Emergency TX of poisoning

Question 1

Which websites should be consulted when managing a patient with toxicity?

Answer 1

Toxbase or the UK national poisons information service

Question 2

What should happen if a patient has features of poisoning?

Answer 2

Should generally be admitted to hospital, even poisons with delayed action

Question 3

Which poisons have delayed action?

Answer 3

aspirin, iron, paracetamol, TCAs, co-phenotrope

Question 4

How should specialist antidotes be stored?

Answer 4

Separate area, and clearly labelled as specialist antidotes

Question 5

What is common in severe poisoning with cns depressants?

Answer 5

Hypotension. Systolic bp of less than 70mmHg may lead to irreversible brain damage. Correct by raising the foot of the bed and administer sodium chloride or colloid. Fluid depletion after hypotension is common

Question 6

What is common after aspirin poisoning?

Answer 6

Fluid depletion due to vomitting, sweating and hyperpnoea

Question 7

What is associated with poisoning due to sympathomimetic drugs?

Answer 7

Hypertension

Question 8

What can occur in acute poisoning with tcas, antipsychotics and antihistamines

Answer 8

Cardiac conduction defects and arrythmias

Question 9

What is associated with overdose with barbituates or phenothiazines

Answer 9

Hypothermia

Question 10

How are convulsions during poisoning treated

Answer 10

Short lived convulsions lasting less than 5 minutes do not require treatment. If the convulsions are protracted or recur frequently, lorazepam or diazepam should be given by slow iv injection into a large vein. Midazolam can be given buccally

Question 11

Discuss the use of charcoal for poisoning

Answer 11

Activated charcoal can bind many poisons in the GI system and reduce their absorption. The sooner it is given, the more effective it is, but it may still be effective up to one hour after ingestion of the poison. Particularly useful with antidepressants

Question 12

When is repeated doses of activated charcoal given in poisoning?

Answer 12

After overdosage with:
carbamazapine
dapsone
phenobarbital
quinine
theophylline

Question 13

What are the symptoms of acute intoxication with alcohol?

Answer 13

Ataxia, dysarthria, nystagmus, drowsiness, hypotension and acidosis, hypogylcaemia can occur.

Question 14

How is alcohol intoxication treated?

Answer 14

Manage patients supportively and maintain clear airway. Blood glucose measured and give glucose if indicated

Question 15

What are the main symptoms of salicylate poisoning?

Answer 15

Hyperventilation, tinnitus, deafness, vasodilation, sweating.

Question 16

How is aspirin poisoning treated?

Answer 16

In hospital, where plasma salicylate, pH and electrolytes can be measured, aspirin absorption may be slow and the plasma conc may continue to rise for several hours. Can give activated charcoal, haemodialysis is the tx of choice if severe

Question 17

What are the symptoms of opioid poisoning?

Answer 17

Coma, respiratory depression, pinpoint pupils

Question 18

How is opioid poisoning treated?

Answer 18

Naloxone, if there is coma or bradypnoea. Has a shorter duration of action, so close monitoring and repeated injections may be necessary according to the respiratory rate.

Question 19

What are the symptoms of paracetamol poisoning?

Answer 19

Nausea and vomitting are the early features, and usually settle within 24 hours. The recurrence of nausea and vomitting after 2-3 days and onset of pain indicates hepatic necrosis.

Question 20

Discuss the use of acetylcysteine following paracetamol overdose

Answer 20

It prevents or reduces the severity of liver damage if given up to and beyond 24 hours after ingesting paracetamol. Most effective if given within 8 hours of ingestion

Question 21

When should patients be referred to hospital in acute paracetamol od?

Answer 21

• ingested with the purpose of self-harm
• symptomatic
  -75mg/kg or more in one hour or less
• 75mg/kg or more

Question 22

When should children be referred to hospital in acute paracetamol overdose?

Answer 22

• symptomatic
• ingested 150mg/kg or more
• uncertainty about the dose ingested/circumstances

Question 23

What are the two IV regimes for acetylcysteine?

Answer 23

The standard 21 hour regimen and the modified 12 hour regimen. For the 21 hour, the dose is given in a total dose divided into 3 consecutive iv infusions over a total of 21 hours.

Question 24

What are the symptoms of overdose with TCAs?

Answer 24

Dry mouth, coma, hypotension, hypothermia, hyperreflexia, extensor plantar responses, convulsions, respiratory failure, cardiac conduction defects and arrythmia, dilated pupils, urinary retention

Question 25

What is the treatment of overdose with TCAs

Answer 25

Assessment in hospital strongly advised, clear the airway, IV lorazepam and diazepam for convulsions, activared charcoal within 1 hour of od.

Question 26

What are the symptoms of overdose with SSRIs

Answer 26

Nausea, vomitting, agitation, tremor, nystagmus, drowsiness, sinus tachycardia, convulsions. Severe poisoning results in serotnin syndrome

Question 27

What is the tx of ssri poisoning

Answer 27

Supportive, activated charcoal within 1 hour of overdose and treat convulsions with benzos

Question 28

What can occur with od of antimalarials

Answer 28

Overdosage is extremely hazardous and difficult to treat. lIFE THREATENING FEATURES SUCH AS ARRYTHMIAS AND CONVULSION

Question 29

What are the symptoms of phenothiazine poisoning?

Answer 29

Hypotension, hypothermia, tachycardia and arrythmias. Dystonic reactions and convulsions may occur

Question 30

What are the symptoms of overdose in second generation antipsychotics

Answer 30

Drowsiness, convulsions, eps, hypotension, ecg abnormalities inckuding prolongation of QT interval. Activated charcoal within one hour

Question 31

What are the symptoms of benzodiazepene od

Answer 31

Drowsiness, ataxia, dysarthria, nystagmus and resp depression/coma.

Question 32

What is the tx of benzo od

Answer 32

Charcoal within one hour, flumenazil

Question 33

What are the features of beta-blockers poisoning

Answer 33

Cardiac effects such as bradycardia, hypotension, syncope, conudction abnormalities and HF.

Question 34

What can sotalol cause in od

Answer 34

Ventricular tachyarrythmias secondary to prolongation of the QT interval eg sotalol

Question 35

What can propranolol cause in od

Answer 35

Prolongation of the QRS interval. Coma and convulsions

Question 36

What are the features of ccb poisoning

Answer 36

Nausea, vomitting, dizziness, agitation, confusin and coma in severe poisoning. Metabolic acidosis and hyperglycaemia can ocur

Question 37

What can verapamil and diltiazem cause in overdose

Answer 37

Profound cardiac depressant effect causing hypotension and arrythmias

Question 38

How is ccb od treated

Answer 38

Charcoal, repeated if mr prep involved. Calc chloride or gluconate can be given if severe and atropine for symptomatic bradycardia

Question 39

What are the symptoms of iron poisoining

Answer 39

Nausea, vomitting, abdo pain, diarrhoea, haematemesis, rectal bleeding. Coma, shock and metabolic acidosis indicate severe poisoning. Desferrioxamine chelates iron

Question 40

What can cause lithium intoxication?

Answer 40

Reduced excretion of the drug due to dehydration, deteriorated renal function, infections, diuretics, NSAIDs.

Question 41

What are the clinical features of lithium toxicity

Answer 41

Early clinical features are non-specific and may include apathy, vomitting, diarrhea, ataxia, weakness, dysarthria, muscle twitiching, tremor. Severe poisoning is associated with convulsions, coma, renal failure, electrolyte imbalance, dehydration and hypotension

Question 42

What is the therapeutic serum lithium conc

Answer 42

0.4-1mmol/litre

Question 43

What conc of lithium indicates toxicity?

Answer 43

In the excess of 2mmol/l

Question 44

What are the symtpoms of stimulant drug poisoning and how is it treated?

Answer 44

Wakefulness, excessive activity, paranoia, hallucinations, hypertension followed by exhaustion, convulsions, hyperthermia and coma. Can control with diazepam/lorazepam

Question 45

What are the symptoms of cocaine overdose?

Answer 45

agitation, dilated pupils, tachycardia, hypertension, hallucinations, hyperthermia, hypertonia, hyperreflexia, chest pain, MI, arrythmias

Question 46

What is the initial tx of cocaine poisoning?

Answer 46

iv diazepam, cooling measures for hyperthermia

Question 47

What are the most serious side effects associated with mdma

Answer 47

delirium, coma, convulsions, ventricular arrythmias, hyperthermia, rhabdomylosis, renal failure, hepatitis, intravascular coagulation, hypotension, haemorrhage, hyponatraemia

Question 48

What are the symptoms of theophylline poisoning?

Answer 48

Vomitting, agitation, restlesness, dilated pupils, sinus tachycardia and hyperglycaemia. Haematemesis, severe hypokalaemia may develop rapidly

Question 49

What is the tx of theophylline poisoning

Answer 49

Repeated doses of activated charcoal if more than an hour has elapsed or taken mr prep. Odansertrin anti emetic and correct hypokalaemia with pot chloride

Question 50

What is the tx of cyanide poisoning

Answer 50

Oxygen administered, dicobalt if not severe.

Question 51

Discuss dicobalt

Answer 51

Toxic and associated with anaphylactoid reactions, potentially fatal if administered in the absence of cyanide posoning

Question 52

What can be given for victims of cyanide smoke inhlation showing signs of significant poisoning?

Answer 52

Hydroxocobalamin - cyanokit

Question 53

What is the tx for ethylene glycol and methanol poisoning?

Answer 53

Fomepizole, or ethanol

Question 54

What is the tx of carbon monoxide poisoning?

Answer 54

move to fresh air, clear air way and give high flow oxygen.

Question 55

What are the symptoms of organophosphorous poisoning

Answer 55

Anxiety, restlesness, dizziness, headache, miosis, nausea, hypersalivation, vomitting, colic, diarrhoea, bradycardia and sweating

Question 56

What is the tx of cardiac glycoside poisoning

Answer 56

Digoxin specific antibody fragments

Question 57

What is the toxic range for digoxin?

Answer 57

1.5-3 micrograms/litre