1 / 29

Case Presentation 18/02/2009 Flip Cloete

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

margret
Download Presentation

Case Presentation 18/02/2009 Flip Cloete

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. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Case Presentation 18/02/2009 Flip Cloete

  2. 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

  3. 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

  4. GCS = 3 T (M2 decerebrate, E1, VT) No signs trauma or injury Examinations ???????

  5. 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

  6. 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 %

  7. ECG:

  8. CXR:

  9. Transfer for CT Brain - ? Trauma CT Brain = Normal Improved – extubated Alledges Overdose of “Blue” tablets Tox Screen: Paracetamol < 5 TCA - 34

  10. Recognised “Phenergan” (Promethazine) 25 mg tabs – took 25 tabs with alcohol. Referred to Psychiatry Discharged on Fluoxetine

  11. 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

  12. Diagnosis • History Type, time, volume, route Reason Prescription drugs • Physical Exam Stabilisation priority • Toxidrome Recognition of toxic syndrome • Diagnostic Tests

  13. Treatment Airway Breathing Circulation DON’T: (dextrose, oxygen, naloxone, thiamine) • Individualize patients

  14. Treatment Cont: • Decontamination • Skin & Eyes • GIT • activated charcoal • Enhanced Elimination • Extracorporeal

  15. Treatment cont: • Focused Therapy • Antidote • Get Toxicology Help

  16. 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

  17. Side Effects : • Drowsiness (>80%) • Dizziness, fatigue, inco-ordination • Seizures , hallucinations • GIT – Nausea, vomiting, epigastric pain • Anticholinergic: dry mouth, blurred vision, urinary retention

  18. 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

  19. Case 2: 10 Yr Girl Washing windows @ school Sitting on bench/ desk Clothes damaged Severe pain buttocks Unable to sit

  20. 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

  21. Reviewed 24 hrs: Wounds blistering Clean Pain improving Plan: Cont daily Flamazine dressings Analgesia

  22. 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.

  23. Management: • A,B,C,D • Exposure • undressed • Euthermic, tepid water for irrigation • Early External warming devices • Pain management • Morphine • Tetanus

  24. 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

  25. 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

  26. 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.

More Related