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ACUTE POISONING

ACUTE POISONING. Major C J Porter RAMC Army Medical Directorate Emergency Medicine Registrar Bristol Royal Infirmary. Outline of lecture. Epidemiology Toxidromes History, examination and detective work General management Specific management Antidotes Scenarios. EPIDEMIOLOGY.

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ACUTE POISONING

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  1. ACUTE POISONING Major C J Porter RAMC Army Medical Directorate Emergency Medicine Registrar Bristol Royal Infirmary

  2. Outline of lecture • Epidemiology • Toxidromes • History, examination and detective work • General management • Specific management • Antidotes • Scenarios

  3. EPIDEMIOLOGY • 4000 UK deaths per year (1/3 CO) • Most deaths outside hospital • 100,000 Hospital admissions (12%) • Not just overdoses: Illicit drugs, Alcohol

  4. EPIDEMIOLOGY • Self poisoning: • F>M • 1/3 >one drug • Taken with alcohol: F: 40% M: 60% • Repeated self-poisoning: 11% of admissions

  5. SUICIDE • 2% of male deaths • 1% of female deaths • Method: • Female: Poisoning 40% • Male: Gas / Hanging / Suffocation • Self-harm parasuicide: • 1% dead after 12 months • 3-5% dead after 5-10 years

  6. Toxidromes • Patterns of signs and symptoms • Useful to help in diagnosis and treatment of unknown poisons

  7. Opiates • Respiratory depression • Cardiovascular depression • Reduced level consciousness • Pinpoint pupils • Pulmonary oedema • Hypothermia • (Rapid response to Naloxone)

  8. Common causes • Opiates – heroin, morphine etc

  9. Sympathomimetics /Stimulants • Agitation/delusions/paranoia • Fight/Flight response • Tachycardia • Hypertension • Arrhythmias • Dilated pupils • Seizures • Hyperpyrexia

  10. Common causes • Cocaine • Amphetamines • Decongestants • Ecstasy

  11. Anticholinergic • Tachycardia • Arrhythmias • Pupils: mid-point or dilated / divergent • Confusion / drowsiness / coma • Seizures • Dry flushed skin • Urine retention • Hypertonia, Hyper-reflexia, Myotonic jerks

  12. Anticholinergic signs • Hot as a hare • Blind as a bat • Dry as a bone • Red as a beet • Mad as a hatter

  13. Common causes • Antidepressants-Tricyclics • Antihistamines • Atropine • Antipsychotics • Antispasmodics

  14. Serotonin Syndrome • Similar to anticholinergic syndrome • loss of consciousness: uncommon • sweating and tremor: common • Agitation • Delirium • Hypertonia / myoclonus • Tachycardia • Tachypnoea

  15. Common Causes • SSRIs • MAOIs (Hyperpyrexia / Hypertensive crisis)

  16. Cholinergic • Brady/tachycardia • Confusion/reduced GCS • Pinpoint pupils • Seizures • Weakness • SLUDGE • Pulmonary oedema

  17. SLUDGE • S sweating salivation • L lacrymation • U urinary frequency urgency • D diarrhoea • G gastrointestinal discomfort • E eyes pinpoint

  18. Common causes • Organophosphates • Physostigmine • Some mushrooms • Nerve agents

  19. Salicylism: Aspirin • Impaired hearing • Tinnitus • Sweating • Warm skin • Hyperventilation • Cinchonism: Quinine (salicylism + blindness)

  20. MANAGEMENT

  21. Management Overview • History & assessment of vital signs • ANY concerns: move patient to RESUS A B C D DEFG • Supportive care (O2, IV Fluids) • Prevent absorption • Increase elimination • Antidotes • PSYCHOLOGICAL ASSESSMENT

  22. History • What? • When? • How much? (mg/kg) • What else? • Why?

  23. Collateral history • Paramedics • Family / friends • Notes • Look in pockets – carefully!!!

  24. Detective work • BNF • Toxbase • Tablet identification aids: TICTAC • Poisons advice: NPIS • Plant identification books • National teratology information service

  25. Initial examination • Treat problems as you find them!! • Airway • Breathing • Circulation • Disability – GCS/AVPU and Pupils • DON’T EVER FORGET GLUCOSE

  26. Observations • Saturations and respiratory rate • Pulse and blood pressure • GCS • Pupils • Temperature • GLUCOSE

  27. Investigations • All Patients • Glucose • U&E • Paracetamol & Salicylate • As indicated • LFT • Co-ag / INR • CK • ABG / VBG • ECG • CXR • Urine toxicology screen

  28. Reduce absorption • Emesis – No role • Activated charcoal within 1 hour • Gastric lavage – rarely • Whole bowel irrigation - rarely

  29. Increase elimination • Urinary alkalinisation • Multi-dose Activated Charcoal • Haemodialysis • Haemoperfusion • Plasma exchange • Forced alkaline diuresis(no longer recommended)

  30. Paracetamol • Very common: 40% poisons admissions • Often asymptomatic • Can be lethal – 200-300 deaths/year • Check blood level at 4 hours • Two treatment lines normal and high risk • Given IV N-acetylcysteine

  31. Paracetamol metabolism • Metabolised by glucuronidation (60%), Sulphation (35%) and oxidation (10%) • Cytochrome p450 produces NAPQI • NAPQI toxic causes hepatocellular necrosis – irreversible binding • NAPQI detoxified by conjugation with glutathione

  32. Prescott Nomogram

  33. High Risk • Increased oxidation • Chronic alcohol use • Drugs • Reduces glutathione stores • Malnutrition • Eating disorders • Chronic liver disease

  34. N-acetylcysteine • Most effective within 8 hours • Precursor for glutathione production • Can cause anaphylactoid reactions • Consider starting before paracetamol result if: • Presenting > 8 hrs & >150mg/kg taken • Staggered overdose

  35. To treat or not to treat?

  36. Patient 1 • 20 year old woman who takes a handful of paracetamol tablets • No drug history • No alcohol use • Fit and well • Blood level is 80mg/l

  37. No need to treat • Patient is not high risk • Level at 4 hours is below even the high risk line

  38. Patient 2 • 70 year old man • Takes 20 paracetamol 6 hours before presenting • Alcoholic • No drug history • Blood level 100mg/l

  39. Treat • Patient is high risk • Level is above the high risk line • Delayed presentation means need to act fast

  40. Patient 3 • 17 year old epileptic • 25 codydramol 2 hours before attendance • Taking carbamazepine • Blood level at 4 hours is 120mg/l

  41. Treat • High risk patient • Level above the high risk line

  42. Patient 4 • 35 year old man who presents after taking 24 paracetamol over a period of 24 hours • No drug history • Fit and well • Blood level 20mg/l

  43. Treat • Staggered overdoses are difficult • Poisons advice is to give IV acetylcysteine • Levels are not that helpful • Need to monitor Liver function, clotting and renal function • May need discussing with Liver Unit if abnormal

  44. PARACETAMOL DEADLY PITFALLS • The Prescott Nomogram High Risk Line • Staggered Overdoses • Management of late presentation • Recheck U&E, LFT, INR after N-acetylcysteine

  45. Tricyclics • Antidepressants • Dangerous: US 60-70% fatal ODs • UK commonest fatal OD per prescription • 10% unconscious patient will fit • Treat fits with diazepam/lorazepam

  46. Tricyclic effects • Anticholinergic toxidrome • The 3 C’s • Coma • Convulsion • Cardiac

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