Toxicology: Alcohol, Aspirin, Opioid, Paracetamol, TCA, SSRI, Benzodiazepines, Beta Blockers, Lithium, Ethylene Glycol/Methanol

Question 1

Paracetamol

• presentation
• investigations
• management and risks

Answer 1

Can be asymptomatic
Main sign - N+V
-RUQ pain => jaundice

Measure serum paracetamol conc 4hrs after OD
-high LFT, INR - high ALT
-FBC - anemia, low plt
-VBG - lactic acidosis
Transfer to liver unit if blood tests worsen

Acute U1hr - charcoal
Acute OD U8hrs - [paracetamol] 4hrs since last dose
Acute OD 8hrs+ - immediate [paracetamol] + NAC
Staggered - NAC

Above or on nomogram line - NAC
-slow infusion over 1hr to reduce risk of anaphylactoid reaction

Liver transplant

• acidemia 24hrs after OD
• PT 100s+ AND creatinine 300+ AND Grade 3-4 encephalopathy

Question 2

Tricyclic antidepressants

• presentation
• investigations
• management
• complications

Answer 2

Anticholinergic syndrome

• mad as a hatter, red as a beet, dry as bone, hot as a hare => METABOLIC ACIDOSIS
• dilated pupils, high HR

CONTINUOUS ECG - prolonged QRS => bicarbonate trial
ABG - metabolic acidosis

Activated charcoal OD U4hrs
Bicarbonate
Supportive - ITU referral

Arrythmias, seizures
Delirium, coma

Question 3

Opiates

• presentation
• investigations
• management
• complications
• harm reduction
• detoxification

Answer 3

RESP DEPRESSION, REDUCED CONSCIOUSNESS, PINPOINT PUPILS

ABG - T2RF
Naloxone trial

Remove OD source
Supportive - O2, resp
Repeated naloxone

Hypoxia, aspiration, ARDS

Detox - methadone/buprenorphine
-compliance monitored with urinalysis
Harm reduction - needle exchange, HIV/HepBC testing

Question 4

Benzodiazepines

• presentation
• management

Answer 4

Low GCS, depression of everything

Supportive
Flumazenil unless severe due to seizure risk

Question 5

Warfarin, heparin

-managament

Answer 5

VitK
Prothrombin complex if actively bleeeding

Protamine

Question 6

Beta blockers

• management
• presentation

Digoxin
-management

Answer 6

Bradycardia => atropine
Resistant => glucagon
-Low BP, HF, syncope

Digoxin-specific AB fragments

Question 7

Ethylene glycol, methanol

• presentation
• management

Answer 7

Low GCS, depression of everything
-high RR => acidosis compensation

ABG - Raised anion gap acidosis
U&E - AKI

Fomepizole or ethanol
Metabolic acidosis - bicarbonate
Hemodialysis if severe

Question 8

Lithium

• presentation
• management

Answer 8

Coarse tremor
Polyuria
Agitation, confusion

Mild, moderate - volume resus with saline
Severe - hemodialysis

Question 9

Aspirin

• presentation
• investigations
• management
• complications

Answer 9

Acute or chronic poisoning

• TINNITUS, N+V
• RESP ALK => MET ACID

Serial ABG
[Salicylate] 2-4hrs post ingestion
U&E, ECG

Asymptomatic - home monitoring
Activated charcoal - U1
Bicarbonate, fluids - metabolic acidosis, electrolytes
Hemodialysis if sevre

ARDS, cardiac arrest, seizures

Question 10

Alcohol

• presentation
• management

Answer 10

6-12hrs - SNS symptoms
36hrs - seizures
48-72hrs - DT

1st line - diazepam/chloridxepoxide + supportive management
-lorazepam in liver failure

Question 11

Carbon monoxide

• presentation
• investigations
• management

Answer 11

Headache, N+V, confusion
Pink skin, mucosa, fever, arrythmias

ABG, VBG

100% high flow O2 NRM