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Anaphylaxis and OD
God have mercy on us all
57
Medical
Undergraduate 4
03/14/2017

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Cards

Term
What is the IM dose of adrenaline? Where is the best place to administer it?
Definition
0.5mg IM = 500 mcg = 0.5ml of 1:1000

It should be repeated after 5 mins if there is no clinical improvement.
the best place to give it is the anterolateral aspect of the middle third of the thigh
Term
What signs suggest airway involvement in anaphylaxis?
Definition
itching of the palate or external auditory meatus
laryngeal oedema (stridor)
wheezing
bronchospasm
Term
what are anaphylactoid reactions?
Definition
These are not IgE mediated but they cause similar mast cell activation.
Term
Which Ig is involved in anaphylaxis?
Definition
IgE.
The allergen reacts with IgE on mast cells and basophilic triggering the release of histamine and formation of new mediators.
Term
Define anaphylaxis
Definition
A severe life threatening generalised or systemic hypersensitivity reaction.
It is a type 1 hypersensitivity reaction.
Term
What dose and route should we give chlorphenamine in anaphylaxis?
Definition
10mg IM or IV slowly

This is an antihistamine
Term
what dose and route of hydrocortisone should we give in anaphylaxis?
Definition
200mg IM or slow IV
Term
How can anaphylaxis be diagnosed in cases where there is ambiguity?
Definition
Measure serum mast-cell tryptase. Tryptase demonstrates mast cell degranulation.

they peak one hour after anaphylactic reaction and stay elevated for 6 hours
Term
What dose of adrenaline is contained in an adult self-use Epipen? Is this the same as in children's?
Definition
300mcg = 0.3ml in 1:1000

the children's pen has 0.3ml 1:2000 = 150mcg
Term
formulate a management plan for pt with life threatening allergy.
Definition
ID allergen so it can be avoided
Organise self use eli pen and demonstrate how to use it
Give a written self management plan and information about anaphylaxis, biphasic reactions and signs and symptoms of a possible severe reaction
Encourage the pt to wear a medical ID bracelet or something similar.
Term
DDx for respiratory depression in drug OD
Definition
opiataes
BDZ
Term
if someone presents with OD and are tachypnoeic what would you be thinking is the cause?
Definition
metabolic acidosis
e.g Salicylate poisoning or methanol
Term
if pt is tachycardic with irregular pulse in drug OD which drugs would you suspect are involved?
Definition
Salbutamol
antimuscarinics
TCA
quinine
phenothiazine
cardiac glycosides
amphetamines
theophylline poisoning.
Term
If pupils are dilated in OD which drugs would you be thinking?
Definition
amphetamines
TCA
anticholinergics
Term
Pin point pupils in drug OD
Definition
Opiates
cholinergics
Term
rx for opiate OD?
Definition

400mcg IV, no response after 1m?

800mcg IV, no response 1m?

Repeat 800mcg, no response?

2mg IVĀ 

review

Term
Causes of unreactive pupils in drug OD?
Which drug can cause strabismus in OD?
Definition
Barbiturates
CO
hydrogen sulphide

carbamazepine can cause strabismus if taken in excess
Term
Which drugs can cause hypoglycaemia? What rx would you give for this?
Definition
Insulin
PO hypoglycemic
alcohol
salicylates

rx: 50ml 50% dextrose IV
Term
Which drugs can cause hyperglycaemia in OD?
Definition
organophosphates
theophyllines
MAOI
salicylates.
Term
what medication can you give to calm seizures in OD?
Definition
Diazepam 5-10mg IV or
Midazolam 0.15mg/kg body weight
Term
in Paracetamol OD which enzyme rise is suggestive of severe liver damage?
Definition
peak ALT > 1000 IU/L
Term
Ingesting how many grams of paracetamol is potentially fatal?
Definition
12g.

<150mg/kg body weight is unlikely to be toxic but
> 250 mg/kg body weight is likely to be toxic
Term
Paracetamol is inactivated by the liver by conjugation. What are the 2 main metabolites?
Definition
Glucuronide
Sulfate

it is then renal extorted via urine
Term
name the toxic metabolite produced in paracetamol OD
Definition
N-acetyl-p-benzoquinone imine (NAPQI)

this is usually inactivated by glutathione but in OD glutathione reserves are depleted to less than ~30% allowing NAPQI to react with nucleophilic aspects of the cell. this causes necrosis in the liver and kidney tubules.
Term
if someone has HIV, (alcoholic) liver disease, CF or is malnutrition what happens to their glutathione reserve levels?
Definition
They decrease.
Term
clinical features of paracetamol OD
Definition
RUQ pain
Jaundice
encephalopathy
oliguria
hypoglycemia
renal failure - develops on day 3
lactic acidosis
Term
what is the significance of asking the pt whether they took alcohol with their paracetamol OD?
Definition
Acute alcohol ingestion will inhibit liver enzymes. This may reduce the production of the toxin NAPQI.

in contrast chronic alcoholism may increase it
Term
What should you ix in paracetamol OD?
Definition
ALT - if it is > 1000 iu/l suggest hepatotoxicity
glucose - hypoglycemia due to liver necrosis
clotting - prothrombin. INR 12 hourly
U and E - look for renal failure
ABG - acidosis
Term
what is the criteria for receiving acetylcysteine in pts who's OD are being timed?
Definition
if the plotted plasma level is on or above the line between 100mg/L at 4hrs and 15mg/L at 15 hours post ingestion
Term
how is acetylcysteine administered?
Definition
initial dose given as infusion over 60 mins.
full rx course consists of 3 doses given consecutively without any breaks. This usually takes 24 hours
Term
what is the King's college Hospital criteria for liver transplant in paracetamol induced ALF?
Definition
you should list pt for transplant if:
Arterial PH <7.3 or lactate >3 after adequate fluid resus OR
if all the following 3 occur in a 24 hour period
1. creatinine > 300
2. PT >100seconds (INR >6.5)
3. Grade III/IV encephalopathy

strongly consider transplant is lactate >3.5 after early fluid resus
Term
in salicylate OD what amount can children/adults ingest and not be admitted if they do not have symptoms?
Definition
< 125mg/kg

ingestion of >250mg/kg likely to cause moderate toxicity
ingestion of >500mg/kg causes severe and possibly fatal consequences.
Term
S and S of mild salicylate poisoning
Definition
Nausea
vomiting
tinnitus
lethargy
dizziness
Term
s and s of severe salicylate poisoning
Definition
dehydration
restlessness
sweating
warm extremities, bounding pulse
increase RR, hyperventilation
deafness

there is disturbance in acid base balance.
hyper/hypo or normoglycemia may be evident.
Term
ix in salicylates OD
Definition
renal fx
FBC
coagulation
urinary pH
blood glucose
plasma potassium check every 3 hours
ABG - mixed respiratory alkalosis and metabolic acidosis with normal or high arterial pH.
Term
describe the ingestion amounts and likely toxicity that can result in salicylate OD
Definition
> 125 mg/kg - mild toxicity
>250 mg/kg - moderate
>500mg/kg - severe possibly fatal
Term
describe the clinical grading of salicylate toxicity e.g. mild moderate and severe
Definition
Mild - tinnitus, nausea, vomiting
moderate - hyperventilation, confusion
severe - hallucinations, seizures, coma cerebral/pulmonary oedema
Term
mx for salicylate OD
Definition
activated charcoal i if presentation <1 hour
gastric lavage if >500mg/kg within 1 hour
agressive rehydration and glucose
urinary alkalisation
sodium bicarbonate if levels are still >500mg/L. correct hypokalemia before giving bicarb.
Hemodyalisis.
Term
when should we consider hemodyalisis in salicylate poisoning?
Definition
levels >700mg/L
AKI
CCF
coma
convulsions
severe metabolic acidosis < 7.2
Term
list some acute opioid withdrawal symptoms
Definition
sweating
watery eyes
runny nose
yawning
hot and cold
anorexia and stomach cramps
nausea, vomiting, diarrhoea, tremor
dilated pupils
goosebumps
increased bowel sounds
coughing
tachycardia
htn
Term
if someone presents with OD and smelling garlic like, what would you assume they had ingested?
Definition
organophosphates.

organophosphates causes small pin point pupils like opiates.
Term
mx for organophosphate poisoning
Definition
activate charcoal if within 2 hours
atropine to reduce secretions and give until hr is at 80-90 bpm
Pralidoxime may be given with atropine
diazepam 5-10 mg IV
Term
what is Pralidoxime?
Definition
Belongs to family of oxides. it binds to organosphosphate inactivated acetylcholinesterase and is used to combat poisoning by organophosphates. it is given in conjunction with atropine and diazepam.
Term
what would you see in the blood film of lead and arsenic poisoning?
Definition
Basophilic stippling.

in lead poisoning you may also get normochromic or microcytic anaemia.
Term
How would you manage mercury poisoning?
Definition
inhaled mercury should be rx with IV hydrocortisone to minimise pulmonary complications
acute intake of inorganic mercury should be treated with chelating agents such as d-penicillamine.
Term
mx for iron poisoning?
Definition
IV desferrioxamine is the antidote
Term
what to give in methanol OD?
Definition
ethanol
Term
rx for BDZ OD?
Definition
Flumenazil
Term
amitryptiline OD? what is the rx?
Definition
sodium bicarbonate
Term
rx for beta blocker OD?
Definition
glucagon
Term
rx for Bupivicaine OD?
Definition
intralipid
Term
rx for cyanide poisoning?
Definition
hydroxycobalamin/Nitrites (inhales)
Term
rx for Digoxin OD?
Definition
Digoxin antibodies
Term
Heparin OD rx
Definition
Protamine
Term
Metheamoglobin poisoning rx?
Definition
Methylene blue
Term
sulfonyurea OD rx?
Definition
octreotide
Term
verapamil OD rx?
Definition
calcium
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