8.5C-D Tox Nsaids, Salicylates, Gout Em

Front 1

Regarding colchicine, which is incorrect
1. potentially lethal ingestion characterised by severe gastroenteritis, followed by MOF
2. at 2-7 days (>24 hours) bone marrow suppression, rhabdomyolysis, renal failure, ARDS, progressive metabolic acidosis, cardiac arrhythmias and risk of SCD are seen
3. cornerstones of management are aggressive decontamination with MDAC, and the administration of colchicine specific antibodies
4. survival to 7 days indicates likely complete recovery
5. leukocytosis on early blood films is common

Back 1

3 INCORRECT - aggressive decontamination with ACTIVATED CHARCOAL (but NOT multidose; technically difficult, not shown to improve outcome, not routinely recommended). Colchicine specific antibodies are not currently available (successful in a case report only).

Front 2

Regarding colchicine which is INCORRECT
1. ALL deliberate overdoses should be admitted
2. patients who don't develop GI sx within 24 hours of ingestion are medically cleared
3. activated charcoal should be immediately administered to any patient with >0.5mg/kg ingestion
4. fatalities have been reported with acute ingestions of 2mg/kg

Back 2

3. correct - prevention absorption even a small amount may be lifesaving
4. INCORRECT, 0.2mg/kg. >0.5mg/kg is associated with 10% mortality, >0.8mg/kg with 100% mortality

Front 3

NSAIDS which is incorrect
1. refractory seizures are commonly a feature of any amount of mefenamic overdose
2. even large ingestions of NSAIDS are usually benign, but massive ingestions are associated with multiorgan system dysfunction and fatalities have been reported
3. massive ibuprofen ingestion can result in rapid onset shock, coma, seizures, ARF and metabolic acidosis
4. CNS symptoms of lethargy and drowsiness are occasionally seen but cardiac arrhythmias are generally not a feature

Back 3

1. INCORRECT - any amount of mefenamic acid in overdose is associated with SELF LIMITING seizures

Front 4

Salicylates T/F
1. morbidity and mortality of chronic intoxication is greater than acute
2. classical sx of acute intoxication include vomiting, tinnitus, hyperventilation, respiratory acidosis and metabolic alkalosis
3. the diagnosis of chronic intoxication is frequently missed; features are nonspecific
4. HD is usually required in addition to charcoal and urinary alkalinisation
5. in acute overdose >150mg/kg is mild-mod intoxication, >300mg/kg severe, 500mg/kg potentially lethal
6. >5ml of oil of wintergreen (contains methyl salicyclate) more cause death in children <6yo; aspirin however rarely causes toxicity in childen
7. Cerebral and pulmonary oedema are more common than in acute poisoning

Back 4

1. T - nonspecific, often missed. Most common in elderly. May present with confusion, delirium, dehydration, fever and unexplained increased AG met acidosis.
2. F - respiratory ALKALOSIS, metabolic ACIDOSIS
3. T
4. F - early charcoal decontamination and urinary alkalinisation usually mean HD is rarely required
5 T
6 T
7 T

Front 5

Regarding salicylate poisoning, which is incorrect?
1. Severe toxicity is usually evident at presentation and deterioration progresses over days
2. Features of intoxication include N, V, tinnitus, decreased hearing, vertigo, seizures, hyperthermia
3. Cerebral oedema and death may result
4. Acidaemia is a late finding indicating imminent demise without intervention
5. activated charcoal is given up to 8/24 post ingestion of >150mg/kg, and a secnd dose is given 4/24 later if levels continue to rise

Back 5

1. INCORRECT - severe toxicity may not be evident until 6-12 hours post ingestion, and once evident deterioration may be very rapid
4. correct NB metabolic acidosis on gas may be present early, but acidAEMIA e.g. altered pH is the late finding

Front 6

Indications for HD in salicylate poisoning are...

What is the concern in intubating these patients?

Back 6

- urinary alkalinisation is not feasible
- levels rising to >4.4mmol/L despite decontamination/urinary alkalinsation
- severe toxicity clinically (= altered mental status, acidaemia, or renal failure)
- very high levels, acute >7.2, chronic >4.4 (similar to Lithium, lower levels have more significance in acute patients)
- lower threshold in elderly e.g. >4.4mmol/L even in acute

NB Haemodialysis is URGENT if intubated for salicylate poisoning (and the concern is to MAINTAIN HYPERVENTILATION so acidosis does not worsen; acidaemia promotes movement of salicylate into CNS). It is NOT indicated if intubated because of other coingestants