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Cases from Downunder

Cases from Downunder. Sophie Gosselin.MD,CSPQ,FRCPC Newcastle Mater Misericordiae NSW, Australia. Case one – Miss R. Call at 01h30 13 yrs old female brought by police and EMS after suspected DSH by ingestion of medication Best friend called at 23h and told « good bye forever ».

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Cases from Downunder

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  1. Cases from Downunder Sophie Gosselin.MD,CSPQ,FRCPC Newcastle Mater Misericordiae NSW, Australia

  2. Case one – Miss R. • Call at 01h30 • 13 yrs old female brought by police and EMS after suspected DSH by ingestion of medication • Best friend called at 23h and told « good bye forever ». • Friend called mother, 000 called and patient ran out back door • Found at 00h30 by EMS and brought to JHH

  3. Case one – Miss R. • On arrival • Alert, oriented 67 kg • HR 120 NSR • RR 16 • BP 110/70 • sat 100% • Glucose 5.1 • T 37.8

  4. Case one – Miss R. • Took around 22h30 • Prednisone 50mg x 20 1000 mg • Paracetamol 500 mg x 64 32 gr • Codeine 30 mg x 24 720 mg • Pseudoephedrine 60 mg x 24 1440 mg • Ibuprofen 200 mg x 24 4800 mg • Medication X 0.5mg x 50-64 25-32 mg • Dimenhydrate 50 mg x 12 600 mg

  5. Case one – Miss R. • What would you do next? • What would you expect to find on physical exam to confirm if she did take all these?

  6. Case one – Miss R. • Level of counsciousness - belligerant • Airways - not a problem • Breathing - not a problem • Circulation – not a problem • Decontamination • Gastric lavage? • Charcoal? • WBI?

  7. Case one – Miss R. • We are 2 hours post ingestion. • Do we have indications to consider decontamination?

  8. Case one – Miss R. Police went home and did medication search. We knew then what Medication X was. Here is what we did and what happened. Can you identify the toxin? Note your answers as we go along Ask all questions you want Do not yell out your answers We will poll the assistance at the end and get a top 5 lists of toxin

  9. Case one – Miss R. • 01h15 • Intubated in ED for decontamination • Charcoal one dose 50 gr • WBI started • N-acetylcysteine started empirically pending level • Admitted to ICU • HR 160 BP 100/60 • ECG sinus tachycardia

  10. Case one – Miss R. • 04h00 • Hbg 137 • WBC 4.3 • Platelets 278 • Na 133 • K 3.0 • Creatinine 57 • BUN 3.5 • INR 1.1 • Paracetamol 950 at 3h30 • CK 146 • Troponin negative

  11. Day one – Miss R. • 04h00 • Sedated • Vomiting +++ • Unable to continue charcoal • HR 160 sinus • BP 95/60 • 14h00 • No change in status • Given Neostigmine 2.5 mg IV • Decontamination continued with charcoal alone until black stools

  12. Day two – Miss R. • HR 160 sinus • BP 75/55 started on norepinephrine • Swan Ganz • Output slightly decreased • Systemic vascular resistance decreased • Labs • Unchanged except CK 1307 • Which investigation would you want?

  13. Day two – Miss R. • Cardiac echo • Normal valves • Impaired LV contraction • EF 35% • No pericardial effusion.

  14. Day three – Miss R. • Still requiring inotropes • Stools black after MDAC • HR 140 BP with support 105/60 • Hgb 133 • WBC 4.9 • Plat 99 • LFTs and INR unchanged NAC stopped.

  15. Day four to six – Miss R. • Still requiring inotropes (dobutamine) • Still intubated • Fever 39 • Abdominal distension • HGB 105 • WBC 2.2 • Platelets 31 • CK 4142 • Troponins 1.87 Given GCSF for 24h

  16. Day six to eight – Miss R. • Weaned off inotropes • Extubated • Treated for Aspiration • Given neostigmine again • HGB 116 • WBC 9.0 • Platelets 111 • CK 541 • Troponins going down • Cardiac echo normal EF

  17. Data on toxin-Miss R. • Significant toxicity • Bound by charcoal • Initial symptoms? • Pancytopenia in 48h • Cardiac depression • Resolution within one week. • ????

  18. Colchicine intoxication • Patient has gout. • Took 0.5 mg x 64 = 32 mg • Per kg = 0.48 • Phase 1 • 0-24h GI, leukocytosis, hypovolemia, DIC • Phase 2 • 2-7 days bone marrow suppression, cardiac depression, hepatic failure, MOF, ARDS • Phase 3 • Resolution • Death • Alopecia

  19. Colchicine intoxication • Alkaloid from Colchicum autumnale • Narrow therapeutic-toxix index • GI side effects • High rates of morbidity • Absorbed 2 h after ingestion • Not delayed in overdose unless by coingestants • First pass hepatic metabolism • Distribution t1/2 45-90 minutes • Excreted in the bile with enterohepatic circulation

  20. Colchicine intoxication • Binds to tubulin • Impairs microtubules formation • Neutrophils, gastrointestinal musco, hematopoeitic cells, hair follicles. • Toxicity is dose related • 0.5 mg/kg or less usual recover • 0.8 mg/kg or more usual die • 3 stages • GI 0-24h • MOF 24-72h • Recovery 6-8 days p.i.

  21. Colchicine intoxication • Asymptomatic initially • N/V/D • GI mucosal damage • Hypovolemic shock • Sepsis • impaired macrophage function • Cardiogenic shock • Rhabdomyolysis • Renal failure • Seizures, ascending paralysis, transverse myelitis

  22. Ingestion known Asymptomatic drug OD Toxic causes of gastroenteritis Iron Salicylates Fluoride Caustics Cardiac glycosides Nicotine OPP/carbamates Paraquat Mushrooms Ingestion unknown Acute abdomen Cardiogenic shock Gastroenteritis Hypovolemic shock Septic shock Colchicine intoxication

  23. Colchicine intoxication • Extensive baseline lab studies • Levels can be done • Takes a few days • Retrospective, post mortem • No increase in AG, osmolar gap • Acid base abnormality are not specific • Early, aggressive GI decontamination • Enhanced elimination not indicated • Large Vd 21L/kg • Intracellular binding sites • GSCF true response versus natural course? • Death are rarely from marrow aplasia • No antidotes commercially available

  24. Colchicine intoxication • Fab antibodies • Similar to digitalis Fab fragment • Produced in goat immunized with conjugate of colchicine and albumin • Effectively reverse toxicity in mice • NEJM Mar 15 1995. Baud and al. • One human case report 27 hrs p.i of 60 mg of colchicine 0.98 mg/kg • Improvement within 30 minutes after Fab • Severe cardiogenic shock • Increased the urinary excretion of Fab-colchicine compound by 6 fold

  25. Colchicine intoxication • Patient has gout. • Took 0.5 mg x 64 = 32 mg • Per kg = 0.48 • Phase 1 • 0-24h GI, leukocytosis, hypovolemia, • Phase 2 • 2-7 days bone marrow suppression, cardiac depression, rhabdomyolysis • Phase 3 • Resolution

  26. Case 2- Mrs. B • 45 years old patient found on highway • After serious MVA • Transported to Trauma Center

  27. Case 2- Mrs. B • A patent • B GAEB • C BP 50/ … HR 40 • No external wounds • No other signs of injury • Normal temperature • Normal glucose

  28. Case 2- Mrs. B • Prolonged QT • Wide QRS • Differential diagnosis • Traumatic injury after OD? • No traumatic injury but signs are the OD?

  29. Traumatic Single vehicule MVA Seatbelt No airbag Unknown speed Damages important Toxicologic No associated signs of injury Traumatic vs toxicologic?

  30. Case 2- Mrs. B • How would you manage this patient?

  31. Case 2- Mrs. B • NaHCO3 infusion? • External pacer • Extracorporeal support • Emergency bypass? • Thoracotomy? • Transthoracic ultrasound? • Gastrointestinal decontamination?

  32. Traumatic Tamponnade Hypovolemic shock? Pneumothorax? CNS bleed? Toxicologic Antidysrhythmic TCA Phenothiazines Cocaine Amantadine Propoxyphene Chloral hydrate OPP Terfenadine BB; CCB; Hypokalemia Hypocalcemia Differential diagnosis?

  33. Case 2- Mrs. B • No significant response to many boluses of NaHCO3 • Normal CXR, Normal FAST • Normal Hgb • Acidosis • High lactate • Started seizing… • Would you give her amiodarone? • Would you start pressors and if so which one?

  34. Vaughan-Williams Classification

  35. Case 2- Mrs. B • Are you able to tell which one is which? • Degree of hypotension? • Degree of bradycardia? • Anticholinergic features? • Presence of seizures?

  36. IA or IC Cardiac conduction delay NaHCO3 ph 7.5 Fluid for hypotension Norepinephrine Magnesium if TDP Overdrive pacing Isoproterenol IB Lorazepam for sz Phenobarbital Fluid for hypotension norepinephrine Treatment

  37. Case 2- Mrs. B • NaHCO3 infusion increasing • Overdrive pacing • Norepinephrine increasing doses • She went in PEA • Arrested • Unable to ressuscitate

  38. Case 2- Mrs. B • Police found suicide note • Empty bottle of flecainide • Could we have done anything to save her?

  39. Flecainide overdose • IC antidysrhythmic • Na channel blockade • All condution pathways depressed • High mortality rate 23% compared with other classes • Quick absorption within 30 minutes • 95% bioavailability • Serious cardiac effect 30-120 minutes • Weak acid ; Alkalinization • Vd 9 L/kg ; dialysis ineffective • Long half life

  40. Flecainide overdose • Hemoperfusion • A blood pressure is needed • ECMO • Critical Care Medicine April 2001 • Case report • After 8 mg epi, 1.2 mg atropine, 125 mmol NaHCO3 • Epi drip 100 mg/min • TC pacer to 100 mA • T pacer to 20 mA asynchronous mode • Fixed dilated pupils, no palpable pulse, pH 7.26 • Successful recovery after 26 hours

  41. Australian experience A paramedical case report

  42. John Hunter Hospital Level 6 trauma center Built 1991 Ressuscitation Room

  43. Combined pediatric Adult emergency department One ressuscitation area

  44. 8 monitored bed 18 acute care beds

  45. Doctors desks

  46. Isolated Monitored beds

  47. Longitudinal hall Departments on either sides

  48. Special 4 isolation ICU type beds « for SARS or the like »

  49. Stand-by isolation ward

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