case presentation 18/02/2009 flip cloete. case 1: 50 yr female history:? overdose found in bed gcs...
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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
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
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.
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