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ACC > Pt/w Deliberate Self Harm > Flashcards

Pt/w Deliberate Self Harm Flashcards

1
Q

What are some early symptoms of paracetamol overdose?

A

FIRST 24 HOURS - NAUSEA AND VOMITING

  • Symptoms of the actual overdose take quite a long time to occur (takes a while for NAPQ to build up)
  • Usually when people are unwell when they come in is because they’ve ingested the pills with a lot of alcohol
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2
Q

What are some of the mid-symptoms of paracetamol OD and when do they occur?

A

24-72h

  • MORE NAUSEA AND VOMITING
  • RUQ pain (this occurs due to inflammation in the liver that stretched the liver capsule)
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3
Q

What are some of the LATE symptoms of paracetamol OD and when do they occur?

A

After 72h-SYMTOMS OF LIVER FAILURE

  • Jaundice
  • Encephalopathy (confusion/drowsines/irritability/seizures)
  • Coagulopathy - bleeding, bruising
  • Hypoglycaemia(glycogen not released from liver-another cause of seizures)

-AKI

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4
Q

If someone comes in with paracetamol OD what is important to find out in the history? (not including psych history)

A

How many tablets did they take?
Did they take anything else?
When did they take them?
Did they take them all at once or did they take breaks?

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5
Q

What makes treating paracetamol OD more difficult to treat?

What is deemed a large overdose?

A

If the person took a STAGGERED OVERDOSE

  • this is if they took the tablets over a time period of 1 hour or longer (if you dont know-pressume it is staggered)
  • Large overdose >10g
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6
Q

pathophysiology of paracetamol OD?

A

-Paracetamol is usually metabolised in the liver
-95% of paracetamol is metabolised to harmless metabolites (glucoronide and sulphate)
-5% of paracetamol is metabolised by the CYP450 system to NAPQ1 (harmful metabolite)
-NAPQ1 is then metabolised by GLUTATHIONE to harmless metabolites
-this pathway is saturated in OD
TOO MUCH PCM = NOT ENOUGH GLUTATHIONE.
-Build up of NAPQ1(toxic to hepatocytes> leading to hepatitis and liver failure)

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7
Q

What medications might decrease someones tolerance to paracetamol?

A

CP450 INDUCERS (crap GPs) because they encourage NAPQ to be produced

-Rifampicin (TB), some anti-convulstants and St Jonh’s Wort

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8
Q

What investigations are needed in someone who has taken a paracetamol OD

A
  • PARACETAMOL LEVELS -take at 4 hours post dose
  • THEN PLOT THIS on a graph of plasma paracetamol concentration vs time since ingestion (treat if ON or above line)
  • LFTS usually normal until at least 18h post OD
  • INR is often good to get - suggestive of liver damage if high
  • ABG (lactic acidosis can occur)
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9
Q

When would you treat someone for paracetamol OD?

A

Paracetamol OD, treat if:
• Dose vs time line indicates you should (on or above line)
• If INR deranged
• If after 8 hours of ingestion (don’t bother with levels, just treat)
• Time of ingestion is UNKNOWN or STAGGERED (1+ hour)
• If symptoms of overdose start prior to 4 hours

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10
Q

What is the treatment for paracetamol OD and how do you decide how much to give an at what rate?
Side effects?

A

N-ACETYL CYSTEINE (NAC)

  • The DOSE and infusion rate depends on the weight of the patient so refer to the table
  • There is also different doses depending on whether it is the first, second or third infusion
  • SE: can look like anaphylaxis: flushed (red hands and face), N+V, congested

IV infusion in 5% glucose (or 0.9% NaCl), 3 consecutive doses over 21 hours

  1. 150mg/kg in 200ml glucose over 1 hour
  2. 50mg/kg in 500ml over 4 hour
  3. 100mg/kg in 1L over 16 hours

(activated charcoal if less than 1hr)

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11
Q

Once the treatment is done what should we measure?

When can you stop treatment?

A
  • After treatment measure Creatinine, ALT and INR (usually normal before 18 hours)
  • Continue to treat with NAC until INR <1.3 and ALT less than 2 times the upper limit of normal
  • If okay then stop treating and refer to PSYCH SERVICES
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12
Q

What are the complications of paracetamol OD?

A

COMPLICATIONS OF PARACETAMOL OD:

  • Acute liver failure
  • Cerebral oedema
  • Renal failure
  • Pancreatitis
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13
Q

How many paracetamol tables can be fatal?

A
  • 150mg/kg is fatal equal to 24 tablets or about 12g

- If malnourished, 75mg/kg can be fatal

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14
Q

What groups of people have low levels of glutathione?

A

Alcoholics and malnourished (very low BMI)

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15
Q

What is the criteria for liver transplant after paracetamol OD:

A 
KING COLLEGE Criteria for liver transplant:
• pH <7.3 24 hours after overdose
• PT > 100 secs(INR >6.5)
• Creatinine > 300
•Grade 3 or 4 encephalopathy
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16
Q

What are common side effects of NAC?

A

Common side effect of NAC:

-Rash (treat with anti-histamine chlorphenamine)

17
Q

How would patients present with an amphetamine overdose?

A

Amphetamine overdose presents with sympathetic overdrive:

  • euphoria
  • agitated
  • dilated pupils
  • palpatations/arrhythmias and tachycardia, hypertension
  • hyperpyrexia and sweating
  • dehydration
  • muscle rigidity
  • rhabdomyalysis and AKI
  • convulsions due to hyponatreamia from polydipsia (and increased ADH production)
  • coma
  • DIC
18
Q

What would a blood gas show in amphetamine OD?

A

amphetamine OD-ABG would show metabolic acidosis

19
Q

Acute management for amphetamine overdose?

A

Management for amphetamine overdose

  • ABCDE assessment
  • refer to TOXBASE (activated charcoal if within 1 hour)

SUPPORTIVE TREATMENT
• Cooling measures and consider dantrolene (muscle relaxant) if temp is over 39
• Correct electrolyte imbalance
• Sodium bicarbonate(metabolic acidosis)
• Diazepam for convulsions
• Metoprolol for narrow complex tachycardias
• Nifedipine (CCB) for hypertension

20
Q

How does an opiate OD present?

A 
Opiate OD presents with parasympathetic overdrive 
• Pinpoint pupils
• Respiratory depression
• Decreased GCS - potential coma
• Hypotension
21
Q

What would a blood gas show in opiate OD?

A

Opiate OD-ABG would show respiratory acidosis

22
Q

Management for opiate OD?

A

Management for opiate OD

  • ABCDE assessment (consider intubation)
  • refer to TOXBASE
  • IV 400microgram bolus of naloxone. Then infusion.
  • Naloxone half life is shorter than morphine so may need to given more often
23
Q

How does an tricyclic antidepressant OD present?

A 
Tricyclic antidepressant OD
CANNOT SEE, PEE, SPIT or SHIT (anticholinergic syndrome)
• Dry skin and mouth
• Dilated unreactive pupils
• Urinary retention
• Constipation
  • Sedation and coma
  • Seizures
  • Hypertonia and hyperreflexia
  • Severe hypotension/collapse
  • Tachycardia
  • Broad complex dysrhythmias (broad complex QRS seen on ECG)
24
Q

What would an ABG show in tricyclic AD OD?

A

tricyclic AD OD-ABG would show metabolic acidosis

25
Q

Acute management of tricyclic AD OD?

A

Management of tricyclic AD OD

  • ABCDE assessment (intubation)
  • Refer to TOXBASE

-IV sodium bicarbonate if QRS prolongation/dyssrhythmias/hypotension
(repeat every few minutes until BP improves and QRS complexes begin to narrow)

  • Treat seizures with IV benzodiazepines (e.g. diazepam 5-10mg)
  • Hyperventilate to maintain higher pH
26
Q

What is important to include in a history for any overdose?

A
  • What? When? Clinical features?
  • Assess capacity
  • Psychiatric history
27
Q

How do you manage ANY OVERDOSE

A
  1. ABCDE assessment
  2. Vital signs including weight
  3. ECG and VBGs in everyone

REFER TO TOXBASE

28
Q

Name the specific antidotes for the following overdoses

  • Paracetamol OD
  • TCADs OD
  • benzodiazepine OD
  • insulin OD
  • local anaesthetic OD
  • Carbon monoxide OD
  • Iron
A

N- Acetyl-cysteine for Paracetamol
Sodium bicarbonate for TCADs arrhythmias
Flumazenil for benzodiazepines
Glucagon for hypoglycaemia
20% lipid emulsion for local anaesthetic toxicity
Oxygen for carbon monoxide
Desferrioxamine (chelation), consider whole bowel irrigation

29
Q

How to do you treat bradycardia?

A

Give atropine for bradycardia

30
Q

How do you treat beta blocker overdose?

A

Betablocker OD can be treated with glucagon

31
Q

Whats the management for iron overdose?

A

1st line Whole-bowel irrigation
Chelation therapy with Deferoxamine (for severe cases)

***activated charcoal does not bind to iron-not indicated

32
Q

What can you do to manage salicylate OD?

A

Activated charcoal if within 1 hour

  • IV sodium bicarbonate in order to maintain blood pH at 7.5-8.0
  • Dialysis if level >700 (or sizures/AKI/heart failure/cerebral odema/pulmonary odema)
33
Q

How does a salicylate OD present?

A
  • Hyperventilation
  • Nausea
  • Vomiting
  • Tinnitus and headache.

If severe:

  • Confusion
  • Coma
  • Seizures
  • Hypoglycaemia
  • Fever
34
Q

What is the ABG in salicylate OD?

A
  • Initially, hyperventilation>respiratory alkalosis
  • Over 24 hours this progresses to a metabolic acidosis and hypokalaemia (SEVER OD)
  • HIGH ANION GAP

ACC (23 decks)

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