slide1 l.
Download
Skip this Video
Download Presentation
Case Presentation 18/02/2009 Flip Cloete

Loading in 2 Seconds...

play fullscreen
1 / 29

Case Presentation 18/02/2009 Flip Cloete - PowerPoint PPT Presentation


  • 145 Views
  • Uploaded on

Case Presentation 18/02/2009 Flip Cloete. Case 1: 50 Yr Female History: ? Overdose Found in Bed GCS 10/15 En Route: GCS 7/15 Intubated 7 ETT Nil drugs Husband intoxicated No further history . 1 Survey: Intubated on ventilator BP: 194/116 P: 127

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Case Presentation 18/02/2009 Flip Cloete' - margret


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1
Case Presentation

18/02/2009

Flip Cloete

slide2
Case 1:

50 Yr Female

History: ? Overdose

Found in Bed

GCS 10/15

En Route: GCS 7/15

Intubated 7 ETT

Nil drugs

Husband intoxicated

No further history

slide3
1 Survey:

Intubated on ventilator

BP: 194/116 P: 127

HGT: 5,2 mmol/l T: 35,5 C

SaO2: 100% FiO2 0.40

Pupils R = 3 mm

L = 5 mm

Bilateral sluggish

slide4
GCS = 3 T (M2 decerebrate, E1, VT)

No signs trauma or injury

Examinations ???????

slide5
Bloods:

Na: 145 mmol/l

K: 4,0

Cl: 106

Urea: 3,0

Creat: 48

WCC : 7,07

HB: 12,6

Plts: 319

GGT: 50

slide6
ABG: FiO2 0,60

pH: 7,325

PaO2: 39,5 Kpa

PaCO2: 5,88

HCO3: 23,0 mmol/l

BE: -3,3

SaO2: 99,9 %

slide9
Transfer for CT Brain - ? Trauma

CT Brain = Normal

Improved – extubated

Alledges Overdose of “Blue” tablets

Tox Screen: Paracetamol < 5

TCA - 34

slide10
Recognised

“Phenergan” (Promethazine) 25 mg tabs – took 25 tabs with alcohol.

Referred to Psychiatry

Discharged on Fluoxetine

slide11
Approach to unknown overdose:

Poisoned Patient

TreatmentDiagnosis

Airway History

Breathing Physical Exam

Circulation Toxidrome

DON’T: Diagnostic Tests

(dextrose, oxygen,

naloxone, thiamine)

Decontamination

Enhanced Elimination

Focused Therapy

Get Tox Help

slide12
Diagnosis
  • History

Type, time, volume, route

Reason

Prescription drugs

  • Physical Exam

Stabilisation priority

  • Toxidrome

Recognition of toxic syndrome

  • Diagnostic Tests
slide13
Treatment

Airway

Breathing

Circulation

DON’T:

(dextrose, oxygen, naloxone, thiamine)

  • Individualize patients
slide14
Treatment Cont:
  • Decontamination
    • Skin & Eyes
    • GIT
      • activated charcoal
  • Enhanced Elimination
    • Extracorporeal
slide15
Treatment cont:
  • Focused Therapy
    • Antidote
  • Get Toxicology Help
slide16
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

slide17
Side Effects :
  • Drowsiness (>80%)
  • Dizziness, fatigue, inco-ordination
  • Seizures , hallucinations
  • GIT – Nausea, vomiting, epigastric pain
  • Anticholinergic: dry mouth, blurred vision, urinary retention
slide18
Management phenothiazine OD:
  • Advanced life support
  • Charcoal in 1-2 hrs
  • ECG, Acid-base, elecs
  • IV Fluid – BP
  • No role dialysis/ haemoperfusion
  • Acute dystonia

Rx: diazepam/ anti-cholinergics (Akineton)

7. Weak cross reaction with TCA lab assay

slide19
Case 2:

10 Yr Girl

Washing windows @ school

Sitting on bench/ desk

Clothes damaged

Severe pain buttocks

Unable to sit

slide21
Science Lab – Teacher sent note

? Nitric Acid / ? HCL

Examination:

Partial thickness burns to buttocks

Left 8 x 12 cm with surrounding erythema

Right 4 x 5 cm

No Anal / Genital involvement

Bear Weight, unable to sit

slide22
Reviewed 24 hrs:

Wounds blistering

Clean

Pain improving

Plan: Cont daily Flamazine dressings

Analgesia

slide23
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.
slide26
Management:
  • A,B,C,D
  • Exposure
    • undressed
    • Euthermic, tepid water for irrigation
    • Early External warming devices
  • Pain management
    • Morphine
  • Tetanus
slide27
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
slide28
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
slide29
Bibliography:
  • Erickson TB, Thompson TM, Lu JJ. The Approach to the Patient with an Unknown Overdose. Emerg Med Clin N Am 25 (2007) 249–281.
  • Demling RH, DeSanti L, Orgill DP. Chemical Burns.Available from: Http://www.burnsergery.org/Modules/initial/part-two/sec6.htm.
  • 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
  • McNeil BK, Jaslow D. Chemical burns. eMedicinehealth, Web MD 2009. Available from: http://www.emedicinehealth.com/chemical-burns/article-em.htm.
  • Gibbon CJ et al, Division clinical pharmacology UCT. SAMF. 8th Edition. Cape Town: FA Print; 2008.