first aid & therapy - Pavol Jozef Šafárik University Poisoning...ACUTE POISONING first aid &...
Transcript of first aid & therapy - Pavol Jozef Šafárik University Poisoning...ACUTE POISONING first aid &...
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ACUTE POISONINGfirst aid & therapy
Jozef Firment
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Acute Poisoning in the
Emergency Department
• Common - 3-5% of ED attendances
• Some of the highest rates of deliberate poisoning
in Europe
• Often multiple drugs
• Don’t forget alcohol !!
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History
• Applies to any episode of poisoning
• What
• How much (ideally mg/kg)
• When
• What else (including alcohol)
• Why
• Use informations from relatives, friends,
paramedics, anyone!!
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General Management
• Take care about vital sings!
• A (Airway)
• B (Breathing)
• C (Circulation)
• D (Disability-AVPU/ Glasgow Coma Scale)• AVPU scale (Alert, Voice, Pain, Unresponsive)
• DEFG (Don’t ever forget the Glucose) and
thiamine
• Get a set of basic observations– Disconnection from poison administration
– Symptomatic treatment
– Target treatment 5
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Recovery position
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Examination
• Use all your senses, search for the clues
• Look
– Track marks
– Pupil size
• Feel
– Temperature, sweating
• Smell
– Alcohol
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General Management
• Decreasing drug absorption
– Gastric Lavage (need to protect the
airway, may push drug through pylorus into
small bowel.)
– Absorbants (Activated Charcoal, usually
within 1 hour of ingestion, longer repeated
doses in drugs that delay gastric emptying
e.g. Aspirin)
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Specific Management
• Increasing drug elimination
– Saline (volume) diuresis - crystalloids
– Alkaline Diuresis (Aspirin)
– Haemodialysis (Aspirin)
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Specific Management
• Antagonising the effects of the poison
– Naloxone (opioids)
– N-acetylcysteine (paracetamol)
– Flumazenil (benodiazepins)
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Specific Poisons-
Paracetamol
• Commonest drug used
• 50% of all Self Poisoning Episodes
• Toxic dose >7 g/adult
• Dangerous and people don’t know it. You feel well
and then the liver failure sets in..
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Paracetamol-Normal
Metabolism
• Paracetamol converted to:
• N-acetyl-p-benzoquinonamine (toxic)
• This is conjugated with Glutathione
• Glutathione stored in the body
• Produces a non toxic metabolite
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Paracetamol Overdose
• Glutathione stores are used up by the
excess Paracetamol
• Toxic Metabolite build up
• Binds irreversibly to Hepatic Cell
membranes
• Resulting in liver necrosis
• N-acetylcysteine. Shown to be advantageous
if given in the first 10 hours
• Refer to specialist liver unit
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Opiate Poisoning - Features
• Action on the µ-receptors giving the
effects in overdose.
– 1. Pinpoint pupils
– 2. Respiratory depression <8 breaths/min!!!
– 3. Coma
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Opiate Overdose
• Naloxone 0,4 mg
– Opioid antagonist
– High affinity for the opiate receptors
– Rapid onset
– Effects last 2-4 h, may need repeated
doses
– Give I-M or I-V
– Other effects - pulmonary oedema!
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Salicylate (Aspirin)
Poisoning
• Toxicity occurs due to disturbance in
Acid-Base Balance
1. Respiratory Alkalosis
2. Metabolic Acidosis
Urinary alkalinisation
Haemodialysis17
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Tricyclic Antidepressants
• Seen relatively frequently
• Can be fatal
• Can be very symptomatic, effects made
worse by alcohol
• Main effects are on the Heart and Brain
• Effects are
– 1. Anticholinergic
– 2. Quinidine like18
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TCA Clinical features
• Anticholinergic effects
– Dry Mouth, Dry Eyes, Dilated Pupils, Urinary
Retention, Blurred Vision, Dizziness, Palpitations,
Pyrexia without sweating
– CNS Effects - Confusion, Delirium, Coma,
Convulsions, Myoclonus and Respiratory
Depression
• Cardiac Toxicity (quinidine effects)
– Heart Block, Asystole, Bradycardia, Tachycardia,
Ventricular Dysrythmias
– ECG Changes - broadening of QRS complex,
Widened QT Interval19
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TCA Overdose
• Activated charcoal if more than 4 mg/kg
within 1 hour.
• Correct hypoxia with Oxygen (airway)
• Correct acidosis with NaHCO3
• Correct any arrythmias with NaHCO3
(i.e start by controlling the acid base
disturbance)
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Indications for Continuous or
Intermittent Renal
Replacement Therapy
• Volume Overload
• Electrolyte Imbalance (K, Na, Ca...)
• Uraemia
• Acid-Base Disturbances
• Drugs
• Sepsis, special haemofilters?
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Intermittent Hemodialysis
• maximum solute
clearance
• best tx for severe
hyper-K+
• ready availability
• limited anti-coagulation
time
• bedside vascular
access
• hemodynamic
instability
• hypoxemia
• rapid fluid + solute
shifts
• complex equipment
• specialized
personnel
advantages disadvantages
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Definition of Terms
• SCUF Slow Continuous Ultrafiltration
• CVVH Continuous Venovenous Hemofiltration
• CVVH-D Continuous Venovenous Hemofiltration with Dialysis
• HP – hemoperfusion(charcoal...)
• Peritoneal Dialysis
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Hemodialysis vs Hemofiltration
Membrane
The hemofiltration membrane consists of relatively straight channels of ever-increasing diameter that offer little resistance to fluid flow.
Hemodialysis membranes contain long,
tortuous inter-connecting channels that
result in high resistance to fluid flow.
Hemodialysis allows the removal of water
and solutes by diffusion across a
concentration gradient.
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Firm
ent
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Specificity in Obsteric
Anaesthesia
Anaesthesia in Cs
• General vs regional
• Mendelson’s sy
• General in emergent situations (bleeding, respiratory
insufficiency...)
• Regional
– When spinal
– When epidural
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Preanaesthetic evaluation & preparation
• Risk of Mendelson’s sy (aspiration)
– Antacids
• Obesity
• Trombsis, Prophylactic administration
• Lower CV syndromme
• Bleeding management (LTH)
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Steps in General anaesthesia
Caesarean Section
• IV anaesthesia
– Propofol vs Thiopental, doses
– Myorelaxants
– Opioids
• Inhalatory agents
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Technics in neuraxial
anaesthesia
• Spinal: Monitoring, positioning, volume preparation, choice of
spinal needle, administration of anaesthetic & opioid, dosage,
level of anaesthesia, analgesia.
• Epidural: Monitoring, positioning, conversion from PEDA or
primary, Tuohy needle (Gauge), ±catheter, administration of
anaesthetic & opioid, dosage, level of anaesthesia, analgesia.
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