- •CONTENTS
- •Preface
- •Contributors
- •1 Introduction to Toxicology
- •1.1 Definition and Scope, Relationship to Other Sciences, and History
- •1.1.2 Relationship to Other Sciences
- •1.1.3 A Brief History of Toxicology
- •1.3 Sources of Toxic Compounds
- •1.3.1 Exposure Classes
- •1.3.2 Use Classes
- •1.4 Movement of Toxicants in the Environment
- •Suggested Reading
- •2.1 Introduction
- •2.2 Cell Culture Techniques
- •2.2.1 Suspension Cell Culture
- •2.2.2 Monolayer Cell Culture
- •2.2.3 Indicators of Toxicity in Cultured Cells
- •2.3 Molecular Techniques
- •2.3.1 Molecular Cloning
- •2.3.2 cDNA and Genomic Libraries
- •2.3.3 Northern and Southern Blot Analyses
- •2.3.4 Polymerase Chain Reaction (PCR)
- •2.3.5 Evaluation of Gene Expression, Regulation, and Function
- •2.4 Immunochemical Techniques
- •Suggested Reading
- •3.1 Introduction
- •3.2 General Policies Related to Analytical Laboratories
- •3.2.1 Standard Operating Procedures (SOPs)
- •3.2.2 QA/QC Manuals
- •3.2.3 Procedural Manuals
- •3.2.4 Analytical Methods Files
- •3.2.5 Laboratory Information Management System (LIMS)
- •3.3 Analytical Measurement System
- •3.3.1 Analytical Instrument Calibration
- •3.3.2 Quantitation Approaches and Techniques
- •3.4 Quality Assurance (QA) Procedures
- •3.5 Quality Control (QC) Procedures
- •3.6 Summary
- •Suggested Reading
- •4 Exposure Classes, Toxicants in Air, Water, Soil, Domestic and Occupational Settings
- •4.1 Air Pollutants
- •4.1.1 History
- •4.1.2 Types of Air Pollutants
- •4.1.3 Sources of Air Pollutants
- •4.1.4 Examples of Air Pollutants
- •4.1.5 Environmental Effects
- •4.2 Water and Soil Pollutants
- •4.2.1 Sources of Water and Soil Pollutants
- •4.2.2 Examples of Pollutants
- •4.3 Occupational Toxicants
- •4.3.1 Regulation of Exposure Levels
- •4.3.2 Routes of Exposure
- •4.3.3 Examples of Industrial Toxicants
- •Suggested Reading
- •5 Classes of Toxicants: Use Classes
- •5.1 Introduction
- •5.2 Metals
- •5.2.1 History
- •5.2.2 Common Toxic Mechanisms and Sites of Action
- •5.2.3 Lead
- •5.2.4 Mercury
- •5.2.5 Cadmium
- •5.2.6 Chromium
- •5.2.7 Arsenic
- •5.2.8 Treatment of Metal Poisoning
- •5.3 Agricultural Chemicals (Pesticides)
- •5.3.1 Introduction
- •5.3.3 Organochlorine Insecticides
- •5.3.4 Organophosphorus Insecticides
- •5.3.5 Carbamate Insecticides
- •5.3.6 Botanical Insecticides
- •5.3.7 Pyrethroid Insecticides
- •5.3.8 New Insecticide Classes
- •5.3.9 Herbicides
- •5.3.10 Fungicides
- •5.3.11 Rodenticides
- •5.3.12 Fumigants
- •5.3.13 Conclusions
- •5.4 Food Additives and Contaminants
- •5.5 Toxins
- •5.5.1 History
- •5.5.2 Microbial Toxins
- •5.5.3 Mycotoxins
- •5.5.4 Algal Toxins
- •5.5.5 Plant Toxins
- •5.5.6 Animal Toxins
- •5.6 Solvents
- •5.7 Therapeutic Drugs
- •5.8 Drugs of Abuse
- •5.9 Combustion Products
- •5.10 Cosmetics
- •Suggested Reading
- •6 Absorption and Distribution of Toxicants
- •6.1 Introduction
- •6.2 Cell Membranes
- •6.3 Mechanisms of Transport
- •6.3.1 Passive Diffusion
- •6.4 Physicochemical Properties Relevant to Diffusion
- •6.4.1 Ionization
- •6.5 Routes of Absorption
- •6.5.1 Extent of Absorption
- •6.5.2 Gastrointestinal Absorption
- •6.5.3 Dermal Absorption
- •6.5.4 Respiratory Penetration
- •6.6 Toxicant Distribution
- •6.6.1 Physicochemical Properties and Protein Binding
- •6.7 Toxicokinetics
- •Suggested Reading
- •7 Metabolism of Toxicants
- •7.1 Introduction
- •7.2 Phase I Reactions
- •7.2.4 Nonmicrosomal Oxidations
- •7.2.5 Cooxidation by Cyclooxygenases
- •7.2.6 Reduction Reactions
- •7.2.7 Hydrolysis
- •7.2.8 Epoxide Hydration
- •7.2.9 DDT Dehydrochlorinase
- •7.3 Phase II Reactions
- •7.3.1 Glucuronide Conjugation
- •7.3.2 Glucoside Conjugation
- •7.3.3 Sulfate Conjugation
- •7.3.4 Methyltransferases
- •7.3.7 Acylation
- •7.3.8 Phosphate Conjugation
- •Suggested Reading
- •8 Reactive Metabolites
- •8.1 Introduction
- •8.2 Activation Enzymes
- •8.3 Nature and Stability of Reactive Metabolites
- •8.4 Fate of Reactive Metabolites
- •8.4.1 Binding to Cellular Macromolecules
- •8.4.2 Lipid Peroxidation
- •8.4.3 Trapping and Removal: Role of Glutathione
- •8.5 Factors Affecting Toxicity of Reactive Metabolites
- •8.5.1 Levels of Activating Enzymes
- •8.5.2 Levels of Conjugating Enzymes
- •8.5.3 Levels of Cofactors or Conjugating Chemicals
- •8.6 Examples of Activating Reactions
- •8.6.1 Parathion
- •8.6.2 Vinyl Chloride
- •8.6.3 Methanol
- •8.6.5 Carbon Tetrachloride
- •8.6.8 Acetaminophen
- •8.6.9 Cycasin
- •8.7 Future Developments
- •Suggested Reading
- •9.1 Introduction
- •9.2 Nutritional Effects
- •9.2.1 Protein
- •9.2.2 Carbohydrates
- •9.2.3 Lipids
- •9.2.4 Micronutrients
- •9.2.5 Starvation and Dehydration
- •9.2.6 Nutritional Requirements in Xenobiotic Metabolism
- •9.3 Physiological Effects
- •9.3.1 Development
- •9.3.2 Gender Differences
- •9.3.3 Hormones
- •9.3.4 Pregnancy
- •9.3.5 Disease
- •9.3.6 Diurnal Rhythms
- •9.4 Comparative and Genetic Effects
- •9.4.1 Variations Among Taxonomic Groups
- •9.4.2 Selectivity
- •9.4.3 Genetic Differences
- •9.5 Chemical Effects
- •9.5.1 Inhibition
- •9.5.2 Induction
- •9.5.3 Biphasic Effects: Inhibition and Induction
- •9.6 Environmental Effects
- •9.7 General Summary and Conclusions
- •Suggested Reading
- •10 Elimination of Toxicants
- •10.1 Introduction
- •10.2 Transport
- •10.3 Renal Elimination
- •10.4 Hepatic Elimination
- •10.4.2 Active Transporters of the Bile Canaliculus
- •10.5 Respiratory Elimination
- •10.6 Conclusion
- •Suggested Reading
- •11 Acute Toxicity
- •11.1 Introduction
- •11.2 Acute Exposure and Effect
- •11.3 Dose-response Relationships
- •11.4 Nonconventional Dose-response Relationships
- •11.5 Mechanisms of Acute Toxicity
- •11.5.1 Narcosis
- •11.5.2 Acetylcholinesterase Inhibition
- •11.5.3 Ion Channel Modulators
- •11.5.4 Inhibitors of Cellular Respiration
- •Suggested Reading
- •12 Chemical Carcinogenesis
- •12.1 General Aspects of Cancer
- •12.2 Human Cancer
- •12.2.1 Causes, Incidence, and Mortality Rates of Human Cancer
- •12.2.2 Known Human Carcinogens
- •12.3 Classes of Agents Associated with Carcinogenesis
- •12.3.2 Epigenetic Agents
- •12.4 General Aspects of Chemical Carcinogenesis
- •12.5 Initiation-Promotion Model for Chemical Carcinogenesis
- •12.6 Metabolic Activation of Chemical Carcinogens and DNA Adduct Formation
- •12.7 Oncogenes
- •12.8 Tumor Suppressor Genes
- •12.8.1 Inactivation of Tumor Suppressor Genes
- •12.8.2 p53 Tumor Suppressor Gene
- •12.9 General Aspects of Mutagenicity
- •12.10 Usefulness and Limitations of Mutagenicity Assays for the Identification of Carcinogens
- •Suggested Reading
- •13 Teratogenesis
- •13.1 Introduction
- •13.2 Principles of Teratology
- •13.3 Mammalian Embryology Overview
- •13.4 Critical Periods
- •13.5 Historical Teratogens
- •13.5.1 Thalidomide
- •13.5.2 Accutane (Isotetrinoin)
- •13.5.3 Diethylstilbestrol (DES)
- •13.5.4 Alcohol
- •13.6 Testing Protocols
- •13.6.1 FDA Guidelines for Reproduction Studies for Safety Evaluation of Drugs for Human Use
- •13.6.3 Alternative Test Methods
- •13.7 Conclusions
- •Suggested Reading
- •14 Hepatotoxicity
- •14.1 Introduction
- •14.1.1 Liver Structure
- •14.1.2 Liver Function
- •14.2 Susceptibility of the Liver
- •14.3 Types of Liver Injury
- •14.3.1 Fatty Liver
- •14.3.2 Necrosis
- •14.3.3 Apoptosis
- •14.3.4 Cholestasis
- •14.3.5 Cirrhosis
- •14.3.6 Hepatitis
- •14.3.7 Oxidative Stress
- •14.3.8 Carcinogenesis
- •14.4 Mechanisms of Hepatotoxicity
- •14.5 Examples of Hepatotoxicants
- •14.5.1 Carbon Tetrachloride
- •14.5.2 Ethanol
- •14.5.3 Bromobenzene
- •14.5.4 Acetaminophen
- •14.6 Metabolic Activation of Hepatotoxicants
- •Suggested Reading
- •15 Nephrotoxicity
- •15.1 Introduction
- •15.1.1 Structure of the Renal System
- •15.1.2 Function of the Renal System
- •15.2 Susceptibility of the Renal System
- •15.3 Examples of Nephrotoxicants
- •15.3.1 Metals
- •15.3.2 Aminoglycosides
- •15.3.3 Amphotericin B
- •15.3.4 Chloroform
- •15.3.5 Hexachlorobutadiene
- •Suggested Reading
- •16 Toxicology of the Nervous System
- •16.1 Introduction
- •16.2 The Nervous system
- •16.2.1 The Neuron
- •16.2.2 Neurotransmitters and their Receptors
- •16.2.3 Glial Cells
- •16.3 Toxicant Effects on the Nervous System
- •16.3.1 Structural Effects of Toxicants on Neurons
- •16.3.2 Effects of Toxicants on Other Cells
- •16.4 Neurotoxicity Testing
- •16.4.1 In vivo Tests of Human Exposure
- •16.4.2 In vivo Tests of Animal Exposure
- •16.4.3 In vitro Neurochemical and Histopathological End Points
- •16.5 Summary
- •Suggested Reading
- •17 Endocrine System
- •17.1 Introduction
- •17.2 Endocrine System
- •17.2.1 Nuclear Receptors
- •17.3 Endocrine Disruption
- •17.3.1 Hormone Receptor Agonists
- •17.3.2 Hormone Receptor Antagonists
- •17.3.3 Organizational versus Activational Effects of Endocrine Toxicants
- •17.3.4 Inhibitors of Hormone Synthesis
- •17.3.5 Inducers of Hormone Clearance
- •17.3.6 Hormone Displacement from Binding Proteins
- •17.4 Incidents of Endocrine Toxicity
- •17.4.1 Organizational Toxicity
- •17.4.2 Activational Toxicity
- •17.4.3 Hypothyroidism
- •17.5 Conclusion
- •Suggested Reading
- •18 Respiratory Toxicity
- •18.1 Introduction
- •18.1.1 Anatomy
- •18.1.2 Cell Types
- •18.1.3 Function
- •18.2 Susceptibility of the Respiratory System
- •18.2.1 Nasal
- •18.2.2 Lung
- •18.3 Types of Toxic Response
- •18.3.1 Irritation
- •18.3.2 Cell Necrosis
- •18.3.3 Fibrosis
- •18.3.4 Emphysema
- •18.3.5 Allergic Responses
- •18.3.6 Cancer
- •18.3.7 Mediators of Toxic Responses
- •18.4 Examples of Lung Toxicants Requiring Activation
- •18.4.1 Introduction
- •18.4.2 Monocrotaline
- •18.4.3 Ipomeanol
- •18.4.4 Paraquat
- •18.5 Defense Mechanisms
- •Suggested Reading
- •19 Immunotoxicity
- •19.1 Introduction
- •19.2 The Immune System
- •19.3 Immune Suppression
- •19.4 Classification of Immune-Mediated Injury (Hypersensitivity)
- •19.5 Effects of Chemicals on Allergic Disease
- •19.5.1 Allergic Contact Dermatitis
- •19.5.2 Respiratory Allergens
- •19.5.3 Adjuvants
- •19.6 Emerging Issues: Food Allergies, Autoimmunity, and the Developing Immune System
- •Suggested Reading
- •20 Reproductive System
- •20.1 Introduction
- •20.2 Male Reproductive Physiology
- •20.3 Mechanisms and Targets of Male Reproductive Toxicants
- •20.3.1 General Mechanisms
- •20.3.2 Effects on Germ Cells
- •20.3.3 Effects on Spermatogenesis and Sperm Quality
- •20.3.4 Effects on Sexual Behavior
- •20.3.5 Effects on Endocrine Function
- •20.4 Female Reproductive Physiology
- •20.5 Mechanisms and Targets of Female Reproductive Toxicants
- •20.5.1 Tranquilizers, Narcotics, and Social Drugs
- •20.5.2 Endocrine Disruptors (EDs)
- •20.5.3 Effects on Germ Cells
- •20.5.4 Effects on the Ovaries and Uterus
- •20.5.5 Effects on Sexual Behavior
- •Suggested Reading
- •21 Toxicity Testing
- •21.1 Introduction
- •21.2 Experimental Administration of Toxicants
- •21.2.1 Introduction
- •21.2.2 Routes of Administration
- •21.3 Chemical and Physical Properties
- •21.4 Exposure and Environmental Fate
- •21.5 In vivo Tests
- •21.5.1 Acute and Subchronic Toxicity Tests
- •21.5.2 Chronic Tests
- •21.5.3 Reproductive Toxicity and Teratogenicity
- •21.5.4 Special Tests
- •21.6 In vitro and Other Short-Term Tests
- •21.6.1 Introduction
- •21.6.2 Prokaryote Mutagenicity
- •21.6.3 Eukaryote Mutagenicity
- •21.6.4 DNA Damage and Repair
- •21.6.5 Chromosome Aberrations
- •21.6.6 Mammalian Cell Transformation
- •21.6.7 General Considerations and Testing Sequences
- •21.7 Ecological Effects
- •21.7.1 Laboratory Tests
- •21.7.2 Simulated Field Tests
- •21.7.3 Field Tests
- •21.8 Risk Analysis
- •21.9 The Future of Toxicity Testing
- •Suggested Reading
- •22 Forensic and Clinical Toxicology
- •22.1 Introduction
- •22.2 Foundations of Forensic Toxicology
- •22.3 Courtroom Testimony
- •22.4.1 Documentation Practices
- •22.4.2 Considerations for Forensic Toxicological Analysis
- •22.4.3 Drug Concentrations and Distribution
- •22.5 Laboratory Analyses
- •22.5.1 Colorimetric Screening Tests
- •22.5.2 Thermal Desorption
- •22.5.6 Enzymatic Immunoassay
- •22.6 Analytical Schemes for Toxicant Detection
- •22.7 Clinical Toxicology
- •22.7.1 History Taking
- •22.7.2 Basic Operating Rules in the Treatment of Toxicosis
- •22.7.3 Approaches to Selected Toxicoses
- •Suggested Reading
- •23 Prevention of Toxicity
- •23.1 Introduction
- •23.2 Legislation and Regulation
- •23.2.1 Federal Government
- •23.2.2 State Governments
- •23.2.3 Legislation and Regulation in Other Countries
- •23.3 Prevention in Different Environments
- •23.3.1 Home
- •23.3.2 Workplace
- •23.3.3 Pollution of Air, Water, and Land
- •23.4 Education
- •Suggested Reading
- •24 Human Health Risk Assessment
- •24.1 Introduction
- •24.2 Risk Assessment Methods
- •24.2.2 Exposure Assessment
- •24.2.3 Dose Response and Risk Characterization
- •24.3 Noncancer Risk Assessment
- •24.3.1 Default Uncertainty and Modifying Factors
- •24.3.2 Derivation of Developmental Toxicant RfD
- •24.3.3 Determination of RfD and RfC of Naphthalene with the NOAEL Approach
- •24.3.4 Benchmark Dose Approach
- •24.3.5 Determination of BMD and BMDL for ETU
- •24.3.6 Quantifying Risk for Noncarcinogenic Effects: Hazard Quotient
- •24.3.7 Chemical Mixtures
- •24.4 Cancer Risk Assessment
- •24.5 PBPK Modeling
- •Suggested Reading
- •25 Analytical Methods in Toxicology
- •25.1 Introduction
- •25.2 Chemical and Physical Methods
- •25.2.1 Sampling
- •25.2.2 Experimental Studies
- •25.2.3 Forensic Studies
- •25.2.4 Sample Preparation
- •25.2.6 Spectroscopy
- •25.2.7 Other Analytical Methods
- •Suggested Reading
- •26 Basics of Environmental Toxicology
- •26.1 Introduction
- •26.2 Environmental Persistence
- •26.2.1 Abiotic Degradation
- •26.2.2 Biotic Degradation
- •26.2.3 Nondegradative Elimination Processes
- •26.3 Bioaccumulation
- •26.4 Toxicity
- •26.4.1 Acute Toxicity
- •26.4.2 Mechanisms of Acute Toxicity
- •26.4.3 Chronic Toxicity
- •26.4.5 Abiotic and Biotic Interactions
- •26.5 Conclusion
- •Suggested Reading
- •27.1 Introduction
- •27.2 Sources of Toxicants to the Environment
- •27.3 Transport Processes
- •27.3.1 Advection
- •27.3.2 Diffusion
- •27.4 Equilibrium Partitioning
- •27.5 Transformation Processes
- •27.5.1 Reversible Reactions
- •27.5.2 Irreversible Reactions
- •27.6 Environmental Fate Models
- •Suggested Reading
- •28 Environmental Risk Assessment
- •28.1 Introduction
- •28.2 Formulating the Problem
- •28.2.1 Selecting Assessment End Points
- •28.2.2 Developing Conceptual Models
- •28.2.3 Selecting Measures
- •28.3 Analyzing Exposure and Effects Information
- •28.3.1 Characterizing Exposure
- •28.3.2 Characterizing Ecological Effects
- •28.4 Characterizing Risk
- •28.4.1 Estimating Risk
- •28.4.2 Describing Risk
- •28.5 Managing Risk
- •Suggested Reading
- •29 Future Considerations for Environmental and Human Health
- •29.1 Introduction
- •29.2 Risk Management
- •29.3 Risk Assessment
- •29.4 Hazard and Exposure Assessment
- •29.5 In vivo Toxicity
- •29.6 In vitro Toxicity
- •29.7 Biochemical and Molecular Toxicology
- •29.8 Development of Selective Toxicants
- •Glossary
- •Index
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CLINICAL TOXICOLOGY |
405 |
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Drug Analysis Flow Chart |
BLOOD |
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URINE (BLOOD) |
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VS |
ANS |
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DAS and GDS |
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Headspace |
Charcoal ext |
M-butyl cl:ether |
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(EIA, TLC, RIA) |
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(GC) |
GC/MS |
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Pos* |
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Others: VS |
Others |
Others |
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Vitreous, |
Salicylated, |
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Benzoylecgonine, |
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Confirmation |
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Bile Tissue |
acetaminophen, |
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THC, Morphine |
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(GLC) |
phenobarbital |
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derivatization |
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Others: Halogenated hydrocarbons, |
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(GC/MS) |
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Arsenic, Cyanide (Colorimetric**) |
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Others |
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Other |
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Metals |
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and halogenated hydrocarbons |
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Headspace |
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(GC/MS)
*If a drug is detected then the appropriate blood screen is conducted
**If a colorimetric test is positive, an appropriate confirmation is performed.
Figure 22.3 Drug analysis flowchart.
to be assayed. A given laboratory will follow an algorithm to handle the analysis. The Volatile Screen (VS) is frequently used for the detection of ethanol. A Drugs of Abuse Screen (DAS) is commonly used for amphetamines, cocaine, marijuana, and so on. When the cause of death is unclear, a General Drug Screen (GDS) is employed. Acidic/Neutral Screen (ANS) is primarily used to detect barbiturates, muscle relaxants, and so on. Basic Drug Screens (BDS) are more specific for the detection of drugs such as cocaine and antidepressants.
It is recommended that the presence of a drug or toxicant be verified in more than one specimen. However, if only one specimen is available, replicate analyses on different occasions should be performed with adequate concurrent positive and negative controls. However, it should be recognized that the compound in question may not necessarily be present in all specimen types. Figure 22.3 shows a typical drug analysis flowchart. The algorithmic approach is employed to adequately identify the drug (or at least drug class) that may be present in a tested specimen.
22.7CLINICAL TOXICOLOGY
As was pointed out at the beginning of the chapter, the analytical toxicology approaches used in forensic toxicology play important roles in a clinical setting. The methods and instrumentation used in a clinical toxicology laboratory are similar to those used in forensic toxicology laboratories. The described approaches have the following benefits in clinical toxicology:
žAids the diagnosis and treatment of toxicoses
žAllows the monitoring of treatment effectiveness
406FORENSIC AND CLINICAL TOXICOLOGY
žIdentification of the nature of exposure
žQuantification of toxicant
22.7.1History Taking
Taking thorough general history aids in the effective treatment of an intoxicated patient. Often it may not be possible to communicate directly with the patient due to a lack of consciousness, altered mental state leading to inaccurate information, or deliberate submission of misleading information. The type of information that is essential and helpful include:
žIdentifying what was taken and when, how much, and by what route
žPresence of preexisting conditions or allergies
žWhether the patient is currently using any medications or substances of any kind
žWhether the patient is pregnant
Historical information can include information obtained from family, friends, law enforcement and medical personnel, and any observers.
22.7.2Basic Operating Rules in the Treatment of Toxicosis
The following concepts are central to approaching a toxicosis patient:
žEnsure airway so that breathing and circulation are adequate
žRemove unabsorbed material
žLimit the further absorption of toxicant
žHasten toxicant elimination
Reducing further exposure to a toxicant is crucial and may include removal of the patient from a toxic environment and the application of decontamination procedures. Immediate decontamination reduces absorption of toxic compounds and represents a primary essential aspect of the treatment regimen.
External/Skin Decontamination. This entails the complete removal of clothing and gentle washing of the victim with copious amounts of lukewarm water. Mild soaps are often useful and may increase effectiveness of the removal of the offending substance.
Internal Decontamination. The most recommended methods of internal decontamination Include gastric lavage, whole bowel irrigation and administration of activated charcoal.
Lavage. This is utilized if a patient has ingested a life-threatening toxicant. It is recommended for use within a few short hours after ingestion and involves the use of a nasogastric or orogastric tube to flush the gastrointestinal tract. A large bore tube is inserted into the stomach and the contents removed with sequential administration and aspiration of small quantities of warm water or saline. This technique is contraindicated
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in cases of ingestion of corrosives (i.e., acids, bases) and hydrocarbons (i.e., fuels, essential oils).
Whole-Bowel Irrigation. This involves the infusion by nasogastric or orogastric tube of a lavage solution consisting of an isosmotic electrolyte (polyethylene glycol electrolyte solution is currently recommended). This procedure is indicated after ingestion of metals (e.g., iron, lithium), controlled release medications (terms to describe formulations that do not release the active compound immediately after oral ingestion), ingestion of a large amount of an anticholinergic drug (e.g., tricyclics, carbamazepine), and after ingestion of large numbers of tablets. A polyethylene glycol electrolyte solution is administer per hour per os (P.O.) or via a nasogastric tube. Antiemetics may be required to control vomiting. This is continued until the rectal effluent is clear (approximately 3 to 6 hours). The goal is to completely irrigate the gastrointestinal tract to prevent or decrease toxicant absorption. The use of an isosmotic compound such as polyethylene glycol results in minimal electrolyte loss and fluid changes.
Activated Charcoal. This is considered the most useful agent for the prevention of absorption of toxicants. Repeated administration (multiple dose activated charcoal) can impair the enteroenteric-enterohepatic circulation of drugs by binding to drugs that undergo significant enterohepatic or enteroenteric recycling, including carbamazepine, digoxin, phenobarbitone, theophylline, and verapamil. The prescribed amount of activated charcoal is administered every hour P.O or via nasogastric tube.
Emesis and Catharsis. Emesis is not recommended as a treatment measure for the toxicosis patient. The danger of aspiration of the gastric contents is great (leading to asphyxiation or aspiration pneumonia). Also a concern is the damage to esophageal and related tissue by ingested corrosive substances. Sorbitol is a commonly used cathartic. Often used in charcoal formulations, it increases the gut motility to improve excretion of poison-charcoal complexes. It is not recommended in poisonings by compounds that cause profuse diarrhea (e.g., organophosphates, carbamates, and arsenic). The use of a cathartic alone has no value in the management of the poisoned patient. Its use is even controversial as a treatment in combination with activated charcoal. Its use is contraindicated in hypotensive patients, when dehydration or electrolyte balance is present, when corrosive substances have been ingested and in cases of abdominal trauma or surgery, and intestinal perforation or obstruction.
22.7.3Approaches to Selected Toxicoses
A number of antidotes are effective by altering the distribution or metabolism of a toxicant. Reducing the distribution of toxic substances to their sites of action can be achieved by a variety of methods including blocking access of specific poisons to their receptors with compounds that can compete with these receptors and by using chelating agents to bind the toxicants (e.g., dimercaprol for arsenic). Biotransformation of a toxic compound into a less toxic form can be achieved by certain agents. For example, thiosulphate is used to increase the conversion of cyanide into thiocyanate.
Ethylene Glycol Toxicosis. Ethylene glycol is commonly used as an antifreeze. It is metabolized by alcohol dehydrogenase to mixed aldehydes, carboxylic acids, and
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oxalic acid. Toxicosis results in nephrotoxicosis (kidney damage). Administration of fomepizole (4-methylpyrazole) or ethanol is effective due to their competition with ethylene glycol for the alcohol dehydrogenase enzyme. Although ethanol has a longterm history of clinical experience and is less costly to acquire, fomepizole treatment is associated with less adverse effects, predictable pharmacokinetics and has a validated efficacy. Hemodialysis is indicated in patients with severe kidney failure.
Ethanol Toxicosis. Absorption of ethanol by the GI tract absorption is rapid. Peak levels can be reached 30 to 60 minutes after ingestion. As a rule of thumb, 1 ml of absolute ethanol per kilogram weight results in a level of 100 mg/100 ml (0.1%) in 1 hour. Supportive treatment is directed toward the control of acidosis and hypoglycemia.
Organophosphates and Carbamates. The adverse effects of organophosphorous and carbamate pesticides are mediated through the inhibition of the cholinesterase enzymes. One form, acetylcholinesterase, is located at neurosynaptic junctions while butyryl cholinesterase is primarily located in the plasma and pancreas. Organophosphate pesticides inhibit cholinesterase by forming covalent bonds via phosphorylation. Enzymatic regeneration half-lives are long, taking days to months. Organophosphates affect both red blood cell and plasma cholinesterase activity. Carbamates primarily affect only the plasma derivative. Carbamate insecticides inhibit cholinesterase activity in reversible manner. Since carbamates interact with cholinesterase by weak, ionic bonding, the cholinesterases can regenerates itself more readily in matter of minutes to hours.
Since organophosphate toxicosis results in respiratory failure, the treatment approach for must include the maintenance of a patent airway. Artificial respiration may also need to be employed. The first pharmacological approach is the administration of atropine. Atropine competes with acetylcholine for its receptor site, thus reducing the effects of the neurotransmitter. N-methylpyridinium 2-aldoxime (2-PAM) is used in with atropine therapy as an effective means to restore the covalently bound enzyme to a normal state. It reacts with the phosphorylated cholinesterase enzyme removing the phosphate group. As previously mentioned, carbamates interact with cholinesterase by weak, ionic bonding; thus 2-PAM is of no use to combat toxicosis caused by these compounds. However, atropine is effective to prevent the effects on respiration.
Arsenic Toxicosis. Urine arsenic is the best indicator of current or recent exposure. Atomic absorption spectrophotometry is preferred as the detection method. Hair or fingernail sampling may also be helpful. Use of blood is useful if analyzed soon after exposure or in cases of continuous chronic exposure. After acute exposure, chelation therapy is instituted utilizing either (1) Dimercaprol BAL (British Anti-Lewisite) and analogues:
DMSA (dimercaptosuccinic acid)
DMPS (dimercaptopropane succinate)
or (2) d-penicillamine. Supportive/symptomatic therapy is also necessary. A higher protein diet and the alleviation of dehydration due to diarrhea and vomiting are beneficial.
Chronic Exposure (Arsenic). Primarily symptomatic treatment is chosen. Chelation therapy is practiced, but its usefulness in cases of chronic exposure is still questionable.
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