1. Case Presentation
18/02/2009
Flip Cloete

2. Case 1:
50 Yr Female
History: ? Overdose
Found in Bed
GCS 10/15
En Route: GCS 7/15
Intubated 7 ETT
Nil drugs
Husband intoxicated
No further history

3. 1 Survey:
Intubated on ventilator
BP: 194/116 P: 127
HGT: 5,2 mmol/l T: 35,5 C
SaO2: 100% FiO2 0.40
Pupils R = 3 mm
L = 5 mm
Bilateral sluggish

4. GCS = 3 T (M2 decerebrate, E1, VT)
No signs trauma or injury
Examinations ???????

5. Bloods:
Na: 145 mmol/l
K: 4,0
Cl: 106
Urea: 3,0
Creat: 48
WCC : 7,07
HB: 12,6
Plts: 319
GGT: 50

6. ABG: FiO2 0,60
pH: 7,325
PaO2: 39,5 Kpa
PaCO2: 5,88
HCO3: 23,0 mmol/l
BE: -3,3
SaO2: 99,9 %

7. ECG:

8. CXR:

9. Transfer for CT Brain - ? Trauma
CT Brain = Normal
Improved – extubated
Alledges Overdose of “Blue” tablets
Tox Screen: Paracetamol < 5
TCA - 34

10. Recognised
“Phenergan” (Promethazine) mg tabs – took 25 tabs with alcohol.
Referred to Psychiatry
Discharged on Fluoxetine

11. Approach to unknown overdose: Poisoned Patient Treatment Diagnosis
Airway History
Breathing Physical Exam
Circulation Toxidrome
DON’T: Diagnostic Tests
(dextrose, oxygen,
naloxone, thiamine)
Decontamination
Enhanced Elimination
Focused Therapy
Get Tox Help

12. Diagnosis
History
Type, time, volume, route
Reason
Prescription drugs
Physical Exam
Stabilisation priority
Toxidrome
Recognition of toxic syndrome
Diagnostic Tests

13. Treatment Airway Breathing Circulation DON’T:
(dextrose, oxygen, naloxone, thiamine)
Individualize patients

14. Treatment Cont: Decontamination Enhanced Elimination Skin & Eyes GIT
activated charcoal
Enhanced Elimination
Extracorporeal

15. Treatment cont:
Focused Therapy
Antidote
Get Toxicology Help

16. Phenothiazines (Neuroleptics)
Promethazine = H1 antihistamine
Toxidrome :
LOC (resp depression)
Extrapyrimidal signs:rigidity, tremor,  reflexia, dyskinesia
Restlessness (hallucinations)
BP & tachycardia
Arrhythmias – QT prolongation
Seizures (uncommon) vs. acute dystonia

17. Side Effects :
Drowsiness (>80%)
Dizziness, fatigue, inco-ordination
Seizures , hallucinations
GIT – Nausea, vomiting, epigastric pain
Anticholinergic: dry mouth, blurred vision, urinary retention

18. Management phenothiazine OD:
Advanced life support
Charcoal in 1-2 hrs
ECG, Acid-base, elecs
IV Fluid – BP
No role dialysis/ haemoperfusion
Acute dystonia
Rx: diazepam/ anti-cholinergics (Akineton)
7. Weak cross reaction with TCA lab assay

19. Case 2:
10 Yr Girl
Washing school
Sitting on bench/ desk
Clothes damaged
Severe pain buttocks
Unable to sit

21. Science Lab – Teacher sent note
? Nitric Acid / ? HCL
Examination:
Partial thickness burns to buttocks
Left 8 x 12 cm with surrounding erythema
Right 4 x 5 cm
No Anal / Genital involvement
Bear Weight, unable to sit

22. Reviewed 24 hrs:
Wounds blistering
Clean
Pain improving
Plan: Cont daily Flamazine dressings
Analgesia

23. Approach to chemical burn:
Acids:
Coagulation necrosis of tissue
Area coag limits injury extension
Alkali:
Liquefaction necrosis
More dangerous
Liquefy tissue: denaturation of proteins saponification of fats
Continue penetration deep into tissue.

26. Management: A,B,C,D Exposure Pain management Tetanus undressed
Euthermic, tepid water for irrigation
Early External warming devices
Pain management
Morphine
Tetanus

27. Management: Decontamination basics
Dilution is the solution to decontamination.
Never attempt neutralization - exothermic reaction + thermal injury/ explosion.
Cutaneous exposure
Powder - brush off
Rinse affected area (tepid tap water)
Liquid - remove clothing & rinse affected area
Copious amounts of fluid

28. Management: Oral and GI Mouth rinsed Do not attempt neutralization
Airway & NPO
No gastric emptying/ lavage or ipecac
Ocular
Solution is dilution.
Rinsed copious ocular irrigation solution min. ½ hr
normal saline pH range 4.5 and 6.0.
Analgesia: Topical & parental
Eye pH checked 30 min increments cont irrigation till pH pH 7-8

29. Bibliography:
Erickson TB, Thompson TM, Lu JJ. The Approach to the Patient with an Unknown Overdose. Emerg Med Clin N Am 25 (2007) 249–281.
Demling RH, DeSanti L, Orgill DP. Chemical Burns.Available from:
Nervi SJ, Schwartz RA, Desposito F, Hostetler MA. Burns Chemical. eMedicine specialities paediatric surgery. Aug 11, Available from:
McNeil BK, Jaslow D. Chemical burns. eMedicinehealth, Web MD Available from:
Gibbon CJ et al, Division clinical pharmacology UCT. SAMF. 8th Edition. Cape Town: FA Print; 2008.