Overdose and toxicology

Question 1

signs of paracetamol overdose

Answer 1

N&V, loin pain, RUQ pain, Jaundice

Question 2

Signs of benzodiazepine overdose

Answer 2

CNS depression, ataxia, slurred speech, respiratory depression

Question 3

Signs of opioid overdose

Answer 3

Resp depression, Pin-point pupils, coma

Question 4

Signs of alcohol overdose

Answer 4

Slurred speech, ataxia, vomiting

Question 5

Investigations for overdose

Answer 5

Physical observations

Physical examination (especially neurological)

ABG/VBG

ECG

Baseline bloods (especially renal and hepatic function)

Serum levels of substance in question

Question 6

Features of alcohol intoxication

What do these result from

Answer 6

Euphoria, social disinhibition, joyousness
Extraversion, decreased reasoning
Ataxia, nausea and vomiting
Anterograde amnesia
CNS depression

From alcohol’s potent GABA and 5HT action

Question 7

Alcohol withdrawal symptoms

Answer 7

sweating, tremor, anxiety, nausea and vomiting

Confusion, hallucinations and seizures

Question 8

What is used to help medically assist withdrawal from alcohol

Answer 8

Chlordiazepoxide

Question 9

Cause of Acute Wernicke’s Encephalopathy and symptoms

Answer 9

Ataxia, ophthalmoplegia and confusion

In alcohol dependency, you don’t have enough vitb12 (thiamine) which leads to biochemical lesions in the CNS.
-ALso occurs because alcoholics are malnourished and don’t get enough b12 from their diet

Question 10

Treatment of Acute Wernicke’s encephalopathy

Answer 10

High dose parenteral thiamine e.g. Pabrinex leads to full resolution of synmtoms

Question 11

Korsakoff’s syndrome

-Presentation

Answer 11

Irreversible brain damage- typically due to chronic alcohol misuse

-Dense anterograde amnesia, confabulation and personality change

Question 12

Investigations for paracetamol overdose

Answer 12

Serum paracetamol levels not before 4hrs post ingestion

Baseline bloods to assess renal and liver function (including INR)

ABG/VBG to assess acid/base status

Weight (guides treatment)

Question 13

HOW to treat paracetamol overdose

Answer 13

Acetylcysteine
-BAseline bloods repeated after final infusion

If overdose is staggered, paracetamol levels are difficult to interpret- treat with acetylcysteine

When clinically stable, and bloods are normal, psychiatric assessment required

Question 14

When to continue treatment of acetylcysteine

Answer 14

ALT more than doubled
ALT 2 times upper limit of normal OR
INR 1.3 or higher

Question 15

When to consider liver transplant in paracetamol overdose

Answer 15

ABG pH <7.3

INR>6.5 and Cr>300 and grade 3 or 4 encephalopathy

Question 16

Psychiatric assessment following paracetamol overdose

Answer 16

Assessing the current mental state (presence of depressive symptoms, evidence of distress/anxiety, presence of psychotic symptoms)

Events leading up to the overdose

Was there planning?

Were there efforts to conceal discovery?

Was there substance use at the time of the overdose?

Access to means

Subjective feeling immediately after the overdose

Events that led them presenting to emergency services

Subjective view on overdose attempt now

Risk assessment is key
What is the current risk to self?
Is this person safe to be discharged?

Involve a specialist opinion (e.g. liaison psychiatry services)