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MENTI CODE: 3558 4067 Nickson Budha Year 4 ncb21@ic.ac.uk nickbudha2002@gmail.com Acute Medicine 1 Substance overdoses, withdrawals, and others MedEd Y3 Written Exam Lectures 2025Session Structure Substances: Overdose → Too much Opioids + Paracetamol + Aspirin Substances: Withdrawal → Too little Alcohol + Vitamins Substances: Other → Everything else Anaphylaxis + Bites/Stings + Tobacco SmokeCondition Overview For every condition, we will explore: Condition Risk Factors Signs and Symptoms Investigations ManagementMentiMeter SBA 1: Substance Overdose An 24-year old man is found lying on the pavement at the side of the road. Paramedics note he is barely conscious, breathing very slowly, and has pinpoint pupils. They also note track marks on his left arm. What is the next most appropriate step for management? A. Intravenous thiamine B. CPR C. Oral naltrexone D. Intravenous naloxone E. Intubation and ventilation SBA 1: Substance Overdose An 24-year old man is found lying on the pavement at the side of the road. Paramedics note he is barely conscious, breathing very slowly, and has pinpoint pupils. They also note track marks on his left arm. What is the next most appropriate step for management? A. Intravenous thiamine B. CPR C. Oral naltrexone D. Intravenous naloxone E. Intubation and ventilation Opioid Overdose Condition Toxicity from excess consumption of opioids / opiates, which causes CNS and respiratory depression - NB: Opioids = Synthetic compounds Opiates = Natural compounds Risk Factors History of drug use Polypharmacy Inpatients - Patient controlled analgesia Opioid Overdose Signs and Symptoms Drowsiness / reduced consciousness Decreased respiratory rate Blue lips (cyanosis) Pinpoint pupils Watering eyes Needle track marks Investigations → Clinical diagnosis Gold standard = Toxicology screen Management → IV / IM Naloxone Long-Term = Methadone for programmes Paracetamol Overdose Condition Toxicity from excess paracetamol, which is hepatotoxic and can cause hepatocellular necrosis. Risk Factors Mental health conditions - freq. suicide Taking liver enzyme-inducers St John’s Wort Alcohol abuse Malnourishment Paracetamol Overdose Signs and Symptoms Typically asymptomatic within 24 HOURS After 24 hours: Nausea Vomiting RUQ pain Late → Liver Failure (jaundice; encephalopathy) Investigations Serum paracetamol concentration → HIGH Must be done after 4 hours ABG → Metabolic Acidosis LFTs/Clotting → Deranged (ALT + / AST +) Paracetamol Overdose Management → Based on time: IF within 1 hour: Activated charcoal N-Acetylcysteine (NAC) ALWAYS: IF within 24 hours: N-acetylcysteine; to be Supportive care infused over 1 hour N-Acetylcysteine (NAC) Supportive care IF after 24 hours + S/S liver failure: SOMETIMES: Liver transplant Activated charcoal → 1 HR N-Acetylcysteine (NAC) Liver transplant → L. Fail Aspirin Overdose Condition Toxicity from excess consumption of aspirin (salicylate), which causes distinct pattern of acid-base imbalance: 1. Respiratory Alkalosis a. Stimulation of respiratory centre 2.Metabolic Acidosis a. Effect of salicylic acid Risk Factors Mental health conditions - intentional OD Young children - Accidental OD Chronic, high-dosage use in elderly Aspirin Overdose Signs and Symptoms Hyperventilation Sweating Nausea Vomiting Tinnitus Seizures / comas Investigations Serum salicylate concentration → HIGH ABGs → Mixed; depends on stage Often presents as metabolic acidosis; resistant to treatment Aspirin Overdose Management → Correct Imbalances Metabolic Acidosis IV Fluids IV Sodium Bicarbonate Electrolyte disturbances Based on what is imbalanced Hemodialysis if severe +/- Activated Charcoal (if < 1 hour) SBA 2: Substance Withdrawal A 58-year-old man is brought to A&E by paramedics. He smells strongly of alcohol, and is reported to be repeatedly asking the staff for a drink. Over time, the man is observed to have tremors, sweating, and anxiety. What is the next most appropriate step for management? A. Diazepam B. Chlordiazepoxide C. Carbamazepine D. Phenytoin E. Supportive care SBA 2: Substance Withdrawal A 58-year-old man is brought to A&E by paramedics. He smells strongly of alcohol, and is reported to be repeatedly asking the staff for a drink. Over time, the man is observed to have tremors, sweating, and anxiety. What is the next most appropriate step for management? A. Diazepam B. Chlordiazepoxide C. Carbamazepine D. Phenytoin E. Supportive care Alcohol Withdrawal Condition The physical and psychological manifestations when a patient with any level of alcohol dependence, stops their alcohol intake → ACUTE Alcohol is a CNS inhibitor depressant (↑ GABA ; X GLUT) Chronic use causes brain to adapt via CNS excitation (↑ GABA ; ↑ GLUT) Withdrawal of alcohol leaves behind overexcited CNS (X GABA ; ↑ GLUT) Risk Factors Chronic alcohol usage +/- Evidence of cessation Malnutrition & dehydration Abnormal liver function Alcohol Withdrawal Signs and Symptoms → Excited CNS 6 - 12 hours → Autonomic symptoms Sweating Anxiety Tremor 12 - 24 hours → Hallucinations 24 - 48 hours → Seizures 48 - 72 hours → Delirium Tremens Confusion Coarse tremor Death Alcohol Withdrawal Investigations → Largely clinical correlates CIWA-AR to screen for alcohol withdrawal Glucose to rule out hypoglycaemia Management → Depends... 1st line = Long acting benzodiazepines Chlordiazepoxide → Weaning off Diazepam → Acute withdrawal Supportive care Rehydration with IV fluids Pabrinex / thiamine Vitamin Deficiencies (General) Vitamin Chemical Name Deficiency State Risk Factors A Retinoids Night-blindness C Ascorbic Acid Scurvy → Gingivitis Poor Diet Malabsorption Rickets (CHILDREN) Crohn’s D Cholecalciferol Osteomalacia (ADULTS) Coeliac Cancer Alcoholism E Tocotrienol Peripheral neuropathy Bariatric surgery K Naphthoquinone Haemorrhagic disease of the newborn Vitamin Deficiencies (B) Vitamin Chemical Name Deficiency State Risk Factors B1 Thiamine Beriberi → Cardiovascular / CNS manifestations B3 Niacin Pellagra → Dermatitis/Diarrhoea/Dementia Poor Diet Malabsorption Crohn’s B6 Pyridoxine Anaemia + Irritability Coeliac Cancer Alcoholism B9 Folic Acid Megaloblastic Anaemia + Neural Tube Defects Bariatric surgery B12 Cyanocobalamin Megaloblastic Anaemia + Peripheral Neuropathy SBA 3: General Substances A 30-year-old man collapses in a restaurant shortly after eating dishes contaminated with peanuts. He has a widespread urticarial rash, audible wheeze, and is hypotensive at 78/40 mmHg. An ambulance is called by the restaurant staff. What is the next most appropriate step for management? A. Administer IV adrenaline B. Administer IM adrenaline C. Lie the patient flat D. Give high-flow oxygen E. Give non-sedating antihistamines SBA 3: General Substances A 30-year-old man collapses in a restaurant shortly after eating dishes contaminated with peanuts. He has a widespread urticarial rash, audible wheeze, and is hypotensive at 78/40 mmHg. An ambulance is called by the restaurant staff. What is the next most appropriate step for management? A. Administer IV adrenaline B. Administer IM adrenaline C. Lie the patient flat D. Give high-flow oxygen E. Give non-sedating antihistamines Anaphylaxis Condition A severe, systemic type-1 hypersensitivity reaction, driven by IgE, and caused by exposure to a sensitised antigen. 1st Exposure = Sensitisation 2nd Exposure = Effector Mechanism → IgE activates MAST/Basophils to release inflammatories Risk Factors Food → Peanuts / Eggs / Fish Drugs → Antibiotics Venom → Wasp stings Anaphylaxis Signs and Symptoms → A / B / C / D Airways Circulation Swelling of airways Tachycardia Hoarse voice Hypotension Stridor Pale Breathing Dermatological Wheeze Urticaria rash Dyspnoea Tachypnoea Pruritus Angioedema Anaphylaxis Investigations → Clinical diagnosis Management → RC UK Guidelines BEFORE IM Adrenaline Identify signs Call for help Lie patient flat Give IM Adrenaline → 1 mg/mL ; 0.5 mL ; thigh AFTER IM Adrenaline Give high flow oxygen Run IV fluid challenge Administer IM/IV antihistamines Bites and Stings Condition Local or systemic reaction following animal/insect bites or stings that puncture the skin barrier. Can lead to a range of outcomes: Minor irritation (MOST COMMON) Infections Anaphylaxis Risk Factors Pets Outdoor activity Travel history → Tropical regions Immunocompromised states Bites and Stings Bite / Sting Type Manifestation Flea Small, red spots - often in clusters Tick Bullseye rash - becomes E. Migrans Bedbugs Itchy, red lumps - very sparse Mosquitos Central punctum and raised skin Bee / Wasp Itchy, painful, isolated red dot Jellyfish Long-line patterns of erythema Anaphylaxis Investigations → Clinical diagnosis Management → Based on severity of response Local response: Remove any stingers / bugs Clean the area Provide safety netting Systemic response: +/- Adrenaline +/- Antibiotics +/- Admission Cigarette Smoking Context: Smoking cigarettes leads to the inhalation of harmful chemicals, including carcinogens. The addictive component of cigarettes is nicotine. Primary Smoking → Inhaling smoke from directly smoking cigarettes Secondary Smoking → Inhaling smoke from other smokers Risk Factors Socioeconomic status (deprivation) Peer pressure (esp. in younger) Other substance misuse → Alcohol Mental health conditionsCigarette Smoking Cigarette Smoking Management → LMAP Lectures... 1) Pharmacological Intervention 2) Behavioural Support 1st = Nicotine replacement therapy NHS Stop Smoking Service Targets nicotine cravings Very Brief Advice (VBA) Often given in 2 forms max. Ask S/E → N&V; headaches Advise 2nd = Buproprion (Zyban) Act 3rd = Varenicline (Champix) Continued support groups SBA 4: Additional A 48-year-old man experiencing homelessness presents to the GP with fatigue, persistent diarrhoea, and a rash on the backs of his hands and forearms that worsens in sunlight. On examination, he appears confused and disoriented. His diet is poor, and he reports drinking several cans of strong lager daily. What is the most likely diagnosis? A. Vitamin B1 deficiency B. Vitamin B3 deficiency C. Vitamin B6 deficiency D. Vitamin B9 deficiency E. Vitamin B12 deficiency SBA 4: Additional A 48-year-old man experiencing homelessness presents to the GP with fatigue, persistent diarrhoea, and a rash on the backs of his hands and forearms that worsens in sunlight. On examination, he appears confused and disoriented. His diet is poor, and he reports drinking several cans of strong lager daily. What is the most likely diagnosis? A. Vitamin B1 deficiency B. Vitamin B3 deficiency C. Vitamin B6 deficiency D. Vitamin B9 deficiency E. Vitamin B12 deficiency Thank you for listening! Any questions? Nickson Budha Year 4 ncb21@ic.ac.uk nickbudha2002@gmail.com