4 TH - PowerPoint Presentation

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TH

INTERNATIONAL

TOXICOLOGICAL CONFERENCESlide2
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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 MDCCUSlide13
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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.Slide16
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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 consumptionSlide22
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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 TOXICITYSlide26
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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 BLOODSlide28
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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