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Hello, everyone. Can someone please confirm in the chat if you can hear me properly? Ok. Hello everyone. My name is Dia and I'm the vice president of grads. Thank you for joining today's talk on assessing and handling intoxication by Doctor Barga. Um Also I would like to remind you guys at the end of the talk today, I will send the feedback form into the chat and after the completion of the feedback form, um the certificate will be sent to you. So I would like to hand over to Doctor Bargo. Um Hi guys. Hi. Uh Can you hear me? Is my voice? Ok. Yeah. Uh All right. Uh I will just start with my topic. Um I'll not go very deep into all the um, overdoses because I just want to cover the common topics which we handle uh on a day to day basis in the ed um in, in uh NHS. Um So this is my topic. So the, I don't think I can hear you. No, uh one second. Uh can you hear me now? Yes, we can hear you. Ok. There's something wrong with my m uh OK. S 00, I can hear you now. Sorry about that. No, it's ok. Uh, so, uh, these are basically the common scenarios that we see in NHS, whenever you work, uh, in a, out of hours medicine rota or whenever you work in the emergency department, uh, these are basically the common things you see. Um, so I'm not gonna cover all the drug overdoses because there's many, many drugs that people can take and come to the hospital. So I'm just gonna do common intoxications and uh paracetamol poisoning as well. Uh Because paracetamol is basically the uh drug which is available over the counter and people usually take that. Um, so I'll start with alcohol intoxication and withdrawal as well. Uh So basically, uh if uh the uh harmless dose, no, I could, I would not say safe dose of um, alcohol, but people should con consume less than 14 units per week, which is considered as a low risk level for a man or a woman. So, patient, uh, any person who consumes more than that might end up in Ed, um as a alcohol intoxication and people usually become dependent on that kind of doses and it is usually the most common uh uh scenario that you get in a, in a patient in Ed. Um, and patients usually usually they present with loss of consciousness and the police, they usually find them on, passed out on the roads. Um, or um, patients usually present with vomiting on the roads and they were brought, they, they are usually brought to the Ed by the police or they themselves present to the Ed and they're usually very drowsy and very agitated and confused as well. People uh who recurrently present with alcohol overdoses, they end up in alcohol related brain damage and they present with seizures. So when you approach a patient with acute into intoxication, the first thing you do is uh ABCD every breathing, circulation and disability and exposure. So in a way, usually, um in a patient who consumes alcohol, uh low gcs is very, very rare. Uh So airway is usually not that compromised, but if patients uh vomit and choke on the vomit and then aspirate a lot of stuff, uh they might have some breathing difficulty and they might need uh respiratory support. And uh if the patient is hemodynamically unstable, like most of the alcohol patient, alcohol overdose patients that we see in ed uh they end up in hospital after drinking almost 1 to 2 bottles of uh vodka, whiskey and they don't eat anything. They basically just binge drink and do not eat anything. Uh So they end up very unstable uh with a very low BP and then uh they end up very, very dehydrated, they will need a lot of uh uh fluid support. So the first thing you need to do is um candidate the patient and start him on IV fluids and send routine bloods along with the routine bloods, we, we do the ethanol levels and also we do bone profile and magnesium because when I see the patients, when they don't eat while drinking alcohol, uh, like addicts, they don't eat anything, they just keep drinking and, uh, they binge drink because they don't, um, find the need to eat because they are very, very, um, how would you call it? Their appetite is very, very low. Uh, and, uh if you check the levels of uh magnesium and phosphate and potassium in those patients, uh they're usually very low. And uh these are called as refeeding bloods in the NHS. So, the refeeding bloods are always low in a um alcohol addict because they don't eat properly and which can actually put them in the risk in risk of arrhythmias. And the refilling syndrome is a very serious condition in the N HS. So we uh we should always make sure the electrolytes are properly uh replaced. And if the patient is presenting with seizures or um very um severe confusion, which is not usual for him, we always do a CT brain and if the patient is presenting with seizures recurrently and then it is uh a recurrent um uh symptom for him uh during acute intoxication, we need to start him on anti epileptic drugs. Usually we start the patient on lamoTRIgine and these seizures uh in the alcoholic patients can be due to hypoglycemia, which we all know that hypoglycemia can cause hypoglycemic seizures and it can be due to um electrolyte as well like hypomagnesemia and hypo phosphatemia. And they end up in hyponatremia because they drink a lot of alcohol. So what happens is the uh solvent, which is the alcohol, this consumption increases and the solute, which is the food that consumption decreases. So, in any patient, uh when they present with low solute intake and more and more solvent intake, they end up in hyponatremia because there is no protein. Uh So all the water is absorbed into the body and it causes dilution. So that results in hyponatremia. Uh So hyponatremia can cause confusion and seizures. So how to manage a patient who came in uh with acute alcohol intoxication. So first, we need to give him IV fluids as I said, to make him hemodynamically stable. And uh second thing is we need to give him IV Thiamine. Uh We all know that uh patients with alcohol uh withdrawal, they end up in a few uh things called delirium thiamine. And then we opathy, I'll talk about that later. So we need to replace him with IV Thiamine, which is B1 vitamin or Inan. It is, it's usually called the SPX by the uh brand name. And we need to give them anti sickness and because they are very, very um uh drowsy sometimes uh they vomit and then choke on it. Uh So we need to put them in a position that they don't choke on it. So we need to put them on their side and give them antisickness. So they don't vomit and choke on it. And if a patient is already in withdrawal, that means the alcohol has, has already left the patient's system. So patient will be craving alcohol now. So he goes into withdrawal. So we do something called a sorry, we do something called a ago scoring and put the patient on Librium, which is a benzodiazepine chlordiazePOXIDE. I'll discuss about that in detail and once the patient is sober. Uh So he needs to be referred to a which is a psychiatric liaison. Uh So the psychiatry uh they provide support to the alcohol addicts. Uh So they refer us, they usually refer patients to alcohol liaison services or help with the addiction in the community. But all this only will happen if the patient agrees. If the patient uh is um keen to uh change and keen to stop alcohol, they usually refer them. Um I will open uh the link. Uh So this is our trust policy to treat alcohol withdrawal. So basically, uh once the patient goes into withdrawal, there's mild to severe symptoms. Uh So the mild to moderate symptoms usually will be tremors and sweating and they have insomnia and nausea and, and uh uh very, they will be very anxious. So, uh alcohol withdrawal is basically categorized into deli tremens, delirium tremens is um basically, patients have uh tremors and they are very paranoid and very agitated and um sometimes they have hallucinations and they are very, very anxious. Uh So this occurs 24 to 72 hours after the alcohol after the last drink. So they have their last drink yesterday at 6 p.m. after 24 hours. So now they will, they'll be uh having an episode of daily drinks. Uh and this can uh last up to three, up to 3 to 5 days. And usually people who drink more than 20 units per day, they have the risk of progressing into daily in interments when they go into withdrawal. And the second one is seizures. So between 12 to 48 hours, uh people usually go into seizures because of hypoglycemia and hypocalcemia and hypomagnesemia. And people who already have a history of epilepsy. They are at very, very high risk of developing seizures due to alcohol withdrawal. And Wernicke's Wernicke's Opathy. I am sure you all have heard of this. So, encephalopathy is basically a medical emergency, we need to. Uh so it is very, very difficult because uh patients with opathy, they, they also present with the same symptoms like confusion or uh uh uh decreased level of consciousness, like loss of consciousness. But so it is very difficult for us to basically differentiate which patient is actually confused and um because of the alcohol intake or which patient is in almost encephalopathy stage. And this can also cause permanent brain damage to the patient. Uh So they present with a very uh what do you call it? Low, low, like loss of consciousness or uh local global confusion state. They won't recognize where they are, they won't recognize if they were the police or with, they're in the hospital. Uh So how we test uh confusion uh or orientation in a person, they will don't recognize it's if it's a day or if it's a night or what day it is or what month it is. And then whenever they walk, it is a very unstable ataxic gait and they have nystagmus. If you check nystagmus, you can see they have like a horizontal or vertical nystagmus and all, all obviously reduced conscious level. And this is usually developed in uh patients with severe signs of malnutrition or malnourishment where people, uh as I told you, people who have refiling syndrome, like who just keep drinking and don't eat anything. Uh Most of the alcoholics actually do that. Uh So they end up in wernickes because of the hypoglycemia and because of uh dyselectrolytemia and they persistent when they persistently vomit. So their oral intake decreases, which give them severe dehydration which causes encephalopathy. Uh again, and uh uh people with low BMI and homelessness, homelessness is basically uh it is indirect factor that they have not been taking care of themselves. They have not been eating anything, have been drinking, uh binge drinking and they have lost you intake. So they end up in encephalopathy, uh extremely um severe encephalopathy and which, which uh usually eventually leads to permanent brain damage. Uh So the scoring I was talking to you about is the go scoring. So go scoring is Glasgow modified alcohol withdrawal scale. So we need to uh basically score the patient on the scale. So we need to ask the patient to uh put his hands forward and then uh hold it in air for like five seconds. So if you can see visible tremors and they will have uh mo uh so you need to ba basically score the tremor as well, even if it's at rest or if it's on movement. So if he is having tremors when he's just rela uh lying on the bed, uh you score two and when you ask the patient to raise his hands and then he has a tremor, it should be one. And if the, if he has no tremor, then it's uh just zero and then sweating as well. You need to score on 012 scale and hallucinations usually um patients uh with hallucinations, they present very, very agitated. So you would uh easily know. But most of the patients, most of the adults, they wouldn't have hallucinations. So mostly the the common uh symptoms you can see is the tremor and sweating and then agitation. Uh people who actually go into withdrawal, they ha they are very, very, very, very anxious. They ask you like every 15 minutes that they want to go home, they want to leave the hospital. So that is the sign that they are very, very anxious and they ask you what is happening. Mm Where is he where like what is, what, what you're going to do uh Next. So they'll be very, very anxious and some people, they don't even ask any questions. They are very disoriented. Uh They are very, they don't even have proper contact if you are, if you talk to them, they don't look at you. So that is basically orientation and then you score them. So when you score them, uh if the score is zero, you should never think that he's not in withdrawal. So you need to wait for at least two hours and repeat the scoring again. And you, you need to do this for four consecutive occasions like every two hours. And then if e even if he's scoring zero, that means he's not in withdrawal and then he's safe to go home. And if the scoring is 1 to 3, it is mild withdrawal, 4 to 6 is moderate and 7 to 10 is severe and 10 is the maximum score of gmos. Uh So, based on the gmos, you need to treat the patient with uh benzodiazepines to treat the withdrawal to reduce that anxiety and everything. Uh So this is the community management which we don't use in the hospital that much, but in the emergency department um the dose we use is this. So if the patient is presenting with mild symptoms, which is GMOs 1 to 3 the first day. So day one is basically when you see the patient as a medical doctor or AE D doctor is the day one, you see the patient and you give 20 mg of clod as a start dose and you put the patient on 20 mg four times daily and you also give APR N dose. So basically patient is allowed to take maximum doses is he can take 20 mg four times a day. Along with this, you need to prescribe 20 mg in a as required section. So he can take 20 as required four times. So it's basically four times daily and four times as required. That is the maximum dose he can take in 24 hours and after 24 hours, you need to assess the GMOs again and based based on the gmos on the next day, you need to do the scoring again and prescribe the uh dose. Uh I'm sure this uh dosage of clo varies between trust to trust. So it is not like a, a rule that you need to give this much dose. It is basically different in every trust. So you need to just go to your trust guidelines and based on that, you need to treat your patient. Uh So this is the alcohol withdrawal um scoring and then coming to uh vitamin B1 that is IV thiamine. Uh So it is called PEX usually. Uh but uh most of the trust in N now, they are out of PEX. So they've been using the IV thiamine now. So you give IV infusion. Um If it's uh PEX, you give two pairs of pabx. Um And for you give this for three day, 33 times daily and until five days, even after five days, if the patient is not improving, then you give PEX after that IV but you reduce to one once daily doses. But if the patient is improving and you feel like patient can manage on oral, you just shift the patient to oral thiamine after five days. Uh and usually uh you have to detox whenever the patient comes. When you admit them, you need to detox the patient until the patient is completely detoxed. You can't send the patient home and every patient who is uh sober, which who is uh detoxed, you need to refer them to I LS and then they, I takes a proper history that you to see if they have guilt or if they have um uh why did they uh do the um you know, overdose of alcohol? So they'll find out everything and then based on that they will refer to addiction team or if the is feels like this is just a one time thing which just happened due to some event. Uh So they will not refer them to anything and they will just give safety advice and send them home. That is how you manage alcohol uh uh intoxication in NHS. And the second one is cocaine. Uh uh So cocaine patients usually don't do cocaine alone. Uh They do alcohol and cocaine. So mm they come with alcohol and cocaine overdose at the same time. So it is very hard for you to distinguish what has the patient taken. But uh usually patients tell you that you, you know, they have taken it. Um and they have these symptoms like tachycardia, hypertension and excessive sweating and agitation and pupil dirt. Uh So if the patients don't tell you what they have taken, you can do something called a urine tox screen and then you will know what all the patient has taken. And the management is similar uh to uh alcohol. So you do ABCD uh to rule out airway compromise and uh make sure that he patient is hemodynamically un uh stable. And usually patients present with hyperthermia, you need to quickly cool them. So like exposure. So you need to check the temperature as well. And in all the patients who present with cocaine overdose, you don't have to basically there is no such treatment of cocaine overdose. You need to observe them for 24 hours. So the cocaine has to go out of their system. Uh they have to be sober and then you can send the patient home. Uh So if you, if agitated, you can give some benzodiazepines to uh this patient as well. And then you do bloods, you repeat routine bloods and everything and do the urine tox screen to rule out if this, if the patient has taken anything else and make sure that the patient has no hypoglycemia and every uh patient with alcohol and cocaine, you need to do a ECG because cocaine is a dysrhythmic. So patients usually um they have a potential to develop arrhythmias and severe toxicity. So you need to make sure that patient has no arrhythmias or patients sometimes usually have ischemia as well. And we give IV fluids for uh circulatory support and give respiratory support and even cocaine. If it's one time event, you don't have to refer to s but if patient is coming with recurrent cocaine overdoses, um which suggests that you have to uh refer the patient to psychiatry once he's sober and then they can take it up from there. So I did not cover much on cocaine because it is mostly similar to alcohol. Um And then this is the, this is paracetamol poisoning. Uh I am sure I have seen many, many patients with paracetamol poisoning because um in, in uh in UK, the most available drug in the uh pharmacy is basically paracetamol uh and patients have them at home. So um this is the main like a regular co like common overdose that I, that I have seen uh from my personal experience. Uh So basically, paracetamol poisoning is paracetamol is basically hepatotoxic and nephrotoxic as we all know. And if uh patients come with paracetamol poisoning, and first thing you do, everybody does is ABCD and then you do blood. And uh we obviously know that it is hepatotoxic. And so we check uh liver function tests, but we should never think that if the liver function tests are normal, we should never think the paracetamol has not affected the patient's liver because it usually takes 3 to 4 days because the liver functions usually lag behind and it takes 3 to 4 days to reach a peak. So you should always be careful and you should always keep an eye on his liver function test. Um So patients who consume excess alcohol along with the paracetamol or are at a more risk of liver injury compared to just taking paracetamol. And uh patients um have a high risk of liver damage if they ingest more than 1 50 mg per kg. Uh but people who come with overdose, it is not ideal that you always measure their body weight. So the uh dictum is that if the patient has taken more than 12 g or 12 g, we always start treatment irrespective of the time of injection. Um So I'm sure that nobody will measure the weight of the patient. So we usually go with the 12 g dose. And the antidote for paracetamol overdose is N acetylcysteine as we all know uh and coming to the time of ingestion. So it is very critical in paracetamol poisoning. Uh that we know that when the patient took the paracetamol because after a certain point, uh you need, you need not wait for the paracetamol levels to come back, you just start treatment. Um So if no, we we need to take a proper history like how many tablets has been, has the patient taken? And at what time did they consume? But sometimes people have a staggered dose, staggered dose means they take four tablets in the morning and then five tablets or 10 tablets in the afternoon and then suddenly they present to the hospital the very anxious. So if that is a situation, if patient has taken a staggered overdose, irrespective of the time interval, even if the patient has taken 10 or 15 paracetamol tablets the day before and presented today with more 15 tablets, you just start the treatment because that that is considered as a staggered overdose. And the first thing we do is the urgent me measurement of patient's plasma paracetamol concentration. But if if you do a serum concentration within four hours of injection, it would not be that informative because there is ongoing drug absorption uh through the liver. So it will not be that effective. You basically have to wait at least four hours to do the paracetamol concentration. So this is the uh treatment line. This is the chart that we use to decide if patient needs treatment or not. So for suppose patient is presenting at four hours of injection and then you do a sorry, you do a paracetamol concentration for the patient and the paracetamol co concentration comes at 50 milligram per liter. And then what do you do is you do not treat the patient. So you should always consider that the patient at w given particular time, the paracetamol concentration should be at the treatment line or above the treatment line. So if a patient is presenting for suppose at 10 hours and the paracetamol concentration is still somewhere around 35 or 40 then you treat them. That means even after 10 hours, he still has 35 or 40 mg per liter of concentration. That means patient has taken at least 12 g or more. So you need to treat that patient. Uh And uh for just for example, again, if patient has presented at 12 hours and the serum concentration is just 10 or five, you don't treat that patient usually because it is below the treatment line. So we usually treat if it meets the treatment line or if it's above the treatment line. But irrespective of this, if the patient is presenting with a staggered overdose taking few tablets at different, different times, you always treat the patient, irrespective of serum paracetamol level, even if the serum paracetamol level is less than 1.2 which is like the minimum minimum even, then you treat the patient if it's a staggered overdose and then for patients who present within eight hours of paracetamol injection. So for, for them, you consider emptying the stomach or giving activated charcoal. Um This is usually not done that much because patients usually present late. Um So this is of very little value after four hours. Uh So we need to take a uh blood for paracetamol estimation after four hours. And we need, we don't have sometimes um if the paracetamol concentration is very high, if the paracetamol tab table tablets, the patient has taken is very high. That means patient has taken around 30 tablets uh of 500 mg, which is equal to 15 g, sometimes clinically, if the patient is unwell, uh few doctors take a call and then they start the patient on N acetylcysteine and not wait for the serum paracetamol concentration. Um So it it is basically your clinical decision as well uh based on the patient. Um So we need to wait for the paracetamol concentration and based on the treatment slide treatment line, again, you need to decide. So if you have taken it within eight hours, so for suppose within eight hours is basically six hours. As I said, you need to see the treatment line. So if it's above 70 or nearly close to 70 you need to treat the patient. And if paracetamol level is not available within eight hours of injection, then you need to see that if it is consumed to more than 12 or 12 g so that you can start the treatment and provide the antidote is started within eight hours of injection. Patient can be discharged after treatment. So if they have presented within eight hours and you have started the treatment and the patient received all the bags of uh n acetylcysteine. Usually you can discharge the patient home if he's clinically well and hemodynamically stable. But you need to uh tell the GP to monitor his liver functions. And you need to also give also sign post the patient saying if the patient has any vomiting or any abdominal pain, they have to come back to the ee again. Uh And we need, we need to tell the GP to check inr and serum creatinine as well because paracetamol usually affects in r because of the liver functions and the coagulation factor. So inr is the main um thing that is affected and for patients who present 18, 8 to 15 hours of ingestion. So if the patient is at risk, sometimes you don't have to wait because already it is past eight hours. So you, you don't have to always wait for the paracetamol concentration if consumed more than 12 or it's a staggered overdose, urgent treatment can be started and you can send the paracetamol concentration anyway simultaneously. And if you think the patient has no risk, you can wait that means patient has consumed just 8 g or 6 g of paracetamol and it is not a standard overdose. Then you can wait for the serum paracetamol level concentration to come back and check if it's above the treatment line and then treat it according to your clinical decision. And here as well, if you give patient um uh an acetylcysteine and if the patient is well, and if all the bloods are normal inr is normal, you can always discharge the patient. But usually after 8 to 15 hours, patient, you when present, when they present with uh paracetamol poisoning and they've taken around 10 or more than 12, they might have some um abnormalities in their bloods usually in R or co screen. So you need to give Vitamin K in those patients uh to prevent uh to, to prevent bleeding and management management of patients who present 15 to 24 hours after injection. So for these patients, you, you should send the paracetamol level on admission, but you need to start all the patients on N acetylcysteine because after 15 hours, it is very, very uh it is not that useful to send a paracetamol level. Be because the paracetamol is already leaving the system. So to prevent the side effects, you need to uh prevent the toxicity, you need to give the N acetylcysteine the antidote and the infusion can be stopped. If the patient is asymptomatic, you don't, you don't have to finish the entire um uh protocol, you can stop it if the patient is asymptomatic and inr and creatinine are normal and uh the plasma concentration is less than 10. So, based on the treatment line, if after 15 hours, so this is 15 hours and the paracetamol concentration is less than 10, then you can stop the treatment. There is no point in treating because the paracetamol has already left the system. And yes, um uh 24 hours after injection provide the time of injection is known. But you need to make sure that a patient uh tells you exactly what time they have taken the paracetamol. Otherwise, you just have to continue with the treatment. And if ABC is not possible, that is if patient is symptomatic and if INR is not normal, creatinine is not normal and if uh you don't know when the patient has taken uh the paracetamol and it is a standard dose, then all of these do not do not apply. And then you have to keep giving an acetylcysteine at least until the third bag. And before discharge any patient before discharge, given uh taking 10 g 8 g 6 g. It doesn't matter. You have to always check inr and creatinine before discharging the patient. And next management of patients who present longer than 24 hours. So if patient is presenting longer than 24 hours, uh it is very um difficult for us to clinically say that this patient needs N acetylcysteine. So we can always ask for a specialist help. So, first thing you need to do is check inr and the creatinine and we have to make sure that the patient is not acidotic and we can call a specialist liver unit. Uh So every trust has a specialist, like specialist liver unit or every dry, has a liver unit. So you can call the consultant or the registrar on call. Uh and you need to discuss with your physician on call basically first. So if you're on an out of hour shift, you always have a physician on call. So you need to discuss with them and call the uh liver unit and ask them. So there's always a registrar who is on call in the liver unit. So you can ask them based on their decision, you can treat or not treat it. Uh So, uh when con when considering paracetamol poisoning, uh to say that it is a severe liver damage, you need to make sure you need to check all of this. Uh So if Inr is greater than three, so the first marker that patient has liver injury is basically inr not even coagulation screen. Uh So if INR is greater than three, then he needs to be transferred to a specialist unit immediately. And creatinine is elevated, that means the paracetamol is nephrotoxic and patient is acidotic and given anything if the patient has encephalopathy, uh then you need to discuss with the liver unit as early as possible. And if the patient has a preexisting liver disease, for suppose there's many patients who, uh, drink alcohol and end up in a decompensated liver disease, uh, like alcoholic liver disease. So they, when they present with, uh, uh, paracetamol poisoning, it is a very, very risky situation because they, their liver functions, they, they are already so their liver couldn't handle much. So, in that cases, we need to speak to the liver unit as early as possible and coming to N acetylcysteine. Uh So we give N acetylcysteine IV. And the dosage would be for the first bag, it would be 1 50 mg per kg and then it would be given under 200 mL, 5% dextrose and the um administration would be over 60 minutes. And uh the second bag would be 50 mg per kg in 500 mL. And you give that over four hours and the third bag is 100 mg per kg in 1 L of 5% dextrose and you give that over 16 hours. So this is the, this 60 minute bag is the first bag and the second, this is the second and this is the third bag. And in some cases people who present with a severe toxicity, the N acetylcysteine is continued even after the third bag. That means in a day, if a person receives one first, 2nd, 3rd bag and the next day if you check their liver functions and they are still abnormal. You give the fourth bag and the fourth bag would be always the third bag, which means I'm sorry, which means the dosage of the third bag. So you keep repeating the third bag. That is the fourth bag would be similar dose 100 mg per kg in 1 L of 5% extra dose over 16 hours. And that would be the fourth bag and the fifth bag would be the same dosage. So you just keep continuing the third bag until you feel like this patient does not need any, any N acetylcysteine. And he is now safe enough without the uh N A and sometimes N acetylcysteine can cause adverse effects, uh like any, like any other medication, it can cause local allergic reaction. Um And so what should, what you should do is uh it usually occurs bef like during the 30 minutes of administration. So immediately what you can do is you can stop the infusion and give an antihistamine like uh chlorproMAZINE or anything and then wait for, wait, wait until the symptoms settle and then you can resume the N acetylcysteine again at a very low infusion rate. But if the patient is hypersensitive and even if they have a rash, once you give antihistamine and then you stop the infusion, you can restart it because always with N acetylcysteine, the benefits, they always outweigh the risks. Uh So you can start the treatment again. So it is not a contraindication. Uh If the patient has some hypersensitivity, you don't have to stop the treatment. You can give antihistamine and restart it again. But if patient has severe allergic reaction, uh severe anaphylactic reactions, then you may have to stop it and then you need to speak with the liver unit. So when do you speak to the specialist liver unit? So there's always a few, uh a few things that you should uh see before speaking to the liver unit. So if inr is greater than three, so you should always speak to the liver unit, irrespective of how much paracetamol patient has taken. And if elevated creatinine, and if this patient patient has evidence of opathy, but like patient is confused, patient is um irritated, agitated and very, very confused. You need to speak to uh uh liver unit. You can also check blood ammonia levels uh to rule out and then call the liver unit. And if uh BP is less than 60 if the patient is very, very hypotensive, that means even if you're giving patient IV fluids, that means you ha you are giving your volume, resuscitating the patient. But patient is still hypotensive. That means patient already has liver injury, then you need to speak to the liver unit immediately. And there is evidence of metabolic acidosis. If Ph is less than 7.3 even after you giving fluids, if ph is still less, less than 7.3 you need to talk to the liver unit. So basically the liver unit uh everybody calls is the King's College because that is the liver. Um because that is where the patients who are um who are, who has, who have severe liver injury. They might be the candidate for transplant. So they might have to be discussed with the liver. It registrar in King's College. Believe me, we have done that once and then uh we book a air ambulance and send the patient to King's Hospital then like as soon as possible. Um So I still have some time. I thought I would discuss a nice case with you about the paracetamol poisoning which we treated. So this is basically a 17 year old patient um who was under the process of gender transformation and he presented to Ed, he or she present, they presented to Ed after intentional overdose of paracetamol. So they consume 64 g of 500 mg which equals 32 g in total. Uh So based on whatever we have learned until now, if it's more than 12 g, irrespective of anything, irrespective of patient having or not having symptoms, we start treatment and but he presented with right upper quadrant pain and vomiting. So on admission, their paracetamol levels were around 128. So when we spoke about the treatment line, they presented even after 24 hours, they presented with 128. So uh at 24 hours. If the paracetamol level is five or four, then we stopped the treatment. If it's more than this, we, we start the treatment but his, the, their paracetamol levels were almost 128. So we were continuing with the treatment and it has been a staggered overdose. So his, uh, so as I said, usually paracetamol affects the liver usually takes around 3 to 4 days. So there was already a mild increase in his transaminases. So as you know, paracetamol usually affects the tran liver transaminases. Uh So there was already if um increase in the transaminases because he was taking a standard overdose over 3 to 4 days and their bilirubin was normal. Uh But inr was 1.1 which is OK. And uh they were immediately started on nar infusion and almost received six bags which means three bags in a day, the 1st, 2nd and 3rd bag and the 16 R bag was repeated on the 4th, 5th and 6th day as well. And we did a ultrasound liver, every patient who comes in with a paracetamol overdose. I forgot to tell you we need to do a ultrasound liver if they have symptoms to make sure that there is no acute hepatitis picture going on. But uh the ultrasound liver was normal and the bloods after two days still, the transaminases were elevated. So we thought the transaminases will reach a peak and then slowly come down as he has taken a staggered overdose. So his bilirubin level was 45. So when you see a patient who comes with a paracetamol overdose. Uh So the point to remember is the transaminases are quickly elevated, but the bilirubin takes a bit of time to uh elevate and then even while improving after the treatment, also, bilirubin takes a little bit of time to come down as well. So if the transaminases are coming down, but the bilirubin is still peaking, you need not think that the treatment is not working. Sometimes the bilirubin take some reaches a peak and then slowly come down and his uh the paracetamol level was less than 1.2 and Inr was one. So thinking that it has been, he has received six packs and his um paracetamol levels are ok and his inr is ok. We've stopped the NAC infusion. So after a while he was supposed to go home, but he did have symptoms. So we put him in the hospital for a few days until his symptoms has resolved. But there was a, we've kept checking his liver functions just to make sure that he is not ending in a severe liver injury. But there was a sudden increase in transaminases and bilirubin because his transaminases came down to around 2 100s which I did not put in this slide 2 100s and suddenly went to 1109 100 H. His bilirubin which was 45 before came to 200 suddenly. So uh the other doctors suspected that he was not only taking paracetamol but other illicit substances which would be like uh add on for the liver injury. But his paracetamol levels were always 1.2 because his overdose was a very, very stagger overdose two tablets here, two tablets there. So it was never visible on the um it was never visible on his blood that his paracetamol was this much in his uh system. And his full liver screen was normal. Full liver screen is basically we do a viral hepatitis screen. So we basically rule out everything. We rule out immunological diseases, autoimmune diseases, uh uh viral diseases and everything. And if all those are negative that uh then you can say for sure that this is because of paracetamol. So the full liver screen was normal. So we were still suspecting that it could be because of the paracetamol and they were started on NAC infusion again. We spoke to the liver unit of, of our trust and they have advised to start them on NAC again. Uh given his uh transaminases worsening again. So we started on NAC and uh we did try to rule out a few other causes for his uh uh I deteriorating liver functions, even when his ultrasound liver was normal, we had to investigate. So we went to his medical history. Uh and as we know he is undergoing gender transformation, he was taking something called azdone which is an OC pill. As we all know, oc pills usually causes uh um p like pulmonary emboli. It can also cause hepatic emboli as well. So we thought this could be significant because he was taking it for a very significant amount of time. So we did something called an ultra ultrasound Doppler in the liver and portal system just to make sure his portal veins and everything were patent and he had no clots. Yeah. But his ultrasound Doppler and liver system was normal. He had no clots. And after a while, the LFT S did not seem to improve. And we all, we all again discussed with the hepatology and royal of of our trust. So they advised to do act triple phase because the ultrasound which was done, which only showed about the hepatic veins but not the arteries. He can also have thrombus in the arteries given his long term c pills intake. And this hepatic artery thrombus can cause his deteriorating liver functions and his uh continuing up right, upper quadrant pain. And he also has a history of vaping which could cause which could put him on the risk. So the seated triple phase was done, which was also normal. So every like it was surprising that his liver functions keep deteriorating, but there was no cause except paracetamol and the transaminases level slowly came down. But the bilirubin was still high as uh I told you, b, Bilirubin takes a bit of time to come down, even with the treatment slowly, it reaches a peak and it comes down. Uh So um but, but the, but given his history and given his ups and downs in his transaminases, we were suspecting that he has a significant injury, but it is not shown on these scans. So we did a liver biopsy on him and liver uh liver biopsy. Basically, it was very inconclusive because in a patient with paracetamol poisoning, uh there would be necrosis of the liver. Um But in this patient, there was necrosis which was explaining paracetamol. But this patient also had very distinguished areas of inflammation which would not be due to paracetamol. So it was very surprising to see that. But uh his bilirubin and transaminases slowly improved. Uh So the plan was to do a deep tissue biopsy. Uh if the if the liver functions are not improving, but his bilirubin came down and transaminases also improved and bilirubin during discharge was 32.3 and transaminases was significantly improving. And then he actually went home. Uh And uh when I was telling you about the N acetylcysteine, this is the one we use. But now a few trusts are changing the uh protocol for paracetamol treatment or dose treatment. So there is something called a snap protocol which is new. Um But we are still following this. So if the patient is around 40 to 49 we take 6.8 g which will be the first bag and it is given over one hour, which is 60 minutes. And you can, this is the approximate dose that we use or we can calculate 1 50 mg per kg and give the nearest dose possible. And this is the second bag and this is the third bag and we keep repeating the third bag every day if you want to continue the uh treatment protocol. And, and I have already discussed about the G OS and we can also in a very agitated patient in alcohol overdose. We can also give, we can also try LORazepam instead of chlordiazePOXIDE or agitated patients. We can also give haloperidol like an adult dose of haloperidol uh oral or im sometimes patients are very, very agitated. You have to give them im to calm them down and not hurt themselves or not hurt anybody in the hospital. Mm So yeah, this is my topic and if you have any questions, I'm happy to answer. I'm sorry, I talk very fast. So this has been like a very small presentation rather than if people has any questions I can answer or if I was not clear with anything I can repeat. I hope I hope I have done, I have I up at least a decent presentation on paracetamol poisoning and that would maybe help you. Thank you so much. OK, guys. Um If there's no questions, I have sent the feedback form into the chat if you guys can kindly fill it out. Um Also our next uh CPD approved talk is on the 16th of October by Dr A on applying for specialty. So, details regarding that is up on our social media and you can also check out our grad scape me page where you can register. Also, we have an in-person B LS course that's happening on the 11th of November. There are few spots available um It's conducted by the first day Bulgaria. So if you are interested, please do uh register ASAP because we will be Hoing the registration soon. So yes. So if you guys can please fill out the feedback form. Also, when someone is finished with the feedback form, please can you write it in the chat so we can maybe end it for today as well? Ok, so that's it for today. Um Thank you, Doctor Barga for the talk and thank you to everyone who joined for today's talk. So have a good night and see you guys for the next talk. Thank you guys. Bye.