Overdose

Case based review: Toxicology on the Acute Medical Unit

Accidental and intentional poisoning from prescribed, illicit and organic substances remains a major cause of morbidity and mortality worldwide and accounts for just under 1% of the total number of NHS hospital admissions, or around 170,000, a year in the UK. A knowledge of the constellation of signs and symptoms that constitute specific poisonings (referred to as toxidromes) may enable early empirical decontamination, antidote administration, enhanced elimination and supportive care, and may also help to predict the clinical course. This paper presents a series of clinical vignettes to demonstrate emerging presentations in toxicology to help inform the practice of Acute Physicians, who alongside colleagues in Emergency Medicine and Critical Care, are at the front line of diagnosing and treating poisoned patients.

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Cardiac arrest following paracetamol overdose complicated by hypokalaemia

Abstract

We present a case of paracetamol overdose in a 34-year-old female with a history of depression and alcoholism. Following treatment with N-acetylcysteine (Parvolex®) our patient developed ventricular tachycardia resulting in cardiac arrest from which she was successfully resuscitated. Subsequent ECG demonstrated prolongation of the QTc interval and repeat blood tests revealed a significant fall in serum potassium from 4.2mmol/l on admission to 2.2mmol/l. The possible mechanisms contributing to the development of hypokalaemia after overdose with paracetamol are discussed. The existing literature relating to paracetamol-induced hypokalaemia is briefly reviewed.

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A review of the clinical and legal issues surrounding refusal of treatment following overdose

Abstract

This article reviews the clinical and legal issues involved in dealing with patients who refuse medical treatment following an overdose. We first describe a real case that has been made anonymous, before discussing a general approach to management.

We then review the relevant legislation, including the Mental Capacity Act (2005), the Mental Health Act (1983) and legal issues surrounding the treatment of young people. We discuss how this legislation may be applied in practice and then conclude with the outcome of the case, sources of further information and some key learning points.

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The Perils Of Grandma’s Medication: Colchicine Toxicity causing Pneumomediastinum.

Abstract

A 19 year old male presented with a deliberate overdose of colchicine (50mg). He had no other significant medical history. 36 hours following admission he developed widespread surgical emphysema. An urgent CT scan of his chest and abdomen demonstrated mediastinal gas of lung origin. He also developed bone marrow suppression and disseminated intravascular coagulopathy. He was treated supportively with intravenous fluids, high flow oxygen and intravenous antibiotics and made a full recovery.

Colchicine toxicity is a rare, but important presentation with high levels of morbidity and mortality. Pneumomediastinum is a potentially important complication. It may be appropriate to monitor patients in the later stages of the condition through an ambulatory setting.

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Problem Based Review: The patient who has taken an overdose of long-acting insulin analogue

Insulin overdose can cause harm due to hypoglycaemia, effects on electrolytes and acute hepatic injury. The established long-acting insulin analogue preparations (detemir and glargine) can present specific management problems because, in overdose, their effects are extremely prolonged, often lasting 48-96 hours. The primary treatment is continuous intravenous 10% or 20% glucose infusion with frequent capillary blood glucose monitoring. Surgical excision of the insulin injection site has been used successfully, even days after the overdose occurred. Once the effects of overdose have receded, diabetes treatment must be restarted with care, especially in patients with type 1 diabetes. Monitoring serum insulin concentration has been successfully used to predict when the effects of the overdose will cease.

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Tricyclic Antidepressant Overdose causing Acute Respiratory Distress Syndrome

Abstract

We report two recent cases of tricyclic antidepressant (TCA) overdose complicated by the development of acute respiratory distress syndrome (ARDS). The previous literature documenting an association between TCAs and ARDS is reviewed. We propose that the respiratory complications of TCA overdose should be more widely publicised and included in national toxicology databases.

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Poisoning And Toxicological Emergencies – Current Trends And Practice

Abstract

Poisoning is a common presentation to hospital acute medical units, and can produce a variety of clinical scenarios. This review discusses the epidemiology of poisoning, a framework for managing patients with drug toxicity and considerations in the diagnosis of toxicity with unknown substances. The commonest substances seen in toxicity in the UK – paracetamol, antidepressants, sedatives and opioids are discussed in more detail.

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Tuberulous Meningitis masked by Temazepam Overdose

A 47 year old Chinese businessman was found unconscious at home following an overdose of 280 mg temazepam. He was found by his sister who had visited because he had not returned her telephone calls for several weeks. He had been resident in England for 8 years but returned to Hong Kong frequently. Since his last visit to Hong Kong, 4 months previously, his mood had been low and he had developed anorexia, weight loss and insomnia. Physical examination and routine investigations were unremarkable and a diagnosis of depression was made. Citalopram 10 mg daily and temazepam 10 mg daily had been prescribed one day prior to admission.

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