INTERNATIONAL TOXICOLOGICAL CONFERENCE DrPSampath Kumar Professor amp Police Surgeon Head of Department of Forensic Medicine amp Toxicology Sri Ramachandra Medical College amp RI Vice Principal Sri Ramachandra University ID: 424555
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4
TH
INTERNATIONAL
TOXICOLOGICAL CONFERENCESlide2Slide3
Dr.P.Sampath
Kumar
Professor & Police Surgeon
Head of Department of Forensic Medicine & ToxicologySri Ramachandra Medical College & RIVice Principal , Sri Ramachandra University, Chennai, India Slide4
PRINCIPLES OF MANAGEMENT IN A CASE OF MULTIDRUG OVERDOSESlide5
Alcohol interacts with a number of drugs thereby resulting in adverse health effects for the drinker.
Alteration can occur either in the metabolism or effects of alcohol and/or the medication.
Alcohol and drug interaction can be of two types Pharmacokinetic interaction Pharmacodynamic
interactionINTRODUCTION:Slide6
A
ntihypertensive drugs constitute leading form of cardiovascular drug overdose
Implicated in 48% deaths resulting from such overdoseMost common among these- Calcium channel blockers and Beta blockersTreating patients with such overdose can be a challenge for even experienced physiciansSlide7
College student- quarrels at home
Consumes ethyl alcohol
Comes home and takes 20-25 antihypertensive tabletsSlide8
Gets
up at midnight with
severe headacheTakes few tablets of aspirin for relief from
headacheStays awake for the next two hours after which he falls asleep againSlide9
Next day morning family leaves for a function leaving the boy at home
Boy
gets up , manages to reach the college
Friends find him drowsy and unable to walk Narrates the incident to themSlide10
Wheel him into the casualty
of a tertiary care hospital
Medical officer seeing him in a wheelchair delays attending to him, thinking its not an emergency
Collapses in the wheeler, on examining pulse feeble, BP not recordableSlide11
Intubated
– put on ventilator, I.V line secured and fluids
ionotropes started
Grave prognosis explained to the relativesOther investigations were conductedDespite the fluid management and ionotropes , his urine output was nil.Slide12
Intensivist
suggested to start ECMO
Shifted to MDCCU
After about half an hour , 15ml of urine is collectedAfter 3 days of ECMO, boy regains consciousnessSpecific antidotes were given in the MDCCUSlide13Slide14Slide15
However
he developed swelling and immobility of the leg in which catheter was placed
Investigations revealed- leg ischemia, that would have necessitated amputation
However appropriate management by a plastic surgeon in a rural centre saved the boy, his leg.Slide16Slide17Slide18Slide19
Alcohol & a number of medications interact with each other
resulting in potentially serious medical consequences
.Interactions alter A)the metabolism or activity of the medication
B)alcohol metabolism.DISCUSSIONSlide20
M
edications and alcohol compete in the body for absorption potency of the medication and/or alcohol is often increased/ decreased. No set formula
Each person is differentResults of this type of potentially fatal cocktail vary based on type and quantity of medication and alcohol ingested the time frame involved individual's tolerance (medication/alcohol) Slide21
Studies focus on the effects of chronic heavy drinking.
Relatively limited information available on medication interactions resulting from moderate alcohol consumptionSlide22Slide23
For these reasons it is difficult to treat even for an experienced physician
ALCOHOL AND CARDIAC DRUGSALCOHOL
ANTIHYPERTENSIVE
DRUGS
profound
hypotension
refractory
bradycardia
cardiogenic
or non cardiogenic pulmonary oedemaSlide24
ALCOHOL and PAIN KILLERS
increase stomach
irritation
impair thinking and motor skills lead to breathing problems.Slide25
Calcium
Therapy:
as calcium gluconate or calcium chlorideCalcium gluconate , 30 mL of 10% solution, can be administered IV over 10-15 minutes in adults
Glucagon Therapy :promotes calcium entry into cells via stimulation of a receptor that is considered to be separate from adrenergic receptorsAdminister glucagon 5-10 mg IV bolus up to 15 mg, followed by an infusionInsulin Therapy : Hyperglycaemia may occur in CCB toxicity, as calcium channel blockade inhibits insulin release. To counter act this Hyperinsulinemia- EuglycemiaTREATMENT OF CCB TOXICITYSlide26Slide27
Extracorporeal Membrane Oxygenation
Oxygen for the body when someone’s lungs and/or heart are not able to supply oxygen on their own
ECMO
VEINECMO
VEIN
ARTERY
DEOXYGENATED BLOOD
OXYGENATED BLOODSlide28Slide29
A known side effect of this therapy is
risk of low blood flow to the distal part of the limb in which catheter is placed
risk of causing clots However this wasn’t given a keen eye to by the treating physician in the MDCCU.Resulted in leg ischemiaSlide30
NEGLIGENCE????????Slide31
Carelessness on part of the physician
Inadequate staffing
Lack of proper communicationNot foreseeing the known complicationsImproper diagnostic techniquesLack of immediate treatmentInsensitivity to patients needs Incompetence of the physician – washing hands off
REASONS Slide32
Buckley N, Dawson AH,
Howarth
D, Whyte IM. Slow-release verapamil poisoning. Use of polyethylene glycol whole-bowel lavage and high-dose calcium. Med J Aust. 1993 Feb 1. 158(3):202-4. [Medline].Hung YM, Olson KR. Acute amlodipine overdose treated by high dose intravenous calcium in a patient with severe renal insufficiency.
Clin Toxicol (Phila). 2007. 45(3):301-3. [Medline].Haddad LM. Resuscitation after nifedipine overdose exclusively with intravenous calcium chloride. Am J Emerg Med. 1996 Oct. 14(6):602-3. [Medline].REFERENCES:Slide33
Levine M, Boyer EW,
Pozner
CN, Geib AJ, Thomsen T, Mick N, et al. Assessment of hyperglycemia after calcium channel blocker overdoses involving diltiazem or verapamil. Crit Care Med. 2007 Sep. 35(9):2071-5.[Medline].
Mycyk MB, Bryant SM. Is simple bedside glucose assessment prognostic in calcium channel blocker overdose?. Crit Care Med. 2007 Sep. 35(9):2216-7. [Medline].http://emedicine.medscape.com/article/2184611-treatment#d17