Week 11

Question 1

what are the steps in the risk assessment-based aproach to poisoning?

Answer 1

• resuscitation
• risk assessment
• supportive care and monitoring
• Investigations
• Decontamination
• Enhanced elimination
• Antidotes
• Disposition

Question 2

what is involved in RESUSCITATION in the risk assessment-based aproach to poisoning?

Answer 2

Airway
Breathing
Circulation
Control seizures
Correct hypoglycaemia
Correct hyperthermia
Consider resuscitation antidotes

Question 3

what is involved in RISK ASSESSMENT in the risk assessment-based aproach to poisoning?

Answer 3

Agent
Dose
Time since ingestion
Clinical features 
Progress of the symptoms
Patient factors

Question 4

What are the S&S of ANTIcholinergic toxicity?

Answer 4

Red as a beet
- flushed

Dry as a bone
- Anhydrosis

Hot as a hare
- Anhydrotic hyperthermia

Mad as a hatter
- Delerium/hallucinations

Full as a flask
- urinary retention

Tachycardia
Decreased/no bowel sounds

Question 5

What are the S&S of CHOlinergic toxicity?

Answer 5

SLUDGE BBB

Salivation
Lacrimation
Urination
Defecation
Gastric Emesis
Bronchoraehea
Bronchospasm
Bradycardia

Question 6

What causes cholinergic toxicity?

Answer 6

insecticides containing organophosphates

Question 7

what are the keys to overdose resus?

Answer 7

 Resuscitation should continue until expert advice can be obtained on the
poison – can be prolonged.

 Transport early if in cardiac arrest and continue CPR to hospital

 Attempts at decontamination does NOT take priority over CPR

Question 8

What should be noted about seizures in an overdose?

Answer 8

– if present, usually generalised. If partial seizures, this indicates a focal neurological
problem that requires further investigation.

– Common causes – Venlafaxine, bupropion, tramadol, amphetamines

– We treat with Midazolam.

Question 9

What should be noted in ABC’s of overdose resus

Answer 9

– Patients can deteriorate quickly so monitor closely and be prepared for change in vitals, including cardiac arrest

– Attention to airway, breathing and circulation is paramount

– There is an increased risk of aspiration in these patients (been noted at GCS of 12).

Question 10

what supportive care and monitoring is required ofr overdose?

Answer 10

 Drugs normally affect the respiratory system, cardiovascular system, the central nervous system.

 Respiratory system
– Full RSA needed.
– Intubation may be required if there is a lowered LOC.
– Secure the airway while you wait for MICA.
– Monitor ventilations regularly. Have bag mask at the ready.

 Cardiovascular system:
– 12 lead ECG essential – rate, rhythm, PRI, QRS width, ST,
– Some drugs will cause arrhythmias
– Fluids
– Monitor closely

 GCS – closely monitor. If changes start your ABCs again

Question 11

Whata re the types of CNS depressants?

Answer 11

 Opiates – morphine, heroin, codeine, tramadol, methadone

 Sedative-hypnotic drugs - benzodiazepines & barbiturates

 GHB - Gamma Hydroxybutyrate

 Alcohol

Question 12

What is the clinical presentation of an Opioid OD?

Answer 12

LIKELY:
 Lowered level of consciousness (drowsy)

 Respiratory depression leading to failure & death

 Pinpoint pupils

POTENTIALLY:
 Could be hypotensive
 May have vomited or be vomiting
 Check setting and history!
 Tramadol OD on the increase
– Doses > 500 mg may cause seizures in adults.
– Deaths have occurred following ingestion of 3-5 g.
– Rarely causes respiratory depression but frequently results in tachycardia,
agitation and seizures (due to serotonin syndrome) .

Question 13

What are the clinical presentations for benzodiazapines?

Answer 13

 Drowsiness, confusion, dizziness

 Slurred speech

 Nystagmus, blurred vision

 Hypotension

 Ataxia, weakness, lack of coordination

 Coma

 Respiratory depression – even arrest

 Cardiac arrest

 Large doses – hypothermia, bradycardia, hypotension may occur

Question 14

What is the clinical presentation of GHB?

Answer 14

 Causes a rapid onset of CNS and respiratory depression

 Other symptoms include myoclonic jerking, bradycardia, sweating,
agitation, vomiting, delirium, cheyne-stokes type breathing

 Recreational doses 30-40 mg/kg

 Can cause coma

 Co-ingestion of other drugs, especially CNS depressants,
increased the risk of respiratory depression, apnoea and death

 Recovery associated with brief period of agitation, delirium and
vomiting

Question 15

what does Naloxone (Narcan ) do?

Answer 15

Opiate antagonist

 Competes for the same receptors as opiates

 Greater affinity

 Shorter half life than opiates – this a problem

 Administer after you have looked after the airway

 Consider size of patient to determine initial dose

Question 16

What are the types of opioid overdoses in the ‘Other opiod arm’ of the CPG

Answer 16

prescription
latrogenic
polypharmacy
unknown

Question 17

what is the clinical presentation of alcohol intoxication/OD

Answer 17

 CNS depression even coma

 Loss of inhibition

 Loss of judgement

 Can add to the depressive effects of other CNS depressants

 Vomiting, loss of airway protection

 Increase in self-confidence

 Agitation, aggression, disorientation

 Slurred speech, Ataxia, nystagmus

 Tachycardia, hypotension, hypothermia

 Inhibition of Anti-diuretic Hormone (ADH) - Increase in urine production - Loss of fluid
volume – Possible hypotension – Dehydration - Loss of electrolytes etc.

Question 18

What is the clinical presentation of alcohol poisoning?

Answer 18

– Confusion
– Loss of coordination
– Vomiting
– Seizures
– Irregular or slow breathing (less than eight breaths a minute)
– Blue-tinged or pale skin
– Low body temperature (hypothermia)
– Stupor – when someone’s conscious but unresponsive
– Unconsciousness – passing out
– hypotension

 Lose gag reflex

Question 19

What are some cardiovascular complications of long-term alcohol abuse?

Answer 19

 Cardiovascular – Afib, cardiomyopathy,

clotting problems

Question 20

What are some GIT complications of long-term alcohol abuse?

Answer 20

 Gastrointestinal – liver disease,
hepatitis, cirrhosis, oesophageal
varices, pancreatitis, chronic gastritis, GI
bleeds, enlarged liver

Question 21

What are some additional complications of long-term alcohol abuse?

Answer 21

 Malnutrition, Vitamin deficiency,
dehydration

 Alcoholic ketoacidosis, electrolyte
imbalances

 CNS - Memory problems (Wernicke’s
encephalopathy), subdural
haemorrhage

Question 22

What are some of the management considerations of alcohol intoxicated patients?

Answer 22

• Hypoxia – breathing rate, depth, asphyxia,
• Hypovolemia / dehydration
• Analgesia
• Nausea and vomiting
• Aggression and compliance
• Competency to make own decisions

Question 23

What are some of the pitfalls and dangers of alcohol intoxicated patients?

Answer 23

• Failure to regard ethanol intoxication as potentially life threatening
• Failure to detect and manage co-existing intoxications or other medical conditions in the intoxicated patient.
• Believing patient is competent to make own decisions re welfare
• Assault to the paramedics
• Crowds could also be a problem
• You may need to modify your behavior or language - You may elect to leave the scene

Question 24

what are some of the physiological problems caused by alcohol withdrawl?

Answer 24

– Autonomic excitation – tremors, sweating, anxiety, agitation, tachycardia,
N&V, hyperthermia, hypertension

– Neuro-excitation – hyper-reflexia, hallucinations, seizures, nightmares

– Delirium tremens – severe form has 8% mortality
 Present in 20% pts admitted to hospital

Question 25

How do you manage alcohol withdrawal?

Answer 25

 Resuscitation, supportive care and monitoring of all vitals  Get a good history  Exclude other non-toxicological causes e.g. hypoxia, metabolic  Establish an IV  Manage acute illness including dehydration and seizures  Is the withdrawal part of a medical plan?  Request MICA

Question 26

What are some common sources of methanol?

Answer 26

``` – Antifreeze preparations – Automobile and furniture polish – Pesticides – Industrial products (oils, detergents) – Paint thinners – Methylated spirits (ethanol + methanol) ```

Question 27

What are the clinical signs of methanol poisoning?

Answer 27

``` – Early symptoms are similar to ethanol intoxication  CNS depression  Loss of inhibition  Ataxia  Nausea ``` – Initial severe symptoms in 12-24 hours (relates to amount ingested) – Possibility of seizures – Vision blurring or loss – Metabolic acidosis – Death

Question 28

What is the management for methanol poisoning?

Answer 28

 ABC’s are paramount  Pt is acidotic so will have respiratory compensation – Hyperventilate to help blow off acid (remember respiratory unit)  MICA for intubation and possibly sodium bicarbonate  Treat seizures  Check BSL  Antidote = fomepizole – not available in Australasia  Quick transport – need dialysis

Question 29

What are common stimulant & psychoactive drugs?

Answer 29

* MDMA / Ecstasy * Methamphetamines * Cocaine

Question 30

what are the immediate S&S of MDMA/Ecstasy?

Answer 30

* Enlarged pupils * Increased heart rate and blood pressure * Increased energy * Feeling of euphoria * Teeth grinding and jaw clenching * Anxiety and panic attacks * Overheating and dehydration * A ‘comedown’ * Nausea, vomiting and dizziness * Visual distortions * Paranoia * Psychosis * Serotonin syndrome * Stroke.

Question 31

what are the long-term S&S of MDMA/Ecstasy?

Answer 31

* Dependence / addiction * Long-term problems with depression * Impairments to memory and attention * Liver problem

Question 32

How does MDMA work?

Answer 32

MDMA/Ecstasy stimulates the body's CNS. Onset of effects can take up to 60 minutes, people may therefore think the first pill isn’t working and take more.

Question 33

How does Methamphetamine work?

Answer 33

• Methamphetamine increases the amount of the neurotransmitter dopamine, leading to high levels of that chemical in the brain.

Question 34

What are the short-term effects of ICE?

Answer 34

* Feelings of pleasure and confidence * Increased alertness and energy (often don’t sleep for days) * Repeating simple things like itching and scratching * Enlarged pupils and dry mouth * Teeth grinding and excessive sweating * Fast heart rate and breathing * Reduced appetite * Increased sex drive * It takes several days to come down from ICE

Question 35

What are long term effects of ICE?

Answer 35

```  Extreme weight loss due to reduced appetite  Restless sleep  Dry mouth and dental problems  Regular colds or flu  Trouble concentrating  Breathlessness  Muscle stiffness  Anxiety, paranoia and violence  Depression  Heart and kidney problems  Increased risk of stroke  Needing to use more to get the same effect, Dependence on ice  Financial, work or social problems  Ice Psychosis ```

Question 36

What are the short term effects of Cocaine

Answer 36

* Happiness and confidence * Talking more * Feeling energetic and alert * Quiet contemplation and rapture * Feeling physically strong, mentally sharp * Reduced appetite * Dry mouth * Enlarged (dilated) pupils * Higher blood pressure * Faster heartbeat and breathing * Higher body temperature * Increased sex drive * Unpredictable, violent behavior * Indifference to pain

Question 37

Whata re the long term effects of cocaine?

Answer 37

``` Regular use may eventually cause: • Insomnia and exhaustion • Depression • Anxiety, paranoia and psychosis • Sexual dysfunction • Hypertension and irregular heartbeat • Heart disease and death ```

Question 38

What are the S&S of cocaine overdose?

Answer 38

* Nausea and vomiting * Extreme anxiety * Chest pain * Panic * Extreme agitation and paranoia * Hallucinations * Tremors * Breathing irregularities * Kidney failure * Seizures * Stroke * Heart problems.

Question 39

What are the common clinical symptoms of CNS stimulants?

Answer 39

 Tachycardia and hypotension is common but hypertension and tachycardia also possible (adrenergic effect)  Dilated pupils (myadrisis) –adrenergic effect  Dysrhythmias  Diaphoresis – adrenergic effect  Agitation (adrenergic), hallucinations and paranoia  Dry mucous membranes – adrenergic effect  Fever, hyperthermia  Seizures, tremors, hyper-reflexia  Poly-pharmacy must always be considered with CNS stimulant use  Ingestion by children is potentially lethal  Known teratogenic effects, leading to miscarriage and fetal demise

Question 40

What are some cardiovascular effects of CNS stimulants?

Answer 40

 Toxicity results from sympathomimetic, vasospastic and sodium channel blocking effects (cocaine).  Vasospasms also means poor myocardial perfusion as well as promotion of platelet aggravation  Blocking of fast sodium channels results in dysrhythmias  Increased vascular dissection  Increased intracranial haemorrhage  Acute cardiomyopathy  Pulmonary oedema

Question 41

What are some major complications of CNS stimulants?

Answer 41

 Hyperthermia – Can result from excited delirium (cocaine) or excessive exercise (MDMA) – Further exacerbated by the environment they are in e.g. hot night club – Can also be a sign of severe serotonin syndrome

Question 42

What can hyperthermia lead to?

Answer 42

– Rhabdomyolysis – Impaired consciousness, – DIC (disseminated intravascular coagulation) – and multi-organ failure

Question 43

What are S&S of serotonin syndrome?

Answer 43

– Confusion, hallucinations – Agitation or restlessness, anxiety, apprehension – Dilated pupils – Headache – Changes in blood pressure and/or temperature – Nausea and/or vomiting, diarrhoea – Rapid heart rate, hypertension, increased RR – Tremor, seizures – Loss of muscle coordination or twitching muscles – Shivering and goose bumps – Heavy sweating, flushing – Increased muscle tone, rigidity, hyper-reflexia ``` Life threatening if: • High fever • Seizures • Rigid muscles • Irregular heartbeat • Unconsciousness ```

Question 44

what are some hallucingenic drugs?

Answer 44

* LSD - (Lysergic acid diethylamide) * Magic mushrooms - psilocybin * Mescaline - peyote cactus

Question 45

what are S&S of psilocybin syndrome?

Answer 45

 Onset usually within 1 hour lasting 4‐6 hours – Nausea and vomiting (more rare, may happen before psychological effects) – Heightened colour perception – Emotional effects – Changes in perception – Anxiety – Delusions

Question 46

What are S&S of LSD?

Answer 46

```  Profound hallucinations – thoughts / perceptions dream like – sensory modalities confused – thoughts disconnected to reality – euphoria or dysphoria – anxiety / panic attacks – enhanced mood or depression – calmness or aggression – decreased libido? ```

Question 47

What are the S&S of ketamine?

Answer 47

``` – Euphoria, relaxation, feeling detached from body – Hallucinations – Disorganised thoughts, confused – Anxiety, agitation, paranoia, panic – Nausea, vomiting – Slurred speech, get blurred vision, and lack of co-ordination – Sweating – more sensitive to touch ```

Question 48

What are some S&S of high doeses of ketamine?

Answer 48

– be drowsy, have seizures or go into a coma – have a near-death experience – get amnesia, not be able to feel pain and have stiff muscles – become paranoid, experience panic, terror or anxiety – hallucinate and have bizarre or scary experiences – behave strangely.