Overdose (paracetamol, opioids, salicylate)

Question 1

Airway

Answer 1

Consult ToxBase or UK National Poisons Information Service

Question 2

Breathing

Answer 2

Look: increased work of breathing
Listen: chest sounds
Feel: percuss, tracheal deviation, chest expansion

RR (slow? - opioids decrease respiratory drive)
O2 - low?

CXR
ABG if sats low

Intrevention:
- start on 15L oxygen via NRBM

Question 3

Circulation

Answer 3

Look: sweating, diaphoresis
Listen: S1+S2+0
Feel: apex beat, CRT, pulses

BP, HR
ECG

Bloods:
1. FBC, UEs, LFTs, TFTs, CRP
2. paracetamol levels
3. salicylate levels
4. clotting

Question 4

Disability

Answer 4

PEARL
BM
GCS score
limbs: tone, body temperature

Question 5

Exposure

Answer 5

• expose: needle track marks?
• rashes
• abdo exam
• calves
• urine dip
• urine toxicology screen

Question 6

General Mx

Answer 6

Consider enhanced GI elimination of drug:

Activated charcoal if present <1hr
Other options: gastric lavage
If require haemodialysis -> escalate

Question 7

Paracetamol

Answer 7

Depending on time post ingestion – give NAC infusion Kings College Criteria for Transplant:
- Acidosis pH <7.35
- INR >6.5 or PT >100
- Creatinine >300
- Grade III or IV
encephalopathy

Question 8

Opioid

Answer 8

treat in B
1. B: 400mcg Naloxone IV/IM
2. Stop opioid administration
3. Continue and come back + reassess at 1 minute Consider: bag-valve mask
4. Then continue ABCDE

Definitive:
1st: naloxone 400mcg
2nd: 800mcg for up to 2 doses at 1 min intervals
3rd: 2mg for 1 dose

Question 9

Salicylate

Answer 9

Aspirin is a weak acid with poor water solubility. It is present in many over the counter preparation. Uncoupling of oxidative phosphorylation leads to anaerobic metabolism and the production of lactete and heat. Effects are dose related and potentiallly fatal.

150mg/kg - mild toxicity
250 mg/kg - moderate
500 mg/kg - severe toxicity
700 mg/L - potentially fatal

Sx - vomiting, dehydration, hyperventilation, tinnitus, vertigo, sweating

Mx:

1. Correct dehydration. Activatd charcoal if <1h
2. Urine: check pH, consider catheterisation
3. Correct acidosis, sodium bicarbonate IC over 3 hours, 1.5L 1.26%, aim for urine pH 7.5-8
4. Monitor K as hypokalaemia may occur
5. Dialysis - may be needed if salicylate level >800 and if aKI or heart failure, PO or cerebral oedema

Acute aspirin or salicylates overdose or poisoning can cause initial respiratory alkalosis though metabolic acidosis ensues thereafter.

Question 10

Escalation

Answer 10

2222 call/ RRT ITU/HDU
If lack capacity can treat under MCA 2005

If capacity but refuse -> Psychiatry
If psychiatric illness may be detained under MHA and treatment given (as a consequence of mental disorder). It must be done by psychiatrist in charge of care.
Consider specialities i.e. hepatology SpR