Case Presentation18/02/2009

Flip Cloete

Case 1:50 Yr FemaleHistory: ? Overdose

Found in BedGCS 10/15

En Route: GCS 7/15Intubated 7 ETTNil drugs

Husband intoxicatedNo further history

1 Survey:Intubated on ventilator BP: 194/116 P: 127HGT: 5,2 mmol/l T: 35,5 CSaO2: 100% FiO2 0.40

Pupils R = 3 mmL = 5 mm

Bilateral sluggish

GCS = 3 T (M2 decerebrate, E1, VT)

No signs trauma or injury

Examinations ???????

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

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 %

ECG:

CXR:

Transfer for CT Brain - ? TraumaCT Brain = Normal

Improved – extubated

Alledges Overdose of “Blue” tablets

Tox Screen: Paracetamol < 5TCA - 34

Recognised “Phenergan” (Promethazine) 25

mg tabs – took 25 tabs with alcohol.

Referred to Psychiatry

Discharged on Fluoxetine

Approach to unknown overdose:Poisoned Patient

Treatment DiagnosisAirway HistoryBreathing Physical ExamCirculation Toxidrome DON’T: Diagnostic Tests(dextrose, oxygen, naloxone, thiamine)

Decontamination Enhanced EliminationFocused TherapyGet Tox Help

Diagnosis• History

Type, time, volume, route ReasonPrescription drugs

• Physical ExamStabilisation priority

• ToxidromeRecognition of toxic syndrome

• Diagnostic Tests

TreatmentAirway

Breathing

Circulation

DON’T: (dextrose, oxygen, naloxone, thiamine)

– Individualize patients

Treatment Cont:

• Decontamination– Skin & Eyes– GIT

• activated charcoal

• Enhanced Elimination– Extracorporeal

Treatment cont:

• Focused Therapy– Antidote

• Get Toxicology Help

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

Side Effects :

• Drowsiness (>80%)

• Dizziness, fatigue, inco-ordination

• Seizures , hallucinations

• GIT – Nausea, vomiting, epigastric pain

• Anticholinergic: dry mouth, blurred vision, urinary

retention

Management phenothiazine OD:

1. Advanced life support

2. Charcoal in 1-2 hrs

3. ECG, Acid-base, elecs

4. IV Fluid – BP

5. No role dialysis/ haemoperfusion

6. Acute dystonia

Rx: diazepam/ anti-cholinergics (Akineton)

7. Weak cross reaction with TCA lab assay

Case 2:

10 Yr Girl

Washing windows @ school

Sitting on bench/ desk

Clothes damaged

Severe pain buttocks

Unable to sit

Science Lab – Teacher sent note ? Nitric Acid / ? HCL

Examination: Partial thickness burns to buttocksLeft 8 x 12 cm with surrounding erythemaRight 4 x 5 cm

No Anal / Genital involvementBear Weight, unable to sit

Reviewed 24 hrs:

Wounds blistering

Clean

Pain improving

Plan: Cont daily Flamazine dressings

Analgesia

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.

Management:

• A,B,C,D• Exposure

– undressed – Euthermic, tepid water for irrigation – Early External warming devices

• Pain management – Morphine

• Tetanus

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

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

normalizes @ pH 7-8

Bibliography:

1. Erickson TB, Thompson TM, Lu JJ. The Approach to the Patient with an Unknown Overdose. Emerg Med Clin N Am 25 (2007) 249–281.

2. Demling RH, DeSanti L, Orgill DP. Chemical Burns.Available from: Http://www.burnsergery.org/Modules/initial/part-two/sec6.htm.

3. Nervi SJ, Schwartz RA, Desposito F, Hostetler MA. Burns Chemical. eMedicine specialities paediatric surgery. Aug 11, 2008. Available from: http://emedicine.medscape.com/article/926537-overview

4. McNeil BK, Jaslow D. Chemical burns. eMedicinehealth, Web MD 2009. Available from: http://www.emedicinehealth.com/chemical-burns/article-em.htm.

5. Gibbon CJ et al, Division clinical pharmacology UCT. SAMF. 8th Edition. Cape Town: FA Print; 2008.