Tox overview & cicm questions

• 14 year old girl took 50 capsules of Diltiazem 90mg SR with half a bottle of vodka 3 hours ago

• Previous self harm attempts

• GCS 13, HR 48, BP 88/50, SpO2 95

Case

• R - Risk assessment & Resuscitation

• S - Signs & Symptoms

• I - Investigations

• D - Decontaminatin

• E - Enhanced elimination

• A - Antidote

• D - Disposition

Approach to the poisoned patient

Risk

Assessment

Resus

Decontamination

NO

Gastric lavage

Decontamination

NO

Activated charcoal

Decontamination

MAYBE

Enhanced Elimination

MAYBE

Enhanced Elimination

•Urea•Metformin• Salicylates• Theophylline (CHP)• Alcohols• Barbituates (HP)• Lithium• Epilepsy drugs –

valproate/carbemazepine (HP/CHP)

Expected deterioration• Patient now intubated Sats 99% on

40%FiO2

• HR42 with 2nd degree AV block

• Invasive BP 70/40 with double strength Norad 20ml/hr. Vasopressin 12ml/hr

• She is cold and shut down U/O 10ml/hr

• What next?

Noradrenaline dose in shock from Calcium Antigonists up to 100mcg/min

Antidotes

Antidotes

IntralipidiAntidotes

Antidotes

Disposition

• A two-year-old boy is suspected of ingesting iron tablets.

• a) List the clinical features, and the underlying pathophysiology, of iron poisoning.(GI/Shock/Kid&Liv/Acidosis)

• b) Briefly outline your management of this child. (RSIDEAD) (20-120mg/kg)

• b) Briefly outline your management of this child.

• A 45-year-old man is admitted to the Emergency Department after ingesting an unknown quantity of “headache tablets”. His initial complaints are nausea, vomiting, shortness of breath and tinnitus. Fluid resuscitation has been commenced. You are asked to assess him as he is getting more dyspnoeic.

• -Describe the acid-base status -What are 4 severe complications of this toxidrome? -What coagulopathy may be present in this toxidrome and what is the treatment? -What are the treatment options for severe toxicity, and what is their rationale?

• A 25-year-old man presents to the Emergency Department following suspected snake bite. He has an effective pressure-immobilisation bandage in situ.

A. List appropriate initial investigations specific to this presentation that should be performed in conjunction with clinical assessment

B. List indications for the use of polyvalent antivenom in snake envenomation.

C. Briefly discuss the role of pharmacological pretreatment prior to the administration of snake antivenom?

D. List 3 parameters that would help you determine that adequate monovalent antivenom has been administered to a patient with snake bite envenomation.

• A 16 year old female is admitted to the ICU following a multiple drug overdose.

• a) Outline the role of activated charcoal in the management of drug overdose. (MDAC -

• b) What are the complications of activated charcoal therapy?

• c) When is dialysis utilised in toxic syndromes?

• d) In the context of an overdose, list 3 drugs for which charcoal haemoperfusion may be useful.

• List and antidote (one drug specific to the agent) in the event of an overdose with each of the agents listed below in the table.

• Benzodiazepine/ Bupivacaine

• Cyanide

• Digoxin

• Ethylene glycol/ Isoniazid

• Methanol/ Methaemaglobinaemia/ Organophosphates/ Opioids/ Lead/ Valproate

• Briefly outline the mechanism of effectiveness of sodium bicarbonate in the management of tricyclic antidepressant overdose.

• With reference to intoxications, list the relevant physical features of hemodialysis and hemoperfusion filters which make them suitable for use and give one example of a toxin cleared by each of these

• List 3 drugs or poisons that, when taken as an overdose, result in both a raised osmolar gap and anion gap. List the major anion associated with each drug responsible for the rise in anion gap.

• With references to intoxications, what do you understand by the term "oxygen saturation gap”