1 Rural Matters 2016: Post Prandial PresentationHaran Sathianathan 25th November 2016

2 Rural Matters 2016: The poisoned patientHaran Sathianathan 25th November 2016

3 The Plan … Definitions Context / Background Principles of managementStabilisation / Resuscitation Reduce Absorption Enhance Elimination Supportive Care [Toxidromes] [Antidotes] [Case Study] Resources

4 Definitions “All things are poison and nothing is without poison; only the dose makes a thing not a poison.” -- Paracelsus Image credit - Touchstone Pictures

5 Definitions POISON = a substance that is harmful if ingested, inhaled, injected, or absorbed through the skin TOXIN = a poison that is produced by living organisms VENOM = a toxin that is injected by living organisms TOXICOLOGY = Study of Poisons TOXINOLOGY = Study of Toxins (Usually venoms) [Credit Unknown]

6 Definitions POISON = a harmful substanceTOXIN = a poison that is produced by living organisms VENOM = a toxin that is injected by living organisms TOXICOLOGY = Study of Poisons TOXINOLOGY = Study of Toxins (Usually venoms) [Credit Unknown]

7 Background Poisoning / overdose / intoxication at LRH (01-06/2016):LRH ED Presentations = 153 (1% of total presentations) LRH ICU Admissions = 21 13.7% of ED presentations 8% of non-elective ICU admissions

8 Background Poisoning / overdose / intoxication at LRH (01-06/2016):LRH ED Presentations = 153 (1% of total presentations) 254, if you include alcohol intoxication (1.5% of total presentations) LRH ICU Admissions = 21 13.7% of ED presentations 8% of non-elective ICU admissions [Please don’t tell Sasha!]

9 Background Poisoning / overdose / intoxication in Victoria (01-12/2015): Victorian Poisons Information Centre (a.k.a. Poisons Hotline) : VPIC = calls (i.e., 107/day!) VPIC toxicologist or registrar = 496 calls [Calls from medical staff = 3976 (13%)]

10 Background Poisoning / overdose / intoxication in U.K.:Poisoning accounts for 10% of all acute medical admissions In-hospital mortality = 1% Total amount continues to 4-5%/year Two-thirds of deaths do not reach hospital 11.2% of survivors represent within 12 months

11 Background Accidental poisoning: Peak incidence = 2 yearsBoys > Girls 80% of poisonings occur in own home 20% analgesics 40% other medications 40% other chemicals Most deaths due to carbon monoxide poisoning

12 Background Deliberate self-poisoning:Attempted poisoning: Women > Men (But gap is reducing) Successful poisoning: Men > Women (But gap is reducing) 1st (or 2nd) most common cause of suicide in women (40% in age > 15) 4th (of 3rd) most common cause of suicide in men (after gassing, hanging, and firearms) Image credit - Touchstone Television ( ) and ABC Studios (2007-)

13 Background Iatrogenic poisoning:Medication errors occur in 5% of all admissions [Credit Unknown]

14 Image credit - Universal TelevisionBackground Homicidal poisoning: Only on TV! Image credit - Universal Television

15 Background Top Ten (VPIC) Paracetamol 2113 Benzodiazepines 1231Ibuprofen SSRI antidepressants Topical antiseptics, hand-sanitisers, etc Bleach (hypochlorite based) 640 Quetiapine Paracetamol/narcotic combination analgesic 587 Silica gel Toilet bowl cleaner/deodoriser: cage/disc type 464

16 Presentation Wide range of symptoms. E.g.:Unconsciousness, nausea, vomiting, burning pain in the mouth or throat, headache, blurred vision, seizures, difficulty breathing, respiratory arrest, cardiac arrest, … Poisoning may be obvious from the chronology Some poisons have typical toxidromes Some poisons have a rapid effect

17 Presentation Wide range of symptoms. E.g.:Unconsciousness, nausea, vomiting, burning pain in the mouth or throat, headache, blurred vision, seizures, difficulty breathing, respiratory arrest, cardiac arrest, … Poisoning may be obvious from the chronology (or not) Some poisons have typical toxidromes Some poisons have a rapid effect

18 Presentation Wide range of symptoms. E.g.:Unconsciousness, nausea, vomiting, burning pain in the mouth or throat, headache, blurred vision, seizures, difficulty breathing, respiratory arrest, cardiac arrest, … Poisoning may be obvious from the chronology (or not) Some poisons have typical toxidromes (others don’t) Some poisons have a rapid effect

19 Presentation Wide range of symptoms. E.g.:Unconsciousness, nausea, vomiting, burning pain in the mouth or throat, headache, blurred vision, seizures, difficulty breathing, respiratory arrest, cardiac arrest, … Poisoning may be obvious from the chronology (or not) Some poisons have typical toxidromes (others don’t) Some poisons have a rapid effect (others delayed)

20 Presentation Poor evidence baseHard to undertake randomised prospective trials “Unethical” Mainly animal studies (rats/rabbits), or human case reports [Credit Unknown]

21 Case (Part 1)

22 Case (Part 1) 33 y/o female BIBA with decreased conscious stateHistory from AV: Had argument with boss (~1300), and then went home Husband found her poorly rousable (~1630), and called AV Image credit - Touchstone Television ( ) and ABC Studios (2007-)

23 Principles of ManagementStabilisation [i.e., Resuscitation] Reduce Absorption Enhance Elimination Supportive Care [Toxidromes] [Antidotes] [Credit Unknown]

24 Stabilisation

25 Stabilisation D R S C A B

26 Stabilisation D R S C A B

27 Danger R S C A B Stabilisation Prevent poisoning of rescuerPrevent further exposure/injury to patient Image credit - Touchstone Television ( ) and ABC Studios (2007-)

28 Danger R S C A B Stabilisation Prevent poisoning of rescuerThe poison can be transferred to the rescuer (e.g., by contact or inhalation in organophosphate poisoning) If more than one person affected, consider environmental contamination (e.g., carbon monoxide poisoning) Image credit - Touchstone Television ( ) and ABC Studios (2007-)

29 Danger R S C A B Stabilisation Prevent poisoning of rescuerEnsure adequate personal protective equipment (PPE) during decontamination and resuscitation If PPE not available, rescue may not be possible Image credit - Touchstone Television ( ) and ABC Studios (2007-)

30 Danger R S C A B Stabilisation Prevent poisoning of rescuerDo NOT put yourself at risk Avoid inhaling fumes Avoid direct contact Image credit - Touchstone Television ( ) and ABC Studios (2007-)

31 Danger R S C A B StabilisationPrevent further exposure/injury to patient I.e., reduce absorption (see later) Image credit - Touchstone Television ( ) and ABC Studios (2007-)

32 D Response S C A B Stabilisation Check for responsiveness[Credit Unknown]

33 D Response S C A B Stabilisation According to ARC:“If unresponsive, commence CPR” [Credit Unknown]

34 D Response S C A B Stabilisation May be drug related, orMay have pathological cause [Credit Unknown]

35 D R Send for help C A B Stabilisation If out of hospital, call 000If in hospital, call MET / or Code Blue Also, consider Victorian Poisons Information Centre on [Credit Unknown]

36 D R S Circulation A B Stabilisation Is circulation adequate?[Credit Unknown]

37 D R S Circulation A B StabilisationCertain drugs have cardiotoxic effects: Hypotension (most common) (e.g., calcium channel blocker) Hypertension (e.g., clonidine) Arrhythmias (e.g., tricyclic antidepressants) [Credit Unknown]

38 D R S Circulation A B Stabilisation Consider: CPR! Vascular accessCardiac monitoring Chemical supports (e.g., inotropes) Mechanical supports (e.g., extracorporeal support) [Credit Unknown]

39 D R S C Airway (+ c-spine) B Stabilisation D R S C Airway (+ c-spine) B Is airway patent? [Credit Unknown]

40 D R S C Airway (+ c-spine) B Stabilisation D R S C Airway (+ c-spine) B Depressed conscious state Airway burns Foreign body [C-spine] [Credit Unknown]

41 D R S C Airway (+ c-spine) B Stabilisation D R S C Airway (+ c-spine) B Depressed conscious state: e.g., benzodiazepine overdose Position the patient or establish a definitive airway [Credit Unknown]

42 D R S C Airway (+ c-spine) B Stabilisation D R S C Airway (+ c-spine) B Airway burns: e.g., caustic substance aspiration Establish definitive airway May be time critical [Credit Unknown]

43 D R S C Airway (+ c-spine) B Stabilisation D R S C Airway (+ c-spine) B Foreign body obstruction: e.g., vomitus, dentures Establish definitive airway Be careful not to convert ‘partial’ to ‘complete’ obstruction [Credit Unknown]

44 D R S C A Breathing Stabilisation Is breathing adequate?[Credit Unknown]

45 D R S C A Breathing StabilisationI.e., Adequacy of oxygenating and ventilation Causes: Central depression (e.g., opiate or benzo overdose) Inhaled toxin Aspiration [Credit Unknown]

46 D R S C A Breathing StabilisationI.e., Adequacy of oxygenating and ventilation Management: If hypoxic, oxygenate If hypercapnic, ventilate [Credit Unknown]

47 Stabilisation [Nb: Only once patient is stable]Concurrent History / Examination / Management [Nb: Only once patient is stable] Image credit - Touchstone Television ( ) and ABC Studios (2007-)

48 Stabilisation Concurrent History / Examination / ManagementExclude other organic causes History is often not possible (e.g., the unconscious or uncooperative patient) Consider collateral history ‘Top-to-toe’ examination Image credit - Touchstone Television ( ) and ABC Studios (2007-)

49 Stabilisation Concurrent History / Examination / ManagementInvestigations are many (may by streamlined if obvious toxidrome): arterial blood gas (Inc. BSL & anion gap) electrolytes/urea/creatinine, (Inc. osmolar gap) liver function tests coagulation profile, full blood count ECG CXR CT Brain (a.k.a. “CAT” SCAN) urinalysis [Credit Unknown]

50 Stabilisation Concurrent History / Examination / ManagementAvailability of onsite drug levels for: Paracetamol Salicylate Carboxyhaemoglobin Methaemoglobin Ethanol Iron Lithium Theophylline Digoxin Paraquat Valproate [Credit Unknown]

51 Case (Part 2)

52 Case (Part 2) Pre-hospital: Ambulance Victoria (1630):D – Nil obvious exposure/contamination risk R – GCS 9-11 at scene S – LRH ED pre-warned C – SBP 112/76, P 98, PIVC x2, NS x1L A – Unsupported B – RR 8, SaO2 93% (RA) -> 90% (NRB) Image credit - Touchstone Television ( ) and ABC Studios (2007-)

53 Case (Part 2) Pre-hospital: Emergency Department (1730):D – Nil apparent R – GCS 8 (E4V1M3) on arrival -> Decision made to intubate S – ICU pre-warned C – SBP 113/62, P109, (T33, BSL 6.2) A – Unsupported B – RR 8, SaO2 90% (NRB) Image credit - Touchstone Television ( ) and ABC Studios (2007-)

54 Case (Part 2) ICU R/V: A: B: 7.5mm ETT @ 22cm 14F NGT inserted SIMVAE L=R SaO2 100% on FiO2 50% Nil sputum on suctioning [Nil ‘vomitus on cords’] Image credit - Touchstone Television ( ) and ABC Studios (2007-)

55 Case (Part 2) ICU R/V: C: D: P 120MAP 60 (Aramine started. CVC/Artline pending) Peripherally cool D: GCS 3/15 50mg/hr) Pupils equal, reactive, and dilated (5) No asymmetry in UL or LL I.e., symmetrical tone and reflexes Image credit - Touchstone Television ( ) and ABC Studios (2007-)

56 Case (Part 2) ICU R/V: E: Nil external signs of trauma/rash/etc.Nil track marks Afebrile (35.5) Image credit - Touchstone Television ( ) and ABC Studios (2007-)

57 Case (Part 2) Collateral history: PMHx: Medications:Major Depression (Inc. previous overdose attempts) Medications: Escitalopram Lorazepam Mersyndol Forte (PRN times/week) Image credit - Touchstone Television ( ) and ABC Studios (2007-)

58 Case (Part 2) DDx: Likely drug ingestionHowever unwitnessed, so need to exclude other pathologies: Head trauma CVA (or other central cause) Dyselectrolytaemia / Hypoglycaemia Sepsis (Both CNS & systemic) Metabolic (e.g., hepatic/uraemia encephalopathy) Post-ictal Etc. Image credit - Touchstone Television ( ) and ABC Studios (2007-)

59 Case (Part 2) Ix: HCG / ABG / ECG / CXR / CTB NADBSL / FBC / UEC / LFT / Coags NAD Procalcitonin – NAD Ammonia – ? Image credit - NBC Universal Television ( ) and Universal Media Studios (UMS) (2007-)

60 Case (Part 2) Ix: Drug screen:Paracetamol 2064 micromol/L (> 1000) mg/L (> 150) Ethanol mmol/L Salicylates neg Cannabinoids neg Cocaine neg Opiates pos Methamphetamine neg Methadone neg Amphetamine neg Barbiturates neg Benzodiazepines pos Tricyclics neg

61 Case (Part 2) Ix: Drug screen:Paracetamol 2064 micromol/L (> 1000) mg/L (> 150) Ethanol mmol/L Salicylates neg Cannabinoids neg Cocaine neg Opiates pos Methamphetamine neg Methadone neg Amphetamine neg Barbiturates neg Benzodiazepines pos Tricyclics neg

62 Case (Part 2) Summary: Likely ingestion of own medications:Mersyndol Forte (paracetamol & opiate positive) Escitalopram (suspected) Lorazepam (benzo positive) [Other obvious pathologies excluded]

63 Supportive Care

64 Supportive Care Time necessary is dependent on:The drug’s pharmacokinetics [I.e., med school stuff, like absorption, distribution, metabolism, excretion, T1/2, etc.] The patient’s organ function [E.g., renal clearance or hepatic metabolism or even presence of red blood cells] Ability to reduce absorption [Next] Ability to enhance elimination [Next Next] Red cell esterases metabolise esmolol and remifentanil [Credit Unknown]

65 Reduced Absorption (A.k.a. Decontamination)

66 Reduced Absorption (A.k.a. Decontamination)Do NOT put yourself at risk: Avoid inhaling fumes Avoid contact contamination

67 Reduced Absorption Separate the victim from the poison Inhalation:Immediately get the person to fresh air, or ventilate the room (open doors & windows) If available, provide oxygen (highest flow possible)

68 Reduced Absorption Separate the victim from the poisonCorneal exposure: Remove contacts Irrigate the eye with running saline or cold water for 15min

69 Reduced Absorption Separate the victim from the poison Skin contactRemove contaminated clothing Irrigate the skin with running saline or cold water for 15min

70 Reduced Absorption Separate the victim from the poison Ingestion:Activated Charcoal Whole Bowel Irrigation Gastric Lavage Induce emesis Cathartics

71 Reduced Absorption Separate the victim from the poison Ingestion:Activated Charcoal: Should NOT be administered routinely [NO evidence that it improves outcome (if used indiscriminately)] Single dose activated charcoal only if: potentially toxic amount of a poison, AND within an hour of ingestion, AND airway is secure Charcoal is NOT effective if: ingested substance is an elemental metal (e.g., iron supplement) ingested substance is a strong acid or base (e.g., solvents)

72 Reduced Absorption Separate the victim from the poison Ingestion:Whole Bowel Irrigation: Should NOT be administered routinely Considered if: MORE than two hours post ingestion, AND Potentially toxic ingestions of : Sustained-release or enteric-coated drugs (e.g., “OxyContin SR”) Metals (e.g., iron, lead, lithium) Ingested packets of illicit drugs (I.e., “Body packers”)

73 Reduced Absorption Separate the victim from the poison Ingestion:Gastric Lavage: No ‘strong’ evidence showing either benefit or harm Recommended up to an hour post ingestion “Should not be performed routinely” [Credit Unknown]

74 Reduced Absorption Separate the victim from the poison Ingestion:Gastric Lavage: No ‘strong’ evidence showing either benefit or harm Recommended up to an hour post ingestion “Should not be performed routinely” NO ROLE for Gastric Lavage Aspiration risk May increase absorption [Credit Unknown]

75 Reduced Absorption Separate the victim from the poison Ingestion:Induce emesis: e.g., syrup of ipecacuanha NO ROLE for inducing emesis Reduces the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation Aspiration risk Forces poison beyond pylorus, and thus can increase absorption Certain specific contraindications (e.g., corrosives)

76 Reduced Absorption Separate the victim from the poison Ingestion:Cathartics: “The administration of a cathartic alone has no role”

77 Reduced Absorption Separate the victim from the poisonIngestion (Summary): Activated Charcoal – selective (i.e., not routine) Whole Bowel Irrigation – selective (i.e., not routine) Gastric Lavage – No Induce emesis – No Cathartics – No

78 Enhanced elimination Elimination can be enhanced by:Urinary alkalinisation (urine pH > 7) Multi-dose activated charcoal Extracorporeal techniques

79 Enhanced elimination Elimination can be enhanced by:Urinary alkalinisation (urine pH > 7) Hasten the clearance of acids E.g., salicylates

80 Enhanced elimination Elimination can be enhanced by:Multi-dose activated charcoal Hasten clearance of drugs with enterohepatic circulation E.g., carbamazepine, phenobarbitone, digoxin

81 Enhanced elimination Elimination can be enhanced by:Extracorporeal techniques Haemodialysis Useful in salicylates, lithium, methanol Not effective if high volume of distribution, or highly protein bound Haemoperfusion Useful in theophylline, phenytoin, carbamazepine Not effective if high volume of distribution Plasma exchange (theoretic benefit only)

82 Case (Part 3)

83 Case (Part 3) Potential Ingestants: What is Mersyndol?:Mersyndol Forte Escitalopram Lorazepam What is Mersyndol?: Tablets ‘Daytime’ ‘Forte’ Paracetamol (mg) 450 500 Codeine Phosphate (mg) 9.75 9.6 30 Doxylamine Succinate (mg) 5 -

84 Case (Part 3) Potential Ingestants: Concerns: ParacetamolCodeine phosphate Doxylamine succinate Escitalopram Lorazepam Concerns: Analgesic. “Liver drug” Liver metabolised (Multiple pathways) Opiate. Liver metabolised (CYP2D6, CYP3A4, UDP-glucuronosyltransferase). Antihistaminic & Antimuscarinic Liver metabolised (N-demethylation + others) SSRI. Liver metabolised (CYP2D6, CYP3A4, N-demethylation). Benzodiazepine. Liver metabolised (conjugation)

85 Case (Part 3) I.e.: Therefore: Potential liver injury (paracetamol)Multiple liver metabolised drugs (ALL!) Decreased gut motility (Codeine & Doxylamine) Therefore: Prolonged absorption Prolonged metabolism [Prolonged ICU stay] [Credit Unknown]

86 Toxidromes

87 Toxidromes A toxidrome, or a “toxic syndrome”, is a “constellation of symptoms and signs characteristic of poisoning from a given class of drug” May help in rapid diagnosis and treatment Useful when serum drug levels not possible (or not possible in a timely manner) Streamline management Image credit - Walt Disney Pictures

88 Toxidromes Not all toxidrome features will be present Polypharmacy ODE.g., in a patient with sympathomimetic poisoning, who is normally on beta blockers, tachycardia may not be present Atypical drugs E.g., unlike other opiates, meperidine does not cause miosis

89 Toxidromes Common toxidromes include:Anticholinergic syndrome (e.g., doxylamine) Cholinergic syndrome Narcosis (e.g., codeine) Sedative – hypnotic (e.g., lorazepam) Hyperthermic syndromes: sympathomimetic syndrome serotonin syndrome (e.g., Escitalopram) neuroleptic malignant syndrome [and anticholinergic syndrome] [And many many more] Image credit - Walt Disney Pictures

90 Toxidromes Anticholinergic syndrome (e.g., amanita muscarina)Cause: antagonism of muscarinic receptors Result: delirium agitation coma gastrointestinal stasis fever mydriasis tachycardia skin flushing urinary retention dry mouth dry eyes dry skin Image credit - Walt Disney Pictures

91 Toxidromes Cholinergic syndrome (e.g., sarin)Cause: activation of muscarinic receptors (essentially causing the opposite) Result: increased secretion (e.g., salivary, tears & sweat) bradycardia hypotension bronchoconstriction miosis seizures flaccid paralysis incontinence (both urinary & faecal) increased gastrointestinal motility

92 Toxidromes Narcosis (e.g., heroine)Cause: activation of opioid receptors Result: miosis central nervous system (CNS) depression respiratory depression decreased gastrointestinal motility [Credit Unknown]

93 Toxidromes Sedative – hypnotic (e.g., Xanax)Cause: activation of GABA receptors Result: sedation normal pupils decreased respirations

94 Toxidromes Hyperthermic syndromesSympathomimetic stimulation (e.g., cocaine) Cause: Sympathetic stimulation Result: Hyperthermia Agitation Seizures Coma Tachycardia Hypertension Diaphoresis [Credit Unknown]

95 Toxidromes Hyperthermic syndromesNeuroleptic malignant syndrome (e.g., Maxolon) Cause: Relative deficiency of dopamine Result: Hyperthermia Hyperreflexia Hypertonia Altered mental state [Credit Unknown]

96 Toxidromes Hyperthermic syndromes Serotonin syndrome (e.g., Zoloft)Cause: Relative excess of serotonin Result: Hyperthermia Hyperreflexia Hypertonia Clonus [Credit Unknown]

97 Toxidromes Anticholinergic syndrome results from antagonism of muscarinic receptors: delirium, agitation, coma, gastrointestinal stasis, fever, mydriasis, tachycardia, skin flushing, urinary retention, dry mouth, dry eyes and dry skin. Narcosis can result from all drugs that activate opioid receptors miosis, central nervous system (CNS) depression, respiratory depression and decreased gastrointestinal motility Serotonin syndrome (e.g., monoamine oxidase inhibitors) results from excess serotonin at receptor sites fever, hyperreflexia, hypertonia and clonus

98 Antidotes

99 Antidotes Specific antidotes only available for a small number of medications Top Seven: N-Acetylcysteine (NAC) - Paracetamol Naloxone - Opiates Atropine - Beta blocker / organophosphate Desferioxamine - Iron Antivenoms - Venom Flumazenil - Benzodiazepines Ethanol - Toxic alcohols (e.g., methanol & ethylene glycol) [Credit Unknown]

100 Antidotes Specific antidotes only available for a small number of medications Grouped into: Receptor antagonists (or agonists) Physiological Chelating agents Metabolic pathway manipulation Antibodies [Credit Unknown]

101 Antidotes Receptor antagonistsCompetitive antagonists at the target receptor. E.g.,: Flumazenil competitive antagonist at benzodiazepine receptors Naloxone competitive antagonist at opiate receptors Atropine competitive antagonist at muscarinic receptors All three are short acting, and thus may need to be infused or switched [Credit Unknown]

102 Antidotes Receptor agonistsCompetitive agonists at the target receptor. E.g.,: Adrenalin in beta blocker overdose Calcium chloride in calcium channel blocker overdose [Credit Unknown]

103 Antidotes Physiological antidotesDo not act on the same receptor as the causative agent. E.g.: Benzodiazepines in amphetamine poisoning Atropine in beta blocker overdose [Credit Unknown]

104 Antidotes Chelating agentsUsed to ‘mop-up’ poisoning from metals. E.g.: Prussian blue for thallium poisoning Desferioxamine for iron overdose [Credit Unknown]

105 Antidotes Metabolic pathway manipulationAct on metabolic pathways to prevent the creation of toxic metabolites. E.g.: Ethanol for methanol and ethylene glycol poisoning prevents formation of formic acid (from methanol) and glycolic acid (from ethylene glycol) N-acetylcysteine for paracetamol poisoning N-acetylcysteine is a glutathione precursor that prevents the metabolism of paracetamol to its toxic metabolites [Very nice drop!]

106 Antidotes Antibodies:Antibodies can be used as antidotes to specific poisons. E.g.: Digoxin specific FAB antibodies (e.g., digibind) for severe digoxin poisoning [Credit Unknown]

107 Antidotes The antidotes mentioned are by no means exhaustiveMost poisons do not have specific antidotes Good supportive care remains the cornerstone of the management of the poisoned patient, even if antidote available

108 Antidotes The antidotes mentioned are by no means exhaustiveMost poisons do not have specific antidotes Good supportive care remains the cornerstone of the management of the poisoned patient, even if antidote available [There is no antidote for Zombie!]

109 Case (Final Part)

110 Case (Final Part) Progress in ICU N-AcetylcysteineStarted ‘as per protocol’ as paracetamol level above nomogram 24 hours upon consultation with VPIC (following drop in levels) 40 hours upon rising paracetamol levels (why checked?) Slow gut motility, and thus delayed absorption 80 hours Image credit - Touchstone Television ( ) and ABC Studios (2007-)

111 Case (Final Part) Progress in ICU 72 hours: SepsisDeveloping fever and increased sputum production Treated for Aspiration pneumonia Runs of wide-complex-tachycardia Improving conscious state Decision to remain intubated because of pneumonia [and “control”] Image credit - Touchstone Television ( ) and ABC Studios (2007-)

112 Case (Final Part) Progress in ICU 96 hours: Liver:Paracetamol level normalised However, rising ALT/AST INR peaked at 1.7 Multiple ventricular ectopics Image credit - Touchstone Television ( ) and ABC Studios (2007-)

113 Case (Final Part) Progress in ICU 120 hours: ExtubatedRemained in ICU for cardiac monitoring Still multiple ectopics Image credit - Touchstone Television ( ) and ABC Studios (2007-)

114 Case (Final Part) Progress in ICU 144 hours: LFTs improvingINR normalised Liver U/S revealed ‘fatty liver’ Ectopics less frequent Image credit - Touchstone Television ( ) and ABC Studios (2007-)

115 Case (Final Part) Progress in ICU 168 hours: A/W psych reviewImage credit - Touchstone Television ( ) and ABC Studios (2007-)

116 Case (Part 3)

117 summary

118 summary Stabilise/Resuscitate Reduce absorption Enhance eliminationReverse the reversible Support the supportable Image credit - NBC Universal Television ( ) and Universal Media Studios (UMS) (2007-)

119 Resources Aus: NZ: UK: US: www.austin.org.au/poisons www.toxinz.com US: (via intranet)

120 Courses Wikitox Cardiff Toxicology: Cardiff Toxicology: American College of Medical Toxicology

121 13 11 26 [A.K.A.: POISONS HOTLINE] Help is available 24/7!VICTORIAN POISONS INFORMATION CENTRE (VPIC) [A.K.A.: POISONS HOTLINE]