Acute multisystem

Question 1

Anticholinergic overdose features

Answer 1

Mad, red, dry, hot (confusion, hallucination, dilated pupils, tacycardia, pyrexia, dty mouth, urinary retention)

Question 2

Cholinergic OD features

Answer 2

SLUDGE-BBB: Salivation, Lacrimaton, Urination, Diaphoresis, GI upset, Emesis, Bradycardia, Bronchospasm, Bronchorrea

Question 3

Serotonergic OD features (ecstasy, SSRI)

Answer 3

Altered mental state, agitation, hyperreflexia, autonomic instability (BP variations)

o DDX: neuroleptic malignant syndrome, Tx: dantrolene

Question 4

Sympathomimetic OD features (organophosphate, cocaine)

Answer 4

HTN, high HT, dilated pupils, agitation

Question 5

ABCDE assessment in overdose

Answer 5

A
* Lost in opioid

B
* Opioid: resp depression

C
* Obs: HR, BP, CRT, urine output, fluid status (See above)
* Bloods: FBC. U&E, toxicology, VBG, LFT, INR, glucose,
* Specific: Paracetamol level, salicylate level.
* Urine tox screen
* ECG, continuous cardiac monitor (QT>450 in TCA OD)

D/E
* AVPU score and GCS
* Consider airway protection of low GCS
* CBG
* Consider fall or fractures
* Check for urinary retention

Question 6

Management summary for OD cases

Answer 6

• ABCDE approach,
• Take full history (what taken, how much, when, co-ingstion) and examination
• 12-lead ECG continuous
• Bloods, urine tox screen, glucose, osmolar/anion gap

Question 7

CVVHF in OD

Answer 7

o Considered in Lithium, Salycilate, Ethanol, Ethylene glycol and methanol poisoning.

Question 8

Coma cocktail when suspecting OD

Answer 8

“Coma cocktail” when suspecting toxic ingestion (mnemonic = “DONT”)

Dextrose (50mg IV)
Oxygen

Naloxone (0.2-0.4mg IV/IM, repeat dose 1-2mg)
 Empiric opioid ingestion treatment

Thiamine (50-100mg)
 Treat or avoid Wernicke encephalopathy
 Though some suggest giving thiamine prior to dextrose, do NOT let this delay treatment of hypoglycemia!
 Case reports of dextrose precipitating Wernicke’s involved thiamine-deficient patients receiving prolonged course of IV glucose, NOT with single bolus

Question 9

Specific mx: Paracetamol OD

Answer 9

If staggered / poor history / above certain level for BW / para level above treatment curve

N-acetylcysteine 150 mg/kg IV over 60 min then 100mg/kg IV over 16 hr
o If above treatment line 4 hours post ingestion,
o SADPERSONS score for re-attempt and need for admission
o DO NOT use treatment line if:
 Staggered overdose
 No memory of how many taken
 High risk patients (taking enzyme inducers)

Question 10

Anticholinergic OD antidote

Answer 10

Phyostigmine

Question 11

Arsenic/Mercury antidote

Answer 11

Dimercaprol

Question 12

BZD antidote

Answer 12

Flumanezil

Question 13

BB OD antidote

Answer 13

Glucagon

Question 14

CCB OD antidote

Answer 14

CaCl 10@10 and insulin 1u/kg/hr with dextrose

Question 15

Clonidine/opiate OD antidote

Answer 15

Naloxone

Question 16

Digoxin OD antidoteq

Answer 16

Digibind

Question 17

Ethlyene glycol / Methanol OD antidote

Answer 17

Fomepizole

Question 18

Fluoride OD antidote

Answer 18

Ca gluconate

Question 19

Heparin OD antidote

Answer 19

Protamine sulfate

Question 20

Iron OD antidote

Answer 20

Desoxiferramine +/- charcoal

Question 21

Isoniazid antidote

Answer 21

Pyridozine

Question 22

Lead OD antidote

Answer 22

EDTA/Succimer

Question 23

Methaemoglobinaemia tx

Answer 23

MEthylene blue

Question 24

Organophosphate OD antidote

Answer 24

Atropine

Question 25

TCA poisoning antidote

Answer 25

Bicarb

Question 26

Sulfonylurea OD antidote

Answer 26

Octreotide

Question 27

Anaphylaxis red flags

Answer 27

acute, wheezy, stridor, fast deterioration, falling BP

Question 28

ABCDE in anaphylaxis

Answer 28

A
* May be obstructed (Stridor): consider adjunct + ADRENALINE now

B
* Wheeze
* RR high, SPO2 low

C
* BP low, HR high, CRT high, UO may be low
* Abdominal pain and diahrrea
* 2x large bore cannulae: VBG, FBC, U&E, LFT, Clotting, G&S, glucose
* Take mast cell tryptase to confirm anaphylaxis

D/E
* AVPU and GCS
* Glucose
* Admit for observation at leadt 6 hours (biphasic reaction)
* F/U allergy clinic
* Assess for rashes
* Consider CXR if ?PTX

Question 29

Management of anaphylaxis

Answer 29

REMOVE ALLERGEN

ABCDE approach, put out peri arrest call

Initial treatment
o Lie patient flat, raise legs
o Treat initially (0.5 (every 5), 5, 200, 10)
 0.5 1:1000 adrenaline IM every 5 mins
 5 mg salbutamol Neb
 200mg IV hydrocortisone
 10mg Chlorphrenamine

Obtain collateral and allergy / exposure history to identify trigger. Document event and allergy.

Admit and monitor for minimum 6 hours post attack - Monitor ECG, contrinue fluids if required

Continue steroid 30-40 mg Pred / day; contrinue chlorphrenamine 4mg PO QDS if itching.

Question 30

CVVHF indications

Answer 30

pH<7.1
K>7 refractory
Bicarb <12
Urea>45 / enceophlaopathy
Fluid overload
Toxin removal [salicylate, lithium, ethanol, ethylene glycol and methanol]