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Flashcards in ED - Toxicology Deck (58)
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1

What do you want to know in the history of overdose

How much?
What they took? More than one drug?
Accurate timing?
Staggered or all together?
With alcohol or water? - alcohol worsens
Do bloods and blood gas
TRAKCARE for drug Hx
Collateral

2

How do you assess

ABCDE
Check BM as reversible cause of low GCS before intubate
ECG
Check vitals, temp, pupil size,
IV access
Bloods

3

What else should you do

Risk assess
Do they have capacity
Do they need psychiatry / police

4

What is good source of information

TOXBASE
Look up drugs to see what they cause and form management
Always suspect possibly overdose if patient with abdominal pain / vomit

5

What is a toxidrome

Signs and symptoms that suggest a specific type of poisoning as patient may not be able to tell you

6

How do you examine

ABCDE
A+B = RR and HR
C = pulse and BP
D = GCS, pupils, reflex, any seizures
E = temp, skin, mucous membrane

7

What drugs cause sympathomimetic / adrenergic toxidrome

Cocaine
Amphetamine
Theophylline
Decongestants
Legal highs

8

What drugs cause sedative / hypnotic toxidrome

Benzodiazepine
Zopiclone
Barbiturates - phenobarbital (CNS depressant)
Alcohol

9

What drugs cause opioid toxidrome

Heroin
Methadone
Codeine
MST

10

What drugs cause anti-cholinergic toxidrome

TCA
Anti-histamine
Anti-psychotics
Oxybutin / tolterodine - incontinence

11

What do sympathomimetic drugs do

Stimulate A and B adrenergic receptors
Prevent uptake of Noradrenaline, dopamine and serotonin
Release Na

12

How do they present

Chest pain - MI can develop
Aortic dissection
Arrythmia- QT prolonged
High HR
High BP - can cause bleed
High RR
Sweating
Fever
Dilated pupils
Brisk reflexes
HYpertonia
Seizure
Metabolic acidosis
Rhabdomyolysis
Excessive speech and motor
Restless
Agitated
Insomnia
Hallucination
Ischaemic colitis

13

How do you treat

IV fluid + cooling
ECG to look for arrhythmia
Control agitation - diazepam / benzo
Check CK
Control BP - GTN infusion (Na nitroprusside)
If chest pain = GTN and PCI if MI develops
- Treat as MI
Anti-pyretic to lower temp
Treat arrythmia
Treat metabolic acidosis

14

How do you treat acidosis / raised CK

IV fluid and sodium bicarb

15

What do you NOT give

BB
leads to unopposed alpha antagonism and HTN crisis

16

How do sedative drug overdose present

Braydcardia
Respiratory depression
Hypotension
Slurred speech
Ataxia
Reduced reflex
Normal skin / membrane
Pupil size normal
May have blurring / diplopia / nystagmus
Hallucination
Delerium
Coma

17

How do you manage sedative overdose

Protect airway
Support ventilation if reduced GCS
Correct hypo - may need vasopressor

18

What drug can be used to manage Benzo OD

Flumazenil

19

When do you use

If 100% confident isolated Benzo OD
Iatrogenic
Severe or would otherwise require ventilation
HIGH RISK OF SEIZURE
Not dependent as risk of withdrawal

20

When do you consider opioid overdose

If person on opioids regularly on drug chart

21

What does opioid toxidrome look like

Resp depression
Bradycardia
Hypotension
Pin point pupil - miosis
Reduced GCS
Hypothermia
Seizure
Normal skin and mucous

22

How do you treat

Nalaxone (competitive antagonist) up to 2mg
Start with 400 microgram
IM or IV
Lasts 45 minutes so may have to keep doing it as opiate will have longer half life

23

What suggests anti-cholinergic overdose

Hot as hare
Dry as bone
Mad as hatter

24

What are ECG changes

Sinus tachycardia
Widen QRS
Long PR
Long QT
Arrythmia

25

What is toxidrome of anti-cholinergic overdose

Hypertension
Tachycardia
Dilated pupil
Brisk reflexes then absent - myoclonus
Pyrexia
Flushed dry skin / dry mouth
Urinary retention
Restless
Arrythmia
Metabolic acidosis
Seizure
Confused
Later drowsy then coma

26

How do you manage

Repeated doses of charcoal if within 1 hour
Check CK
Correct acidosis
IV bicarb = 1st line to reduce risk of seizure
Glucagon if severe hypo / HF or cariogenic shock
Many anti-arrythmics CI as prolong QT

27

What do you do if CK raised

Fluid

28

When do you give sodium bicarb

Metabolic acidosis
QRS prolonegd
Arrythmia
Hypo not responding

29

How does paracetamol overdose present

N+V
Coma
Severe metabolic acidosis
Abdo pain = late sign
After 2-3 days hepatic necrosis = RUQ pain, jaundice, renal failure, coma

30

Where is paracetamol conjugated and broken down

What puts you at increased risk of hepatotoxicy

Liver by p450 enzyme

Patients taking p450 inducers
Malnourished patient as enzyme to break down depleted
Acute alcohol therefore may be protective as p450 inhibitor