POISONING AND OVERDOSES Flashcards

1
Q

Pathophysiology of paracetamol poisoning?

A

Once ingested, paracetamol reaches peak concentration at 4 hours with an average half life of 2 hours (may be significantly increased if hepatic dysfunction)
Paracetamol is primarily metabolised in the liver via conjugation with the addition of glucuronide to form a water soluble metabolite that can be excreted in the urine. When there is excess paracetamol conjugation becomes saturated and paracetamol is converted into the metabolite NAPQI
NAPQI has a short half-life and is usually conjugated by the addition of glutathione, which is then renally excreted. When glutathione stores are depleted, excess NAPQI binds to hepatocellular proteins and results in oxidative damage, mitochondrial dysfunction and ultimately hepatocellular injury.

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2
Q

What can increase the risk of severe hepatotoxicity in paracetemol OD?

A

Anything that affects glutathione reserves such as fasting, malnourished, chronic excess alcohol consumption and certain liver enzyme-inducing drugs (rifampicin, phenytoin, carbamazepine, St John’s wort)

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3
Q

How does acute alcohol consumption affect paracetamol OD?

A

Evidence says it may have a protective effect against hepatotoxicity by inhibiting microsomal acetaminophen oxidation and thereby reducing NAPQI production

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4
Q

Whats the most common cause of acute liver failure requiring liver transplantation in the UK?

A

Paracetamol OD

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5
Q

What doses of paracetamol OD are associated with serious or fatal effects?

A

Unlikely to cause toxicity unless staggered <75mg/kg
Serious adverse effects when >150mg/kg
Potentially fatal when >12g

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6
Q

What is a staggered ingestion of paracetamol?

A

excessive ingestion of paracetamol over a period longer than one hour, usually in the context of self-harm.

Serious toxicity may occur in patients who have ingested > 150 mg/kg in any 24 hour period.
Rarely, toxicity may occur for ingestions between 75-150 mg/kg.
Doses consistently < 75 mg/kg in any 24 hour period are unlikely to be toxic. However, if paracetamol above the recommended daily dose (4g/24 hours in adults) is ingested for the two preceding days or more, the risk increases.

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7
Q

How should you treat pt if you do not know the time of ingestion of paracetamol in a OD?

A

Treat as a staggered OD to be on the safe side

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8
Q

Natural history of symptoms after a paracetamol OD?

A

Asymptomatic in early stages
12-36 hours later they may get abdo pain. Some may have N&V
48-72 hours RUQ pain, n&v, jaundice, AKI, hepatic encephalopathy (indicates hepatic necrosis)

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9
Q

Investigations after a paracetamol OD?

A

FBC
U&E
LFTs
Bone profile
VBG or ABG - pH, bicarbonate, lactate
BM (can cause hypoglycaemia later when liver is damaged)
Paracetemol levels
Salicylates levels

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10
Q

When can we use a nomogram for a paracetamol OD?

A

If single paracetamol ingestion where an accurate time is known
Not applicable if co-ingestants or modified release ingestions
Can’t be used before 4 hours or after 16 hours

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11
Q

What is the paracetamol nomogram?

A

A graph that plots paracetamol concentration against time from ingestion

If the paracetamol concentration lies on or above the treatment line, NAC should be administered. This is used for patients who have ingested paracetamol over one hour or less and presented within 8 hours. As the plasma paracetamol concentration reaches its peak at 4 hours, it is important not to take a paracetamol level within 4 hours of the last ingestion.

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12
Q

How to use a nomogram on obese pt who had a paracetamol OD?

A

Use a max body weight of 110kg even if they weight over this so that we dont underestimate

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13
Q

MOA of NAC?

A

Precursor to glutathione so increases glutathione stores that can bind to NAPQI and reduce the toxic efefcts

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14
Q

Management of paracetamol OD if they present within 1 hour?

A

50g activated charcoal if they have taken >12g or 150mg/kg
Otherwise watch and wait

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15
Q

Management of a single ingestion paracetamol OD if they present <8 hours?

A

Consider activated charcoal if they present wtihin 1 hour
Measure serum paracetamol and LFTs after 4 hours and plot nomogram -> start NAC if over line

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16
Q

Management of a single ingestion paracetamol OD if they present 8-24 hours?

A

Start IV NAC if dose >150mg/kg
Then measure paracetamol and LFTs and plot on nomogram. If under treatment line and ALT/AST <50 then stop NAC

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17
Q

Management of a single ingestion paracetamol OD if they present >24 hours?

A

If clearly jaundiced or hepatic tenderness or ALT high then start IV NAC immediately
Measure serum patacetamol and LFTs. If paracetamol still detectable and ALT raised and INR >1.3 then keep on NAC

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18
Q

Management of a staggered OD of paracetamol?

A

Start IV NAC
If >4 hours since last ingestion then check serum paracetamol levels and do bloods.
Only stop if paracetamol <10, INR <=1.3, ALT is normal and no symptoms of liver damage

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19
Q

Prognosis if given NAC <8 hours after ingestion in paracetamol OD?

A

Survival should be 100%

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20
Q

What is the new protocol for giving NAC after a paracetamol OD?

A

Scottish and Newcastle Acetylcysteine Protocol (SNAP) - a 12 hour protocol to try to reduce the rate of adverse reactions

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21
Q

Complications of paracetamol OD?

A

Severe hepatocellular necrosis -> acute liver failure and encephalopathy
Renal tubular necrosis
Coma
Death

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22
Q

How do we make the decision to refer a pt to a liver transplant centre after a paracetamol OD/

A

Using the Kings College Criteria

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23
Q

What is the kings college criteria for ?transplant after a paracetamol OD?

A

Arterial pH <7.3 after resuscitation and >24 hours since ingestion
Lactate >3

OR the following 3 criteria:
- hepatic encephalopathy stage 3/4
- Serum creatinine >300umol/L
- INR >6.5

24
Q

What are liaison psychiatry?

A

provide mental healthcare to people being treated for physical illness in general hospitals
This is critical for pt who present with self-harm or overdose
They can assess the pts ongoing suicidal risk and need for mental health input

25
Q

Symptoms of opioid OD?

A

Decreased level of consciousness
Respiratory depression
Miosis

Less commonly : N&V, confusion

26
Q

Treatment of opioid OD?

A

Support breathing with ventilation and oxygen
IV naloxone if signs of respiratory depression otherwise watch and wait - if it is an opioid OD they should significantly improve within minutes of naloxone

27
Q

Symptoms of aspirin OD?

A

Air hunger, high RR, sweating, tinnitus
Later - metabolic acidosis, hypoglycaemia, coma

28
Q

Management of aspirin OD?

A

Activated charcoal if within 1 hour of ingesting >125mg/kg
Replace fluid losess
Urinary alkalinization with IV sodium bicarbonate (correct K+ first)
If severe then may require haemodialysis

29
Q

Symptoms of benzos OD?

A

Drowsy
Ataxia
Dysarthria
Nystagmus

Very high doses of- hypotension, coma, bradycardia, respiratory depression

30
Q

Treatment of benzos OD?

A

Most commonly W&W
Flumazenil can be used but risk if a mixed OD as this can cause seizures

31
Q

How might local anaesthetic systemic toxicity present?

A

Respiratory failure
Seizures
Palpitations
Irregular heart action
Basically any abnormal cardiovascular or neurological symptoms

32
Q

Antidote for local anaesthetic?

A

Intralipid

33
Q

Symptoms of TCA OD?

A

Early - dry mouth, dilated pupils, agitation, sinus tachycardia, blurred vision
Severe - arrhthmias, seizures, metabolic acidosis, coma

34
Q

Management of TCA OD?

A

Activated charcoal if within 1 hour
IV bicarbonate for arrhythmias or hypotension
IV lipid emulsion is increasingly being used to bind the free drug and reduce toxicity

35
Q

Symptoms of a beta blocker OD?

A

Bradycardia
Hypotension
Syncope
Heart failure

Others:
Conduction abnormalities e.g. AV block
Drowsiness
Confusion
Hallucinations
Respiratory depression
Bronchospasm
Hypoglycaemia
Hyperkalaemia
Rare - ventricar tachycardia, seizures and coma

36
Q

Which beta blockers can cause VTs and why?

A

Sotalol can prolong the QT interval
Propanolol can prolong the QRS duration

37
Q

Management of beta blocker OD?

A

For the hypotension: Adequate fluid resuscitation. Inotropes or vasopressors can be used. If very severe or shock then IV glucagon
For persistent metabolic acidosis - IV sodium bicarbonate
Symptmatic bradycardia - atropine sulfate IV or temporary pacemaker
For Bronchospasm - nebulised bronchodilators or corticosteroids
Tx for seizures if prolonged or recurrent

38
Q

Toxidrome for sympathomimetics e.g. cocaine, amphetamines?

A

Tachycardia, hypertension
Tachypnoeic
Hyperthermic and sweating
Mydriasis
Bowel sounds present

39
Q

Toxidrome for sedative-hypnotics e.g. barbiturates, muscle relaxants, benzos?

A

Bradycardia
Hypotension
Bradypnoea
Hypothermia
Absent bowel sounds

40
Q

Antidote for ethylene glycol or methanol OD?

A

Fomepizole
If necessary ethanol can be used with caution

41
Q

Symptoms of CO poisoning?

A

Headache
Dizziness
Flushing
N&V
Vertigo
Personality changes

Exposure to higher levels:
Weakness
Confusion
Chets and muscle pain
SOB
Hypotension
MI
Seizures, cerebral oedema and metabolic acidosis

42
Q

Management of CO poisoning?

A

Measure exhaled CO levels and take a VBG
High flow 100% oxygen until symptom free - usually 4-5 hours
Hyperbaric oxygen is sometimes used
If cerebral oedema occurs then IV mannitol

43
Q

Symptoms of organophosphate poisoning?

A

Anxiety
Pinpoint pupils
Restlessness
Dizziness
Headache
N&V
Hypersalivation
Abdominal colic
Diarrhoea
Bradycardia
Sweating
Later may be muscle weakness and fasciculations which may become flaccid paralysis

In severe cases - convulsions, coma, pulmonary oedema, hypoxia, arrhythmias

44
Q

Management of organophosphate poisoning?

A

IV atropine sulfate

45
Q

A->E for the poisoned pt?

A

A- consider intubation
B - if sats <95% on oxygen then consider naloxone. ABG.
C - ECG, BP, cannula, take bloods, give fluids
D - BM, temperature, GCD/AVPU, pupils, stop seizures
E - inspect skin look for medication patches

46
Q

Toxidrome for opioids?

A

Bradycardia
Hypotension
Bradypnoeic
Hypothermic
Pinpoint pupils
Absent bowel sounds

47
Q

Toxidrome for cholinergics e.g. pilocarpine, mushrooms, organophosphate?

A

Pinpoint pupils
Sweating

48
Q

Toxidrome for Anticholinergics e.g. atropine and antihistamines?

A

Tachycardia
Hypertension
Hyperthermia
Mydriasis
Absent bowel sounds

49
Q

How do we manage lithium toxicity?

A

Mild-moderate toxicity may respond to volume resuscitation with normal saline
Haemodialysis may be needed in severe toxicity

Sodium bicarbonate is sometimes used to increase alkalinity of urine and promote excretion but limited evidence

50
Q

Antidote for warfarin?

A

Vitamin K
Prothrombin complex

51
Q

Antidote for heparin?

A

Protamine sulphate

52
Q

MOA of Fomepizole?

A

Inhibitor of alcohol dehydrogenase which prevents metabolism of ethylene glycol and methanol to their toxic metabolites

53
Q

Treatment of iron toxicity?

A

Desferrioxamine - a chelating agent

54
Q

Treatment of lead toxicity?

A

Dimercaprol or calcium edetate

55
Q

Antidote for cyanide?

A

Hydroxocobalamin

56
Q

Outline how a salicylate OD affects acid-base balance?

A

It causes a mixed respiratory alkalosis and metabolic acidosis

Early stimulation of the respiratory centre -> resp alkalosis
Later the direct acid effects of salicylates combines with acute renal failure -> metabolic acidosis

57
Q

How does TCA overdose affect the ECG and what are the risks of this?

A

Can cause sinus tachycardia, widening of QRS and prolongation of QT interval
Widening of QRS >100ms = increased risk of seizures
Widening of QRS >160mg = increased risk of ventricular arrhythmias