SUBSTANCE ABUSE

Question 1

Paracetemol overdose

when does hepatic necrosis occur

IVX:

Management;

Answer 1

· Risk of severe liver damage
o <150mg/kg = unlikely
o >250mg/kg = likely
Paracetemol is metabolised by an alternative pathway ==> NAPQI –> necrosis in live and kidney tubules

Often asymtomatic first 24 hrs or N+V
Hepatic necrosis develops after 24 hours –> RUQ pain and jaundice, encephalopathy

IVX: paracetemol levels 4 hours post ingestion
Bloods: INR, LFT and CK - U+Es, ABG

Management: times plasma paracetemol on nomogram 
IV acetlycycsteie (PARVOLEX)

Refer to ICU if fulminent liver failure
- transplant if PH <7.3

Question 2

Opiate overdose

aka heroin or morphine

Answer 2

• analgesic and euphoric effect
• Withdrawal syx
• sweating
• runny nose
• yawning
• feeling hot and cold
• tremor
• dialated pupils
• screen for hep b,c + his

Management:
- detoxification 28 days inpatient
- methadone
(naloxone for overdose)

Question 3

Aspirin overdose (salicyic acid)
- used as blood thinner, pain and fever tx

Answer 3

• Moderate OD: between 300 and 500 mg/kg
• acute OD
  tinnitus, hyperventilation, vomiting and double vision, drowsy, coma
• chronic OD more common in elderly

IVX: Plasma salicylate concentrations
Take sample 2 hrs (for Sx pts) or 4 hrs (for unSx pts) following ingestion, ABG - mixed resp and metabolic acidosis

MANAGEMENT: oral activated charcoal

Question 4

Alcohol intoxication + alcoholism

acute withdrawal signs?

live disease signs?

Wernicke-Korsakoff syndrome?

TX

Answer 4

Clinical Features
Coarse tremor and tachycardia.
Liver diseasr: palmar erythema, gynaecomastia, spider naevi and jaundice
· Hepatomegaly (in chronic alcoholic liver disease the liver is shrunken).
· Ascites; gonadal atrophy.
· Atrial fibrillation and cardiomyopathy.

Wernicke-Korsakoff syndrome (ataxia, confusion, ophthalmoplegia), amnesic problems, peripheral neuropathy and dementia

IVX: CAGE, FBC, thiamine levels

Management: community detox, benzos to prevent withdrawal, thiamine PABRINEX

Question 5

Alcohol withdrawal

Answer 5

Problems ass with withdrawal can include:
· Delirium tremens.
· The Wernicke-Korsakoff syndrome.
· Seizures.
· Depression.
· Polysubstance abuse.
· Electrolyte disturbances.
· Complications due to associated liver disease

–> 6-12 hours after alcohol has stopped = tremor, anxiety, sweating, insomnia, palpitations
–> 12-24 Alcoholic hallucinosis (can appear
o Includes visual, auditory ortactile hallucinations
–> 24-48 hours Withdrawal seizures
o Generalised tonic-clonic seizures.
—> 48-72 hours = Alcohol withdrawal delirium or ‘delirium tremens’
- altered mental state Hallucinations
- Confusion
- Delusions
- Severe agitation

TX: Chlordiazepoxide

Ivx: Assess severity of withdrawal, FBC, LFT, Clotting, ABG