MyCpdZw - Protocols Details

POISONING & OVERDOSE – GENERAL PRINCIPLES

The general principles of management of drug poisoning are summarized.

Diagnosis

Common presentation both deliberately & accidentally.

Presentations often associated with alcohol consumption.

Multiple drugs often involved.

Beware that histories may be unreliable; however obtain as much detail as you can:

· Drug(s) consumed, route, dose, number & time of ingestion,

· Establish reason & intent of poisoning

· Letters written

· Mode of presentation- found, phoned for help etc

· Look for symptoms of toxicity

Full examination essential to confer with history, establish pharmaceutical effects or find other causes of illnesses.

Some drugs have a very characteristic smell- acetone (with isopropyl alcohol, chloroform & acetone!)Ammonia (Valproate), Almonds (Cyanide), Eggs (Disulphuram, Hydrogen Sulphate) & Garlic (Arsenic).

Information gained from pulse, BP, pupils etc are essential in diagnosis.

“Overdose Syndromes”:

Hyperthemia: Cocaine, Neuroleptics,Salycilates, Tricyclics, Serotonin Uptake Inhibitors

Hypothermia: CNS depressants

Cholinergic: DUMBELS- Defecation, Urination, Meiosis, Bradycardia, Emesis, Lacrimation.

Anticholinergic: Dry mouth & skin, Urinary retention, mydriasis, tachycardia, hyperthemia, delirium. Drug examples include benztropine, hyoscine, antihistamines, tricyclics

Sympathetic: Hypertension, tachycardia, sweating, excitation, tremor, convulsions. Drug examples include cocaine, amphetamines, theophylline

Serotonin Syndrome: Fever, sweating, tachycardia, hypertension, mydriasis, confusion, agitation, ataxia, hypertonia

Opiate: Decreased LOC, meiosis, hypoventilation, hypotension

Management

1. ABC’s & Resuscitation as indicated,

2. As indicated FBC, U&E’s, LFT’s, Urinalysis,

3. Drug levels (Alcohol, CO, Paracetamol, Dogoxin, Iron, Lithium) as indicated,

4. Consider HCG, ABG’s, CXR,

5. Many don’t require any treatment apart from symptomatic support.

Decrease drug absorption:

1. Emesis with Ipecacuanha syrup & gastric lavage are generally not useful,

2. Activated charcoal 50-100 g only if there is no potential for loss of consciousness or airway protection. Best used in the first hour & with the following drugs: Amphetamines, Opiates, Aspirin, Paracetamol, Barbiturates, Digoxin 7 Benzodiazepines. Poorly absorbs Iron, Lithium, Cyanide, Caustics, Methanol, Ethanol, Malathion & Etheylene glycol.

Enhancing elimination:

1. Maintain adequate hydration,

2. Haemodyalisis for drug induced renal failure or toxic drugs with long half-lifes: Etheylene glycol, Salicylates, Lithium or Methanol,

3. Urinary pH manipulation for enhancing elimination of salycilates, phenobarbitone.

Drug manipulation or antidotes:

1. Opiates:

· Naloxone

· Beware the half life of most opiates is greater than that of Naloxone (Methadone T1/2=15-20 hours!).

· Be ready for acute opiate withdrawal reaction (“Cold Turkey”).

· Will therefore require period of observation following recovery.

2. Paracetamol: N-Acetylcysteine (see Paracetamol overdose),

3. Dogoxin: F-antibodies for severe poisoning,

4. Iron; Desferrioxamine IV 15 mg/kg/hr,

5. Benzodiazepines: Flumazenil but beware might precipitate seizures in OD & its half life is much shorter than most benzodiazepines,

Beta-blockers: Glucagon.

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