists). There is no universal antidote (exception: Activated carbon- nonspecific sorbent).
Specific antidotes exist for a small number of toxicants. the use of antidotes is far from safe; some of them cause serious adverse reactions, therefore, the risk of prescribing antidotes should be comparable to the effect of its use.
When prescribing an antidote, one should be guided by the basic principle - it is used only if there are clinical signs of poisoning by the substance for which the antidote is intended.
Classification of antidotes:
1) Chemical (toxicotropic) antidotes affect the physicochemical state of the substance in the gastrointestinal tract (activated carbon) and the humoral environment of the body (unithiol).
2) Biochemical (toxicokinetic) antidote s provide a beneficial change in the metabolism of toxic substances in the body or the direction of the biochemical reactions in which they participate, without affecting the physicochemical state of the toxic substance itself (cholinesterase reactivators in case of FOS poisoning, methylene blue in case of poisoning with methemoglobin formers, ethanol in case of methanol poisoning).
3) Pharmacological (symptomatic) antidotes have a therapeutic effect due to pharmacological antagonism with the effect of the toxin on the same functional systems of the body (atropine for poisoning with organophosphorus compounds (OPC), proserine for poisoning with atropine).
4) Antitoxic immunotherapy has become most widespread for the treatment of poisoning by animal venoms due to snake and insect bites in the form of antitoxic serum (anti-snake - “anti-gurza”, “anti-cobra”, polyvalent anti-snake serum; anti-karakurt; immune serum against digitalis preparations (digitalis-antidote)).
Antidote therapy remains effective only in the early, toxicogenic phase of acute poisoning, the duration of which varies and depends on the toxicokinetic characteristics of the toxic substance. Antidote therapy plays a significant role in the prevention of irreversible states in acute poisoning, but does not have a therapeutic effect during their development, especially in the somatogenic phase of these diseases. Antidote therapy is highly specific, and therefore can be used only if there is a reliable clinical and laboratory diagnosis of this type of acute intoxication.
5. Removing absorbed poison is carried out by enhancing natural and using artificial detoxification of the body, as well as using antidote detoxification.
Stimulates natural detoxification achieved by stimulating excretion, biotransformation and immune system activity.
Lecture No. 34.
Basic principles of treatment of acute poisoning medicines.
Therapeutic measures aimed at stopping the effects of toxic substances and removing them from the body in the toxicogenic phase of acute poisoning are divided into the following groups: enhancement methods natural processes cleansing, artificial detoxification methods and antidote detoxification methods
Basic methods of detoxifying the body.
1. Methods to enhance the body's natural detoxification:
Gastric lavage;
Purgation;
Forced diuresis;
Therapeutic hyperventilation.
2. Methods of artificial detoxification of the body
· intracorporeal:
Peritoneal dialysis;
Intestinal Dialysis;
Gastrointestinal sorption.
· extracorporeal:
Hemodialysis;
Hemosorption;
Plasmasorption;
Lymphorrhea and lymphosorption;
Blood replacement;
Plasmapheresis.
3. Antidote detoxification methods:
· chemical antidotes:
Contact action;
Parenteral action;
· biochemical:
Pharmacological antagonists.
Methods to enhance the body's natural detoxification.
Cleansing the gastrointestinal tract. The occurrence of vomiting in some types of acute poisoning can be considered as a protective reaction of the body aimed at eliminating a toxic substance. This process of natural detoxification of the body can be artificially enhanced by the use of emetics, as well as gastric lavage through a tube. None of these methods has encountered serious objections in cases of oral poisoning since ancient times. However, there are situations that present known limitations in methods of emergency gastric cleansing.
In case of poisoning with cauterizing liquids, spontaneous or artificially induced vomiting is undesirable, since repeated passage of acid or alkali through the esophagus can increase the degree of its burn. There is another danger, which is the increased likelihood of aspiration of the cauterizing fluid and the development of a severe burn to the respiratory tract. In a coma state, the possibility of aspiration of gastric contents during vomiting also increases significantly.
These complications can be avoided by gastric lavage. In comatose states, gastric lavage should be performed after tracheal intubation, which completely prevents aspiration of vomit. The danger of inserting a gastric lavage tube in case of poisoning with cauterizing liquids has been greatly exaggerated.
In some cases, gastric lavage is abandoned if a lot of time has passed since the poison was taken. However, if the stomach was not washed, then at autopsy, even after long time after poisoning (2-3 days), a significant amount of poison is found in the intestines. In case of severe poisoning with narcotic poisons, when patients are unconscious for several days, it is recommended to rinse the stomach every 4-6 hours. The need for this procedure is explained by the repeated entry of the toxic substance into the stomach from the intestine as a result of reverse peristalsis and paresis of the pylorus.
The value of the method is very great, especially in the treatment of acute oral poisoning with highly toxic compounds such as chlorinated hydrocarbons (CHCs). In case of severe poisoning with these drugs, there are practically no contraindications for emergency gastric lavage using the tube method, and it should be repeated every 3-4 hours until the stomach is completely cleared of poisons. The latter can be established using sequential laboratory chemical analysis of the washing liquid. In case of poisoning with hypnotics, if tracheal intubation at the prehospital stage is impossible for any reason, gastric lavage should be postponed until the hospital, where both measures can be performed.
After gastric lavage, it is recommended to administer various adsorbents or laxatives orally to speed up the passage of the toxic substance through the gastrointestinal tract. There are no fundamental objections to the use of sorbents; activated carbon (50-80 g) is usually used along with water (100-150 ml) in the form of a liquid suspension. Any other drugs should not be used together with charcoal, as they will be sorbed and inactivate each other. The use of laxatives is often questionable because they do not act quickly enough to prevent the absorption of much of the poison. In addition, in case of poisoning with narcotic drugs due to a significant decrease in intestinal motility, laxatives are not given desired result. It is more favorable to use Vaseline oil (100-150 ml) as a laxative, which is not absorbed in the intestine and actively binds fat-soluble toxic substances, such as dichloroethane.
Thus, the use of laxatives has no independent value as a method of accelerated detoxification of the body.
More reliable way cleansing the intestines from toxic substances - washing it using direct probing and introducing special solutions (intestinal lavage). This procedure can be used as an initial step for subsequent intestinal dialysis. With this method of detoxification, the intestinal mucosa plays the role of a natural dialysing membrane. Many methods of dialysis through the digestive tract have been proposed, including gastric dialysis (continuous gastric lavage through a double-lumen tube), dialysis through the rectum, etc.
Forced diuresis method . In 1948, the Danish physician Olsson proposed a method of treating acute poisoning with hypnotics by administering large amounts of isotonic solutions intravenously simultaneously with mercury diuretics. There was an increase in diuresis to 5 liters per day and a decrease in the duration of the coma. The method has become widespread in clinical practice since the late 50s. Alkalinization of the blood also increases the release of barbiturates from the body. A slight shift in arterial blood pH to the alkaline side increases the content of barbiturates in plasma and slightly reduces their concentration in tissues. These phenomena are caused by the ionization of barbiturate molecules, which causes a decrease in their permeability through cell membranes according to the law of “nonionic diffusion.” In clinical practice, urine alkalinization is created by intravenous administration of sodium bicarbonate, sodium lactate, or trisamine.
The therapeutic effect of water load and alkalinization of urine in severe poisoning is significantly reduced due to insufficient diuresis due to increased secretion of antidiuretic hormone, hypovolemia and hypotension. Additional administration of diuretics, more active and safe than mercury, is required to reduce reabsorption, i.e., promote faster passage of the filtrate through the nephron and thereby increase diuresis and elimination of toxic substances from the body. These goals are best served by osmotic diuretics.
The effectiveness of the diuretic effect of the drug furosemide (Lasix), which belongs to the group of saluretics and used in a dose of 100-150 mg, is comparable to the effect of osmotic diuretics, however, with its repeated administration, more significant losses of electrolytes, especially potassium, are possible.
The method of forced diuresis is a fairly universal way to accelerate the elimination of various toxic substances excreted from the body in the urine. However, the effectiveness of diuretic therapy is reduced due to the strong connection of many chemicals with proteins and blood lipids.
Any method of forced diuresis involves three main stages:
Preliminary water load,
Rapid administration of a diuretic,
Replacement infusion of electrolyte solutions.
The peculiarity of the method is that when using the same dose of diuretics, a higher rate of diuresis is achieved (up to 20-30 ml/min) due to more intensive administration of fluid during the period of the highest concentration of diuretics in the blood.
The high speed and large volume of forced diuresis, reaching 10-20 liters of urine per day, pose the potential danger of rapid “washing out” of plasma electrolytes from the body.
It should be noted that strict accounting of the injected and excreted fluid, determination of hematocrit and central venous pressure make it possible to easily control the body’s water balance during treatment, despite the high rate of diuresis. Complications of the forced diuresis method (overhydration, hypokalemia, hypochloremia) are associated only with violation of the technique of its use. With long-term use (more than 2 days), in order to avoid thrombophlebitis of a punctured or catheterized vessel, it is recommended to use subclavian vein.
The method of forced diuresis is contraindicated in cases of intoxication complicated by acute cardiovascular failure (persistent collapse, circulatory disorders of II-III degree), as well as in cases of impaired renal function (oliguria, azotemia, increased blood creatinine), which is associated with a low filtration volume. In patients over 50 years of age, the effectiveness of the forced diuresis method is noticeably reduced for the same reason.
Methods of enhancing the body's natural detoxification processes include therapeutic hyperventilation, which can be caused by inhalation of carbogen or by connecting the patient to an artificial respiration apparatus. The method is considered effective for acute poisoning with toxic substances, which are largely removed from the body through the lungs.
IN clinical settings the effectiveness of this detoxification method has been proven for acute poisoning with carbon disulfide (up to 70% of which is released through the lungs), chlorinated hydrocarbons, carbon monoxide. However, its use is significantly limited by the fact that long-term hyperventilation is impossible due to the development of disturbances in the gas composition of the blood (hypocapnia) and acid-base balance (respiratory alkalosis).
Methods of artificial detoxification of the body.
Among the methods of artificial detoxification of the body, three fundamental phenomena can be distinguished on which they are based: dialysis, sorption and replacement.
Dialysis (from the Greek dialysis - decomposition, separation) - removal of low molecular weight substances from solutions of colloidal and high molecular weight substances, based on the property of semi-permeable membranes to pass low molecular weight substances and ions corresponding in size to their pores (up to 50 nm) and retain colloidal particles and macromolecules. The liquid to be dialyzed must be separated from the pure solvent (dialysis solution) by an appropriate membrane, through which small molecules and ions diffuse according to the laws of general diffusion into the solvent and, if it is changed frequently enough, are almost completely removed from the dialyzed liquid.
Natural membranes (serous membranes) and artificial synthetic membranes (cellophane, cuprofane, etc.) are used as semi-permeable membranes. The ability of various substances to penetrate through the pores of these membranes is called dializability.
Sorption (from Latin sorbeo - absorb) - absorption of molecules of gases, vapors or solutions by the surface solid or liquid. The body on the surface of which sorption occurs is called an adsorbent (sorbent), the adsorbed substances are called an adsorbent (adsorbate).
Basically, physical adsorption is observed, in which the molecules of the adsorbate substance retain their structure. During chemical adsorption, a new surface chemical compound is formed. Adsorption occurs under the influence of various forces: van der Waals, hydrogen, ionic, chelate. The type of bond formed and its energy determine the dissociation constant of the entire complex.
The main process of adsorption in blood plasma is carried out by van der Waals forces, which lack specificity. Therefore, proteins that have the largest total surface area of the total interphase area have the greatest sorption properties - 8200 μm 2 in 1 μm 3 of blood.
There are biological, plant and artificial sorbents. An almost exclusive monopoly in biological sorption processes belongs to albumin.
Substitution - the process of replacing a biological fluid containing toxic substances with another similar biological fluid or an artificial environment in order to remove toxic substances from the body.
The most widespread is bloodletting, known since time immemorial as a means of reducing the concentration of toxic substances in the body, followed by replacement of the lost volume with donor blood (blood replacement surgery). IN last years There has been increased interest in removing lymph from the body for the purpose of detoxifying lymph (lymphorrhea), followed by the introduction of electrolyte and protein solutions to compensate for their inevitable losses.
Among the many methods of extra-renal cleansing of the body peritoneal dialysis considered the simplest and most accessible. Back in 1924, Gunter proved the possibility of removing toxic substances from the blood by washing the abdominal cavity. Soon the method was applied in the clinic. However, the danger of developing peritonitis, noted by many researchers, has long prevented the widespread use of this method of detoxifying the body.
There are two types of peritoneal dialysis - continuous and intermittent. The mechanisms of diffusion exchange in both methods are the same; they differ only in the technique of execution. Continuous dialysis is carried out through two catheters inserted into the abdominal cavity. Fluid is injected through one catheter and removed through another. The intermittent method involves periodically filling the abdominal cavity with a special solution of about 2 liters, which is removed after exposure. The dialysis method is based on the fact that the peritoneum has a fairly large surface (about 20,000 cm 2), which is a semi-permeable membrane.
The greatest clearance of toxic substances is obtained in hypertonic dialysate solutions (350-850 mOsm/l) due to the ultrafiltration they create with the direction of the liquid flow (5-15 ml/min) towards the peritoneal cavity (“osmotic trap”). According to histological data, indicated hypertonic solutions do not lead to hydropia of the peritoneum and do not disrupt the microcirculation processes taking place in it.
In case of poisoning with barbiturates and other toxic substances that have the properties of acids, the optimal solution is a hypertonic dialysate solution (350-850 mOsm/l) with an alkaline pH (7.5-8.4).
To remove chlorpromazine and other toxic substances that have the properties of a weak base from the body, it is better to use dialysate solutions with increased osmotic pressure (350-750 mOsm/l) at a slightly acidic pH (7.1-7.25), which also creates the effect of “ionic traps."
When albumin is added to the dialysis solution, the clearance of barbiturates and chlorpromazine increases in proportion to the binding coefficients of these substances to blood proteins. This occurs due to the formation of large molecular protein complexes. The effect of such a “molecular trap” is created when oil solutions that bind fat-soluble poisons are introduced into the abdominal cavity (lipid dialysis).
In clinical practice, peritoneal dialysis is performed as an emergency detoxification measure for any type of acute “exogenous” poisoning, if reliable laboratory confirmation of the presence of a toxic concentration of a chemical substance in the body is obtained.
Hemodialysis , carried out in the early toxicogenic phase of acute poisoning with the aim of removing toxic substances that caused poisoning from the body, is called “early hemodialysis”. Its effectiveness is due, first of all, to the ability of a toxic substance to freely pass from the blood through the pores of the cellophane membrane of the dialyzer into the dialysate fluid.
Currently, early hemodialysis is widely used for severe poisoning with barbiturates, compounds heavy metals, dichloroethane, methyl alcohol, ethylene glycol, FOS, quinine and a number of other toxic substances. In this case, a significant decrease in the concentration of toxic substances in the blood is observed, exceeding that with conservative therapy, and an improvement in the clinical condition of patients. This prevents the development of many serious complications, which are the most common cause fatalities.
You can use single-use dialyzers that require minimal time to prepare them for work (almost during the time of sewing in the arteriovenous shunt, such devices are always ready for work).
The device is connected in patients with acute poisoning using the artery-vein method using a pre-sewn arteriovenous shunt in the lower third of one of the forearms.
A contraindication to early hemodialysis using these “artificial kidney” devices is a persistent drop in blood pressure below 80-90 mmHg. Art.
In clinical practice, the operation of early hemodialysis is most widely used for barbiturate poisoning: in 1 hour of hemodialysis, the same amount of barbiturates is released from the body as is independently excreted in the urine in 25-30 hours.
In the 70s, another promising method of extracorporeal artificial detoxification was developed - adsorption foreign blood substances onto the surface of the solid phase. This method is like an artificial analogue and addition to the process of adsorption of toxic substances, which occurs on the macromolecules of the body. Ion exchange resins (ion exchangers) and activated carbons have found practical use.
The surface of the adsorbents is very large, as a rule, reaching 1000 cm 2 /g. The degree of sorption is determined by two factors: the polarizability of the molecule and its geometric characteristics.
The hemosorption method for the treatment of poisoning was used in the clinic by Greek doctors Yatsidisidr in 1965. They showed that columns filled with active carbon absorbed a significant amount of barbiturates during blood perfusion, which made it possible to bring patients out of a comatose state. As an unfavorable effect of hemosorption, a decrease in the number of platelets, increased bleeding, chills with hyperthermia and a decrease in blood pressure in the first minutes from the start of the operation were noted.
A series of experimental studies have also been carried out in our country to study the sorption properties, selection and selective synthesis of domestic grades of activated carbons. Granular carbons of the SKT-6a and IGI brands with a special coating with blood proteins of the patient himself, which is done immediately before the operation, as well as the synthetic sorbent SKN, satisfy the most optimal requirements.
The hemosorption operation is carried out using a detoxifier of various designs, which is a portable mobile device with a blood pump and a set of columns with a capacity of 50 to 300 cm 3 (Fig. 16). The device is connected to the patient's bloodstream through an arteriovenous shunt. The effectiveness of the operation is assessed by the dynamics of the patient’s clinical condition and the data of laboratory toxicological studies.
The method of detoxification hemosorption has a number of advantages compared to methods of hemo- and peritoneal dialysis. This is primarily the technical simplicity of implementation and the high speed of detoxification. In addition, an important advantage of the method is its non-specificity, i.e. the possibility effective use in case of poisoning with drugs that are poorly or practically not dialyzable in the “artificial kidney” machine (short-acting barbiturates, phenothiazines, benzdiazepines, etc.).
For acute poisoning since the 40s, on the initiative of prof. O. S. Glozman (Alma-Ata) began to be widely used blood replacement surgery (BRO). It was the first method of active artificial detoxification in widespread clinical practice. It has been established that to completely replace the recipient's blood with donor blood, 10-15 liters are needed, i.e., an amount that is 2-3 times the volume of circulating blood, since part of the transfused blood is constantly removed from the body during simultaneous bloodletting. Considering the difficulties in obtaining the large amount of blood required for surgery and the danger of an immunological conflict, in clinical practice OZK is used in much smaller volumes (1500-2500 ml). When a toxic substance is distributed in the extracellular sector of the body (14 l), OZK, carried out in such a volume, can remove no more than 10-15% of the poison, and when it is distributed throughout the entire water sector (42 l) - no more than 5-7%.
For OBC, single-group, Rh-compatible donor or cadaveric (fibrinolysis) blood of various storage periods is used within the limits established by the instructions. In the clinic, OZK was used in patients with severe poisoning by toxic substances of more than 30 types. The operation is performed simultaneously using the continuous jet method using veno-venous or veno-arterial pathways through vascular catheterization.
Complications of OCH include temporary hypotension, post-transfusion reactions and moderate anemia in the postoperative period. Complications during surgery are largely determined by the clinical condition of patients at the time of surgery. In the absence of pronounced hemodynamic initial disturbances and a technically correctly performed operation, the level of blood pressure remains stable. Technical errors (disproportions in the volume of injected and removed blood) lead to temporary fluctuations in blood pressure within the range of 15-20 mmHg. Art. and can be easily corrected by restoring disturbed balance. Severe hemodynamic disorders are observed during acute cardiac arrest in patients with exotoxic shock.
Post-transfusion reactions (chills, urticarial rash, hyperthermia) are more often observed during transfusion of long-term stored blood (more than 10 days), which corresponds to a period of high reactogenicity of preserved blood. The cause of anemia is probably the homologous blood syndrome of an immunobiological nature, which is associated with blood transfusion from different donors.
It is advisable to identify absolute indications for OZK surgery, when it is assessed as a pathogenetic treatment and has advantages over other methods, and relative readings, which may be dictated by specific conditions if it is impossible to use more effective detoxification methods (hemodialysis, peritoneal dialysis).
An absolute indication for OZK is poisoning with substances that have a direct toxic effect on the blood, causing severe methemoglobinemia, increasing massive hemolysis (aniline, nitrobenzene, nitrites, arsenous hydrogen) and changes in blood enzymatic activity (BER). The significant advantages of OZK are the comparative simplicity of the method, which does not require special equipment, and the possibility of its use in any hospital setting. Contraindications to the use of OZK are severe hemodynamic disorders (collapse, pulmonary edema), as well as complicated heart defects, thrombophlebitis of the deep veins of the extremities.
One of the new methods of artificial detoxification of the body, introduced into clinical practice recently, is the possibility of removing large amounts of lymph from the body with subsequent compensation for the loss of extracellular fluid - detoxification lymphorrhea . Lymph is removed by catheterization of the thoracic lymph duct in the neck (lymphatic drainage). Compensation for the loss of lymph, which in some cases reaches 3-5 liters per day, is carried out using intravenous administration of an appropriate amount of plasma-substituting solutions. The results of using this method in case of poisoning with sleeping pills do not have advantages compared to other methods of accelerated detoxification of the body (forced diuresis, hemodialysis, etc.), since in a relatively small amount of lymph received per day (1000-2700 ml) no more than 5-7 % of the total amount of toxic substances dissolved in total volume of fluid in the body (42 l), which approximately corresponds to the rate of natural detoxification of the body in this pathology. It is usually not possible to achieve a more intense lymph outflow due to the instability of hemodynamic parameters, low level central venous pressure and symptoms of cardiovascular insufficiency. There is the possibility of reintroducing lymph, purified of toxic substances, into the body using dialysis with an “artificial kidney” machine or the lymphosorption method. This may be useful to compensate for possible loss of proteins, lipids and electrolytes.
Thus, the clinical effectiveness of the detoxification lymphorrhea method is limited to the small volume of lymph removed from the body. The method does not yet have independent clinical significance for emergency detoxification in acute exogenous poisoning, but can be used in combination with other methods, especially if it is possible to provide “lymphodialysis” or “lymphosorption”. More promising is the use of this method for endotoxicosis accompanying acute hepatic-renal failure.
The most effective in the clearance of most toxic substances are surgical methods of artificial detoxification (hemo- and peritoneal dialysis operations, detoxification hemosorption using active carbons). The main obstacle for successful application of these methods is the development of exotoxic shock, which puts forward a number of additional conditions to the detoxification method. These conditions require comprehensive consideration of the capabilities of each surgical method in terms of the amount of clearance obtained and the effect (positive or negative) on hemodynamic parameters.
Methods of extracorporeal blood purification are characterized by the most noticeable decrease in blood pressure at the beginning of the operation due to an increase in the total volume of the bloodstream and intensive redistribution of blood, which occurs according to the type of “centralization” of blood circulation with the movement of blood into the small circle.
Antidote detoxification.
Already at the turn of the 18th-19th centuries, the development of chemistry and biology made it possible to offer a number of chemical preparations for medicinal purposes, the antidote effect of which was associated with the neutralization of toxic substances of the inorganic series (acids, alkalis, oxides, etc.) through a chemical neutralization reaction and turning them into insoluble salts, and organic substances (alkaloids, protein toxins, etc.) - through the process of adsorption on vegetable charcoal.
The therapeutic effectiveness of these methods was strictly limited by the possibility of influencing the toxic substance located in gastrointestinal tract. Only relatively recently, 20-30 years ago, did it become possible to use new biochemical antidotes that can act on toxic substances present in the internal environment of the body: in the blood, parenchymal organs, etc.
A detailed study of the processes of toxicokinetics of chemical substances in the body, the paths of their biochemical transformations and the implementation of toxic effects allows us now to more realistically assess the possibilities of antidote therapy and determine its significance in different periods acute diseases chemical etiology.
1. Antidote therapy remains effective only in the early toxicogenic phase of acute poisoning, the duration of which varies and depends on the toxic-kinetic characteristics of a given toxic substance. The longest duration of this phase and, therefore, the duration of antidote therapy is observed in case of poisoning with heavy metal compounds (8-12 days), the shortest - when the body is exposed to highly toxic and rapidly metabolized compounds (cyanides, chlorinated hydrocarbons, etc.).
2. Antidote therapy is highly specific and therefore can be used only if there is a reliable clinical and laboratory diagnosis of this type of acute intoxication. Otherwise, if the antidote is mistakenly administered into high dose its toxic effect on the body may occur.
3. The effectiveness of antidote therapy is significantly reduced in the terminal stage of acute poisoning with the development of severe disorders of the circulatory system and gas exchange, which requires simultaneous implementation of the necessary resuscitation measures.
4. Antidote therapy plays a significant role in the prevention of irreversible states in acute poisoning, but does not have a therapeutic effect during their development, especially in the somatogenic phase of diseases.
Among the numerous medicines proposed at different times and by different authors as specific antidotes (antidotes) for acute poisoning by various toxic substances, 4 main groups can be distinguished.
1. Drugs,influencing the physicochemical state of a toxic substance in the gastrointestinal tract (chemical antidotes of contact action). Numerous chemical antidotes have now practically lost their importance due to a sharp change in the “nomenclature” of chemical substances that cause poisoning, and significant competition from methods for accelerated evacuation of poisons from the stomach using lavage through gastric tube. Gastric lavage is the simplest, always accessible and reliable way to reduce the resorption of toxic substances through the oral route. The use of activated carbon internally as a nonspecific sorbent retains its importance, 1 g of which absorbs up to 800 mg of morphine, 700 mg of barbital, 300-350 mg of other barbiturates and alcohol. In general, this method of treating poisoning is currently classified as a group of artificial detoxification methods called “gastrointestinal sorption.”
2. Drugs that have a specific physical and chemical effect on toxic substances in the humoral environment of the body (chemical antidotes of parenteral action). These drugs include thiol compounds (unithiol, mecaptide), used to treat acute poisoning with compounds of heavy metals and arsenic, and chelating agents (EDTA salts, thetacin), used to form non-toxic compounds (chelates) in the body with salts of certain metals (lead, cobalt, cadmium, etc.).
3. Drugs that provide beneficial changes in the metabolism of toxic substances in the body or the direction of biochemical reactions in which they participate. These drugs do not affect the physicochemical state of the toxic substance itself. This most extensive group is called “biochemical antidotes”, among which the greatest clinical use is currently found by cholinesterase reactivators (oximes) - for poisoning with FOS, methylene blue - for poisoning with methemoglobin formers, ethyl alcohol - for poisoning with methyl alcohol and ethylene glycol, nalorphine - for poisoning opium preparations, antioxidants - for carbon tetrachloride poisoning.
4. Drugs that have a therapeutic effect due to pharmacological antagonism with the action of toxic substances on the same functional systems of the body (pharmacological antidotes). In clinical toxicology, the most widely used pharmacological antagonism is between atropine and acetylcholine in case of FOS poisoning, between proserine and pachycarpine, potassium chloride and cardiac glycosides. This allows you to stop many dangerous symptoms of poisoning with these drugs, but rarely leads to the elimination of all clinical picture intoxication, since this antagonism is usually incomplete. In addition, pharmacological antagonist drugs, due to their competitive action, must be used in sufficiently large doses to exceed the concentration of the toxic substance in the body.
Biochemical and pharmacological antidotes do not change the physicochemical state of the toxic substance and do not come into any contact with it. However, the specific nature of their pathogenetic therapeutic effect brings them closer to the group of chemical antidotes, which makes it possible to use them in a complex called “specific antidote therapy.”
Application detoxification methods for chronic poisoning has its own characteristics, which depend on the specific conditions for the formation of chronic diseases in a given pathology.
Firstly, since in chronic poisoning there is usually deposition of toxic substances, that is, their strong connection with the organic or inorganic structures of cells and tissues, removing them from the body is extremely difficult. At the same time, the most common methods of accelerated cleansing of the body, such as hemodialysis and hemosorption, turn out to be ineffective.
Secondly, the main place in the treatment of chronic poisoning is occupied by the use of drugs that act on the xenobiotic entering the body and the products of its metabolism, i.e., a kind of chemotherapy, which has a toxic agent as the main object of its influence. As part of this therapy, two main groups should be distinguished: specific antidote detoxification agents and drugs for nonspecific, pathogenetic and symptomatic therapy.
The first group includes complexing compounds - salts of aminoalkylpolycarboxylic acids (thetacin and pentacine), effective against poisoning with lead, manganese, nickel, cadmium, and salts of aminoalkylpolyphosphonic acids (phosphicine and pentaphoscine), accelerating the elimination of beryllium, uranium, and lead. In addition, dithiols (unithiol, succimer, penicillamine) exhibit their protective properties against chronic poisoning with mercury, arsenic, lead, and cadmium.
The action of all complexing compounds has much in common, related to their selective ability to chelate (capture) and remove many toxic metals and metalloids bound in urine. To do this, they are used for a long time (1-2 months) in repeated courses, which leads to a decrease in the content of these substances in the body and, as a result, the symptoms of poisoning.
The second group includes numerous drugs that are widely used for general detoxification therapy for various diseases. Yes, treatment courses ascorbic acid reduce the toxic effects of certain metals - lead, chromium, vanadium; B vitamins with glucose - chlorinated hydrocarbons, etc. In case of manganese intoxication with parkinsonism syndrome, L-dopa is successfully used, as a result of which the formation of norepinephrine in patients increases, muscle tone, gait, and speech improve.
A feature of the clinical use of these drugs is the need for their long-term use in repeated courses.
Acute poisoning with chemicals, including drugs, is quite common. Poisonings can be accidental, deliberate (suicidal) and related to the characteristics of the profession. The most common acute poisonings are ethyl alcohol, hypnotics, psychotropic drugs, opioid and non-opioid analgesics, organophosphate insecticides and other compounds. Special toxicology centers and departments have been created for the treatment of poisoning by chemical substances. The main task in the treatment of acute poisoning is to remove the substance that caused intoxication from the body. In case of serious condition of patients, this should be preceded by general therapeutic and resuscitation measures aimed at ensuring the functioning of vital important systems- breathing and blood circulation. DELAY IN THE ABSORPTION OF A TOXIC SUBSTANCE INTO THE BLOOD Most often, acute poisoning is caused by ingestion of substances. Therefore, one of the important methods of detoxification is cleansing the stomach. To do this, induce vomiting or wash out the stomach. Vomiting is caused mechanically (by irritation of the posterior wall of the pharynx), by taking concentrated solutions of sodium chloride or sodium sulfate, or by administering the emetic apomorphine. In case of poisoning with substances that damage the mucous membranes (acids and alkalis), vomiting should not be induced, as additional damage to the mucous membrane of the esophagus will occur. In addition, aspiration of substances and burns of the respiratory tract are possible. Gastric lavage using a tube is more effective and safe. First, the contents of the stomach are removed, and then the stomach is washed with warm water, isotonic sodium chloride solution, potassium permanganate solution, to which activated carbon and other antidotes are added, if necessary. To delay the absorption of substances from the intestine, adsorbents (activated carbon) and laxatives (salt laxatives, petroleum jelly) are given. In addition, intestinal lavage is performed. If the substance that causes intoxication is applied to the skin or mucous membranes, it is necessary to rinse them thoroughly (preferably with running water). If toxic substances enter the lungs, you should stop inhaling them (remove the victim from the poisoned atmosphere or put a gas mask on him). When a toxic substance is administered subcutaneously, its absorption from the injection site can be slowed by injecting an epinephrine solution around the injection site, as well as cooling the area (an ice pack is placed on the skin surface). If possible, apply a tourniquet, which impedes the outflow of blood and creates venous stagnation in the area where the substance is administered. All these measures reduce the systemic toxic effect of the substance. REMOVAL OF TOXIC SUBSTANCE FROM THE BODY
If the substance is absorbed and has a resorptive effect, the main efforts should be aimed at removing it from the body as quickly as possible. For this purpose, forced diuresis, peritoneal dialysis, hemodialysis, hemosorption, blood replacement, etc. are used.
ELIMINATING THE EFFECT OF AN ABSORBED TOXIC SUBSTANCE
If it is established what substance caused the poisoning, then they resort to detoxification of the body with the help of antidotes.
Antidotes are drugs used for the specific treatment of poisoning by chemical substances. These include substances that inactivate poisons through chemical or physical interaction or through pharmacological antagonism (at the level of physiological systems, receptors, etc.)
SYMPTOMATIC THERAPY OF ACUTE POISONING
Important role Symptomatic therapy plays a role in the treatment of acute poisoning. It becomes especially important in case of poisoning with substances that do not have specific antidotes.
First of all, it is necessary to support vital functions - blood circulation and breathing. For this purpose, cardiotonics, substances that regulate blood pressure, agents that improve microcirculation in peripheral tissues are used, oxygen therapy is often used, sometimes respiratory stimulants, etc.
Drugs that reduce the sensitivity of afferent nerves, classification. Local anesthetics, classification, mechanism of action, Comparative characteristics individual drugs, main effects and indications for use, undesirable effects.
Agents that reduce the sensitivity of the endings of afferent fibers include local anesthetics, and agents that prevent the action of irritating substances on them include astringents and adsorbents. Local anesthetics are substances that can temporarily, reversibly block sensory receptors. First of all, pain receptors are blocked, and then temperature and tactile ones. In addition, local anesthetics disrupt the conduction of excitation along nerve fibers. First of all, the conduction along sensory nerve fibers is disrupted; however, at higher concentrations, local anesthetics can also block motor fibers. Mechanism of action local anesthetics caused by blockade of Na+ channels in the membranes of nerve endings and fibers. Due to the blockade of Na+ channels, the processes of depolarization of the membrane of nerve endings and fibers, the occurrence and propagation of action potentials are disrupted. Local anesthetics are weak bases. The non-ionized (non-protonated) part of the substance molecules penetrates into the nerve fibers, where an ionized form of the anesthetic is formed, which acts on the cytoplasmic (intracellular) part of the Na+ channels. In an acidic environment, local anesthetics are significantly ionized and do not penetrate the nerve fibers. Therefore, in an acidic environment, in particular, with tissue inflammation, the effect of local anesthetics is weakened. With the resorptive effect of local anesthetics, their effect on the central nervous system may occur. In this case, local anesthetics can cause anxiety, tremor, convulsions (suppression of inhibitory neurons), and in higher doses have a depressing effect on the respiratory and vasomotor centers. Local anesthetics inhibit myocardial contractility, dilate blood vessels (direct effect associated with blockade of Na+ channels, as well as a inhibitory effect on sympathetic innervation), lower blood pressure. The exception is cocaine, which strengthens and increases heart rate, constricts blood vessels, and increases blood pressure. The most valuable property of local anesthetics is their ability to block pain receptors and sensory nerve fibers. In this regard, they are used for local anesthesia ( local anesthesia), in particular during surgical operations.
Local anesthetics are classified into esters (ANESTHESIN, DICAINE, NOVOCAINE) and substituted amides (LIDOCAINE, TRIMECAINE, BUPIVACAINE).
Tetracaine (dicaine) is an active and toxic anesthetic. Due to its high toxicity, tetracaine is used mainly for superficial anesthesia: anesthesia of the mucous membranes of the eye (0.3%), nose and nasopharynx (1-2%). The highest single dose of tetracaine for anesthesia of the upper respiratory tract is 3 ml of a 3% solution. In case of overdose, even with local application tetracaine can be absorbed through mucous membranes and have a resorptive toxic effect. In this case, excitation of the central nervous system develops, which in severe cases is replaced by its paralysis; death occurs from paralysis of the respiratory center. To reduce the absorption of tetracaine, adrenaline is added to its solutions.
Benzocaine (anesthesin), unlike other local anesthetics, is slightly soluble in water; soluble in alcohol and fatty oils. In this regard, benzocaine is used exclusively for surface anesthesia in ointments, pastes, powders (for example, with skin diseases, accompanied severe itching), in rectal suppositories (for lesions of the rectum), as well as orally in powders for stomach pain and vomiting.
Procaine (Novocaine) is an active anesthetic whose effect lasts 30-45 minutes. The drug is highly soluble in water and can be sterilized using conventional methods. With certain precautions (adding a solution of adrenaline, observing the dosage), the toxicity of procaine is low. Procaine solutions are used for infiltration (0.25-0.5%), conduction and epidural (1-2%) anesthesia. To prevent the absorption of procaine, a 0.1% solution of adrenaline is added to its solutions. Procaine is sometimes used for spinal anesthesia, and in high concentrations (5-10%) - for superficial anesthesia. Bupivacaine is one of the most active and long-acting local anesthetics. For infiltration anesthesia, a 0.25% solution is used, for conduction anesthesia - 0.25-0.35% solutions, for epidural anesthesia - 0.5-0.75% solutions, and for subarachnoid anesthesia - a 0.5% solution. The resorptive effect of bupivacaine can be manifested by symptoms such as headache, dizziness, blurred vision, nausea, vomiting, ventricular arrhythmias, and atrioventricular block.
Lidocaine (xycaine, xylocaine). For superficial anesthesia, 2-4% solutions are used, for infiltration anesthesia - 0.25-0.5% solutions, for conduction and epidural anesthesia - 1-2% solutions. The toxicity of lidocaine is slightly higher than that of procaine, especially when used in high concentrations (1-2%). Lidocaine solutions are compatible with adrenaline (1 drop of 0.1% adrenaline solution per 10 ml of lidocaine solution, but not more than 5 drops for the entire amount of anesthetic solution). Lidocaine is also used as an antiarrhythmic agent.
Drugs that reduce the sensitivity of afferent nerves, classification. Astringents, enveloping and adsorbing agents, main drugs and indications for use, undesirable effects.
Astringents when applied to inflamed mucous membranes, they cause compaction (coagulation) of mucus proteins. The resulting protein film protects the cells of the mucous membrane and sensitive nerve endings from the action of various irritants. This reduces pain, swelling and hyperemia of the mucous membrane. Thus, astringents act as local anti-inflammatory agents. Organic - tannin, tanalbin, oak bark, blueberries, sage leaf, St. John's wort. Inorganic - lead acetate, basic bismuth nitrate, alum, zinc oxide, zinc sulfate, silver nitrate, xeroform. MD: coagulation of proteins of the superficial mucous membranes with the formation of a film. E: local narrowing of blood vessels, decreased permeability, decreased exudation, inhibition of enzymes. Adsorbent- talc, activated carbon, white clay. MD: adsorb substances on their surface. E: protect the endings of the senses. nerves, prevent the absorption of poisons. P: inflammation of the gastrointestinal tract, flatulence, diarrhea. PE: constipation, drowsiness. Annoying- mustard plasters, purified turpentine oil, menthol, ammonia solution. MD: irritate sensitive nerve endings of the skin and mucous membranes. E: suppress pain, improve trophism internal organs. P: neuralgia, myalgia, arthralgia, fainting, intoxication. PE: skin redness, swelling.
31. Drugs affecting efferent innervation, classification.
Most often in the general structure of poisonings are poisonings with cauterizing liquids, followed by drug poisonings. These are, first of all, poisoning with sleeping pills, tranquilizers, FOS, alcohol, carbon monoxide. Despite the difference etiological factors, measures of assistance at the stages of medical benefits are fundamentally similar. These principles are as follows: 1) COMBAT UNABSORBED POISON FROM THE GITTERINAL TRACT. Most often this is required in case of oral poisoning. Most often, acute poisoning is caused by ingestion. A mandatory and emergency measure in this regard is gastric lavage through a tube even 10-12 hours after poisoning. If the patient is conscious, gastric lavage is carried out using a large amount of water and subsequent induction of vomiting. Vomiting is caused mechanically. In an unconscious state, the patient's stomach is lavaged through a tube. It is necessary to direct efforts to the adsorption of the poison in the stomach, for which activated carbon is used (1 tablespoon orally, or 20-30 tablets at a time, before and after gastric lavage). The stomach is washed several times after 3-4 hours until the substance is completely cleared.
Vomiting is contraindicated in the following cases: - in comatose states; - in case of poisoning with corrosive liquids;
In case of poisoning with kerosene, gasoline (possibility of bicarbonate pneumonia with necrosis of lung tissue, etc.).
If the victim is a small child, then it is better to use saline solutions in small volumes (100-150 ml). It is best to remove poison from the intestines using saline laxatives. Therefore, after washing, you can introduce 100-150 ml of a 30% solution of sodium sulfate, or even better, magnesium sulfate, into the stomach. Saline laxatives are the most powerful, acting quickly throughout the intestines. Their action obeys the laws of osmosis, so they stop the action of the poison within a short period of time.
It is good to give astringents (tannin solutions, tea, bird cherry), as well as enveloping agents (milk, egg whites, vegetable oil). If the poison comes into contact with the skin, it is necessary to rinse the skin thoroughly, preferably with running water. If toxin enters the lungs, inhalation should be stopped by removing the victim from the poisoned atmosphere.
When tox is administered subcutaneously, its absorption from the injection site can be slowed down by injecting an adrenaline solution around the injection site, as well as cooling the area (ice on the skin at the injection site).
2) The second principle of assistance in acute poisoning is the INFLUENCE ON THE ABSORBED POISON, REMOVING IT FROM THE ORG-MA. In order to quickly remove toxins from the body, forced diuresis is used first of all. The essence of this method is to combine increased water load with the introduction of active, powerful diuretics. We carry out flooding of the body by drinking plenty of fluids to the patient or administering various intravenous solutions (blood replacement solutions, glucose, etc.). The most commonly used diuretics are FUROSEMIDE (Lasix) or MANNITOL. Using the method of forced diuresis, we seem to “wash” the patient’s tissues, freeing them from toxins. This method only manages to remove only free substances that are not associated with proteins and blood lipids. It is necessary to take into account the electrolyte balance, which when using this method can be disturbed due to the removal of a significant amount of ions from the body. In acute heart failure, severe nar-i f-i kidneys and the risk of developing cerebral or pulmonary edema, forced diuresis is contraindicated.
In addition to forced diuresis, hemodialysis and peritoneal dialysis are used, when blood (hemodialysis, or artificial kidney) passes through a semi-permeable membrane, freeing itself from toxins, or the peritoneal cavity is “washed” with a solution of electrolytes.
METHODS OF EXTRACORPORAL DETOXIFICATION. A successful detoxification method that has become widespread is the method of HEMOSORPTION (lymphosorption). IN in this case tox substances in the blood are adsorbed on special sorbents (granulated carbon coated with blood proteins, allospleen). This method makes it possible to successfully detoxify the body in case of poisoning with neuroleptics, tranquilizers, FOS, etc. The hemosorption method removes substances that are difficult to remove by hemodialysis and peritoneal dialysis.
BLOOD REPLACEMENT is used when bloodletting is combined with donor blood transfusion.
3) The third principle of combating acute poisoning is to REMOVAL THE ABSORBED POISON by introducing ANTAGONISTS and ANTIDOTES. Antagonists are widely used for acute poisoning. For example, atropine for poisoning with anticholinesterase drugs, FOS; nalorphine - in case of morphine poisoning, etc. Typically, pharmacological antagonists competitively interact with the same receptors as the substances that caused the poisoning. In this regard, the creation of SPECIFIC ANTIBODIES (monoclonal) against substances that are especially often the cause of acute poisoning (monoclonal antibodies against cardiac glycosides) looks very interesting.
For the specific treatment of patients with chemical poisoning, ANTIDOTE THERAPY is effective. ANTIDOTS are means used to specifically bind poison, neutralizing, inactivating poisons either through chemical or physical interaction. Thus, in case of poisoning with heavy metals, compounds are used that form non-tox complexes with them (for example, unithiol for arsenic poisoning, D-penicillamine, desferal for poisoning with iron preparations, etc.).
4) The fourth principle is to carry out SYMPTOMATIC THERAPY. Symptomatic therapy is especially important for poisoning with substances that do not have special antidotes.
Symptomatic therapy supports vital functions: BLOOD CIRCULATION and BREATHING. They use cardiac glycosides, vasotonics, agents that improve microcirculation, oxygen therapy, and respiratory stimulants. Convulsions are eliminated with injections of sibazon. For cerebral edema, dehydration therapy (furosemide, mannitol) is performed. analgesics are used and blood acid-base level is corrected. If breathing stops, the patient is transferred to artificial ventilation with a set of resuscitation measures.
1. Stopping the flow of poison into the patient’s body.
2. Accelerated removal of poison from the body, the use of antidote therapy, detoxification therapy methods.
3. Symptomatic therapy aimed at correcting vital important functions body.
Treatment is etiotropic in nature.
Methods of detoxification therapy (according to E.A. Luzhnikov)
I. Methods of stimulating the natural processes of cleansing the body. A. Stimulation of excretion
Cleansing the gastrointestinal tract:
emetics (apomorphine, ipecac),
gastric lavage (simple, tube),
intestinal lavage (tube lavage 500 ml/kg - 30 l, enema),
laxatives (salt, oil, herbal), pharmacological stimulation of intestinal motility (KCI + pituitrin, serotonin adipate).
Forced diuresis:
water-electrolyte load (oral, parenteral), osmotic diuresis (urea, mannitol, sorbitol), saluretic diuresis (Lasix).
Therapeutic hyperventilation of the lungs.
B. Stimulation of biotransformation
Regulation of enzymatic function of hepatocytes:
enzymatic induction (zixorine, phenobarbital),
enzymatic inhibition (chloramphenicol, 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 replacement drugs (hemodesis),
hemapheresis (blood replacement),
plasmapheresis,
lymphpheresis, perfusion of the lymphatic system.
Dialysis and filtration.
Extracorporeal methods:
hemo- (plasma-, lympho-) dialysis,
ultrafiltration,
hemofiltration,
hemode filtration.
Intracorporeal methods:
peritoneal dialysis,
intestinal dialysis.
Sorptive.
Extracorporeal methods:
hemo- (plasma-, lympho-) sorption,
application sorption,
biosorption (spleen), allogeneic liver cells.
Intracorporeal methods: enterosorption. Physio- and chemohemotherapy: ultraviolet irradiation of blood, laser irradiation of blood,
magnetic blood treatment,
electrochemical oxidation of blood (sodium hypochlorite), ozone hemotherapy.
In case of oral poisoning, mandatory and emergency measures
The solution is to lavage the stomach through a tube, regardless of the time that has passed since the moment of intoxication. Patients with impaired consciousness/inappropriate behavior must be securely restrained; In patients with impaired pharyngeal reflexes and those in a comatose state, tracheal intubation is first performed.
In case of poisoning with cauterizing liquids, gastric lavage through a tube is mandatory in the first hours after taking the poison. The presence of blood in the rinsing waters is not a contraindication for this procedure. In these cases, the probe is generously lubricated with petroleum jelly before insertion, and 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 purpose significantly worsens the patient’s condition due to significant expansion of the stomach by the resulting carbon dioxide. In case of poisoning with cauterizing poison, laxatives 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 membranes of the lips, oral cavity, and tongue, use a 1% solution of ascorbic acid.
In case of poisoning with gasoline, kerosene and other petroleum products, before rinsing, it is necessary to inject 100-150 ml of Vaseline oil into the stomach, and then rinse according to the usual scheme.
At severe forms poisoning in patients who are unconscious (poisoning with organophosphorus insecticides, sleeping pills, etc.), gastric lavage is carried out repeatedly, 2-3 times in the first day after poisoning, since due to a sharp slowdown in resorption in a comatose state in the gastrointestinal tract a significant amount of a toxic substance can be deposited and reabsorbed.
After lavage is completed, you can administer it into the stomach as a laxative. magnesium sulfate or in case of poisoning with fat-soluble substances, 100 ml of petroleum jelly. It is also necessary to cleanse the intestines using siphon enemas. In case of poisoning with cauterizing poisons, these measures are contraindicated.
The administration of emetics and inducing vomiting by irritation of the posterior pharyngeal wall in patients in a stuporous and unconscious state, as well as in cases of poisoning with cauterizing poisons, are contraindicated. To adsorb toxic substances in the gastrointestinal tract orally before and after gastric lavage, activated carbon with water is used in the form of a slurry (enterosorption).
For snake bites, subcutaneous or intramuscular injection of toxic doses of drugs, cold is used topically for 6-8 hours. Introducing a 0.1% adrenaline solution into the injection site and circular novocaine blockade above the point of entry of toxins.
In case of poisoning through the skin, the patient must be freed from clothing, and the skin must 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, you should first of all take the victim out of the affected atmosphere, lay him down, ensure airway patency, free him from restrictive clothing, and give oxygen inhalation. Treatment depends on the substance that caused the poisoning. Personnel working in the affected area must have individual means protection.
When toxic substances enter the rectum, it is washed with a cleansing enema.
To remove toxic substances from the bloodstream, the method of forced diuresis is most often used, which consists of carrying out a water load followed by the administration of osmotic diuretics or saluretics. The method is indicated for most poisonings with water-soluble poisons, when they are eliminated primarily 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 conditions of which the rate of transition of toxic substances from tissues to the blood increases. For this purpose, puncture and catheterization of the vein are performed according to Seldinger. Short-acting hemodilutants are used (0.9% isotonic sodium chloride solution; Ringer's solution, as well as other electrolyte solutions or mixtures of electrolytes, 5.10% glucose solutions). The second stage is the administration of diuretics to stimulate diuresis. Classically, osmotic diuretics such as urea and mannitol are used as diuretics. However, Lasix has now become the leading drug. It is administered in a dose of 40 mg after administration of 150 -200 ml of infusion solutions. When using Lasix, significant losses of electrolytes are observed, so treatment must be carried out under strict control of water and electrolyte balance. When carrying out forced diuresis, constant monitoring of the volume of injected solutions and excreted urine is necessary. When selecting infusion solutions
creations should REMEMBER that. that for some poisons (in particular for organophosphorus compounds) alkalization is undesirable, because in an alkaline environment the process of “lethal synthesis” occurs more intensely, that is, the formation of products more toxic than the original substance.
The method of forced diuresis is contraindicated in cases of intoxication complicated by acute and chronic cardiovascular failure (persistent collapse), as well as in cases of impaired renal function.
Hemodialysis using an artificial kidney machine is effective method treatment of acute poisoning with dialysable substances (barbiturates, salicylates, methyl alcohol, etc.), especially in early period intoxication for the purpose of accelerated removal of toxic substances from the body.
Hemodialysis for poisoning with heavy metal salts and arsenic should be carried out in combination with specific therapy (intravenous administration of a 5% unithiol solution at the time of dialysis), 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 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 fatty tissues or bind tightly to plasma proteins.
Peritoneal dialysis surgery is possible in any surgical hospital. Peritoneal dialysis is carried out intermittently after a special fistula is sewn into the abdominal wall. Dialysis fluid is injected into the abdominal cavity through the fistula using a polyethylene catheter. The amount of liquid required for a single rinse of the abdominal cavity 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 failure, which distinguishes it favorably from other methods of accelerated removal of toxic substances from the body.
Hemosorption detoxification using perfusion of the patient's blood through a special column with a sorbent is the most effective method of 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 donor blood is indicated for acute poisoning with certain chemicals that cause toxic damage blood - formation of methemoglobin (aniline), long-term decline cholinesterase activity (organophosphorus insecticides), massive hemolysis (hydrogen arsenous), as well as in severe poisoning with drugs (amitriptyline, belloid, ferrocyrone) and plant poisons (capillary toadstool), etc.
For blood replacement, single-group Rh-compatible individually selected donor blood is used. A positive effect is observed after replacing 25% of the bcc. Optimal replacement is 100% bcc.
On average, BCC = 70-75 ml/kg body weight.
To remove blood from the victim, 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 at a time) and the same amount of donor blood is introduced in return. The replacement rate is no 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 injected intravenously for every 100 ml of blood transfused. After the operation, it is necessary to monitor the electrolyte balance of the blood, and the next day - a study general analysis urine and general blood test.
The operation is contraindicated in case of 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 cleansing various methods(filtration, sorption). The advantages of plasmapheresis include the absence of harmful effects on hemodynamics.
