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4TH YEAR - CPTP > Poisoning > Flashcards

Poisoning Flashcards

1
Q

What groups are most commonly affected by poisoning?

A
  • Young children

- Adolescents and young adults

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2
Q

What substances are most commonly used to poison?

A
  1. Paracetamol
  2. Ibuprofen
  3. Citalopram
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3
Q

What substances carry the highest mortality?

A
  • Paracetamol
  • TCAs
  • Opiates
  • Carbon monoxide
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4
Q

What are the components of an initial assessment of somebody with suspected poisoning?

A

Obs - temp, RR, BP, HR
GCS
Pupils, tone, reflexes
Inspection for needle marks, blisters, lacerations

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5
Q

What are the 4 components of management of poisoning?

A
  1. Prevent absorption
  2. Increased drug elimination
  3. Specific antidotes/chelating agents
  4. Supportive care
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6
Q

What tools can be used if you dont have enough information about the poisoning?

A

Toxibase

Ring NPIS

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7
Q

What are the 3 main methods of prevention of absorption of drug?

A
  1. Activated charcoal - adsorbs poison in the GI tract
  2. Gastric lavage - only use in very large overdoses and ensure to protect the airway
  3. Induced emesis - rarely used
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8
Q

What are the indications and contraindications for activated charcoal?

A

I - <1hr since ingestion, alert, most poisons

CI - ileus, impaired gag reflex, unsafe swallow

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9
Q

Which poisons will activated charcoal not adsorb?

A 
Elemental salts eg. lithium, iron
Insecticides
Cyanides
Strong acids/alkalis
Alcohols
Hydrocarbons
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10
Q

What are the indications and contraindications for gastric lavage?

A

I - Iron overdose

CI - hydrocarbons, caustic substance ingestion (due to risk of aspiration and perforation)

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11
Q

What are the main methods of drug elimination in poison management?

A
  1. Multiple dose activated charcoal - give 50g at start followed by 25g every 2 hours, with a laxative ‘GI dialysis’
  2. Haemodialysis/haemoperfusion
  3. Haemofiltration
  4. Combined methods
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12
Q

What are the indications for haemodialysis/haemoperfusion?

A

Only drugs that have a small volume of distribution and low clearance rate
eg. theophylline, phenytoin, carbamazepine

HD only - methanol, valproate, lithium

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13
Q

What is the specific antidote to:

a) paracetamol
b) salicyclate
c) opiate
d) iron
e) TCAs
f) benzos

A

a) NAC
b) sodium bicarbonate
c) naloxone
d) desferrioxamine (chelating agent)
e) sodium bicarbonate
f) flumazenil

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14
Q

How can the following aspects of poisoning be managed (supportive care):

a) hypotension
b) fits
c) vomiting
d) acidosis
e) renal failure

A

a) IV fluids
b) lorazepam/diazepam
c) antiemetics
d) sodium bicarbonate
e) dialysis

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15
Q

What is the number one cause of fulminant hepatic failure?

A

Paracetamol overdose

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16
Q

How does paracetamol OD present?

A

Early - non-specific, N&V, abdo pain
Delated (2-3 days) - hepatic necrosis, jaundice, RUQ pain, encephalopathy, coagulopathy
Death (3-6 days)

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17
Q

What are the complications of paracetamol OD?

A 
Liver failure
Renal failure
Pancreatitis
Death
Hypoglycaemia
Metabolic acidosis
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18
Q

What is the mechanism behind paracetamol OD?

A

Normal glucaronide pathway is saturated so large amounts of NAPQI are produced.
Liver reserves of glutathione are depleted so the NAPQI, instead of being converted to a detoxified product, leads to hepatocellular injury.

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19
Q

What investigations should be done for someone with suspected paracetamol OD?

A

Blood paracetamol levels - ideally 4 hr after
Clotting (PT/INR increased due to liver failure)
ALT (massively increased)
U&E (creatinine elevated in renal damage)
ABGs (look for metabolic acidosis - indicates poor prognosis)

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20
Q

How is paracetamol OD treated?

A
  1. Prevent absorption - activated charcoal ASAP
  2. Administer NAC (if paracetamol level over 100), ideally within 8 hours, give IV over 21 hours.
  3. Supportive - vit K, FFP, monitor ICP, dialysis
  4. Monitor - falling INR is a good sign
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21
Q

What is an anaphylactoid reaction? How is it managed?

A

Urticaria, wheeze etc in response to admin of NAC - due to release of histamine from mast cells.
This is not a true anaphlactic reaction so you can give anti-histamine and continue the infusion but reduce rate.

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22
Q

What are some poor prognostic features of paracetamol OD?

A
  • Creatinine >300
  • PT/INR still high after day 3
  • PT >180s
  • Bilirubin >70
  • Metabolic acidosis
  • Encephalopathy
  • Raised lactate
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23
Q

How does salicylate/aspirin OD present?

A

TINNITUS, HYPERVENTILATION, dizziness, sweating, vomiting, agitation, delirium
Coma (in kids especially)

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24
Q

What are the complications of salicylate OD?

A

Brain swelling
Seizures
Cardiac arrest

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25
Q

What is the mechanism behind salicylate OD?

in terms of ABG

A
  • Initially you get respiratory alkalosis due to hyperventilation
  • After 24 hours you get metabolic acidosis due to uncoupled oxidative phosphorylation
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26
Q

What investigations should be done if you suspect salicylate OD?

A
  • Blood salicylate levels
  • U&Es (expect hypokalemia)
  • Blood glucose (expect hypo)
  • ABGd (resp alkalosis then metabolic acidosis)
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27
Q

How is salicylate OD treated?

A
  1. Prevent absorption - activated charcoal within 1 hr
  2. Prevent CNS penetration - sodium bicarb
  3. Enhance eliminiation - sodium bicarb, MDAC, haemodialysis
  4. Supportive - airway, fluids, ventilation, glucose, K
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28
Q

What are the indications for haemodialysis in salicylate OD?

A

pH<7.3
>700mg/l aspirin
Renal failure

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29
Q

How does an opiate OD present?

A
  • Pin prick pupils
  • Respiratory depression
  • Hypotension
  • Hallucinations
  • Rhabdomyolysis
  • Non cardiac pulmonary oedema
30
Q

What is the mechanism of opiate OD?

A

Overstimulation of MU receptors in the CNS

31
Q

How is an opiate OD managed?

A
  1. ABCDE
  2. Administer naloxone if RR<10, GCS<10
  3. Supportive care
32
Q

How is naloxone administered?

A

Adults - start 400 micrograms and titrate up

Kids - 0.1mg/kg???

33
Q

What is the half life of naloxone?

A

60 mins

34
Q

What are the complications of naloxone administration?

A
  • Withdrawal may precipitate leave from hospital
  • Hypertension
  • Behavioural disturbance
  • Pain unmasking

ONLY GIVE ENOUGH TO RESTORE BREATHING BUT MAINTAIN SEDATION

35
Q

Give 2 examples of TCAs

A

Amitriptylline
Dosulepin

(-ine is often a TCA)

36
Q

How does a TCA OD present?

A

Anticholinergic effects - dry skin, dilated pupils, tachycardia, agitation, fits, delirium , hypertonia, hyperreflexia
Na channel blockade - arrhythmias, prolonged QRS/QT interval
Alpha blockade - hypotension

37
Q

What is the mechanism behind TCA OD?

A

Blocks certain receptors - sodium channel, alpha receptors, cholinergic receptors

38
Q

What investigations should be done if you suspect TCA OD?

A
  • U&E
  • Blood glucose
  • ABG (acidosis)
  • ECG - look for long QRS/QT ‘sigmoid shape’
  • Constant CVS monitoring for arrhythmias
39
Q

What are the complications of TCA OD?

A
  • Cardiac arrest
  • Life threatening seizures
  • Bowel obstruction
40
Q

How is TCA OD treated?

A
  1. Prevent absoption - activated charcoal within 1h
  2. Enhance elimination - MDAC every 2 hrs
  3. Prevent arrhythmias - sodium bicarbonate, consider DC cardioversion, DONT GIVE ANTI-ARRHYTHMIA DRUGS
  4. Prevent fits - diazepam, lorazepam
  5. Supportive care
41
Q

How does an iron overdose present?

A

Early (0-6hrs) - N&V, abdo pain, bloody diarrhoea
Delayed (2-72 hours) - black stools, fits, circulatory collapse, coma
Late (2-4 days) - acute liver necrosis, renal failure
Very late (2-5 weeks) - gastric strictures

42
Q

What investigations should be done if you suspect iron overdose?

A
  • Iron levels (repeat every 2/3hrs)
  • Blood count (leucocytosis)
  • U&E
  • ABG (monitor bicarb)
  • Glucose (hyper)
  • LFTs
43
Q

How is iron overdose treated?

A
  1. Prevent absorption - NOT ACTIVATED CHARCOAL, do gastric lavage or induced emesis in small children
  2. Chelating agent - DESFERRIOXAMINE, will be excreted in urine (red)
  3. Supportive care
44
Q

What if the indications and contraindications for desferrioxamine?

A

I - severe toxicity with fits, coma, GI symptoms, leucocytosis
CI - renal failure

45
Q

What are the side effects of desferrioxamine?

A

Hypotension

Pulmonary oedema

46
Q

How does benzo overdose present?

A

CNS depression -drowsiness, impaired balance, ataxia, slurred speech

47
Q

What is the mechanism behind benzo overdose?

A

Enhanced GABA effect, causing CNA depression and potential coma

48
Q

What are the complications of benzo overdose?

A

Cardiac arrest

Deep coma

49
Q

How is benzo OD diagnosed?

A

Clinically - use plasma conc to confirm the diagnosis but not as a prognostic marker as it does not correlate with severity

50
Q

How is benzo OD treated?

A
  1. Prevent absorption - only use charcoal if OD is in combo with other drugs
  2. Specific antidote - FLUMENAZIL
  3. Supportive care - this is the mainstay of treatment
51
Q

What are the contraindications for flumenazil?

A
  • Long term benzo use
  • Wide QRS complex
  • Seizure history
  • Anything that lowers the seizure threshold
52
Q

What are the signs of alcohol withdrawal? What meds are used for addiction and withdrawal?

A

Increased pulse, low BP, terror, confusion fits and hallucinations, 10-72 hours after drinking

Addiction - acamprosate, disulfiram
Withdrawal - chlordiazepoxide, diazepam

53
Q

What are some general side effects of antipsychotics?

A
  • Antimuscarinic (dry mouth, blurred vision, urinary retention)
  • EPS - Parkinsonism (tardive dyskinesia)
  • Sedation and weight gain
  • Raised prolactin
  • Neuroleptic malignant syndrome
  • Reduced seizure threshold
  • Prolonged QT interval (haliperidol)
54
Q

Name 3 typical/first generation antipsychotics

A

Haloperidol, perphenazine, chlorpromazine

55
Q

Name 5 atypical/second generation antipsychotics

A

Olanzapine, risperidone, quetiapine, aripiprazole, clozapine

56
Q

What are the advantages of atypical over typical antipsychotics?

A
  • Lower risk of extrapyramidal side effects as they have a lower affinity for D2 receptors (so fewer nigrostriatal side effects)
  • Affinity for 5-HT receptors aswell, so dual action
57
Q

What are the advantages of typical over atypical antipsychotics?

A
  • Lower risk of metabolic side effects (nausea, ado pain, indigestion) and weight gain
58
Q

What is the risk of using clozapine?

A

Agranulocytosis

59
Q

A patient experiences muscle stiffness, increased temperature, confusion and increased heartbeat after using an antipsychotic. What is the name of the antipsychotic and the syndrome?

A

Risperidone - neuroleptic malignant syndrome

Risperidone is used in schizophrenia and aggressive behaviour in Alzhemiers. It is a D2, A1 and H1 receptor antagonist

60
Q

What EPS are associated with typical antipsychotics?

A

Tardive dyskinesia, dystonia, parkinsonism, akinesia, neuroleptic malingnant syndrome

NB some of these remain even after drug withdrawal

61
Q

What are the ICD 10 criteria for depression?

A

3 core symptoms:

  • Low mood
  • Low energy
  • Loss of enjoyment in things
Plus...GAPES
Guilt
Appetite loss
Attention loss
Pessimism
Esteem (low)
Suicidal intent
Sleep disturbance
62
Q

What is the monoamine theory of depression?

A

Depression is due to depletion in the levels of serotonin, norepinephrine, and/or dopamine in the central nervous system.

63
Q

Name 6 classes of drug used to treat depression, accompanied by examples

A 
SSRI - fluoxetine, citalopram, sertraline (1st line)
SNRI - venlafaxine, duloxetine
TCAs - amitriptyline, clomiparime
NaSSA - mirtazapine
NDRI - bupropion
MAOI - phenlzine
64
Q

Why are TCAs used less these days?

A 
They have antimuscarinic side effects (ABCDS):
Anorexia
Blurry vision
Constipation/ Confusion
Dry Mouth
Sedation/ Stasis of urine

They are dangerous in overdose:
Hallucinations
Arrhythmia

65
Q

What are the side effects of SSRIs/SNRIs?

A
  • Nausea
  • Dry mouth
  • Constipation
  • Headache
  • Sexual dysfunction
66
Q

What is serotonin syndrome?

A

Fever, agitation, hypertonia, dilate pupils and hyperreflexia.

Caused by admin of two or more serotonergic drugs (SSRIs, SNRIs, MAOIs, triptans, TCAs, tramadol)

67
Q

Which mood stabilisers are used for mania?

A 
Lithium
Anticonvulsants:
- Lamotrigine
- Carbemazepine
- Sodium valproate
Atypical antipsychotics (quietapine)
68
Q

When should mood stabilisers not be prescribed?

A

Pregnancy - teratogenic

69
Q

What is the SE of using carbamazepine, rarely?

A

Agranulocytosis

70
Q

What is used to treat anxiety?

A

Benzodiazepines (anxiolytic)- diazepam, lorazepam

Zopiclone (hypnotic)

4TH YEAR - CPTP (19 decks)

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