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Anaesthetics, ED and Plastics > ED - Toxicology > Flashcards

ED - Toxicology Flashcards

(58 cards)

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1
Q

What do you want to know in the history of overdose

A 
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
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2
Q

How do you assess

A 
ABCDE
Check BM as reversible cause of low GCS before intubate
ECG 
Check vitals, temp, pupil size, 
IV access
Bloods
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3
Q

What else should you do

A

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

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4
Q

What is good source of information

A

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

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5
Q

What is a toxidrome

A

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

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6
Q

How do you examine

A 
ABCDE
A+B = RR and HR 
C = pulse and BP 
D = GCS, pupils, reflex, any seizures
E = temp, skin, mucous membrane
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7
Q

What drugs cause sympathomimetic / adrenergic toxidrome

A 
Cocaine
Amphetamine
Theophylline 
Decongestants
Legal highs
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8
Q

What drugs cause sedative / hypnotic toxidrome

A

Benzodiazepine
Zopiclone
Barbiturates - phenobarbital (CNS depressant)
Alcohol

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9
Q

What drugs cause opioid toxidrome

A

Heroin
Methadone
Codeine
MST

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10
Q

What drugs cause anti-cholinergic toxidrome

A

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

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11
Q

What do sympathomimetic drugs do

A

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

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12
Q

How do they present

A 
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
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13
Q

How do you treat

A 
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
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14
Q

How do you treat acidosis / raised CK

A

IV fluid and sodium bicarb

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15
Q

What do you NOT give

A

BB

leads to unopposed alpha antagonism and HTN crisis

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16
Q

How do sedative drug overdose present

A 
Braydcardia
Respiratory depression
Hypotension
Slurred speech
Ataxia
Reduced reflex
Normal skin / membrane
Pupil size normal 
May have blurring / diplopia / nystagmus 
Hallucination
Delerium
Coma
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17
Q

How do you manage sedative overdose

A

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

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18
Q

What drug can be used to manage Benzo OD

A

Flumazenil

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19
Q

When do you use

A 
If 100% confident isolated Benzo OD 
Iatrogenic 
Severe or would otherwise require ventilation 
HIGH RISK OF SEIZURE 
Not dependent as risk of withdrawal
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20
Q

When do you consider opioid overdose

A

If person on opioids regularly on drug chart

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21
Q

What does opioid toxidrome look like

A 
Resp depression
Bradycardia
Hypotension
Pin point pupil - miosis
Reduced GCS
Hypothermia
Seizure
Normal skin and mucous
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22
Q

How do you treat

A

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

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23
Q

What suggests anti-cholinergic overdose

A

Hot as hare
Dry as bone
Mad as hatter

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24
Q

What are ECG changes

Study These Flashcards
A 
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
31
How do you investigate paracetamol overdose
Do levels 4 hours after overdose LFT as well + clotting (PT bad) Bloods - FBC, U+E, LFT, clotting, INR Do VBG for acid base balance / pH - gives instant result - Abnormal LFT, acidosis, hypoglycaemia, coag abnormalities Get paracetamol level after 4 hours to see if need NAC If present >8 hours take straight away and give NAC immediate This allows you to decide if patient needs NAC Mental health referral
32
How do you treat
Activated charcoal if <1 hour N-acetylcysteine (NAC)- Allows safe metabolism of toxin Liver transplant
33
When should NAC be commenced
Within 8 hours to be fully effective | 21 hour infusion
34
What do you do if staggered overdose (not all taken within 1 hour)
Level in blood not helpful | Just work out if toxic overdose >150ml/kg and give nAC
35
What is liver transplant indicated / referral to liver unit
King's College Criteria - pH <7.3 24 hours later OR All 3 of - PT >100 or INR >6.5 - Creatinine >300 - Grade 3 -4 encephalopathy
36
How does CO poisoning present
``` Headache = 90% N+V Malaise FAtigue Flu like symptoms Chest pain Confusion Vertigo Weakness Diarrhoea Drowsy ``` Severe Bizarre neuro / extra-pyramidal if severe Pink mucosa Arrhythmia
37
How do you Dx
ABG or VBG showing elevated HbCO | Pulse oximetry can read high as similar to HbO
38
What else should you do
ECG + cardiac biomarkers to look for ischaemia
39
What other tests
``` CK / urine myoglobullin - rhabdo in severe cases FBC U+E - hypokalaemia LFT Glucose - hyperglycaemia Blood lactate - severity Toxicology - if suspect suicide Urinanalysis - +ve albumin / glucose in chronic ```
40
How do you Rx
100% O2 non rebreather mask Continue till symptoms resolved but minimum 6 hours Intubate if coma Cardiac monitoring + pulse oximetry
41
Pathophysiology behind
CO has high affinity for oygen | Shifts oxo-haemoglobin curve to the left resulting in hypoxia
42
Indications for Hyperbarci oxygen
LOC Neuro signs Arrhythmia Pregnancy
43
How do you manage BB overdose
Atropine if Brady | Glucagon if resistant
44
How do manage heparin overdose
Protamine sulphate
45
What are features of Salicylate overdose (Aspirin)
``` Tinnitus Lethargy Sweating Pyrexia N+V Hyper or hypoglycaemia More severe = hyperventilation and resp alkalosis AKI Confusion Seizure Coma ```
46
What acid base
Respiratory alkalosis due to early stimulation of resp = late Metabolic acidosis due to AKI / direct effect = early
47
How do you Rx
ABC Charcoal if acute Urinary alkalisation with sodium bicarbonate Haemodialysis
48
What are indications for dialysis
``` High concentration Resistant acidosis AKI PUlmonary oedema Siezure Coma ```
49
How does ecstasy poisoning present
``` Neuro - agitation, confusion, ataxia CVS - tachy + HTN Hyponatraemia Hyperthermi Rhabdomyolysis ```
50
How do you Rx
Supportive | Dantrolene for hyperthermia if fails
51
What is activated charcoal used for
Reduce absorption and accelerate excretion following overdose Give 50g within 1 hour of overdose Binds free drug Can cause vomiting
52
Lithium toxicity
IV saline | Dialysis if severe
53
Theophylline toxiciity
Activated charcoal | Dialysis
54
Antitode to opiate
Nalaxone
55
Antitotde to BB
Glucagon
56
Antitode to Iron
Desferroxamine
57
Antitode to CO
Hyperbaric O2
58
Antitode to digoxn
Digiband

Anaesthetics, ED and Plastics (14 decks)

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