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Roomies Collab Deck 6: Fluids, Haematology and Respiratory > Poisoning, Emergency Treatment > Flashcards

Poisoning, Emergency Treatment Flashcards

1
Q

How should patients who have features of poisoning be managed?

A

Generally with hospital admission

  • Patients who have taken poisons with delayed action should also be admitted, even if they appear well
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2
Q

Which drugs in overdose have a delayed onset of action? (5)

A
  1. Aspirin
  2. Iron
  3. Paracetamol
  4. TCAs
  5. Co-phenotype (diphenoxylate and atropine)

*the effects of modified-release preparations are also delayed

(And others)

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3
Q

It is often impossible to establish with certainty the identity of the poison and the size of the dose. This is not usually important because __________________

A

only a few poisons (such as opioids, paracetamol, and iron) have specific antidotes

*In most patients, treatment is directed at managing symptoms as they arise

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4
Q

It is often impossible to establish with certainty the identity of the poison and the size of the dose. This is not usually important because only a few poisons (such as opioids, paracetamol, and iron) have specific antidotes; few patients require active removal of the poison. In most patients, treatment is directed ___________________

A

at managing symptoms as they arise

  • Nevertheless, knowledge of the type and timing of poisoning can help in anticipating the course of events.
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5
Q

All relevant information should be sought from the poisoned individual and from carers or parents. However, such information should be interpreted with care because __________________

A

it may not be complete or entirely reliable

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6
Q

_______________ is often impaired in unconscious patients.

A

Respiration; An obstructed airway requires immediate attention

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7
Q

In the absence of trauma, the airway should be opened with simple measures such as _______________

A

chin lift or jaw thrust

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8
Q

An oropharyngeal or nasopharyngeal airway may be useful in patients with reduced consciousness to prevent obstruction, provided ______________ is adequate

A

ventilation

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9
Q

An ______________ or _______________ airway may be useful in patients with reduced consciousness to prevent obstruction, provided ventilation is adequate

A

oropharyngeal

nasopharyngeal

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10
Q

Intubation and ventilation should be considered in patients whose ________________ or who have _____________________

A

respiratory acidosis because of inadequate ventilation

airway cannot be protected

*such patients should be monitored in a critical care area

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11
Q

Most poisons that impair consciousness also depress ________________

A

respiration; Assisted ventilation (either mouth-to-mouth or using a bag-valve-mask device) may be needed

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12
Q

True or False: Oxygen administration alone is sufficient in patients with compromised ventilation

A

FALSE: Oxygen is not a substitute for adequate ventilation, although it should be given in the highest concentration possible in poisoning with carbon monoxide and irritant gases

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13
Q

Oxygen is not a substitute for adequate ventilation, although it should be given in the highest concentration possible in poisoning with ___________________ and ________________

A

carbon monoxide

irritant gases

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14
Q

________________ is common in severe poisoning with central nervous system depressants

A

Hypotension

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15
Q

A systolic blood pressure of less than _______ mmHg may lead to irreversible brain damage or renal tubular necrosis.

A

70

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16
Q

A systolic blood pressure of less than 70 mmHg may lead to irreversible _______________ or ________________.

A

brain damage

renal tubular necrosis

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17
Q

What are the initial measures for correcting hypotension? (2)

A
  1. Raising the foot of the bed
  2. Administration of NaCl or a colloid
  • Vasoconstrictor sympathomimetics are rarely required
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18
Q

True of False: vasoconstrictor sympathomimetics are first line in the treatment of poisoning-related hypotension

A

FALSE: Vasoconstrictor sympathomimetics are rarely required; conservative measures are usually sufficient (raising foot of bed and administering fluids)

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19
Q

Fluid depletion without hypotension is common after _____________ and after ____________ poisoning due to vomiting, sweating, and hyperpnoea.

A

prolonged coma

aspirin

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20
Q

_________________ without _______________ is common after prolonged coma and after aspirin poisoning due to vomiting, sweating, and hyperpnoea.

A

Fluid depletion

hypotension

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21
Q

Hypertension, often transient, occurs less frequently than hypotension in poisoning; it may be associated with sympathomimetic drugs such as ______________, _______________, and ______________

A

amfetamines

phencyclidine

cocaine

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22
Q

Cardiac conduction defects and arrhythmias can occur in acute poisoning, notably with ________________, some _______________, and some ________________

A

tricyclic antidepressants

antipsychotics

antihistamines

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23
Q

How are poisoning-associated arrhythmias corrected? (2)

A
  1. Correction of underlying hypoxia, acidosis, or other biochemical abnormalities
  2. Ventricular arrhythmias that cause serious hypotension require treatment

*If the QT interval is prolonged, specialist advice should be sought because the use of some anti-arrhythmic drugs may be inappropriate

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24
Q

True or False: Supraventricular arrhythmias are seldom life-threatening and drug treatment is best withheld until the patient reaches hospital

A

True

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25
Q

__________________ may develop in patients of any age who have been deeply unconscious for some hours, particularly following overdose with barbiturates or phenothiazines

A

Hypothermia

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26
Q

Hypothermia may develop in patients of any age who have been deeply unconscious for some hours, particularly following overdose with __________________ or ________________

A

barbiturates

phenothiazines

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27
Q

Hypothermia may be missed unless core temperature is measured using a ___________________ or by some other means

A

low-reading rectal thermometer

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28
Q

How should hypothermia be managed?

A

Prevention of further heat loss and appropriate re-warming as clinically indicated

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29
Q

_______________ can develop in patients taking CNS stimulants; children and the elderly are also at risk when taking therapeutic doses of drugs with antimuscarinic properties

A

Hyperthermia

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30
Q

Hyperthermia can develop in patients taking ______________; children and the elderly are also at risk when taking therapeutic doses of drugs with antimuscarinic properties

A

CNS stimulants

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31
Q

What is the initial management of hyperthermia?

A
  1. Remove all unnecessary clothing
  2. Use a fan
  3. Sponge with tepid water to promote evaporation
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32
Q

Sponging with ____________ (temperature) water will promote evaporation

A

tepid

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33
Q

Advice should be sought from the National Poisons Information Service on the management of severe hyperthermia resulting from conditions such as the _________________

A

serotonin syndrome

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34
Q

Both hypothermia and hyperthermia require ___________________ for assessment and supportive treatment

A

urgent hospitalisation

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35
Q

What is the management of single short-lived convulsions (lasting less than 5 min) associated with poisoning?

A

No treatment required

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36
Q

If poisoning-associated convulsions are protracted or recur frequently, _______________ or ________________ should be given by slow intravenous injection into a large vein

A

lorazepam

diazepam (preferably as emulsion)

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37
Q

True or False: Benzodiazepines can be given IM for the treatment of convulsions

A

False; benzos should not be given IM for convulsions

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38
Q

If the intravenous route is not readily available for administration of benzodiazepines in the treatment of convulsions, _________________ can be given by the ________________ route or _______________ can be administered as a _______________ solution

A

midazolam oromucosal solution [unlicensed use in adults and children under 3 months]

buccal

diazepam

rectal

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39
Q

Drug- or chemical-induced methaemoglobinaemia should be treated with ________________ if the methaemoglobin concentration is 30% or higher, or if symptoms of tissue hypoxia are present despite oxygen therapy

A

methylthioninium chloride

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40
Q

Drug- or chemical-induced _________________ should be treated with methylthioninium chloride if the methaemoglobin concentration is 30% or higher, or if symptoms of tissue hypoxia are present despite oxygen therapy

A

methaemoglobinaemia

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41
Q

What is methemoglobinemia?

A

Blood disorder in which an abnormal amount of methemoglobin is produced; methemoglobin is the oxidized form of hemoglobin (Fe3+) which cannot readily bind oxygen and therefore cannot transport it to tissues

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42
Q

Which drugs can cause methemoglobinemia? (4)

A
  1. Dapsone
  2. Local anesthetics
  3. Phenacetin (anesthetic/anti-pyretic)
  4. Antimalarials

(And others)

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43
Q

What is the mechanism of action of methylthioninium chloride in the treatment of methemoglobinemia?

A

Reduces ferric iron (Fe3+) of methemoglobin back to ferrous iron of hemoglobin (Fe2+)

*in high doses, methylthioninium chloride can itself cause methaemoglobinaemia

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44
Q

In high doses, methylthioninium chloride can itself cause ________________

A

methaemoglobinaemia

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45
Q

Given by mouth, ______________, activated can bind many poisons in the gastro-intestinal system, thereby reducing their absorption

A

charcoal

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46
Q

The sooner activated charcoal is given the more effective it is, but it may still be effective up to ____________ after ingestion of the poison—longer in the case of modified-release preparations or of drugs with antimuscarinic (anticholinergic) properties

A

1 hour

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47
Q

Activated charcoal is particularly useful for the prevention of absorption of poisons that are ________________, such as antidepressants

A

toxic in small amounts

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48
Q

Activated charcoal should be prescribed with caution in which patients? (3)

A
  1. Comatose patients (risk of aspiration)
  2. Drowsy patients (“ “)
  3. Reduced GI motility (risk of obstruction)
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49
Q

What are the side effects of activated charcoal? (4)

A
  1. Bezoar
  2. Constipation
  3. Diarrhea
  4. GI disorders
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50
Q

What is a bezoar?

A

Collection of partially digested material that collects in the stomach; sometimes the material is not digested at all and tightly packs itself into the digestive tract causing a blockage in the stomach or intestines

*human equivalent of a hairball hehe

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51
Q

Repeated doses of charcoal, activated by mouth enhance the elimination of some drugs after they have been absorbed; repeated doses are given after overdosage with … (5)

A
  1. Carbamazepine
  2. Dapsone
  3. Phenobarbital
  4. Quinine
  5. Theophylline
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52
Q

If vomiting occurs after dosing with activated charcoal it should be treated (e.g. with an antiemetic drug) since it ________________

A

may reduce the efficacy of charcoal treatment

  • In cases of intolerance, the dose may be reduced and the frequency increased but this may compromise efficacy.
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53
Q

Charcoal, activated should not be used for poisoning with which substances? (6)

A
  1. petroleum distillates
  2. corrosive substances
  3. alcohols
  4. malathion
  5. cyanides
  6. metal salts including iron and lithium salts
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54
Q

Hemodialysis may be used in the treatment of poisoning with which substances? (6)

A
  1. Ethylene glycol
  2. Lithium
  3. Methanol
  4. Phenobarbital
  5. Salicylates
  6. Sodium valproate
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55
Q

Alkalization of urine with sodium bicarbonate may be useful in the treatment of _____________ poisoning

A

Salicylate

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56
Q

Alkalization of urine with __________________ may be useful in the treatment of salicylate poisoning

A

IV sodium bicarbonate (enhances urinary elimination)

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57
Q

What are the indications for hemodialysis in salicylate overdose? (6)

A
  1. Serum concentration > 700 mg/L
  2. Metabolic acidosis resistant to treatment
  3. Acute renal failure
  4. Pulmonary edema
  5. Seizures
  6. Coma
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58
Q

What is the mechanism of poisoning with salicylate overdose?

A

salicylates cause the uncoupling of oxidative phosphorylation leading to decreased adenosine triphosphate production (ATP), increased oxygen consumption and increased carbon dioxide and heat production

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59
Q

Lithium has a very narrow therapeutic range ( ________ mmol/L) and a long plasma half-life being excreted primarily by the kidneys. Lithium toxicity generally occurs following concentrations > ________ mmol/L.

A
  1. 4-1.0

1. 5

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60
Q

What are the methods of removal of drugs for the GI tract? (2)

A
  1. Gastric lavage
  2. Whole bowel irrigation (by means of bowel cleansing preparation)

Induction of emesis is NOT recommended

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61
Q

Gastric lavage is rarely required and should only be carried out if ________________

A

The airway can be protected adequately

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62
Q

For substances that cannot be removed effectively by other means (e.g. iron), gastric lavage should be considered only if _______________ within the previous _______________

A

a life-threatening amount has been ingested

hour

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63
Q

Gastric lavage is contra-indicated if a ______________ substance or a ______________ has been ingested, but it may occasionally be considered in patients who have ingested drugs that are not adsorbed by charcoal, such as iron or lithium

A

corrosive

petroleum distillate

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64
Q

Gastric lavage is contra-indicated if a corrosive substance or a petroleum distillate has been ingested, but it may occasionally be considered in patients who have ingested drugs that are not adsorbed by charcoal, such as ______________ or ______________

A

iron

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65
Q

_________________ (e.g. with ipecacuanha) is not recommended because there is no evidence that it affects absorption and it may increase the risk of aspiration

A

Induction of emesis

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66
Q

Induction of emesis (e.g. with ipecacuanha) is not recommended because ________________ and it may _________________

A

there is no evidence that it affects absorption

increase the risk of aspiration

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67
Q

How is whole bowel irrigation achieved?

A

By means of a bowel cleansing preparation

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68
Q

Whole bowel irrigation (by means of a bowel cleansing preparation) has been used in poisoning with certain _______________ or ______________ formulations, in severe poisoning with _____________ and _____________, and if ______________ (‘body-packing’)

A

modified-release

enteric-coated

iron

lithium salts

illicit drugs are carried in the gastro-intestinal tract

  • However, it is not clear that the procedure improves outcome and advice should be sought from the National Poisons Information Service
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69
Q

Acute intoxication with alcohol (ethanol) is common in adults but also occurs in children. The features include ataxia, dysarthria, nystagmus, and drowsiness, which may progress to ____________, with ______________ and _____________.

A

coma

Hypotension

acidosis

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70
Q

_______________ is a special hazard associated with alcohol intoxication and ______________ may occur in children and some adults

A

Aspiration of vomit

hypoglycaemia

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71
Q

How is alcohol intoxication managed in patients?

A

Supportively, with particular attention to maintaining a clear airway and measures to reduce the risk of aspiration of gastric contents

Blood glucose is measured and glucose given if indicated

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72
Q

What are the main features of aspirin overdose? (6)

A
  1. Hyperventilation
  2. Tinnitus
  3. Deafness
  4. Vasodilation
  5. Sweating
  6. Coma (uncommon but indicates very severe poisoning)
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73
Q

Treatment of aspirin overdose must be in hospital, where _____________, ____________, and ____________ can be measured

A

plasma salicylate

pH

electrolytes

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74
Q

Absorption of aspirin may be ___________ and the plasma-salicylate concentration may continue to rise for several hours, requiring ___________

A

slow

repeated measurement

75
Q

Generally, the clinical severity of poisoning is less below a plasma-salicylate concentration of ____________ mg/litre (3.6 mmol/litre), unless there is evidence of metabolic acidosis

A

500

76
Q

Activated charcoal can be given within 1 hour of ingesting more than __________ mg/kg of aspirin

A

125

77
Q

Fluid losses should be replaced in aspirin overdose and _____________ may be given (ensuring plasma-potassium concentration is within the reference range) to enhance urinary salicylate excretion (optimum urinary pH 7.5–8.5)

A

intravenous sodium bicarbonate

78
Q

Plasma-potassium concentration should be corrected before giving sodium bicarbonate as _________________

A

hypokalaemia may complicate alkalinisation of the urine

79
Q

______________ concentration should be corrected before giving sodium bicarbonate as hypokalaemia may complicate alkalinisation of the urine

A

Plasma-potassium

80
Q

______________ is the treatment of choice for severe salicylate poisoning and should be considered when the plasma-salicylate concentration exceeds 700 mg/litre (5.1 mmol/litre) or in the presence of severe metabolic acidosis

A

Haemodialysis

81
Q

Haemodialysis is the treatment of choice for severe salicylate poisoning and should be considered when the plasma-salicylate concentration exceeds __________ mg/litre (5.1 mmol/litre) or in the presence of severe _____________

A

700

metabolic acidosis

82
Q

Opioids (narcotic analgesics) cause what symptoms? (3)

A
  1. coma
  2. respiratory depression
  3. pinpoint pupils
83
Q

The specific antidote of opioid poisoning, _________________, is indicated if there is coma or bradypnoea

A

naloxone hydrochloride

84
Q

The specific antidote of opioid poisoning, naloxone hydrochloride, is indicated if there is ______________ or _______________

A

coma

bradypnoea

85
Q

Since naloxone has a shorter ______________ than many opioids, close monitoring and _____________ are necessary according to the respiratory rate and depth of coma

A

duration of action

repeated injections

86
Q

Since naloxone has a shorter duration of action than many opioids, close monitoring and repeated injections are necessary according to the _______________ and _______________

A

respiratory rate

depth of coma

87
Q

When repeated administration of naloxone is required, it can be given by ________________ and the rate of infusion adjusted according to vital signs

A

continuous intravenous infusion (instead of IV injection)

88
Q

When repeated administration of naloxone is required, it can be given by continuous IV infusion and the rate of infusion adjusted according to _______________

A

vital signs

89
Q

The effects of some opioids, such as ______________, are only partially reversed by naloxone

A

buprenorphine

90
Q

_________________ and _______________ (opioids) have very long durations of action; patients may need to be monitored for long periods following large overdoses

A

Dextropropoxyphene

methadone

91
Q

Naloxone reverses the opioid effects of dextropropoxyphene. The long duration of action of dextropropoxyphene calls for _______________ and ______________ may be required

A

prolonged monitoring

further doses of naloxone

92
Q

Norpropoxyphene, a metabolite of dextropropoxyphene, also has ______________ effects which may require treatment with sodium bicarbonate or magnesium sulfate, or both. Arrhythmias may occur for up to 12 hours

A

cardiotoxic

93
Q

Norpropoxyphene, a metabolite of dextropropoxyphene, also has cardiotoxic effects which may require treatment with ________________ or ______________, or both. Arrhythmias may occur for up to 12 hours

A

sodium bicarbonate

magnesium sulfate

94
Q

Norpropoxyphene, a metabolite of dextropropoxyphene, also has cardiotoxic effects which may require treatment with sodium bicarbonate or magnesium sulfate, or both. ______________ may occur for up to ____________

A

Arrhythmias

12 hours

95
Q

In all cases of ______________ paracetamol poisoning clinicians are encouraged to contact the National Poisons Information Service for advice on risk assessment and management

A

intravenous

96
Q

Toxic doses of paracetamol may cause severe ___________________ and, much less frequently, ___________________

A

hepatocellular necrosis

renal tubular necrosis

97
Q

________________ and ______________, the early features of paracetamol poisoning, usually settle within 24 hour

A

Nausea

vomiting

98
Q

The recurrence of nausea and vomiting after 2–3 days after paracetamol poisoning, often associated with the onset of right subcostal pain and tenderness, usually indicates development of _______________

A

hepatic necrosis

99
Q

Liver damage is maximal ___________ after paracetamol overdose and may lead to liver failure, encephalopathy, coma, and death

A

3–4 days

100
Q

Liver damage is maximal 3–4 days after paracetamol overdose and may lead to _______________, _______________, _____________, and _______________

A

liver failure

encephalopathy

coma

death

101
Q

To avoid underestimating the potentially toxic paracetamol dose ingested by obese patients who weigh more than __________ kg, use a body-weight of ___________ kg (rather than their actual body-weight) when calculating the total dose of paracetamol ingested (in mg/kg)

A

110

110

102
Q

_________________ prevents or reduces the severity of liver damage if given up to, and possibly beyond (in patients at risk of severe liver disease) 24 hours of ingesting paracetamol

A

Acetylcysteine

103
Q

Acetylcysteine prevents or reduces the severity of liver damage if given up to, and possibly beyond (in patients at risk of severe liver disease) _______ hours of ingesting paracetamol

A

24

104
Q

N-Acetylcysteine is most effective if given within ________ hours of paracetamol ingestion, after which effectiveness declines

A

8

105
Q

What is the mode of administration of acetylcysteine?

A

IV

Very rarely, giving acetylcysteine by mouth [unlicensed] is an alternative if intravenous access is not possible (for further information, see Acetylcysteine—oral doses, available from TOXBASE).

106
Q

Acute overdose involves ingestion of a potentially toxic dose of paracetamol in ___________ or less.

A

1 hour

*vs a staggered overdose involves ingestion of a potentially toxic dose of paracetamol over more than 1 hour, with the possible intention of causing self-harm

107
Q

For adults and children aged 6 years and over, serious toxicity is unlikely to occur from a single ingestion of less than _________ mg/kg of paracetamol taken in less than 1 hour.

A

75

108
Q

In which situations should you refer a patient to hospital for medical assessment in the context of acute paracetamol overdose? (4)

A
  1. Ingested paracetamol in the context of self-harm
  2. Are symptomatic (nausea and vomiting)
  3. Have ingested 75 mg/kg or more in 1 hour or less
  4. The time of ingestion is uncertain but the dose is 75 mg/kg or more
109
Q

For children aged under 6 years, serious toxicity is unlikely to occur from a single ingestion of less than _________ mg/kg of paracetamol taken in less than 1 hour.

A

150

110
Q

Refer children to hospital for medical assessment in the context of acute paracetamol overdose if … (3)

A
  1. They are symptomatic (nausea or vomiting)
  2. They have ingested 150 mg/kg or more in 1 hour or less
  3. There is uncertainty about the dose ingested or the circumstances of ingestion
111
Q

Although the benefit of gastric decontamination is uncertain, charcoal, activated should be considered if the patient presents within ______________ of ingesting paracetamol in excess of 150 mg/kg

A

1 hour

112
Q

Patients at risk of liver damage and therefore requiring acetylcysteine, can be identified from a single measurement of the

A

plasma-paracetamol concentration related to the time from ingestion, provided this time interval is not less than 4 hours; earlier samples cannot be interpreted

113
Q

A 24 year old female is brought to A&E by her partner following an overdose of 30 tablets of paracetamol 2 hours ago. Should she be admitted? Should she be given activated charcoal? Should her plasma-paracetamol concentration be measured?

A

Yes; intent for self-harm

No; more than 1 hour has passed since ingestion

Not until 4 hours have passed since the time of ingestion; earlier samples cannot be interpreted

114
Q

The concentration is plotted on a paracetamol treatment graph, with a reference line (‘treatment line’) joining plots of 100 mg/litre (0.66 mmol/litre) at _____ hours and 3.13 mg/litre (0.02 mmol/litre) at _____ hours

A

4

24

(The ideal window of treatment with acetylcysteine)

115
Q

Acetylcysteine treatment should commence in patients patients who satisfy which criteria? (4)

A
  1. Plasma paracetamol concentration falls on or above the treatment line
  2. Who present within 8 hours of ingestion of more than 150 mg/kg of paracetamol if there is going to be a delay of 8 hours or more in obtaining the paracetamol concentration after the overdose
  3. Who present 8–24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available
  4. Who present more than 24 hours after ingestion of an overdose if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal (patients with chronically elevated ALT should be discussed with the National Poisons Information Service), their INR is greater than 1.3 (in the absence of another cause), or the paracetamol concentration is detectable
116
Q

Patients should be treated with acetylcysteine if they present within 8 hours of paracetamol overdose (>150 mg/kg) if…

A

There is going to be a delay of 8 hours or more in obtaining the paracetamol concentration

117
Q

Patients should be treated with acetylcysteine if they present 8-24 hours of acute paracetamol overdose (>150 mg/kg) if…

A

If nothing lol

They should be treated. Even if the plasma-paracetamol concentration is not yet available

118
Q

Patients should be treated with acetylcysteine if they present within >24 hours of paracetamol overdose (>150 mg/kg) if… (4)

A
  1. They are clearly jaundiced or have hepatic tenderness
  2. Their ALT is above the upper limit of normal
  3. Their INR is greater than 1.3 (in the absence of other causes)
  4. The paracetamol concentration is detectable
119
Q

Patients should be treated with acetylcysteine if they present within 8 hours of paracetamol overdose (>150 mg/kg) if they are clearly ___________ or have ___________, their _________ is above the upper limit of normal, their INR is greater than ____________, or the paracetamol concentration is. ____________

A

jaundiced

hepatic tenderness

ALT

1.3 (in the absence of another cause)

detectable

120
Q

Consider acetylcysteine treatment in patients who present within 24 hours of an overdose if biochemical tests suggest ____________, even if the plasma paracetamol concentration is below the treatment line on the paracetamol treatment graph

A

acute liver injury

121
Q

Where the time of paracetamol ingestion is unknown, patients should be managed as a ________________

A

staggered overdose

122
Q

Patients who have ingested more than _________ mg/kg of paracetamol in any 24-hour period are at risk of serious toxicity

A

150

123
Q

Toxicity rarely occurs with paracetamol doses between _________ mg/kg in any 24-hour period.

A

75–150

124
Q

Doses consistently less than 75 mg/kg in any 24-hour period are very unlikely to be toxic; however risk may be increased if this dose is repeatedly ingested over ______ or more days

A

2

125
Q

What is therapeutic excess in the context of paracetamol overdose?

A

ingestion of a potentially toxic dose of paracetamol with intent to treat pain or fever and without self-harm intent during its clinical use

126
Q

All patients exposed to a toxic dose of paracetamol in the context of therapeutic excess should be referred to hospital for medical assessment if they meet any of the following criteria … (3)

A
  1. Are symptomatic
  2. Have ingested more than the licensed dose and more than or equal to 75 mg/kg in any 24 hour period OR
  3. Have ingested more than the licensed dose but LESS than 75 mg/kg/24 hours on each of the preceding 2 or more days
127
Q

Patients with clinical features of hepatic injury such as _____________ or ______________ should be treated urgently with acetylcysteine

A

jaundice

hepatic tenderness

  • For other patients, management is determined by the maximum dose of paracetamol ingested in any 24-hour period
128
Q

When there is uncertainty about whether the presentation was due to therapeutic excess, the patient should be managed as a ______________

A

staggered overdose

129
Q

A staggered overdose involves ingestion of a potentially toxic dose of paracetamol over more than __________, with the possible intention of causing

A

1 hour

self-harm

130
Q

True or False: All patients who have taken a staggered overdose should be referred to hospital for medical assessment

A

True; furthermore, the MHRA advises that all patients who have ingested a staggered overdose should be treated with acetylcysteine without delay

131
Q

True or False: All patients who have ingested a staggered overdose of paracetamol should be treated with acetylcysteine without delay

A

True

132
Q

Clinically significant hepatotoxicity is unlikely and the patient is not considered to be at risk if… (5)

A
  1. There has been at least 4 hours or more since the last paracetamol ingestion AND
  2. The patient has no symptoms suggesting liver damage
  3. The paracetamol concentration is less than 10 mg/L
  4. Their ALT is within the normal range
  5. And their INR is 1.3 or less
133
Q

What are the two IV acetylcysteine regimens?

A
  1. The standard 21-hour regimen

2. The modified 12-hour regimen (AKA the SNAP regimen), not endorsed by the MHRA

134
Q

For the standard 21-hour regimen, acetylcysteine is given in a total dose that is divided into _____ consecutive intravenous infusions over a total of 21 hours.

A

3

135
Q

How is dosage of acetylcysteine determined?

A

Based on body weight, varies between 3 doses
(Tables available on BNF)

*should be added to glucose 5% or N/S 0.9% intravenous infusion

136
Q

First infusion (based on an acetylcysteine dose of approx. ________ mg/kg)—add requisite volume of Acetylcysteine Concentrate for Intravenous Infusion to _______ mL Glucose 5% or sodium chloride 0.9% Intravenous Infusion; infuse over _________

A

150

200

1 hour

137
Q

Second infusion (based on an acetylcysteine dose of approx. ________ mg/kg; start immediately after completion of first infusion)—add requisite volume of Acetylcysteine Concentrate for Intravenous Infusion to ________ mL Glucose 5% or sodium chloride 0.9% Intravenous Infusion; infuse over _________

A

50

500

4 hours

138
Q

Third infusion (based on an acetylcysteine dose of approx. ______ mg/kg; start immediately after completion of second infusion)—add requisite volume of Acetylcysteine Concentrate for Intravenous Infusion to ______ Glucose 5% or sodium chloride 0.9% Intravenous Infusion; infuse over _______

A

100

1 litre

16 hours

139
Q

What are the symptoms of TCA overdose? (11)

A
  1. Dry mouth (antimuscarinic effects)
  2. Coma
  3. Hypotension
  4. Hypothermia
  5. Hyperreflexia
  6. Extensor plantar responses
  7. Convulsions
  8. Respiratory failure
  9. Cardiac conduction defects, arrhythmias
  10. Dilated pupils
  11. Urinary retention
140
Q

_______________ may complicate severe TCA poisoning

A

Metabolic acidosis

141
Q

What symptoms are common during TCA overdose recovery? (3)

A
  1. Delirium with confusion
  2. Agitation
  3. Visual and auditory hallucinations
142
Q

Assessment in hospital is strongly advised in case of poisoning by tricyclic and related antidepressants but _______________ can be given before transfer and _______________ are mandatory

A

symptomatic treatment (eg IV lorazepam)

Supportive measures to ensure a clear airway and adequate ventilation during transfer

143
Q

_____________ given within 1 hour of TCA overdose reduces absorption

A

Activated charcoal

144
Q

Although arrhythmias are worrying, some will respond to _____________

A

correction of hypoxia and acidosis

145
Q

In the case of arrhythmias resulting from TCA overdose, ___________ should be avoided. Instead ___________ can arrest arrhythmias and prevent them in those with an extended QRS duration

A

Anti-arrhythmic drugs

IV infusion of sodium bicarbonate

146
Q

What drug can be given to patients experiencing delirium as a result of TCA overdose?

A

Diazepam, PO (large doses may be required)

147
Q

What are the symptoms of SSRI overdose? (8)

A
  1. Nausea and vomiting
  2. Agitation
  3. Tremor
  4. Nystagmus
  5. Drowsiness
  6. Sinus tachycardia
  7. Convulsions
  8. Serotonin syndrome (rare)
148
Q

What are the symptoms of serotonin syndrome? (7)

A
  1. Marked neuropsychiatric effects
  2. Neuromuscular hyperactivity
  3. Autonomic instability
  4. Hyperthermia
  5. Rhabdomyolysis
  6. Renal failure
  7. Coagulopathies
149
Q

What is the management of SSRI overdose?

A

Supportive; activated charcoal IF given within an hour of ingestion and convulsions treated with lorazepam/diazepam/midazolam

150
Q

Overdosage with quinine, chloroquine, or hydroxychloroquine is extremely hazardous and difficult to treat. Urgent advice from the National Poisons Information Service is essential. Life-threatening features include _______________ (which can have a very rapid onset) and ________________ (which can be intractable)

A

arrhythmias

convulsions

151
Q

______________ cause less depression of consciousness and respiration than other sedatives

A

Phenothiazines

152
Q

What are the complications of phenothiazine (prochlorperazine and trifluoperazine) poisoning?

A
  1. Hypotension
  2. Hypothermia
  3. Sinus tachycardia
  4. Arrhythmias

*dystonic reactions and convulsions may occur at therapeutic doses

153
Q

In cases of phenothiazines overdose, arrhythmias may respond to _____________ but should not be treated with _____________, which may worsen them

A

Correction of hypoxia or acidosis

Anti-arrhythmic drugs

154
Q

Dystonic reactions caused by phenothiazines rapidly respond to injection of ____________ or ______________

A

Procyclidine

Diazepam

155
Q

What are the features of poisoning with second generation antipsychotics? (5)

A
  1. Drowsiness
  2. Convulsions
  3. Extrapyramidal symptoms
  4. Hypotension
  5. ECG abnormalities (including QT prolongation)
156
Q

What ECG abnormality may result from overdose of second-generation antipsychotics?

A

QT prolongation

157
Q

What is the management of overdose of second-generation antipsychotics?

A

Supportive; activated charcoal may be given within 1 hour of ingestion

158
Q

Benzodiazepines taken alone can cause what symptoms? (6)

A
  1. Drowsiness
  2. Ataxia
  3. Dysarthria
  4. Nystagmus
  5. Respiratory depression
  6. Coma
159
Q

Activated charcoal can be given within 1 hour of ingesting a significant quantity of benzodiazepine, provided ________________

A

the patient is awake and the airway is protected

160
Q

Benzodiazepines ________________ of other central nervous system depressants taken concomitantly

A

potentiate the effects

161
Q

Flumazenil should be avoided in which scenarios? (2)

A
  1. Mixed overdoses (ie those involving TCAs)

2. Benzodiazepine-dependent patients (may precipitate withdrawal)

162
Q

In patients experiencing symptoms of benzodiazepine overdose, _______________ may prevent the need for ventilation, particularly in patients with severe respiratory disorders

A

Flumazenil

163
Q

Flumazenil should be used on expert advice only and not as a _______________ in patients with a reduced level of consciousness.

A

diagnostic test

164
Q

What are the symptoms of beta-blocker overdose? (7)

A
  1. Bradycardia (most common)
  2. Hypotension
  3. Syncope
  4. Conduction abnormalities
  5. HF
  6. QT prolongation (sotalol)
  7. QRS prolongation (propranolol)
165
Q

The effects of overdosage can vary from one beta-blocker to another; propranolol overdosage in particular may cause _____________ and ______________

A

coma

convulsions

(As well as QRS prolongation)

166
Q

Which beta-blocker in overdose is associated with QT prolongation and associated arrhythmias?

A

Sotalol

167
Q

All patients who have been exposed to beta-blockers as a result of ___________ should be referred for assessment

A

self-harm

168
Q

For patients presenting with beta-blocker overdose, _______________. Although the benefit of gastric decontamination is uncertain, charcoal, activated can be considered if the patient presents within 1 hour of ingestion of more than a potentially toxic dose

A

maintain a clear airway and adequate ventilation

169
Q

For the management of hypotension associated with beta-blocker overdose, ensure adequate fluid resuscitation; in an emergency, _____________ and ______________ can be initiated under the advice of an experienced physician

A

vasopressors

inotropes

  • Intravenous glucagon [unlicensed] is a treatment option for severe hypotension, heart failure, or cardiogenic shock
170
Q

In severe cases of beta-blocker toxicity, an ____________ and ____________ infusion can improve myocardial contractility and systemic perfusion, especially in the presence of acidosis

A

insulin

glucose

  • Intravenous glucagon [unlicensed] is also a treatment option for severe hypotension, heart failure, or cardiogenic shock
171
Q

In cases of beta-blocker overdose, consider intravenous _________________ for correction of metabolic acidosis that persists despite correction of hypoxia and adequate fluid resuscitation—rapid correction is particularly important if __________________

A

sodium bicarbonate

QRS duration is prolonged

172
Q

In cases of beta-blocker toxicity, give intravenous _________________ for symptomatic bradycardia; a temporary cardiac pacemaker can be used to increase the heart rate

A

atropine sulfate

*dobutamine [unlicensed] or isoprenaline [unlicensed] (available from ‘special-order’ manufacturers or specialist importing companies) may be considered if bradycardia is associated with hypotension.

173
Q

Treat beta-blocker associated bronchospasm with ______________ and _______________

A

nebulised bronchodilators

corticosteroids

174
Q

What is the management of convulsions associated with beta-blocker overdose? (3)

A

Give oxygen

Correct acid-base and metabolic disturbances as required

Prolonged and frequent convulsions should be controlled with IV diazepam, lorazepam, or midazolam

175
Q

What are the features of CCB (dihydropyridines) poisoning? (8)

A
  1. Nausea and vomiting
  2. Dizziness
  3. Agitation
  4. Confusion
  5. Coma
  6. Metabolic acidosis
  7. Hyperglycemia
  8. Hypotension (profound peripheral vasodilation)
176
Q

What are the symptoms of verapamil and diltiazem in overdose (non-dihydropyridine CCBs)? (2)

A
  1. Hypotension (negative inotropic effects)

2. Arrhythmias including complete heart block and asystole

177
Q

_____________ should be considered if the patient presents within 1 hour of overdosage with a calcium-channel blocker

A

Activated charcoal; repeated doses of activated charcoal are considered if a modified-release preparation is involved

178
Q

In patients with significant features of CCB poisoning, ______________ or ____________ is given by injection; atropine sulfate is given to correct symptomatic bradycardia

A

calcium chloride

calcium gluconate

179
Q

In patients with significant features of CCB poisoning, calcium chloride or calcium gluconate is given by injection; ______________ is given to correct symptomatic bradycardia

A

atropine sulfate

180
Q

In severe cases of CCB poisoning, an ______________ and _______________ infusion may be required in the management of hypotension and myocardial failure

A

insulin

glucose

181
Q

Iron poisoning in childhood is usually ________________

A

Accidental

182
Q

What are the symptoms of iron poisoning? (10)

A
  1. Nausea and vomiting
  2. Abdominal pain
  3. Diarrhea
  4. Hematemesis
  5. Rectal bleeding
  6. Hypotension (later)
  7. Hepatocellular necrosis (later)
  8. Coma
  9. Shock
  10. Metabolic acidosis
183
Q

Mortality from iron poisoning is reduced by intensive and specific therapy with ______________

A

desferrioxamine mesilate (chelates iron)

*The serum-iron concentration is measured as an emergency and intravenous desferrioxamine mesilate given to chelate absorbed iron in excess of the expected iron binding capacity. In severe toxicity intravenous desferrioxamine mesilate should be given immediately without waiting for the result of the serum-iron measurement.

Roomies Collab Deck 6: Fluids, Haematology and Respiratory (24 decks)

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