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Case Presentation 18/02/2009 Flip Cloete

Case Presentation 18/02/2009 Flip Cloete. Case 1: 50 Yr Female History: ? Overdose Found in Bed GCS 10/15 En Route: GCS 7/15 Intubated 7 ETT Nil drugs Husband intoxicated No further history . 1 Survey: Intubated on ventilator BP: 194/116 P: 127

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Case Presentation 18/02/2009 Flip Cloete

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  1. Case Presentation 18/02/2009 Flip Cloete

  2. Case 1: 50 Yr Female History: ? Overdose Found in Bed GCS 10/15 En Route: GCS 7/15 Intubated 7 ETT Nil drugs Husband intoxicated No further history

  3. 1 Survey: Intubated on ventilator BP: 194/116 P: 127 HGT: 5,2 mmol/l T: 35,5 C SaO2: 100% FiO2 0.40 Pupils R = 3 mm L = 5 mm Bilateral sluggish

  4. GCS = 3 T (M2 decerebrate, E1, VT) No signs trauma or injury Examinations ???????

  5. Bloods: Na: 145 mmol/l K: 4,0 Cl: 106 Urea: 3,0 Creat: 48 WCC : 7,07 HB: 12,6 Plts: 319 GGT: 50

  6. ABG: FiO2 0,60 pH: 7,325 PaO2: 39,5 Kpa PaCO2: 5,88 HCO3: 23,0 mmol/l BE: -3,3 SaO2: 99,9 %

  7. ECG:

  8. CXR:

  9. Transfer for CT Brain - ? Trauma CT Brain = Normal Improved – extubated Alledges Overdose of “Blue” tablets Tox Screen: Paracetamol < 5 TCA - 34

  10. Recognised “Phenergan” (Promethazine) 25 mg tabs – took 25 tabs with alcohol. Referred to Psychiatry Discharged on Fluoxetine

  11. Approach to unknown overdose: Poisoned Patient TreatmentDiagnosis Airway History Breathing Physical Exam Circulation Toxidrome DON’T: Diagnostic Tests (dextrose, oxygen, naloxone, thiamine) Decontamination Enhanced Elimination Focused Therapy Get Tox Help

  12. Diagnosis • History Type, time, volume, route Reason Prescription drugs • Physical Exam Stabilisation priority • Toxidrome Recognition of toxic syndrome • Diagnostic Tests

  13. Treatment Airway Breathing Circulation DON’T: (dextrose, oxygen, naloxone, thiamine) • Individualize patients

  14. Treatment Cont: • Decontamination • Skin & Eyes • GIT • activated charcoal • Enhanced Elimination • Extracorporeal

  15. Treatment cont: • Focused Therapy • Antidote • Get Toxicology Help

  16. Phenothiazines (Neuroleptics) Promethazine = H1 antihistamine Toxidrome : • LOC (resp depression) Extrapyrimidal signs:rigidity, tremor,  reflexia, dyskinesia Restlessness (hallucinations) • BP & tachycardia Arrhythmias – QT prolongation Seizures (uncommon) vs. acute dystonia

  17. Side Effects : • Drowsiness (>80%) • Dizziness, fatigue, inco-ordination • Seizures , hallucinations • GIT – Nausea, vomiting, epigastric pain • Anticholinergic: dry mouth, blurred vision, urinary retention

  18. Management phenothiazine OD: • Advanced life support • Charcoal in 1-2 hrs • ECG, Acid-base, elecs • IV Fluid – BP • No role dialysis/ haemoperfusion • Acute dystonia Rx: diazepam/ anti-cholinergics (Akineton) 7. Weak cross reaction with TCA lab assay

  19. Case 2: 10 Yr Girl Washing windows @ school Sitting on bench/ desk Clothes damaged Severe pain buttocks Unable to sit

  20. Science Lab – Teacher sent note ? Nitric Acid / ? HCL Examination: Partial thickness burns to buttocks Left 8 x 12 cm with surrounding erythema Right 4 x 5 cm No Anal / Genital involvement Bear Weight, unable to sit

  21. Reviewed 24 hrs: Wounds blistering Clean Pain improving Plan: Cont daily Flamazine dressings Analgesia

  22. Approach to chemical burn: Acids: • Coagulation necrosis of tissue • Area coag limits injury extension Alkali: • Liquefaction necrosis • More dangerous • Liquefy tissue: denaturation of proteins saponification of fats • Continue penetration deep into tissue.

  23. Management: • A,B,C,D • Exposure • undressed • Euthermic, tepid water for irrigation • Early External warming devices • Pain management • Morphine • Tetanus

  24. Management: • Decontamination basics • Dilution is the solution to decontamination. • Never attempt neutralization - exothermic reaction + thermal injury/ explosion. • Cutaneous exposure • Powder - brush off • Rinse affected area (tepid tap water) • Liquid - remove clothing & rinse affected area • Copious amounts of fluid

  25. Management: • Oral and GI  • Mouth rinsed • Do not attempt neutralization • Airway & NPO • No gastric emptying/ lavage or ipecac • Ocular • Solution is dilution. • Rinsed copious ocular irrigation solution min. ½ hr • normal saline pH range 4.5 and 6.0. • Analgesia: Topical & parental • Eye pH checked 30 min increments cont irrigation till pH normalizes @ pH 7-8

  26. Bibliography: • Erickson TB, Thompson TM, Lu JJ. The Approach to the Patient with an Unknown Overdose. Emerg Med Clin N Am 25 (2007) 249–281. • Demling RH, DeSanti L, Orgill DP. Chemical Burns.Available from: Http://www.burnsergery.org/Modules/initial/part-two/sec6.htm. • Nervi SJ, Schwartz RA, Desposito F, Hostetler MA. Burns Chemical. eMedicine specialities paediatric surgery. Aug 11, 2008. Available from: http://emedicine.medscape.com/article/926537-overview • McNeil BK, Jaslow D. Chemical burns. eMedicinehealth, Web MD 2009. Available from: http://www.emedicinehealth.com/chemical-burns/article-em.htm. • Gibbon CJ et al, Division clinical pharmacology UCT. SAMF. 8th Edition. Cape Town: FA Print; 2008.

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