Overdoses

Question 1

Lithium Toxicity

• Precipitants
• Symptoms
• Management

Answer 1

Precipitants:
Dehydration, renal failure, drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.

Symptoms:
Coarse tremor, hyperreflexia, acute confusion, polyuria, seizure, coma

Management:
IV saline, haemodialysis if severe

Question 2

Digoxin toxicity

• Precipitants
• Symptoms
• Management

Answer 2

Precipitants:
Hypokalemia, increasing age, renal failure, myocardial ischaemia
hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis, hypoalbuminaemia, hypothermia, hypothyroidism, other drugs partciularly cardiac or fluid related

Symptoms:
Generally unwell, lethargy, nausea & vomiting, anorexia, confusion,** yellow-green vision**, arrhythmias, gynaecomastia

Management:
Digibind

Question 3

Ethylene glycol toxicity

• Symptoms
• Management

Answer 3

Symptoms:

Stage 1: symptoms similar to alcohol intoxication: confusion, slurred speech, dizziness
Stage 2: metabolic acidosis with high anion gap and high osmolar gap. Also tachycardia, hypertension
Stage 3: acute kidney injury

Management:
Fomepizole, ethanol, haemodialysis

Question 4

Theophylline toxicity

• Precipitants
• Symptoms
• Management

Answer 4

Precipitants: CYP450 inhibitors

Symptoms:
Vomiting, agitation, dilated pupils,tachycardia, hyperglycaemia, hypokalaemia

Management:
Activated charcoal, supportive treatment, haemodialysis

Question 5

Quinine toxicity (cinchonism)

• Symptoms
• Management

Answer 5

Symptoms:
Cardiac arrhythmia, flash pulmonary oedema, hypoglycemia, tinnitus, visual blurring, flushed and dry skin and abdominal pain 9effects can be permanent)

Management:
Measure salicylate levels to differentiate from aspirin poisoning, Supportive management, ionotropes, bicarbonate

Question 6

Paracetamol overdose/toxicity

• Precipitants
• Symptoms
• Management

Answer 6

Precipitants:
CYP450 inducers, malnourishment, chronic alcohol intake (acute may be protective)

Symptoms:
Asymptomatic, nausea/vomiting, RUQ pain, hypotension, liver and renal failure

Mangement:
Activated charcoal if staggered overdose
Acetylcysteine if staggered overdose, above treatment line, more than 150mg/kg between 8-24 hours or signs of liver failure
Liver transplantation if pH<7.3 at 24 hrs or PT>100s + creatinine>300 + grade 3 or 4 encephalopathy

Question 7

Tricyclic overdose

• Symptoms
• Management

Answer 7

Symptoms:
Dry mouth, dilated pupils, agitation, sinus tachycardia, blurred vision, arrhythmias, seizures, metabolic acidosis, coma, sinus tachycardia, widening QRS, prolongation of QT interval

Management:
IV bicarbonate

Question 8

Salicylate overdose

• Symptoms
• Management

Answer 8

Symptoms:
Hyperventilation (centrally stimulates respiration), tinnitus, lethargy, sweating, pyrexia, nausea/vomiting, hyperglycaemia and hypoglycaemia, seizures, coma

Management:
Charcoal, urinary alkalisation, haemodialysis

Question 9

Beta blocker toxicity

• Symptoms
• Management

Answer 9

Symptoms:
Bradycardia, hypotension, heart failure, syncope

Management:
Atropine, glucagon

Question 10

Opiod overdose

• Symptoms
• Management

Answer 10

Symptoms:
Rhinorrhoea, pinpoint pupils, drowsiness, watering eyes, yawning, respiratory depression

Management:
Naloxone

Question 11

LSD intoxication

• Symptoms
• Management

Answer 11

Symptoms:
Acute panic reactions, psychosis, tachycardia, hypertension, mydriasis, paresthesia, hyperreflexia, pyrexia, respiratory arrest, coma, hyperthermia, autonomic dysfunction, bleeding disorders

Mangement:
Supportive and guided by presentation

Question 12

Benzodiazepine toxicity

• Symptoms
• Management

Answer 12

Symptoms: Slurred speech, lethargy, ataxia, reduced levels of consciousness (may compromise airway), respiratory depression
Large overdoses may cause hypotension, bradycardia and hypothermia

Mangement:
Flumazenil

Question 13

Organophosphate poisoning

• Symptoms
• Management

Answer 13

Symptoms:
Dizziness, anxiety and restlessness, headache, miosis, nausea/vomiting, hypersalivation and copious bronchial secretions, colicky abdominal pain and diarrhoea, bradycardia, sweating
Muscle weakness and fasciculations
Flaccid paralysis (may lead to respiratory failure), arrhythmias, convulsions and coma

Management:
Atropine

Question 14

Cyanide

• Symptoms
• Management

Answer 14

Symptoms:
Nausea/vomiting, headache, tachycardia, hypertension, tachypnoea, loss of consciousness, seizures, respiratory depression, raised lactate

Mangement:
Dicobalt edetate (toxic if incorrect diagnosis) hydroxycobalamin

Question 15

MDMA

• Symptoms
• Management

Answer 15

Symptoms: Nausea and vomiting, hallucinations, agitation and psychosis
delirium, hyperreflexia, tremor, hyperthermia, diaphoresis, flushing, mydriasis, tachycardia, hypertension arrhythmias, rhabdomyolysis, seizures
cardiovascular collapse, hyponatraemia, serotonin syndrome
acute renal failure, disseminated intravascular coagulation, coma

Management:
Supportive

Question 16

Cocaine

• Symptoms
• Management

Answer 16

Symptoms:
coronary artery spasm → myocardial ischaemia/infarction, both tachycardia and bradycardia may occur, hypertension, QRS widening and QT prolongation, aortic dissection, seizures, mydriasis, hypertonia, hyperreflexia, psychiatric effects, agitation, psychosis, hallucinations,
ischaemic colitis, hyperthermia, metabolic acidosis, rhabdomyolysis

Management:
Benzodiazepines and GTN