Poisoning and Overdose
Section A- choose the correct drug
1. A 25 year old is rushed to A&E presenting with confusion and
temperature of 38.9oC. Her blood pressure is fluctuating and she has a
markedly raised creatinine phosphokinase.
2. A man says that his depressed partner has taken an overdose. She is
drowsy and hypotensive with signs of respiratory depression. There is
no response to naloxone.
Drugs
Captopril
Amitriptyline
Atenolol
Paracetamol
Ecstasy
Heroin
Diazepam
Cocaine
Risperidone
3. A 40-year-old depressed man is brought to A&E with dilated pupils, blurred
vision and seizures. On examination he is tachycardic and his ECG shows wide
QRS complexes.
4. A 35-year-old intravenous drug user (IVDU) presents comatose with pin-point
pupils and respiratory depression.
Section B- choose the correct treatment
5. A 40-year-old drowsy woman is brought to A&E with headache and
vomiting with flushed cherry-pink skin. Carboxyhaemoglobin (COHb) is
40 per cent.
6. A 20-year-old woman presents to A&E with confusion, sweating and
blurred vision after taking some ecstasy. She has a rectal temperature
of 40.5°C. Creatine kinase is 4000 U/l.
Treatment
Desferrioxamine
N-acetylcysteine
Naloxone
Oxygen
Atropine
Atenolol
IV fluids
Vitamin K
Metoclopramide +
paracetmol
7. A 32-year-old woman presents 6 hours after a paracetamol overdose. The paracetamol
level is above the treatment line.
8. A 7-year-old boy presents to A&E with constricted pupils, sweating and
increased salivation after drinking a bottle of insecticide lying in the garden.
Common Toxidromes
Toxidromes
Anticholinergic
Cholinergic
(muscarinic)
Sedative/Hypnotic
Drugs involved
Antihistamines, tricyclic
antidepressants (amitriptyline),
atropine
Organophosphates (nerve gases,
insecticides), Carbamates
(insecticides)
Benzodiazepines, barbiturates,
alcohols, opioids (heroin),
anticonvulsants, antipsychotics
Sympathomimetic
Salbutamol, amphetamines,
MDMA, cocaine,
Serotonin syndrome
Commonly with combinations of
drugs that affect serotonin
reuptake:
 MAOi + any other
antidepressant
 Antidepressant +
pethidine/tramadol
 Antidepressant +
MDMA/LSD
Any antipsychotic
Neuroleptic
malignant syndrome
Withdrawal
Principles of management
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Presentation
Tachycardia, hyperthermia, mydriasis, warm
and dry skin, urinary retention, ileus, delirium
SLUDGE syndrome (salivation, lacrimation,
urination, defecation, GI cramps, and emesis),
miosis, bronchorrhea, wheezing, bradycardia
Sedation, hypoventilation, hypotension
Opioids + barbiturates also cause:
 miosis, possibly hypothermia
Tachycardia, hypertension, mydriasis,
agitation, seizures, diaphoresis, hyperthermia,
psychosis (after chronic use)
Common:
 Diarrhoea, sweating, ataxia, tremor,
disorientation, hypomania
Distinguishing:
 Myoclonus, hyperreflexia
Extreme pyrexia, stiffness, confusion,
autonomic instability (BP and pulse up and
down), raised WBC, raised creatinine
phosphokinase ++++
Tachycardia, hypertension, mydriasis,
diaphoresis, agitation, restlessness, seizures,
hyperreflexia, piloerection, yawning,
abdominal cramps, lacrimation, hallucinations
Drug
Paracetamol
Opioid
Iron
Carbon monoxide
Ethylene
glycol/methanol
Digoxin
Cholinergics
Antidote
N-acetylcysteine
Naloxone
Desferrioximine
Oxygen
Ethanol/fomepizole
Full history including:
o HPC:
 Quantity and route
 Timing
 Staggered?
 Patient’s own medication or other
Digoxin antibodies
source
Atropine
 Coingestions
 Symptoms/events following ingestion
 Collateral history
o Assessment of suicidal risk
o Past psychiatric history
Refer to TOXBASE
For most poisonings, treatment is symptomatic and supportive care
Gastric decontamination if recommended (e.g. gastric lavage, oral activated charcoal)
Antidotes (relatively few)
Enhanced elimination if recommended (e.g. haemodialysis, haemofiltration, charcoal haemoperfusion