RCP Wales Physicians at the Cutting Edge

It’s a Drugs Life

Dr Nerys Conway @drnezcon

Consultant in Acute Medicine Royal Glamorgan Hospital, Cwm Taf University Health Board This talk contains…

• A bit about drugs • A pretty plant • A little bit of nasty • A few learning points "All things are poisonous and nothing is without poison; only the dose makes a thing not poisonous." Poisoning…..

• 100,000 hospital admissions/ year

• 10% of medical admissions

• 4,000 deaths per annum from poisoning Toxicology Clerking

• What have they taken? • When did they take it? • With what? • Occupation • Concerning factors

• Followed by a thorough examination Lets start with something simple…. Number of admissions Encephalopathy

Nausea and Vomiting

Right upper abdominal pain

Renal Failure Management

• If staggered or ingestion time uncertain IV NAC • Otherwise follow treatment line • Is the patient obese? 110kg is maximum weight (mg/kg) • Reactions to IV NAC usually mean paracetamol levels are low or absent The future of paracetamol poisoning

• Aladote (Calmangafodipir) Study in Scotland • New biomarkers - MIR-122 and HMGB1

Identifies those that will get injury Prognosis despite NAC • Using a combination of the new biomarkers could individualise IV NAC regimes Paracetamol and Pregnancy

• Fetus can metabolise paracetamol from approximately 18 weeks

• DO NOT HOLD IV NAC

• IV NAC dose use the patients current weight

Treat the pregnant patient the same as the non pregnant patient Refer to hepatology

 Arterial pH <7.3  Grade III or IV Hepatic encephalopathy  Creatinine > 300 micromol/L  Prothrombin time > 100 sec  Lactate > 3.5 mmol/L on admission (or > 3.0 mmol/L 24 hours post-paracetamol ingestion or after fluid resuscitation) What is this? Which Royal College has an Opium Poppy on their coat of arms? What you might come across..

• Codeine • • Fentanyl • • Hydromorphine •

Many different forms! On the take…THINK

• Unconscious patient • Unconscious patient • Unconscious patient

• The elderly unwell unconscious patient! Reduced GCS

Pinpoint Pupils

Low RR Look for patches (everywhere!)

Check for track marks, signs of abscess, skin infection and endocarditis Management

• Naloxone infusion Use 60% of the initial dose required for resuscitation per hour • Do not hold naloxone in pregnancy • Check those drug charts at the “unconscious patient” 2222 • IVDU check for blood borne viruses

Causes

• SSRIs • MAOIs • • Anxiety Restlessness

Delirium

Hyperpyrexia Hypertension

Sweating

Diarrhoea

Tachycardia

Hypereflexia

Myoclonus Rigidity Management

• Supportive • Don’t forget to check Creatine Kinase • Cool the patient • Muscular hyperactivity Dantrolene • Agitation • If severe SS consider or • alkalinisation • If severe AKI/ high K+ consider haemofiltration What is this?

• Very large volume of distribution • Dosulepin is very effective but incredibly lethal • Produce some great ECGs……

Seizure Coma Confusion

Drowzy Dry mouth

Hot dry skin Dilated pupils

Ataxia

Myoclonus Management

• For hypotension IV fluids • Terminate seizures Benzodiazepines • Prolonged QRS, cardiac arrthymias, acidosis or persistent hypotension (50mls 8.4% through CVP line) • Haemodialysis is ineffective • CPR should continue for at least 1 hour Nerve agents

• Novichok used in Salisbury • G series and V Series (Sarin in Syria) • Acetylcholinesterase inhibitor • Leads to a cholinegic crisis Constricted Pupils Foaming of the mouth

Vomiting

Bradycardia

Sweating

Urination

Diarrhoea Management

• Discuss with NPIS without delay! • • Pradlidoxime/ Obidoxime • Persistently hypotensive Noradrenaline • Critical Care

In such situations think toxidromes What plant is this? More likely to see…

Generally unwell /non specifically unwell elderly patient

Ask yourself - Are they on digoxin? - Is someone at home on digoxin?

Xanthopsia (yellow vision) Headache

Hallucinations

Nausea and Vomiting

Diarrhoea Management

• Hyperkalaemia is a feature of severe poisoning Digibind (Digoxin-specific antibody) - Cardiac arrthymias - Severe hyperkalaemia Beta-Blockers

• • • • • (long QRS) • (long QT) Management

• Give Atropine • If persistently hypotensive give Glucagon • IV Insulin has been shown to improve myocardial contractility and systemic perfusion • Fluid resus with crystalloid • Lipid Emulsion if still cardiotoxic What has the patient taken?

Conway N et al BMJ Case Rep. 2012 Oct 19;2012 An Unusual Abdominal X-Ray Mercury Poisoning

• Ingestion, inhalation, skin lightening products! • Acute or Chronic • Occupational • Mercury poisoning may have a delayed sequelae

Management is generally supportive Mephedrone

• Twice as common in Wales • Top hot spots - Llanelli - Swansea - Bridgend • Mephedrone taster avaliable for as little as 20p in Swansea Mephedrone

Features include; - Tachycardia - Convulsions - Anxiety - Sweating - Chemical Smell - Urinary retention* - Hypertension - Dilated Pupils - May get Syndome

Supportive Management (Benzos, Fluids)

* Conway N et al, BMJ Case Rep 2013 Feb 21;2013 Urinary retention Secondary to Mephedrone Don’t get caught out!

• Always check paracetamol levels

• Don’t forget a good clerking and thorough examination

• Elderly patients presenting with delirium/generally unwell

• Don’t be nervous of the pregnant patient

• Most poisoning requires supportive management

• Prolonged CPR in poisoned patients

• Consider blood bourne virus screening in high risk patients