Acute multisystem Flashcards
Anticholinergic overdose features
Mad, red, dry, hot (confusion, hallucination, dilated pupils, tacycardia, pyrexia, dty mouth, urinary retention)
Cholinergic OD features
SLUDGE-BBB: Salivation, Lacrimaton, Urination, Diaphoresis, GI upset, Emesis, Bradycardia, Bronchospasm, Bronchorrea
Serotonergic OD features (ecstasy, SSRI)
Altered mental state, agitation, hyperreflexia, autonomic instability (BP variations)
o DDX: neuroleptic malignant syndrome, Tx: dantrolene
Sympathomimetic OD features (organophosphate, cocaine)
HTN, high HT, dilated pupils, agitation
ABCDE assessment in overdose
A
* Lost in opioid
B
* Opioid: resp depression
C
* Obs: HR, BP, CRT, urine output, fluid status (See above)
* Bloods: FBC. U&E, toxicology, VBG, LFT, INR, glucose,
* Specific: Paracetamol level, salicylate level.
* Urine tox screen
* ECG, continuous cardiac monitor (QT>450 in TCA OD)
D/E
* AVPU score and GCS
* Consider airway protection of low GCS
* CBG
* Consider fall or fractures
* Check for urinary retention
Management summary for OD cases
- ABCDE approach,
- Take full history (what taken, how much, when, co-ingstion) and examination
- 12-lead ECG continuous
- Bloods, urine tox screen, glucose, osmolar/anion gap
CVVHF in OD
o Considered in Lithium, Salycilate, Ethanol, Ethylene glycol and methanol poisoning.
Coma cocktail when suspecting OD
“Coma cocktail” when suspecting toxic ingestion (mnemonic = “DONT”)
Dextrose (50mg IV)
Oxygen
Naloxone (0.2-0.4mg IV/IM, repeat dose 1-2mg)
Empiric opioid ingestion treatment
Thiamine (50-100mg)
Treat or avoid Wernicke encephalopathy
Though some suggest giving thiamine prior to dextrose, do NOT let this delay treatment of hypoglycemia!
Case reports of dextrose precipitating Wernicke’s involved thiamine-deficient patients receiving prolonged course of IV glucose, NOT with single bolus
Specific mx: Paracetamol OD
If staggered / poor history / above certain level for BW / para level above treatment curve
N-acetylcysteine 150 mg/kg IV over 60 min then 100mg/kg IV over 16 hr
o If above treatment line 4 hours post ingestion,
o SADPERSONS score for re-attempt and need for admission
o DO NOT use treatment line if:
Staggered overdose
No memory of how many taken
High risk patients (taking enzyme inducers)
Anticholinergic OD antidote
Phyostigmine
Arsenic/Mercury antidote
Dimercaprol
BZD antidote
Flumanezil
BB OD antidote
Glucagon
CCB OD antidote
CaCl 10@10 and insulin 1u/kg/hr with dextrose
Clonidine/opiate OD antidote
Naloxone
Digoxin OD antidoteq
Digibind
Ethlyene glycol / Methanol OD antidote
Fomepizole
Fluoride OD antidote
Ca gluconate
Heparin OD antidote
Protamine sulfate
Iron OD antidote
Desoxiferramine +/- charcoal
Isoniazid antidote
Pyridozine
Lead OD antidote
EDTA/Succimer
Methaemoglobinaemia tx
MEthylene blue
Organophosphate OD antidote
Atropine
TCA poisoning antidote
Bicarb
Sulfonylurea OD antidote
Octreotide
Anaphylaxis red flags
acute, wheezy, stridor, fast deterioration, falling BP
ABCDE in anaphylaxis
A
* May be obstructed (Stridor): consider adjunct + ADRENALINE now
B
* Wheeze
* RR high, SPO2 low
C
* BP low, HR high, CRT high, UO may be low
* Abdominal pain and diahrrea
* 2x large bore cannulae: VBG, FBC, U&E, LFT, Clotting, G&S, glucose
* Take mast cell tryptase to confirm anaphylaxis
D/E
* AVPU and GCS
* Glucose
* Admit for observation at leadt 6 hours (biphasic reaction)
* F/U allergy clinic
* Assess for rashes
* Consider CXR if ?PTX
Management of anaphylaxis
REMOVE ALLERGEN
ABCDE approach, put out peri arrest call
Initial treatment
o Lie patient flat, raise legs
o Treat initially (0.5 (every 5), 5, 200, 10)
0.5 1:1000 adrenaline IM every 5 mins
5 mg salbutamol Neb
200mg IV hydrocortisone
10mg Chlorphrenamine
Obtain collateral and allergy / exposure history to identify trigger. Document event and allergy.
Admit and monitor for minimum 6 hours post attack - Monitor ECG, contrinue fluids if required
Continue steroid 30-40 mg Pred / day; contrinue chlorphrenamine 4mg PO QDS if itching.
CVVHF indications
pH<7.1
K>7 refractory
Bicarb <12
Urea>45 / enceophlaopathy
Fluid overload
Toxin removal [salicylate, lithium, ethanol, ethylene glycol and methanol]
