Corrections - Paracetamol & Alcohol, Overdoses Flashcards

1
Q

Why is urea raised disproportionately to creatinine in dehydration?

A

As some urea is reabsorbed with the increased water reabsorption that occurs in dehydration.

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2
Q

What scoring system is used to assess alcohol withdrawal severity?

A

The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale

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3
Q

Presentation of serotonin syndrome?

A

1) neuromuscular excitation:
- hyperreflexia
- myoclonus
- rigidity

2) autonomic nervous system excitation:
- hyperthermia
- sweating

3) altered mental state: confusion

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4
Q

Management of serotonin syndrome?

A

1) supportive including IV fluids

2) benzodiazepines

3) more severe cases: use serotonin antagonists e.g. cyproheptadine and chlorpromazine

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5
Q

What is a transaminitis (elevated ALT and AST) in the 10,000s most commonly caused by?

A

Paracetamol overdose

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6
Q

Pathophysiology in carbon monoxide poisoning?

A

1) Carbon monoxide binds readily to haemoglobin, forming carboxyhaemoglobin –> reduced oxygen-carrying capacity

2) In carbon monoxide poisoning the oxygen saturation of haemoglobin decreases leading to an early plateau in the oxygen dissociation curve.

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7
Q

What may questions regarding carbon monoxide poisoning hint at?

A

Questions may hint at badly maintained housing e.g. student houses.

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8
Q

Features of carbon monoxide poisoning?

A

1) headache (90%)

2) N&V (50%)

3) vertigo (50%)

4) confusion (30%)

5) subjective weakness (20%)

6) severe toxicity:
- ‘pink’ skin and mucosae
- hyperpyrexia
- arrhythmias
- extrapyramidal features
- coma
- death

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9
Q

Why may a pulse ox be falsely high in carbon monoxide poisoning?

A

Due to similarities between oxyhaemoglobin and carboxyhaemoglobin.

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10
Q

1st line investigation in carbon monoxide poisoning?

A

VBG or ABG

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11
Q

Management of carbon monoxide poisoning?

A

1) 100% high-flow oxygen via a non-rebreather mask: target sats 100%

2) hyperbaric oxygen

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12
Q

What is the single most important prognostic factor in paracetamol overdose?

A

ABG pH (indicative factor of a poor outcome requiring liver transplantation).

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13
Q

What is the liver transplantation criteria in paracetamol overdose regarding pH?

A

pH <7.3 more than 24 hours after ingestion

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14
Q

What type of urinary incontinence can TCAs cause?

A

Overflow

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15
Q

What is the King’s criteria for liver transplantation (paracetamol liver failure)?

A

1) arterial pH <7.3, 24 hours after ingestion

Or all of the following:

2) prothrombin time > 100 seconds

3) creatinine > 300 µmol/l

4) grade III or IV encephalopathy

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16
Q

Management options for salicylate OD?

A

1) urinary alkalinisation with IV bicarbonate

2) haemodialysis if indications e.g. pulmonary oedema, metabolic acidosis

17
Q

Management options for benzo OD?

A

Flumazenil.

Note - The majority of overdoses are managed with supportive care only due to the risk of seizures with flumazenil. It is generally only used with severe or iatrogenic overdoses.

18
Q

Management options for TCA OD

A

IV bicarbonate: may reduce the risk of seizures and arrhythmias in severe toxicity

19
Q

Which medications are contraindicated in TCA OD?

A

1) class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide): as prolong depolarisation

2) Class III drugs such as amiodarone: as prolongs QT interval

20
Q

Is dialysis effective in TCA OD?

A

No

21
Q

Management of lithium OD?

A

1) Mild-mod: may respond to volume resuscitation with normal saline

2) Severe: haemodialysis

22
Q

Reversal agent for heparin?

A

Protamine sulphate

23
Q

Reversal agent of iron?

A

Desferrioxamine, a chelating agent

24
Q

Management of lead OD?

A

Dimercaprol, calcium edetate

25
Q

Management of CO poisoning?

A
  • 100% oxygen
  • hyperbaric oxygen
26
Q

Management of cyanide OD?

A

Hydroxocobalamin

Also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate

27
Q

Management of paracetamol OD if presentation 8-24 hours after ingestion?

A

If OD >150 mg/kg –> start acetylcysteine even if the plasma-paracetamol concentration is not yet available

28
Q

Management of beta blocker OD?

A

1) if bradycardic –> atropine

2) in resistant cases –> glucagon

29
Q

Typical ABG results in salicylate overdose?

A

Initial respiratory alkalosis (due to hyperventilation) followed by metabolic acidosis (due to lactic acid accumulation)

30
Q

Normal QRS duration?

A

Between 0.08 and 0.10 seconds

31
Q

Normal QT interval?

A

From 0.4 to 0.44 seconds

Note - women have a longer QT interval than men

32
Q

How can acute hypoperfusion (e.g. low BP secondary to blood loss) affect the liver?

A

Can cause ischaemic hepatitis.

This is often characterised by marked elevation in aminotransferase liver enzymes (AST and ALT) which peak 1-3 days after the insult.

Will also be rise in LDH.

33
Q

Features of a beta blocker OD?

A
  • hypotension
  • bradycardia
  • AV block
  • HF
  • bronchospasm
  • hypoglycaemia, hyperkalaemia
34
Q

What type of reaction can N-Acetylcysteine cause?

A

N-Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release)

35
Q
A