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URGENT DETOXICATION

Depending on the ways of penetration of toxic substances into the organism and their removal from it the following methods of urgent detoxication are applied: gastric lavage, enterosorption, forced diuresis, hemosorption, hyperventilation, washing the skin and mucous membranes.

In case of poison peroral intake prior to a gastric lavage, one should give the patient one tablespoon of water suspension of activated charcoal. It is necessary to carry out a gastric lavage irrespective of the time elapsed since the moment of poisoning and the dose of intoxicating substance. A stomach is washed out through a thick gastric tube with 15-20 liters of tap water of room temperature (in poisoning with corrosive poisons if it is accompanied by a gastrointestinal hemorrhage, it is expedient to use a chilled water) with portions of no more than 300-500 ml, as long as in case of the overfilled stomach a vomiting or regurgitation may arise bypassing the tube with a threat of vomits aspiration. After a gastric lavage a laxative — liquid petrolate or castor oil may be introduced through the tube.

In poisoning with corrosive poisons a gastric tube is abundantly oiled with liquid petrolate or sunflower oil and introduced only after a preliminary subcutaneous or intramuscular administration of anesthetizing agents (morphine, promedol, omnopon, etc.), the laxatives are not used after lavage.

A burn of the digestive tract is not a contraindication for a gastric lavage, as long as a threat of perforation is overestimated.

It is impermissible to use solutions of alkalies and acids to neutralize acid or alkali in the stomach because it may cause a generation of gas with an acute distention of the stomach and significantly aggravate a patient's condition.

Except an activated charcoal as a universal sorbent, other substances may be introduced into the stomach in some intoxications. For example, in barium chloride intoxication — magnesium sulfate that forms insoluble salt of barium sulfate is applied. In poisoning with silver nitrate — sodium chloride solution that forms insoluble and nontoxic silver chloride is used. In poisoning with chlorinated carbons (dichlorethane, carbon tetrachloride, chloroform) it is compulsory to introduce a liquid petrolate up to 100 ml into the stomach that is not practically absorbed in the digestive tract, and dissolving in itself the above poisons, impedes their entry into the blood; in poisoning with salts of heavy metals and arsenic a unithiol solution 20-30 ml is prescribed before and after a gastric lavage.

If there is an opportunity to intubate the trachea with a tube with inflated cuff, it is compulsory to fulfil it prior to a gastric lavage of the patients being in a comatose state with the absence of cough or laryngeal reflexes to prevent an aspiration of vomits and wash waters.

In case of inhalation poisoning, first of all, it is necessary to carry the patient away from a gassed zone, ensure a patency of the respiratory tract and carry

out a respiratory resuscitation with the use of manual respirator avoiding a "mouth-to-mouth" and "mouth-to-nose" respiration, but with a compulsory oxygen inhalation. A rescuer evacuating a patient from a dangerous zone must be with a gas mask on.

Toxic substances getting onto the skin or into the eyes are carefully removed by washing out, and from the cavities (rectum, vagina, auditory passages) — by irrigation.

In injection type of poisoning a cold is applied locally, 0.1% adrenalin solution, a circular novocaine blockade of the extremity above the place of injection.

Elimination of toxic substances absorbed into the blood, as far as possible is carried on in the specialized resuscitation units or toxicologic centers. In the above institutions or even at the prehospital stage (at the place of accident or in the ambulance if a patiemt's condition allows) an early forced diuresis is urgently carried out. Its procedure is as follows:

1. Preliminary water load. Systems of intravenous infusions are adjusted and for the first hour 500 ml 5% glucose solution are infused.

2. Application of diuretics. Simultaneously with water load 300-600 ml 20% mannitol solution (0.5-1 g of dry substance per 1 kg of the patient's body mass) are stream infused for 10-15 min or 20-40 mg (1-2 ampules) of furosemid (lasix). Both preparations in the above indicated doses may be used at the same time. The length of effect of such a dose is 3-4 hours, later, in case of need to continue a forced diuresis the above given dose is repeated. Other diuretics may be also applied, for example, 2.4% euphilline solution by 0.5 ml i/v every 15 min for the first 3 hours.

3. Support of diuresis. While carrying out a forced diuresis a catheter is introduced into the urinary bladder and left for a few hours until the procedure continues. This helps to register diuresis and prevents a delay of the urine as a result of the urinary bladder atonia. A forced diuresis is considered as effective if it reaches 10 ml/min (normally — 1-1.5 ml/min). In order to maintain the rate of urine generation it is necessary continuously to replenish water and electrolytes that are being lost with the urine by infusion of salt solutions (0.9% sodium chloride isotonic solution with addition of 50 ml 3% potassium chloride solution, Ringer or Philipps solution per every 400 ml). The volume of infused solutions in every subsequent hour must be equal to the volume of the urine excreted for a preceding hour, i.e., on the average, 500 ml/hour.

4. Alkalinization of plasma. It is achieved with intravenous infusion of 4% sodium hydrocarbonate solution in the amount of about 200 ml/hour for the first three hours, by 100 ml/hour subsequently. The indicator of effectiveness is pH 7-8 of the freshly excreted urine that is determined by a litmus test strip. Plasma alkalinization is, particularly, indicated in poisoning with barbiturates, OPC, dichlorethane, quinine hydrochloride and pachycarpine hydroiodide, as well as in case of massive intravascular hemolysis.

Method of forced diuresis is contraindicated in acute and chronic cardiovascular insufficiency (persistent collapse, II—III degree circulatory insufficiency), renal function disorder (oliguria, azotemia). In the patients, aged over 50, this method may be less effective as a result of sclerotic changes in the kidneys.

An effective method of detoxication is hemosorption. For its carrying out in a nonspecialized medical institutions and at the prehospital stage a portable system for hemosorption USOK-100 P (Fig. 51) was designed at the department of anesthesiology of the Odessa State Medical University. A factory package of hemosorbent in disposable sterile column made of polymeric biocompatible materials excludes a need in mounting and sterilization of this system prior to the procedure of hemosorption. Inclusion of the additional lavsan microfilters in the column able to stop minute blood clots and particles of sorbent makes it absolutely safe for the patient.

Fig. 51. Hemosorption system USOK-100 P:

a — sorption column; b — manual gastric pump;

c — dropper with a filter; d — injection units;

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