Overdose in Adolescence Flashcards
Stephanie, 15 years old, BIBA to ED
Altered conscious state, found with 1 empty packet of 10x 5mg diazepam and 2 empty packets of 28 x 20mg escitalopram near here
O/E: eyes opening to speech, slurring words, GCS 13, no outward signs of self harm, RR 12, SaO2 98%, HR 120, BP 110/65
Last seen well by her parents 3/24 ago
What is the first priority when assessing this patient?
What are useful adjuvant tests when assessing OD?
Are there any specific antidotes to consider in this case?
First priorities: vitals (including GCS), Hx (dose, timing to determine if peak levels of drug have been reached, anything else she’s taken, general health), triage category (probably 2, must be seen within 10 mins; 1 usually granted if arrest or peri-arrest)
Tests: ECG, BSL, paracetamol level (takes an hour, not useful unless measured 4 hours post-ingestion)
Antidote: there are options (e.g. flumazenil, charcoal) but they are not typically used
Escitalopram
SSRI
SEs: higher incidence of seizures, serotonin syndrome
Diazepam
Benzodiazepine
Stephanie, 15 years old, presents with acute overdose
O/E: eyes opening to speech, slurring words, GCS 13, no outward signs of self harm, RR 12, SaO2 98%, HR 120, BP 110/65
What are the early Mx priorities?
Early Mx priorities: monitoring, either resusc or monitored cubicle
When is charcoal used? What are the CIs to charcoal? Why is it no longer commonly used?
May be considered in SSRI (up to 3-4 hours)
CI: seizures, altered conscious state
Very toxic to respiratory epithelium with aspiration (likely deadly)
Stephanie, 15 years old, presents with acute overdose Formal blood work pending Initial BSL 5.3 ECG shows prolonged QT What next?
Move to monitored area for IV fluids and close observation
What qualifies as a prolonged QTc for women and men?
Women: >440ms
Men: >460ms
Stephanie, 15 years old, presents with acute overdose
Repeat vitals: HR 105, BP 105/50, afebrile, Sa02 94% on 2L/min by nasal prongs, GCS 11
6 hours after arrival in the ED, Stephanie is easily roused and conversant with staff
Vital signs now normal and she wants to go home
Repeat ECG performed, Enhanced Crisis Assessment and Treatment team (ECAT) are notified she is able to be fully assessed
After discussion with Stephanie and her family ECAT decide to admit as there are several ongoing issues that make her too high risk to discharge immediately for community follow-up
Medical staff are happy for her to be transferred to a mental health ward as cardiac monitoring is no longer required, her GCS is normal and there is no evidence of serotonin syndrome
Next steps?
Needs further evaluation of mental state to assess whether she is safe for discharge: undertake a mental health assessment (Hx, MSE, risk assessment) in an optimal setting (e.g. privacy and confidentiality, esp with regards to communicating with parents)
Develop a Mx plan with the patient
Consider specific issues for adolescents
Distinguishing serotonin syndrome from others (e.g. malignant HTN, anticholinergic syndrome)
Myoclonus
What are the key risk factors for an OD event?
Planned vs impulsive
Intention to die
First episode vs Hx of deliberate self-harm (biggest risk factor for completed suicide is previous attempts)
Hx of impulsivity
Alcohol/substance use disorder
Social and/or family isolation
Actual supports and perception of supports
FHx of suicide attempt and/or suicide completion, psychiatric disorders, alcohol or drug abuse, dependence disorders
Rural vs urban living situation
List 7 additional risk factors for mental health issues which are particularly relevant to adolescents
Adolescence is the typical age of onset for many major mental disorders
Mood lability
Poor impulse control
Individual identity not yet established
Intimacy skills not yet established
Increased susceptibility to peer group pressure
Self-worth
What is the rate of suicide in Australia? What is the rate of hospitalisation for self-harm? Describe its epidemiology
~2300 Australians commit suicide each year
30,000 Australians are hospitalised for self-harm annually
75% male
Indigenous Australians have 2-3x the rate of all others
Highest rates in age-adjusted populations are in elderly (generally decrease with age)
Highest rates of attempted suicide are in teens (esp women)
What are the possible mechanisms of actions of interventions which may be used in a significant acute overdose?
Decrease absorption
Enhance elimination
Use of specific antidotes
Sociodemographic and educational risk factors for self-harm and suicide in adolescents
Sex (female for self-harm, male for suicide)* Low SES* LGBTI Restricted educational achievement* *Shown to be related to suicide
Suicide Risk Assessment
Sex: male Age: 40 Depression Previous attempt EtOH Rational thinking lost Separated (break-up/widowed/divorced) Organised plan No supports Stated intent
Individual negative life events and family adversity which may serve as risk factors for self-harm and suicide in adolescents
Parental separation or divorce* Parental death* Adverse childhood experiences* Hx of physical or sexual abuse Parental mental disorder* FHx of suicidal behaviour* Marital or family discord Bullying Interpersonal difficulties* *Shown to be related to suicide
What % of patients who self-harm go on to complete suicide?
1% (2x for the rest of the population)
Psychiatric and psychological risk factors for self-harm and suicide in adolescents
Mental disorder* (esp depression, anxiety, ADHD) Drug and alcohol misuse* Impulsivity Low self-esteem Poor social problem-solving Perfectionism Hopelessness* *Shown to be related to suicide
Risk factors more specific for suicide in adolescents
Male sex Low SES Restricted educational achievement Parental separation or divorce Parental death Adverse childhood experiences Parental mental disorder FHx of suicidal behaviour Interpersonal difficulties Mental disorder (esp depression, anxiety, ADHD) Drug and alcohol misuse Hopelessness (strong risk factor!)
What is the major risk with a prolonged QTc?
QTc >500 associated with increased risk of Torsades de Pointes
When is a QTc considered abnormally short?
If
What is the “rule of thumb” for determining if the QT interval is normal?
Normal QT interval is less than half the preceding RR interval
