Qns :
Mrs Lim, 29y, is admitted for drug overdose. She mentioned that she has taken 60 tabs Paracetamol 1hr ago, after a quarrel with her husband. She is under considerable stress as she has recently lost her job and the family is in financial dificulties. Her husband has been unemployed for 6 months. Mrs Lim has no history of psychologicla illnesses, suicidal tendencies or any medical illness.
On examination,
- She appears fearful and anxious
- Cognitive status - conscious and normal
- VS - BP : 100/65mmhg, HR : 100/min, RR : 25/min
- c/o nausea and abdominal cramps
- Vomitted 200ml of whitish fluids
Discuss the emergency management for Mrs Lim. Give rationales for the management taken.
* Note : Mrs Lim's VS is indicative of shock
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(A) Assessment
(i) Triage Priority
- Based on given scenario, vital signs, other factors (eg. age, GCS) -> Cat 2
(ii) VS + SpO2 + GCS + I&O + Physical examination
- To determine current condition for baseline comparison
- Highlight possible deterioration (Eg. renal failure, respi distress)
- Observe for subsequent vomitting
(iii) Reason for Admission
- Poisoning -> intentional, suicide
- To ensure police report is made
- To handle specimens obtained as per hospital protocol (intact police seal)
- To inform next of kin on whereabouts of individual
(iv) Severity of Poisoning
1. Drug - Amount and type. Also note TIME consumed
2. Route of Poisoning - Oral/ingestion
3. Host Susceptibility - Body weight, extent of distribution/ absorption
(v) Medical History & Medication
- Underlying medical conditions? (past and current)
- Drug/Food Allergy
- Addiction?
- Psychosis?
- Identifies factors that may worsen condition
(B) Investigations
(i) Blood Tests
- Blood for toxicolgy, Biochem studies for drug levels
- FBC, PR/PTT, LFT, GXM, U/E/Creat, Glucose, ABG
(ii) ECG
- Assess cardiac rhythm and function
(iii) CXR
(iv) Urinalysis
(v) Vomitus for toxicology/drug analysis
- Ensure intact police seal and proper despatch protocol
(c) Interventions
1. Principles of Poison Management
(i) Maintain Vital Function (ABC) + I/V Access
(ii) Clinical Evaluation
(iii) Decontamination
(iv) Neutralize Poison
(v) Enhance Elimination
(vi) Prevent Re-exposure
(i) Maintain Vital Function (ABC) + I/V Access
a. Remove from contaminated source if possible
b. Establish ABC
c. Oro-airway + O2
- Via non re-breather mask
- To flush out inhalants
d. Continous monitoring of VS + SpO2 + GCS + I&O
(ii) Clinical Evaluation
- Clear history of individual's medical condition, medication, allergies etc
- Type of poison? Mode of exposure? Time of ingestion? Specimen of poison?
- Symptoms the individual manifests (eg. drowsiness, ab cramps)
- Identification of psychosocial problems?
- Evidence of abuse?
(iii) Decontaminate
a. Topical Decontamination
- Remove from source
- Brush excess powder off skin, taking care not to break skin
- Remove contaminated clothing + others
- Flush with plenty of H2O
- Save H2O for proper disposal + testing
b. GI Decontamination
(1) Dilution (H2O)
- Aim : To decrease gastric irritation
- Child 100-200ml, Adult 200-400ml
Contraindications :
- Capsules, Tablets
- Drowsy, Coma, Seizures
- Absence of gag reflex
- Corrosive substances
Rationale : Increase risk of aspiration
(2) Emesis
- Only done when the substance is suspected to still be in the stomach (eg. under 4hrs post ingestion)
- Done when a potentially toxic dose is ingested
- Done via pharnygeal stimulation/ medication
Contraindications:
- Drowsy, coma, seizures
- No gag reflex
- Under 6months old
- Corrosives
(3) Gastric Lavage
- Indications : 1-6hr post ingestion
- Up to 12hrs for salicylates, barbiturates, carbamazepines, tricylic antidepressants
- Precaution - To insert CUFFED ETT prior to commencement to prevent aspiration (esp for comatose)
Procedure :
- Left lateral position
- Insert appropriate sized NGT
- Aspirate contents til clear (and send for investigation with police seal)
- Intro 250ml h2O (adults)
- Wait 2min
- Aspirate contents
- Repeat till clear
Contraindications :
- Parraffin + Corrosive solutions, as NGT may perforate esophagus
(4) Oral Adsorbents - Activated Charcoal
- Aim : To reduce poison absorption
- Given post gastric lavage/induced emesis
- Adult : initial dose 50-100g , subsequently, 15-20g 4-8hrly x24hr (PO/NGT)
- Most effective within 1hr of poisoning (up to 12hrs for salicylate or tricyclic antidepressants)
- Indications : Paracet, Aspirin, Phenytoin, Phenobarbitones, Theophylline, Digoxin
Contraindications :
Methanol, ethanol, corrosives, heavy metal, Antidotes
(5) Catharsis
- Aim : Induce diarrhea to hasten elimination of poison from GIT (although there is controversy over efficacy)
- Currently used to neutralize constipating effects of activated charcoal
- Indications : Paraquat, Salicylates, Iron, Digoxin
- Agents used : Mg Sulfate, Na Sulphate, Sorbitol
- Precautions : F&E must be replaced as diarrhea -> low K/Na
Contraindications :
Paralytic ileus, Corrosives
(iv) Neutralize Poison - Antidotes
- Paracetamol -> N-acetylcysteine (NAC), Methionine
- Opiates (ie. Morphine, Pethidine) -> Naloxone, Narlophine
- Organophosphates -> Atropine, Pralidoxime
- Benzodiazapines (ie. Diazapam) -> Flumazenil
- Anticholinergics (ie. Atropine) -> Physostigmine
(v) Enhance Elimination
(1) Forced Diuresis
- Aim : Increase excretion of poisons
- With or without manipulation of urine pH
Indications : Aspirin + other salicylates, Phenobarbitone
- 1 cycle = 3 x 500ml infusion in following order
- At rate of 500ml/hr
- 500ml D5% + NaCHO3 8.4% (alkaline)
- 500ml D5% + 30ml KCL 7.45%
- 500ml N/S
- Number of cycles are dependent on the amount of poison in the blood
- I/V Frusemide 20mg at the end of each cycle
Nurse's Responsilibilties
- To monitor VS + GCS + CVP + output (insert IDC)
- Test urine for pH (expected to be alkaline due to bicarb infusion)
- Observe for complications : Eg. Fluid retention, electrolyte imbalance, cerebral/pulmonary edema
(2) Dialysis
- Aim : To remove high levels of poison in the bloodstream
- Types :
- Haemodialysis
Indications - Renal Failure, Barbiturates, Lithium, Ethylene Glycol, Methyl Alcohol, Salicylates - Charcoal Haemoperfusion
Indications - Paraquat, Digoxin, Phenobaritone, Tricyclic Antidepressants, Theophylline
- Indications : For severe clinical intoxication, grade 4 coma, hypotension, hyper/hypothermia
(vi) Evaluation
(1) Effectiveness of intervention
- Stability of VS + GCS + SpO2
(2) Handling of specimens under appropriate protocol
- Intact police seal
(3) Prevent re-exposure
- Through education, counselling, referral to Psy to address underlying emotional issues
(4) Provide Psychogical Support + Suicide Precaution (Safety)
- Overt and Covert monitoring
- Suicide Chart
- Notify all staff of status
- Observe for signs of depression
- Medication to be taken in STAT in presence of nurse
- No isolation
(5) Accurate Documentation
- Medical legal issues
(6) Apply for transfer to ward/ICU as appropriate
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Please note that the answers provided are written with the help of open lecture notes. I have compiled most of the interventions, and management typically goes beyond the given scenario.
This was done as a revision booster for me and all those who are stuck wandering online. I hope i have been of some help. Cheers to all those who have unselfishly shared their slides =)
