cases from downunder sophie gosselin.md,cspq,frcpc newcastle mater misericordiae nsw, australia
TRANSCRIPT
Cases from Downunder
Sophie Gosselin.MD,CSPQ,FRCPCNewcastle Mater Misericordiae
NSW, Australia
Case one – Miss R.Call at 01h3013 yrs old female brought by police and EMS after suspected DSH by ingestion of medicationBest friend called at 23h and told « good bye forever ».Friend called mother, 000 called and patient ran out back doorFound at 00h30 by EMS and brought to JHH
Case one – Miss R.On arrivalAlert, oriented 67 kgHR 120 NSRRR 16BP 110/70sat 100%Glucose 5.1T 37.8
Case one – Miss R.Took around 22h30
Prednisone 50mg x 20 1000 mgParacetamol 500 mg x 64 32 gr Codeine 30 mg x 24 720 mgPseudoephedrine 60 mg x 24 1440 mgIbuprofen 200 mg x 24 4800 mgMedication X 0.5mg x 50-64 25-32 mgDimenhydrate 50 mg x 12 600 mg
Case one – Miss R.What would you do next?What would you expect to find on physical exam to confirm if she did take all these?
Case one – Miss R.Level of counsciousness - belligerant Airways - not a problemBreathing - not a problemCirculation – not a problemDecontamination
Gastric lavage?Charcoal?WBI?
Case one – Miss R.We are 2 hours post ingestion.Do we have indications to consider decontamination?
Case one – Miss R.Police went home and did medication search.We knew then what Medication X was.
Here is what we did and what happened.Can you identify the toxin?Note your answers as we go alongAsk all questions you wantDo not yell out your answersWe will poll the assistance at the end and
get a top 5 lists of toxin
Case one – Miss R. 01h15
Intubated in ED for decontaminationCharcoal one dose 50 grWBI startedN-acetylcysteine started empirically pending levelAdmitted to ICUHR 160 BP 100/60ECG sinus tachycardia
Case one – Miss R. 04h00
Hbg 137WBC 4.3Platelets 278Na 133K 3.0Creatinine 57BUN 3.5INR 1.1Paracetamol 950 at 3h30CK 146Troponin negative
Day one – Miss R. 04h00
SedatedVomiting +++Unable to continue charcoal HR 160 sinusBP 95/60
14h00No change in statusGiven Neostigmine 2.5 mg IV Decontamination continued with charcoal alone until black stools
Day two – Miss R.HR 160 sinusBP 75/55 started on norepinephrineSwan Ganz
Output slightly decreasedSystemic vascular resistance decreased
LabsUnchanged except CK 1307
Which investigation would you want?
Day two – Miss R.Cardiac echo
Normal valvesImpaired LV contractionEF 35%No pericardial effusion.
Day three – Miss R.Still requiring inotropesStools black after MDACHR 140 BP with support 105/60Hgb 133WBC 4.9Plat 99LFTs and INR unchanged NAC stopped.
Day four to six – Miss R.Still requiring inotropes (dobutamine)Still intubatedFever 39Abdominal distensionHGB 105WBC 2.2Platelets 31CK 4142Troponins 1.87
Given GCSF for 24h
Day six to eight – Miss R.
Weaned off inotropesExtubatedTreated for Aspiration Given neostigmine againHGB 116WBC 9.0Platelets 111CK 541Troponins going downCardiac echo normal EF
Data on toxin-Miss R.Significant toxicityBound by charcoalInitial symptoms?Pancytopenia in 48hCardiac depressionResolution within one week.
????
Colchicine intoxicationPatient has gout.Took 0.5 mg x 64 = 32 mgPer kg = 0.48Phase 1
0-24h GI, leukocytosis, hypovolemia, DIC
Phase 22-7 days bone marrow suppression, cardiac depression, hepatic failure, MOF, ARDS
Phase 3 Resolution DeathAlopecia
Colchicine intoxicationAlkaloid from Colchicum autumnaleNarrow therapeutic-toxix index
GI side effects
High rates of morbidityAbsorbed 2 h after ingestionNot delayed in overdose unless by coingestantsFirst pass hepatic metabolismDistribution t1/2 45-90 minutesExcreted in the bile with enterohepatic circulation
Colchicine intoxicationBinds to tubulin Impairs microtubules formationNeutrophils, gastrointestinal musco, hematopoeitic cells, hair follicles.Toxicity is dose related
0.5 mg/kg or less usual recover0.8 mg/kg or more usual die
3 stagesGI 0-24hMOF 24-72hRecovery 6-8 days p.i.
Colchicine intoxicationAsymptomatic initiallyN/V/D
GI mucosal damage
Hypovolemic shockSepsis
impaired macrophage function
Cardiogenic shockRhabdomyolysisRenal failureSeizures, ascending paralysis, transverse myelitis
Colchicine intoxicationIngestion known
Asymptomatic drug ODToxic causes of gastroenteritis• Iron• Salicylates• Fluoride• Caustics• Cardiac glycosides• Nicotine• OPP/carbamates• Paraquat• Mushrooms
Ingestion unknownAcute abdomenCardiogenic shockGastroenteritisHypovolemic shockSeptic shock
Colchicine intoxicationExtensive baseline lab studiesLevels can be done
Takes a few daysRetrospective, post mortem
No increase in AG, osmolar gapAcid base abnormality are not specificEarly, aggressive GI decontaminationEnhanced elimination not indicated
Large Vd 21L/kgIntracellular binding sites
GSCF true response versus natural course?Death are rarely from marrow aplasia
No antidotes commercially available
Colchicine intoxicationFab antibodiesSimilar to digitalis Fab fragmentProduced in goat immunized with conjugate of colchicine and albuminEffectively reverse toxicity in miceNEJM Mar 15 1995. Baud and al.
One human case report 27 hrs p.i of 60 mg of colchicine 0.98 mg/kgImprovement within 30 minutes after FabSevere cardiogenic shockIncreased the urinary excretion of Fab-colchicine compound by 6 fold
Colchicine intoxicationPatient has gout.Took 0.5 mg x 64 = 32 mgPer kg = 0.48Phase 1
0-24h GI, leukocytosis, hypovolemia,
Phase 22-7 days bone marrow suppression, cardiac depression, rhabdomyolysis
Phase 3 Resolution
Case 2- Mrs. B45 years old patient found on highwayAfter serious MVATransported to Trauma Center
Case 2- Mrs. BA patentB GAEBC BP 50/ … HR 40No external woundsNo other signs of injuryNormal temperatureNormal glucose
Case 2- Mrs. BProlonged QTWide QRS
Differential diagnosisTraumatic injury after OD?No traumatic injury but signs are the OD?
Traumatic vs toxicologic?
TraumaticSingle vehicule MVASeatbeltNo airbagUnknown speedDamages important
ToxicologicNo associated signs of injury
Case 2- Mrs. BHow would you manage this patient?
Case 2- Mrs. BNaHCO3 infusion?
External pacerExtracorporeal supportEmergency bypass?Thoracotomy?Transthoracic ultrasound?Gastrointestinal decontamination?
Differential diagnosis?Traumatic
TamponnadeHypovolemic shock?Pneumothorax?CNS bleed?
ToxicologicAntidysrhythmic TCAPhenothiazinesCocaineAmantadinePropoxypheneChloral hydrateOPPTerfenadineBB; CCB;HypokalemiaHypocalcemia
Case 2- Mrs. BNo significant response to many boluses of NaHCO3
Normal CXR, Normal FASTNormal HgbAcidosisHigh lactateStarted seizing…Would you give her amiodarone?Would you start pressors and if so which one?
Class
Effect Clinical Drugs
IA Decreases upstrokeDecreased conductionNa and K blockade
QT prolongationQRS wideningHypotensionLethargy, coma
QuinidineProcainamide
IB Depresses rapid action potential
Confusion,SeizuresAsystoly, Ventricular Wide QRS
Lidocaine
IC Marked depression rapid action potentialNo K blockade
QT prolongationHypotension,BradycardiaComa, seizures
PropafenoneFlecainide
II B receptors blockade Beta-blockers
III K channel blockadeLittle or no Na blockade
Rapid hypotension, QTIncreased PR, bradycardiaProfound coma, hypotension
SotalolAmiodaroneBretylium
IV L type Ca channel BradycardiaPeripheral D
CCB
Vaughan-Williams Classification
Case 2- Mrs. BAre you able to tell which one is which?
Degree of hypotension?Degree of bradycardia?Anticholinergic features?Presence of seizures?
IA or ICCardiac conduction delayNaHCO3 ph 7.5
Fluid for hypotensionNorepinephrineMagnesium if TDPOverdrive pacingIsoproterenol
IBLorazepam for szPhenobarbitalFluid for hypotensionnorepinephrine
Treatment
Case 2- Mrs. BNaHCO3 infusion increasing
Overdrive pacingNorepinephrine increasing dosesShe went in PEAArrestedUnable to ressuscitate
Case 2- Mrs. BPolice found suicide noteEmpty bottle of flecainide
Could we have done anything to save her?
Flecainide overdoseIC antidysrhythmicNa channel blockadeAll condution pathways depressedHigh mortality rate 23% compared with other classesQuick absorption within 30 minutes95% bioavailabilitySerious cardiac effect 30-120 minutesWeak acid ; AlkalinizationVd 9 L/kg ; dialysis ineffectiveLong half life
Flecainide overdoseHemoperfusion
A blood pressure is needed
ECMOCritical Care Medicine April 2001Case report • After 8 mg epi, 1.2 mg atropine, 125 mmol NaHCO3
• Epi drip 100 mg/min• TC pacer to 100 mA• T pacer to 20 mA asynchronous mode• Fixed dilated pupils, no palpable pulse, pH 7.26
Successful recovery after 26 hours
Australian experienceA paramedical case report
John Hunter HospitalLevel 6 trauma centerBuilt 1991Ressuscitation Room
Combined pediatric Adult emergency department One ressuscitation area
8 monitored bed18 acute care beds
Doctors desks
Isolated Monitored beds
Longitudinal hallDepartments on either sides
Special 4 isolation ICU type beds« for SARS or the like »
Stand-by isolation ward