Management Overview History & assessment of vital signs ANY concerns: move patient to RESUS ABCD DEFG Supportive care (O 2, IV Fluids) Prevent absorption Increase elimination Antidotes PSYCHOLOGICAL ASSESSMENT
History What? When? How much? (mg/kg) What else? Why?
Collateral history Paramedics Family / friends Notes Look in pockets – carefully!!!
Detective work BNF Toxbase Tablet identification aids: TICTAC Poisons advice: NPIS Plant identification books National teratology information service
Initial examination Treat problems as you find them!! Airway Breathing Circulation Disability – GCS/AVPU and Pupils DONT EVER FORGET GLUCOSE
Observations Saturations and respiratory rate Pulse and blood pressure GCS Pupils Temperature GLUCOSE
Paracetamol Very common: 40% poisons admissions Often asymptomatic Can be lethal – deaths/year Check blood level at 4 hours Two treatment lines normal and high risk Given IV N-acetylcysteine
Paracetamol metabolism Metabolised by glucuronidation (60%), Sulphation (35%) and oxidation (10%) Cytochrome p450 produces NAPQI NAPQI toxic causes hepatocellular necrosis – irreversible binding NAPQI detoxified by conjugation with glutathione
High Risk Increased oxidation –Chronic alcohol use –Drugs Reduces glutathione stores –Malnutrition –Eating disorders –Chronic liver disease
N-acetylcysteine Most effective within 8 hours Precursor for glutathione production Can cause anaphylactoid reactions Consider starting before paracetamol result if: –Presenting > 8 hrs & >150mg/kg taken –Staggered overdose
To treat or not to treat?
Patient 1 20 year old woman who takes a handful of paracetamol tablets No drug history No alcohol use Fit and well Blood level is 80mg/l
No need to treat Patient is not high risk Level at 4 hours is below even the high risk line
Patient 2 70 year old man Takes 20 paracetamol 6 hours before presenting Alcoholic No drug history Blood level 100mg/l
Treat Patient is high risk Level is above the high risk line Delayed presentation means need to act fast
Patient 3 17 year old epileptic 25 codydramol 2 hours before attendance Taking carbamazepine Blood level at 4 hours is 120mg/l
Treat High risk patient Level above the high risk line
Patient 4 35 year old man who presents after taking 24 paracetamol over a period of 24 hours No drug history Fit and well Blood level 20mg/l
Treat Staggered overdoses are difficult Poisons advice is to give IV acetylcysteine Levels are not that helpful Need to monitor Liver function, clotting and renal function May need discussing with Liver Unit if abnormal
PARACETAMOL DEADLY PITFALLS The Prescott Nomogram High Risk Line Staggered Overdoses Management of late presentation Recheck U&E, LFT, INR after N-acetylcysteine
Tricyclics Antidepressants Dangerous: US 60-70% fatal ODs UK commonest fatal OD per prescription 10% unconscious patient will fit –Treat fits with diazepam/lorazepam
Salicylate Metabolic and acid-base disturbance Complex Respiratory alkalosis – direct stimulation to over breathe Metabolic acidosis- acid, impaired normal metabolism, production of lactic acid Check ABG / VBG
Scenario 1 20 year old IVDU found by ambulance crew unconscious Needle lying by side Resp rate 6, Sats 94% on air 60bpm BP 100/55 Responds to pain
What next? A – Give naloxone B – Check airway C – Take history D – Give flumazenil
Check airway Check airway patent Give oxygen Call for senior help Check glucose Give naloxone IM and IV
Scenario 2 30 year old woman Taken some white tablets 4 hours earlier Feels completely well Felt depressed after argument with partner Usually fit and well
What next? A – Start N-Acetylcysteine B – Discharge as she is obviously well C – Find out what the tablets are D –Take blood for paracetamol levels
Take bloods Early treatment is essential in paracetamol overdose Need to know what her levels are as soon as possible
Scenario 3 45 year old man works in local aquarium Put right hand into tank and got stung by a lion fish Respiratory rate 16 sats 100% on air Pulse 100 bpm 160/80 Fully conscious Extreme pain in hand
What next? A – Panic you know nothing about lion fish! B – Look on Toxbase C – Ring local zoo D – Ask a senior who also knows nothing about Lion fish!
Toxbase Patient needs cardiovascular monitoring Analgesia Hand in water as hot as can tolerate Lion fish toxin is heat labile Carefully remove spines if present Few hours later patient feels much better goes home
Summary Common Approach using: A B C D DEFG Consider the toxidromes Early senior help / Early ITU referral Supportive Care Antidotes Psychological assessment