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YEAR 4 - ACC > Substance Abuse > Flashcards

Substance Abuse Flashcards

1
Q

How does amphetamine ingestion present?

A 
Euphoria
Agitation
Sweating
Dilated pupils
Palpitations
Tachycardia
Hypertension
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2
Q

How does an amphetamine overdose present?

A

Sympathetic overdrive

Hyperpyrexia
Dehydration
Muscle rigidity
Convulsions (due to hyponatraemia from polydipsia) 
Rhabdomyolysis
Arrhythmias 
Coma
DIC
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3
Q

How do you manage an amphetamine overdose?

A

Refer to TOXBASE
Activated charcoal if <1hr after ingestion

Supportive treatment:

  • Cooling measures, if rectal temp > 39 consider dantrolene
  • Correct electrolyte imbalance
  • Sodium bicarbonate
  • Diazepam for convulsions
  • Metoprolol for narrow complex tachycardias
  • Nifedipine for hypertension
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4
Q

How does an opiate overdose present?

A

Parasympathetic overdrive

Pinpoint pupils
Respiratory depression
Decreased GCS - potential coma
Hypotension

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5
Q

What would an ABG show in amphetamine overdose?

A

Metabolic acidosis

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6
Q

What would an ABG show in opiate overdose?

A

Respiratory acidosis

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7
Q

What is the treatment for opiate overdose?

A

IV naloxone 0.4-2mg - repeat every 2 min until breathing adequate

Naloxone’s half life is shorter than morphine so may need to be given often

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8
Q

How is paracetamol normally metabolised?

A

Metabolism occurs in the liver

By glucuronidation, 95% 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

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9
Q

How does paracetamol overdose affect its metabolism?

A

In overdose, the pathways are saturated and there is insufficient glutathione to metabolise all the NAPQ1 so there is a build up of NAPQ1

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10
Q

What dose of paracetamol is potentially fatal?

A

150mg/kg
12g = 24 tablets
If malnourished, 75mg/kg can be fatal

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11
Q

How does paracetamol overdose present depending on the time since ingestion?

A

<24 hours: nausea and vomiting (or asymptomatic)

24-72 hours

  • Nausea + vomiting
  • RUQ pain

> 72 hours = symptoms of liver failure

  • Jaundice
  • Confusion
  • Coagulopathy - bleeding, bruising
  • Hypoglycaemia
  • AKI
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12
Q

How do you decide whether to treat a paracetamol overdose?

A

Do blood paracetamol level at 4 hours post dose
Plot graph of plasma concentration of paracetamol vs time since dose
Treat if the point is above the line

If symptoms of overdose prior to 4 hours, start treatment ASAP
If time of ingestion is unknown or staggered, treat anyway

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13
Q

What defines a staggered dose of paracetamol?

A

Doses taken over more than one hour

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14
Q

What is important to find out in the psychiatric assessment of somebody who has taken a paracetamol overdose?

A

Intentions at time

  • Was it a suicide attempt and was it planned?
  • Any precautions against being found?
  • Did they seek help after?
  • Was there a final act e.g. suicide note?

Present intentions

  • Do you feel suicidal?
  • Do you wish it had worked?

What problems led to the act

Is there a psychiatric disorder?

What are your resources?
- Friends, family, work, personality

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15
Q

What factors increase the likelihood of suicide risk?

A

SAD PERSONS scale for suicide risk

Sex - Male
Age - <19 or >45 years old 
Depression or hopelessness
Previous suicide attempts or psychiatric disorder
Excessive alcohol or drug use
Rational thinking loss
Unemployed
Separated/divorced/widowed
Organised or serious attempt
No social supports
Stated future intent
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16
Q

What is the criteria for liver transplant?

A

King’s College Hospital criteria for paracetamol-induced liver failure

Either:
- pH < 7.3 24 hours after ingestion
Or all of: 
- PT > 100 secs
- Creatinine > 300
- Grade 3 or 4 encephalopathy
17
Q

What LFTs would be deranged in paracetamol overdose?

A

ALT > 1000 indicates hepatotoxicity
AST increased
INR increased

18
Q

How is paracetamol overdose managed if it’s before 4 hours since the overdose?

A

0-1hr: activated charcoal

0-4hr: wait for 4hr to measure paracetamol levels BUT if symptoms start N-acetylcysteine ASAP

19
Q

How is N-acetylcysteine administered in paracetamol overdose?

A

IV infusion in 5% glucose, 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 1 L over 16 hour
20
Q

What are the side effects of n-acetylcysteine?

A

Rash - treat with chlorphenamine

Nausea and vomiting

Sweating and flushing

Congested face - runny nose, puffy eyes

21
Q

When should you continue treating with N-acetylcysteine until?

A

Until clotting is normal - INR <1.3 and ALT less than 2 times the upper limit of normal

22
Q

How does tricyclic antidepressant overdose present?

A

Can’t see, pee, shit, spit

  • Dry skin and mouth
  • Dilated unreactive pupils
  • Urinary retention
  • Jerky limb movements, ataxia
  • Drowsiness, coma
  • Tachycardia
  • Hypertonia and hyperreflexia
23
Q

What might tricyclic depressant overdose be mistaken for?

A

Ventricular tachycardia - Broad QRS complexes seen on ECG

24
Q

What is seen on ABG of TCA overdose?

A

Metabolic acidosis

25
Q

What is the treatment for TCA overdose?

A

IV sodium bicarbonate to treat acidosis and arrhythmias

26
Q

How is paracetamol overdose managed if it’s 4-8 hours since the overdose?

A

Take bloods - plot paracetamol levels on the graph and if above the treatment line, give NAC

27
Q

How is paracetamol overdose treated if it’s > 8 hours since the overdose?

A

Start NAC straight away and take bloods for reference

28
Q

In which patients should you start NAC immediately if they present with paracetamol overdose?

A

Administer NAC immediately if there is increased risk of toxicity

  • Patient on long-term enzyme inducers
  • Regular alcohol excess
  • Pre-existing liver disease
  • Glutathione-deplete states: eating disorders, malnutrition and HIV

YEAR 4 - ACC (11 decks)

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