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Y5 Substance Abuse > List I - Core Conditions > Flashcards

List I - Core Conditions Flashcards

1
Q

What is the treatment for paracetamol overdose?

A
  • Activated charcoal if ingested <1 hour
  • N-acetylcysteine (NAC)
  • Liver transplant if at serious risk
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2
Q

What is the treatment for salicylate (aspirin) overdose?

A
  • Urinary alkalinization is now rarely used - contraindicated in cerebral and pulmonary oedema, most units proceed straight to haemodialysis in cases of severe poisoning
  • Haemodialysis
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3
Q

What is the treatment for opiates/opioid overdose?

A
  • Naloxone 0.4-2mg IV/IM
  • Can repeat every 2 minutes until breathing is adequate
  • Alternatively can give doxapram for respiratory depression
  • Add Lomotil 2 tablets/6 hrs PO (combined diphenoxylate and atropine for cramps/diarrhoea from opiate withdrawal
  • Methadone can be used for opiate withdrawal
  • 10-30mg/12h PO if opiate withdrawal
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4
Q

What is the treatment for benzodiazepine overdose (lorazepam, diazepam, midazolam)?

A
  • Flumenazil
  • Most cases are managed with supportive care due to the risk of seizures with flumenazil - generally only used with severe or iatrogenic overdoses
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5
Q

What is the management of warfarin overdose?

A
  • Vitamin K, prothrombin complex
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6
Q

What is the management of heparin overdose?

A
  • Protamine sulphate
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7
Q

What is the management of Beta-blocker overdose?

A
  • If the patient is bradycardic then atropine

* In resistant cases glucagon may be used

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8
Q

What is the management of ethylene glycol (anti-freeze) poisoning?

A
  • Fomepizole - inhibitor of alcohol dehydrogenase is now used first line
  • Ethanol was used previously as it competes for the enzyme alcohol dehydrogenase
  • Limits the formation of toxic metabolites (e.g. glycoaldehyde and glycolic acid) responsible for the haemodynamic/metabolic features of poisoning
  • Haemodialysis also has a role to play
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9
Q

What is the management of methanol (methyl alcohol) poisoning?

A
  • Fomepizole or ethanol

* Haemodialysis

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10
Q

What is the management of organophosphate insecticide (phosphate ester) poisoning?

A
  • Atropine
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11
Q

What is the management of digoxin poisoning?

A
  • Digoxin-specific antibody fragments
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12
Q

What is the management of iron poisoning?

A
  • Desferrioxamine - a chelating agent
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13
Q

What is the management of lead poisoning?

A
  • Dimercaprol - calcium edetate
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14
Q

What is the management of carbon monoxide poisoning?

A
  • 100% oxygen

* Hyperbaric oxygen

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15
Q

What is the management of cyanide poisoning?

A
  • Hydroxocabalamin, also combination of amyl nitrite, sodium nitrite and sodium thiosulfate
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16
Q

What is the management of tricyclic antidepressant overdose?

A
  • IV sodium bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity
  • Correction of acidosis is the first line in the management of tricyclic induced arrhythmias
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17
Q

What is the management of lithium overdose/toxicity?

A
  • Mild-moderate toxicity may respond to volume resuscitation with normal saline
  • Haemodialysis may be needed in severe toxicity
  • Sodium bicarbonate is sometimes used but there is limited evidence to support this- by increasing the alkalinity of the urine it promotes lithium excretion
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18
Q

What are the clinical features of aspirin (salicylate) overdose?

A
  • Hyperventilation (centrally stimulates respiration)
  • Tinnitus
  • Lethargy
  • Sweating, pyrexia
  • Nausea/vomiting
  • Hyperglycaemia and hypoglycaemia
  • Seizures
  • Coma
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19
Q

What are the principles of treatment for aspirin (salicylate) overdose?

A
  • General ABC
  • Urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine
  • Haemodialysis
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20
Q

What is the criteria for haemodialysis in salicylate overdose?

A
  • Serum concentration of >700 mg/L
  • Metabolic acidosis resistant to treatment
  • Acute renal failure
  • Pulmonary oedema
  • Seizures
  • Coma
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21
Q

What is the pathophysiology of salicylate overdose?

A
  • Salicylates cause the uncoupling of oxidative phophorylation leading to decreased adenosine triphosphate production, increased oxygen consumption and an increased carbon dioxide and heat production
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22
Q

What is the blood gas picture for a patient with aspirin overdose?

A
  • Leads to a mixed respiratory alkalosis and metabolic acidosis
  • Raised anion gap
  • Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis
  • In children metabolic acidosis tends to predominate
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23
Q

What level is considered less severe in aspirin overdose?

A
  • Plasma salicylate concentration of less than 500 mg/litre (3.6 mmol/litre) is considered less severe
24
Q

How should urine excretion be managed in aspirin overdose?

A
  • Fluid losses should be replaced and IV sodium bicarbonate may be given (ensuring plasma potassium concentration is within the reference range to enhance urinary salicylate excretion)
  • Plasma potassium concentration should be corrected before giving sodium bicarbonate as hypokalaemia may complicate alkalinisation of the urine
25
Q

What fluid regime should be given for alkalinisation of urine after salicylate OD?

A
  • Correct dehydration/hypokalaemia (fluids, K+ supplements
  • Take salicylate level after 2 hrs
  • If level is >500mg/L (3.6mm/L) consider alkalinisation of urine
  • Use 1.5 L 1.26% NaHCO with 40 mmol KCl IV over 3 hrs
  • Aim to make the urine pH 7.5 - 8.5
  • Monitor UO, blood glucose, U and E’s especially K+ as can reduce serum pH, ECG
  • If >700mg/L consider dialysis or if renal HF, seizures, severe acidosis, persistently high levels
26
Q

What is the current recommended level of alcohol for men and women in the UK?

A
  • No more than 14 units per week
  • If you do drink as much as 14 units per week it is best to spread this evenly over 3 days or more
  • Pregnant women should not drink alcohol
27
Q

What is one unit of alcohol equivalent to?

A
  • 10 mL of pure ethanol

Examples include:

  • 25ml single measure of spirits (ABV 40%)
  • 1/3 of a pint of beer (ABV 5 to 6%)
  • 1/2 a 175ml standard glass of red wine (ABV 12%)
28
Q

How can you calculate the number of units of alcohol in a drink?

A
  • Multiply the number of millilitres by the ABV and divide by 1000
  • For example:
  • 1/2 175ml standard glass of red wine = 87.5 * 12 / 1000 = 1.05 units
  • 1 bottle of wine = 750 * 12 / 1000 = 9 units
  • 1 pint of 5% beer or lager = 568 * 5 / 1000 = 2.8 units
29
Q

What is the mechanism of acute alcohol withdrawal?

A
  • Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
  • Alcohol withdrawal is thought to lead to decreased inhibitory GABA and increased NMDA glutamate transmission
30
Q

How does acute alcohol withdrawal present?

A
  • Symptoms start at 6-12 hours - tremor, sweating, tachycardia, anxiety
  • Peak incidence of seizures is at 36 hours
  • Peak incidence of delirium tremens is at 48-72 hours - course tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
31
Q

What is the management of acute alcohol withdrawal?

A
  • Patients with history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
  • First-line: benzodiazepines such as chlordiazepoxide (lorazepam may be preferable in patients with hepatic failure - typically given as part of a reducing dose protocol) or carbamazepine
  • People with decompensated liver disease who are being treated for acute alcohol withdrawal should be offered advice from a health care professional experienced in this area
  • Offer information about how to contact local alcohol support services - Forward Leeds
32
Q

What can be used to quantify severity of alcohol withdrawal?

A
  • Clinical Institute Withdrawal Assessment - Alcohol, revised scale is a validated 10-item assessment tool to quantify the severity of the alcohol withdrawal syndrome and to monitor and medicate patients throughout withdrawal
  • Patients with scores < or equal to 8 typically do not require medication for withdrawal
33
Q

For people being managed for acute alcohol withdrawal, what is the management for delirium tremens?

A
  • Offer oral lorazepam first line

* Haloperidol second line

34
Q

For people being managed for acute alcohol withdrawal, what is the management for withdrawal seizures?

A
  • Consider offering a quick acting benzodiazepine such as lorazepam
    (Do not offer phenytoin to treat alcohol withdrawal seizures)
35
Q

What is Wernicke’s encephalopathy?

A
  • Acute neurological condition characterised by a triad of ophthalmoparesis with nystagmus, ataxia, and confusion
  • Life threatening illness caused by thiamine deficiency which primarily affects the peripheral and central nervous systems
36
Q

What should patients in acute alcohol withdrawal be given to reduce the risk of them developing Wernicke’s encephalopathy?

A
  • Offer B1 thiamine in high doses (Pabrinex)

* Should be given for a minimum of 5 days

37
Q

Which patients should be offered prophylactic thiamine (B1)?

A
  • Harmful (35 units or more for men or 50 units or more for women) or dependent drinkers if they are:
  • Malnourished
  • Have decompensated liver disease
  • Are in acute withdrawal
  • Before and during a planned medically assisted alcohol withdrawal
38
Q

What can be used to formally assess a person who is drinking alcohol to excess to identify the nature and severity of their alcohol misuse?

A
  • AUDIT or AUDIT-C (Alcohol Use Disorders Identification Test)
  • Can help to identify whether a brief intervention is required or not and if so what type (AUDIT-C is an abbreviated version
  • Low-risk drinking score 1-7
  • Hazardous drinking score 8-15
  • Harmful drinking score 16-19
  • Possible alcohol dependence score of 20 or more

** If the AUDIT score suggests alcohol dependence, consider assessing its severity using the SADQ (Severity of Alcohol Dependence Questionnaire) or LDQ (Leeds Dependence Questionnaire)

Cut-offs for the SADQ are:

  • Mild — 15 or less
  • Moderate — 15–30
  • Severe — 31 or more.

Cut-offs for the LDQ are:

  • Low dependence — less than 10
  • Medium dependence — 10–22
  • High dependence —over 22
39
Q

What brief advice can be given to a person who is drinking hazardous or harmful amounts of alcohol?

A
  • FRAMES principles
  • Feedback - on the persons risk of having alcohol problems
  • Responsibility - change is the person’s responsibility
  • Advice - provision of clear advice when requested
  • Menu - what are the options for change
  • Empathy - an approach that is warm, reflective and understanding
  • Self-efficacy - optimism about the person’s ability to change their own behaviour
40
Q

What are the possible psychological interventions people with alcohol problems may benefit from?

A
  • CBT and behavioural therapies - one 60 minute session per week for 12 weeks
  • Social network and environment based therapies - focused of alcohol related problems should usually consist of 8 x 50 minute sessions over 12 weeks
  • Behavioural couples therapy - focused on alcohol related problems and their effect on the person’s relationships - should usually consist of one 60 minute session per week for 12 weeks
41
Q

What are the main points regarding smoking cessation from NICE guidance?

A
  • Patients should be offered nicotine replacement therapy, varenicline or bupriopion - clinicians should not favour one over another
  • This should normally be prescribed as part of a commitment to stop smoking on or before a particular date (target stop date)
  • Prescription should last only until 2 weeks after the target date to stop - normally this will be after 2 weeks of NRT and 3-4 weeks for varenicline and bupropion to allow for different methods of administration and mode of action
  • In unsuccessful do not offer a repeat prescription with 6 months unless special circumstances have intervened
  • Do not offer NRT, varenicline or bupropion in any combination
42
Q

What is varenicline?

A
  • A nicotinic receptor partial agonist
43
Q

How should varenicline be administered?

A
  • Should be started 1 week before the patients target date to stop
  • Recommended course of treatment is 12 weeks but patients should be monitored regularly and treatment only continued if not smoking
  • Has been shown in studies to be more effective than bupropion
  • Nausea is the most common adverse side effect, other common problems include headache, insomnia, abnormal dreams
  • Varenicline should be used with caution in patients with a history of depression or self harm
  • Contra-indicated in pregnancy and breast feeding
44
Q

What is bupropion?

A
  • A norepinephrine and dopamine reuptake inhibitor and nicotinic antagonist
45
Q

How should bupropion be administered?

A
  • Should be started 1 to 2 weeks before patients target date to stop
  • Small risk of seizures 1/1000
  • Contraindicated in epilepsy, pregnancy and breast feeding
  • Having an eating disorder is a relative contraindication
46
Q

How should pregnant women be management in terms of smoking cessation?

A
  • NICE guidance recommends that all pregnant women should be tested for smoking using carbon monoxide detectors - some women find it difficult to say that they smoke because the pressure not to smoke in pregnancy is so intense
  • All women who smoke or have stopped smoking within the last 2 weeks or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services
47
Q

What interventions can be used for pregnant women who want to stop smoking?

A
  • First line in pregnancy should be CBT, motivational interviewing or structured self help and support from NHS Stop Smoking Services
  • NRT if the above measures fail
  • Varenicline and Bupropion are contraindicated in pregnancy
48
Q

What is the mechanism of action of cocaine?

A
  • Cocaine blocks the uptake of dopamine, noradrenaline and serotonin
49
Q

What are the cardiovascular adverse effects of cocaine toxicity?

A
  • Myocardial infarction
  • Both tachycardia and bradycardia may occur
  • Hypertension
  • QRS widening and QT prolongation
  • Aortic dissection
50
Q

What are the neurological adverse effects of cocaine toxicity?

A
  • Seizures
  • Mydriasis
  • Hypertonia
  • Hyper-reflexia
51
Q

What are the psychiatric adverse effects of cocaine toxicity?

A
  • Agitation
  • Psychosis
  • Hallucinations
52
Q

What other systemic complications can cocaine toxicity lead to?

A
  • Ischaemic colitis - should be considered in patients complaining of abdominal pain or rectal bleeding
  • Hyperthermia
  • Metabolic acidosis
  • Rhabdomyolysis
53
Q

How should cocaine toxicity be managed?

A
  • In general benzodiazepines are first line for most cocaine related problems
  • Chest pain - benzodiazepines + glyceryl trinitrate - if MI develops then PCI
  • Hypertension - benzodiazepines + sodium nitroprusside + beta blockers
54
Q

What is ecstasy?

A
  • MDMA 3,4 Methylenedioxymethamphetamine
55
Q

What are the clinical features of ecstasy toxicity?

A
  • Neurological - agitation, anxiety, confusion, ataxia
  • Cardiovascular - tachycardia, hypertension
  • Hyponitraemia
  • Hyperthermia
  • Rhabdomyolysis
56
Q

What is the management of ecstasy toxicity?

A
  • Supportive measures

* Dantrolene may be used for hyperthermia if simple measures fail

Y5 Substance Abuse (2 decks)

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