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Hello, everyone and welcome to our um session on Topology today. Um We've got San joining us again, so we want it to be very interactive. Lots of questions to be asked in the chat and we'll get through as many as we can. As always, your feedback form will be delivered in an hour's time to your inbox. Please fill it out so I can pass on your feedback to Sandra as well and, and then your um attendance certificate will be on your med account. Ok. So if you have any further ado because I know Sandra has got a jam packed session for you today, I'm gonna hand you straight over. All right. Thank you. Thank you, sir. Good afternoon. Good morning, good night. Wherever you are, this is good afternoon. Um It's a bit dry weather where I am in, in the United Kingdom, but really welcome again. Hope some of you who have listened to my trauma talk and respiratory emergencies are here. And if so welcome, welcome to the new uh attenders. Uh Today's talk is on toxicology and as you know, you know, it's a vast subject uh you know, toxins or, or drugs or substances. There are so many and each one has their own specific features of presentation and management, some generic, some specific. But so we, we have, we can't cover everything in details. I hope I'll be, I'll be able to give you a snapshot of some common approaches. Uh I think that's the word I'll use approach to um an assessment management of some of the common. Um and we'll touch on the, on the non common ones of, of, of, of the toxins um or, or uh uh drug overdoses or whatever. Uh What I can't cover is uh withdrawal of alcohol. That was one of the objectives. And um and, and so, so, uh you know, the general general objectives will be for you to uh enable you to, you know, learn and revise your knowledge, existing knowledge on how to assess how to approach, how to take a history, how to manage um uh AAA drug overdose or poisoning. Um We won't be covering the other poisonings, you know, the, the, the snake bites and the, the, the scorpion and the, we won't cover that. It's mainly substances. Ok. So specific objectives, what I'm gonna cover as much as I can in this uh next uh 55 minutes. Um What is toxicology? What is drug overdose? What is poisoning? They are interrelated but they have their own definitions. Uh But when we talk in emergency medicine about um about this topic, we mean drug overdoses or substance, overdoses, substance misuse as well. Ok, then we'll talk about, we'll see how you can assess how one can assess and manage the common drug overdoses. OD is overdose. Um, now a lot of the drugs that people present in the emergency department having taken an overdose, uh, they can be, uh, they, they can be treated with specific antidotes. So, these are, these are substances that will, uh, nullify the effect of the harmful effect. So we'll talk, we'll look into that and finish up with a bit on alcohol intoxication or alcohol poisoning. Yeah. And then we'll summarize and then obviously you'll have your uh opportunity to ask questions. So anyone who, what is toxicology, what do you mean by it? Any thoughts in the chat box? Anyone? Ok. Good evening. So, so anyone uh what is toxicology? Just uh a comment? Nope. Ok. I haven't seen any. So I'll move on. Uh OK, the study of poison, excellent Gloria. Uh So it is a branch of science concerned with the nature effects and detection of poisons. Ok. Uh Poisons. If you take the global poisons, it, it not only substances or drugs but it's other poisons. So, y you know, uh the poisonous effect of a, um, a gas that uh you know, ii if you, if you think of the, the, the carb bit, um, you know, uh uh uh leak the gas leaks or, or, or a snake bite for instance. And also, it consists, it, it, it, it comprises of the measurement and analysis of the potential toxins those substances produce and that can intoxicate uh in, you know, intoxicating or banned substances for instance, and even prescribe medications in the person. What effect uh that it's having on the, on the person's body? Ok. So that's toxicology. So, so if that's toxic, what is, what is uh drug overdose, then what do you mean that's what we see in the emergency department or as an acute physician or emergency physician? What do you, what, what is drug overdose? What do you mean by it? When does a drug ingestion become an overdose? Any thoughts in the chat box? Anyone for a one? Ok. So Nimi, uh, increased levels of drug in the body to the point it is harmful. Absolutely. Absolutely. Let's see. So a drug overdose is when you take too much of a substance. So, you've, you've got a therapeutic, uh, dose, isn't it that all of us know of each of the drug? I technical, if you take too much of it over a 24 hour period or too much of it at one go. That is drug overdose. Ok. Now, it could be prescribed drugs or over the counter that you get in the pharmacy, it could be legally taken or illegal. It could be, uh, taken intentionally or even accidentally as you can see. So the intentional ones are the ones who want to do self harm. So in those patients, remember you've got to manage the medical issue as well as the manage the psychosocial issue that led the patient to take the overdose. So uh involve the psycho, you know, psychiatrists and so forth. If it's a child, then there are some safeguarding issues that you've got to bring into place that and, and some, and discuss with the parents or carer as to why the child did it accidentally. Usually it's accidental but teenagers do present with intentional overdose. But if it's an accidental in a child, what can the parents do the carer do next time to prevent the happening? So maybe leaving the uh the drugs too accessible or leaving the cover loose so that they can because child and Children are inquisitive. Yeah. Excellent. Right. So then what is poisoning because the drugs if they're taken or substances taken above a certain level or those at one go over 25 24 hours can lead to poisoning of the body system. So any thoughts what is poisoning? It's good to understand these before we go into the depths of it. Anyone. So, Sneha says any drug more than the actual dosage. Absolutely. Right. Absolutely. Right. I think they are interrelated. Not, not huge amount of difference excessive beyond critical level. That's right. Uh So, so poisoning is once. So the, if you, if you look at that, that chap uh on the sofa, he's taking too much of alcohol to the point that it's caused toxic, toxic symptoms and signs in his system and that lead, that's what we call poisoning. So uh illness or injury or even death caused by any substance that is harmful to your body and, and you know, you don't have to take a certain amount of uh dose or an amount. Um So, so says the chemical reaction occurs after any drug overdose. Yes. So that's what we call poisoning, the illness effect, the injury effect, injury to the organs. Yeah, uh or even result in calamity. So with that in the background, um what what I'm going to say here is the the poisoning or overdose or toxicolog toxi toxicological emergencies, whatever you call it. Uh We said it before, intentional or accidental and the substances are wide ranging. Ok. Very difficult to cover in one hour topic. And what it does is as physicians or emergency physicians, they pose to us a unique and urgent challenge in the emergency medicine department. Yeah. Why is the challenge because we are faced with the situation where we go to provide effective and efficient and quick. Yeah, assessment and, and and recognition. So can you see I put assessment first because assessment is I if you heard a few of my talks, II am absolutely obsessed with the primary survey of ABCD way of assessing. So that is important because you want to save the patient then comes once you've saved the patient then comes recognition, what have they taken. And that has a lot of other questions that you've got to inquiries you've got to make because patient may not be a fit state to tell you. Yeah. So, uh, you know, um, carers uh or, or relatives, et cetera. Um and then uh put some specific management in place. Yeah. So what we're here to do is what you are here to do is to imbibe or enhance your knowledge and skills. We need the knowledge and skills. That's what we are here to do to provide that efficient and effective care. Yeah. Ok. So, so what are the consequences of a drug overdose? You know, what can a drug overdose do to you to, to a person? Any thoughts? So it can cause serious medical complications. We know that the clinical features and it can cause death. So what about severity? You know um what, what, what factors uh determine severity of a of a drug overdose? Any thoughts? What makes mental status hampered? Yes. Ok. So that's one of so all the system can be impaired. So respiratory depression or heart rate. Yeah, cardiovascular system either depressed or exaggerated. Ok. Level of consciousness, de depressed, et cetera or temperature either down or hyperpyrexia, that kind of thing. So medical complications and and and also death. Yeah, respiratory rate uh I can breath. So severity depends on the drug, what drug it is, how much they have taken, how much they have consumed the amount that they've taken and also depends on the background of the patient. So the medical history of the patient as opposed to somebody who's fit and well, no medical conditions, as opposed to somebody who's got medical problems, they can be enhanced, the severity can be enhanced. Yeah. So uh I can see g saying, flushing respiratory rate. Yes. AGA says type of substances and amount taken. Absolutely. Spot on blindness is another feature. Yes. OK. Now, then can you think of some risk factors uh that can uh you know, perpetuate or enhance the drug overdose? Some risk factors, dryness here. Another feature depending. So, you know, uh cholinergic uh anticholinergic like substances can cause dryness. Yes. So the risk factors um I'll wait probably another minute, see if anyone says anything. The risk factors for Children, accidental overdose are storage. Um ok. Cardiovascular history is important hypertension. Ok. Says Nimi says cardiovascular history is a risk factor. Ok. So, so risk factor, no, what I meant is risk factor from the consume uh cons you know, consuming the drug overdose. So let's say storage, as I was saying in Children, if the storage is a risk factor, are you keeping it to accessible to the child or you're keeping the bottles which are not, you know, nowadays, there are child protected or safety uh covers on the bottles. Now, uh dosage instruction. So one of the things is the dosage, if it's not written properly on the medication that can lead certainly older people, um, confused as to how much they, they can, they can take. So instead of taking one tablet, they can take two. Now, if you're supposed to take 13 times a day and you take 23 times a day, that's an overdose. Technically. And you've got to deal with it. Yeah. Um, now the other risk factor is, is, is, is the patient misusing a particular drug uh uh or, or addictive to a particular drug uh or history of mental illness. So he history of mental health uh can perpetuate uh as a risk factor to, to, to, to, to, to get the patient to take the drug overdose. OK. So says easily accessible. Absolutely. Omon uh says depression. OK. Move on now then. Uh so poisoning, as we said, no drug overdose, let's, let's, let's whatever it is. Yeah, we, we, we can, we can call it, how does it happen? Uh how does it happen? Uh And, and we II think I won't spend too much of time because we said either it's accidental or intentional. Yeah, or it can be as an assault. So uh very, you know, somebody can actually cause a body assault by giving overdose. Yeah, or mixing something in a food for instance, that that acts as a poison. Yeah. Homicide. Yeah, that's correct. Absolutely. Now, just throw some statistics here. Um from 2019 to 2010. Very recent drug overdose deaths grew by about 4% nearly and the deaths are more in men than women. As you can see, roughly half 50% lower in women. And in terms of what drugs resulted in the deaths, as you can see, nearly 50% are from opiates. So what are opiates like, you know, heroin, morphine, et cetera? And there's been a about a 5% growth in that uh you know, opiate consumption and leading to death. But also a, a percentage was from cocaine use, which is used as a, as a street drug or, or misuse drug. Um and there's a growth of 9.7%. So these are the two drugs that are seen causing deaths in patients. Ok. Uh a bit more stats uh sort of the small print, uh you know, about nearly 5000 deaths were related drug poisoning that was in 2021 in England and Wales, that's very recent and about 84.4 deaths per million. That is that equates to and that's 6.2% higher than it was in 2020. Yeah, again, male, compared to female as you can see uh roughly twice in terms of drug poisoning deaths in 2021. Uh and in terms of numbers, you can see about 3000, you know, drug misuse. Uh and half of all drug poisoning deaths are registered were opiates. So this is statistics from England. Yeah. Uh about 50% opiates and cocaine. Uh about 8.1%. Ok. So we need to have knowledge of recognition, assessment management of these are two important, not all of it, but these two key drugs because we see a lot of patients being brought in, found on the street collapsed, having taken heroin. And they come really in a, in a very clapped out unconscious state. So, uh can you think of the drugs that are prone? We come to drug overdose now. Um any what drugs that you're aware of that are prone to be taken as overdose? Any thoughts? What drugs have you seen in your, in your, in your clinical practice? Some common, some not that common morphine. OK. Opiates G one says good contributions even. Thank you. OK, Angeline paracetamol, the commonest drug that's taken as an overdose in self harm. Little proportion accidental. I, I'll come to that. Ok. Melica uh deleted the answer. OK, let's move on. Let's move on. So I've, I've got some drugs. So cardiovascular system, drugs like beta blockers or aspirin. Ok. Monta Dados diazePAM, Benzodiazepines, I'll come to that in a minute. I've gone in alphabetical order. So cardiovascular drugs, beta blockers, digoxin. Yeah. Um those who are on digoxin can take over dose of digoxin. OK, beta blockers. So those are hypertensive taking beta blockers. Yeah, I think if he says paracetamol against ethyl and Glycol M is aspirin, paracetamol. Yes, antipsychotics. So mental health patients or those who are not known to be in the mental health service. But, uh wanted to do self harm. Now, self harm means they want to kill themselves. Yeah. As part of suicide attempt, they can take another common drug is antidepressants or antipsychotics. Now, the common, at one point, antidepressant tricyclic antidepressant TC was very common. Yeah. And they used to kill people patients. But now with the advent of the SSRI S, the serotonin reuptake inhibitor drugs uh are the the side effects are less common. Patients still take them. Um And, and you know, there's no antidote but one of the worries is cardiovascular side effect uh of of tricyclic, we still get some tricyclic antidepressant overdose, paracetamol. No question, the commonest overdose. So majority times is self harm. But you know what the when, when the patients arrive, uh when you, when you go into the depths of the history, they, they, they haven't taken and the fact that they haven't taken enough and the fact that they've seek sought help means it was more than often a parasuicide or attention seeking rather than actually wanting to kill themselves. Nevertheless, we have to uh you know, be careful in, in treating them. Now, how can they take accidental paracetamol overdose? So, patients who are in pain are taking paracetamol and they want to get rid of the pain and instead of taking uh you know, uh 42 which is 1 g uh over four times a day, uh 18 in the 24 hours, they take every two hours, they take two tablets and that's an overdose. What we call is a staggered overdose. So overdose can be taken as one go. So a tablet you take 100 of them at one go. That's an overdose or if you take staggered. So you know, in, in, in frequencies that is not recommended, that's an overdose as well. So G says chest pain, depression consumption or Moro. Yeah. Ok. That's old answer. And another common drug aga again, analgesia is salicylate, what we call aspirin, who some, some of you have said now salicylate also can kill. But what salicylate does is again, there's no antidote but it delays the gastric emptying. So when we talk, when we come and talk about gastric decontamination, uh there is a role of gastric lavage in uh in, in, in, in salicylate poisoning now and, and, and one of the things to treat the blood levels of the paracetamol salicylate are, are absolutely key. So has chronic pain. Yeah. Ok. Uh insulin. Uh those are diabetics. Uh they often take insulin too much uh and they present with hypoglycemia. Ok. And all you've got to do is identify that make sure ABC S are OK and give some uh dextrose. Yeah, or glucose. Ok. Drugs of abuse. So some, some of you have mentioned heroin, benzodiazepine, I've mentioned benzos. So benzos uh or diazePAM uh you know, LORazepam, et cetera. Uh heroin, uh as you know, can be taken intravenous or, you know, the drug addicts take it all over the place in, in, in the veins, in forearm, in the groin. So much so they've been taking, they can sniff it. Um uh and, and cocaine as well. You know, you can sniff it as well. Amphetamine and GHB, that's carbo hydroxybutyric acid and, and quite a nasty drug can result in respiratory depression to a point that they need invasive ventilation. They need intubation. Uh, and, and then ventilation. Uh, that, that's, that's how serious it can be. Ok. Now, in certain, certain countries, certainly developing countries. Uh, and I'm from India and I've seen farmers commit suicide using pesticides. They use pesticides during, uh, for farming paraquat of that. That's, that's, but it's got a nice antidote called Fulla that can be used. The other drug that I mentioned is carbon carbo, uh, carbon monoxide and, and especially, uh, you know, where there's faulty heating or there's a fire or those who commit suicide, uh, using, uh, you know, the car exhaust fumes, uh, putting it into the, into the, uh, car chamber, um, that can cause poisoning as well. And especially inhalation, injury of smoke can cause co poisoning. And the, the basis to treat is by getting the COHB level done and you can do it through a venous blood gas. You don't need arterial blood gas and you look at the carboxyhemoglobin level and uh the higher the level, the more the symptoms and all you need is oxygen. Um sometimes if it's severe um level and the patients are, you know, unconscious or having seizures, then they might need hyperbaric oxygen. And there are certain centers that you can send the patient. Ok. Ok. So now that we know some of the drugs that cause overdose, can you think of some symptoms? Now, you know, just generic symptoms, what patients can complain of what they present with in drug overdose? Any thoughts and then we'll, we'll see. Wait a minute, palpitation. Yes. So, drugs that act on the cardiovascular system can either raise the heart rate causing palpitation or depress the heart rate causing bradycardia. Excellent va N says dilated pupils. Yes. So those who are those anticholinergic drugs, sympathic peoples or heroin or, or uh opiates can cause constricted people? Yeah. Ok. So drowsiness, depressing of the level of consciousness. So alcohol, for instance, bradycardic vertigo. Yes. Vomiting, nausea, vomiting, abdominal pain, excellent montosa, vomiting, headaches, nausea, vomiting, fatigue. Ok. Uh I'll, I'll move on because, um, I think you've said a lot loss of coordination. So, uh just I'll come back to this. Ok. Here you are. So range of symptoms and some are generic and some are specific uh to the drug that they have taken. Now, I do not have time to get go to individual drug and describe the clinical features and management. So, nausea vomiting. Those who act on the gi system can cause and vomiting is good because they, you, if they are still in the stomach within four hours or you can institute or inside vomiting, you can get the drug out. Ok? L OC loss of consciousness or depression of Glasgow coma score is when or drowsiness as some of you said hypoglycemia. Yes. Um If, if it acts on the oo on the central nervous system, ok. If it acts on the respiratory system can cause breathlessness, like uh you know, opiates, they can stop the breathing. The patient can go into respiratory arrest where you have to uh might have to uh give them either protect their airway or assisted ventilation. But the magic drug called Narcan, as soon as you give it, you can give it im or you can give it IV. The patient just, you know what we have seen is patient just wakes up and rips everything, uh IV access and everything and then runs. Ok. And, and that's the downside of it. So you've got to, you know, be careful of that ataxia. Yes, in coordination. Again, acting on the central nervous system, agitation again, you know, central nervous system, either you can depress it or it can, especially the uh the street drugs, the amphetamines and the cocaines, they can cause agitation, aggression and violence. Absolutely alcohol at different levels. So from uh the, the funny behavior to a feeling of um nicety to uh slowly becoming uh lo lowering the G CS and becoming comatose um dilated peoples. You've said tremor. Yeah, seizure, some drugs cause convulsions and hallucination delusion especially the, the, the street drugs. Yeah, the amphetamines, uh the cocaines right now in terms of initial assessment, uh you know, II was going to ask you but you know, uh time doesn't permit me. So be when you confront a patient with overdose, the first thing to do is initial assessment based on the ABCD, you, you know by now, OK, you assess the airway, you make sure it's open and the drug to give at that airway point is what, what drug to give it's freely available and you give as much as you can absolutely high flow oxygen, 15 L per minute and then you move on to b OK. Check the respiratory rate, uh check the saturation because if the depressing the level of consciousness can lower the SS SATS. Uh you know, do you need to, are they causing any problem in the breathing bronchospasm? For instance, uh that I need to treat, then you go to see you assess, are they in shock? Some drugs can cause shock. So if they're tachycardic, they are cold, then you start the shock therapy, you get access. Now tell me what bloods would you take? It's very essential in an overdose management. You get some bloods and what would you send them for? A and when you're putting a cannula. That's the best time to take the bloods out. You got some routine which I know people will mention. But there is some special blood arterial blood gas. Yes. If it's causing, if it's causing respiratory depression, yes, you need to know the acid base status. Venous blood gas is very important. That will tell you because some drugs cause like aspirin can cause metabolic acidosis. Uh so venous blood gas is is important. Uh Yeah. Ok. Sneha says VG electrolytes. Ok? Because sometimes can cause uh you know, renal function, depression, liver function, depression. So FTS liver function test toxic screen. Absolutely. This is the special test. Amon says you've got to send bloods for toxic screen and the two common drugs we send certainly in UK is paracetamol and salicylate because if you get the levels back, you can treat it based on the levels. Ok? Um So that's c now remember as part of don't, don't forget monitoring of the patient and cardiac monitoring is essential. Get a 12 E CG done because some drugs can have an impact on cardiovascular system and can cause arrhythmias. So tricyclic antidepressant or digoxin. So you need to know the rhythm. Ok. So that's important and then start the fluids and this fluid that you start doesn't matter, crystalloid, small amount, not massive. Yeah. So 500 mils a warm crystalloid and you start and then uh other drugs that you can think of at the same time. You know, if it's hypoglycemia, give some glucose or Narcan or uh flumil antidote if it's benzodiazepine, that kind of thing. Ok. And the, the thing not to forget is blood sugar. So get a blood sugar done and, and treat it. Ok. We talked about I IV fluids once you stabilize the patient. So DGC S think that is the Glasgow coma score depressed because of the drug they have taken. Now some drugs can cause problem in the, in, in, in, in the brain or is it a AAA another uh effect of o of uh another medical problem? Think, do I need to do a CT scan in terms of e make sure if they are cold, maintain um you know, uh a warm environment. And then, then the next thing to do is to think if they are presenting within an hour, uh think about gastric decontamination. I'll come back to that in a minute. And also then to think is the drug that they've taken has got an antidote. Now, in your department, there should be a cupboard that stocks the standard antidotes and, and you've got to find that out and, and some antidotes you might have to get from Regional Center, unfortunately. Yeah. Ok. So we talked about initial assessment. Uh OK. This was another bit of stats basically saying the rate of drug poisoning continues to increase and the deaths have continued to increase. Ok. Now, just a word on self poisoning. This is self harm where the pa the patient has taken a, a drug to kill themselves. OK. Now, in terms of types, uh what I meant was um that they can have a mental health problem or may not have mental health problem or it can be recurrent, OK, dynamic presentation because they can keep coming back. Ok. Uh and, and these can have all sorts of common system problems, involvement, cardiovascular, respiratory, central nervous system, hepatic renal metabolic are less common, but those key systems are important. Ok. Um What, what, what, what you know, can you think of drugs that cause self poisoning? I think the ones that you've named already, they, all of them can cause self poisoning. All of them can be taken uh as self harm drugs. Yeah. Ok. I think this is just to uh you know, elaborate which I we've talked already high flow oxygen, uh you know, breathing and ventilation circulation. Um not forgetting you somebody, some of you has mentioned toxic toxicology screen but some drugs like the opiates or other metabolites can, can be seen in urine. So it's good to get a urine sample. If the patient is unconscious, stick a catheter in to monitor the intake output fluids, but get a urine sample, monitor the temperature important, especially the hyperthermic. Then you might have to think of another drug. There's a drug called Dantrolene that might need it for hyperthermia. Uh check the pupils. So uh low G CS constricted pupils is uh potential. E even if you don't know the story because the story takes time to filter. You haven't got evidence in the patient's pocket or something. Uh then think opiate and give. Um now paramedics already prehospital, they give opiate, they are allowed, they, they are authorized to give, but you can give as well. You can give up to, you know, uh you can get 400 mcg of IM or IV uh uh NARC M and you can go up to, you know, 1.2 mg, um uh pupils can be dilated as well. Um There's nothing specific for that, but then think of the drug that causes it. Um uh we talked about blood glucose if they are fitting, then treat as its status epilepticus. That's a different topic in itself. So give the uh benzodiazepine, then think of other drugs, ok. And then gastric decontamination, which will come in a minute. Now, this is important uh that wherever you're in the world, this is an online poisons information uh resource that you need to get subscribed to. Your department needs to subscribe to talk space information, you need your password and your username. So if you, so somebody while you're managing, somebody's getting that information and print it out and have it in front of you while you are cross checking the patient's symptoms, signs and management plan. It's evidence based, it's updated regularly. You can blindly follow the talk space info. I do that. I would strongly recommend you do that as well. Ok. So now the patient is stable. Ok. You, you, you sort of know what the drug is uh but you want to take some more details, isn't it? So what kind of history, it's a specific history, um you know, type of history that you need to take in terms of uh overdose. What, what kind of history would you take? Any thoughts before I move on about the drug concern? Any OK. Any background, psychiatric history. Excellent Agathia and GVA. OK. Regarding the drug itself, any, any questions, how many pills? So how many risk assessment? Ok. Any prescribe anything else you've taken? Are they prescribed or have you brought it over the counter? OK, let's move on. So these are the specific history because to know to get to know more information, you need to ask this question, what have they taken? Let's say you don't know, patient can tell you or if they don't tell you, they don't want to tell you, then you find it out from other sources. So uh relatives, you know, paramedics, if they can find some information, uh somebody who's a company, how much they have taken? Absolutely key to get to measure their toxic level and, and the toxic based information will tell you at what level, what dose level and, and the doses are calculated per kilo body weight. So it's essential either you measure the body, body weight of the patient if you can, if not eyeball, get an estimated body weight and calculate mg per kilo body weight. Yes. Uh Lula says when, so when have they taken? That was the next question because the time from take ingestion is important which especially in paracetamol because the blood level that you get, you plot it on a chart which I'll show you and it'll tell you, um, you know that that information is absolutely key. G says checking pockets of patient might give some info. Yes, uh bracelets, checking in uh pockets and why have they taken? That's, that's a question really for later on by the mental health people. But you can ask, you know, very gently, why have you taken uh truly self harm or have you taken it before that kind of thing? Have you taken it? Sometimes drugs are taken with something and the commonest drug that's taken with another drug overdose is alcohol? Yeah. Have you taken alcohol? How much you've taken, et cetera? Is there a concomitant alcohol intoxication as well? Then ask the symptoms, which we've talked about and, and just dwell. Is it a recurrent because the more the time they have taken, the more the lethality increases, the more chance of them really succumbing to the overdose? That's important. So those questions are key says, I in regards to what drug? Yeah. OK. OK. We, we talked about decontamination we mentioned. So uh what, what is the aim of de why do we need to decontaminate? And what does decontamination mean? Any thoughts? Any thoughts? So what does the contamination do? What are you trying to do here to take out the, take off the clothes? Ok. Fair enough. So this is the pa this is usually if they have taken, if they have ingested the drug, if they've taken intravenous or, or uh that won't work. So Mohammad Shafi says uh absorption of the drug using charcoal, that's one way excellent neutral. So what you do is your, you, your, your aim is to bind or remove the ingested material. The drug that they've taken before it is absorbed into the system. Yeah, into the circulation and, and, and then you're able to exert its toxic effect. So, before the drug gets absorbed into the circulation and exert its toxic toxic effect, you want to get it out of the, out of the stomach. Yeah. And you're using substances that either will uh and, and, and what are the types? Any, any thought? What are the types of different decontamination? I think you said gastric lavage uh or charcoal. So, charcoal is absorbent, gastric lavage, you lavage the with the tube inside the stomach and wash it out. So the drug mixed with water will come out. Um uh gastric emptying. Ok. Uh And Choses is choses is, is en ensuring uh uh how shall I say stimulating um uh lax, what laxatives. Do you know passing it out to the other end? Ok. Now, when is the greatest benefit? When would a gastric decontamination work based on evidence? What is the best time to, to give it any thought within one hour? G one says, absolutely spot on. If they present within one hour, if they present within one hour, try that. If the patient is unconscious, then you can intubate the patient protect the airway and then insert the and give them charcoal by a nasogastric tube. But airway needs protected. That's important. If they're conscious, you can let them. Now, sometimes the charcoal is mixed with uh uh uh uh uh uh uh flavor, especially for ice cream and you know, other, other drinks, especially for Children. If they present after one hour, there's less benefit. We don't use it unless they have taken a drug that prolongs or delays the gastric entity. So, uh you know, Aspirin is one of them salicylate. OK. Bowel irrigation. Not really bowel irrigation. It's CSIS. Yeah. OK. Excellent. Well done. Activated charcoal. Some of you said so activated charcoal, you have to calculate the dose. Uh standard is 50 g. Uh You can mix it with things to make it palatable. And in Children, you've got to get a lesser amount. OK. Now, antidote. So, so you're given gastric decontamination, you've stabilized the patient. Now, you, you know what the drug is and you have to think, oh God, have I got an antidote to that. So can you think of some antidotes of common overdose drugs? Any thoughts flumazenil for benzodiazepine? Mohammad Shafi says excellent naloxone for opiates. Mohamed Safi said says naloxone again. Brilliant. OK. I'll move on. Thank you for interacting. Um OK. N AC Yeah for paracetamol, naloxone amet says it says paracetamol acetylsalicy dig for digoxin acetylcyst acetyl cysteine protamine sulfate with K for uh yes, anticoagulant warfarin for instance, a one says Glucagon. OK. Right. So atropine like substances, anticholinergic that causes dry skin, dry eyes, et cetera, pupil dilated pyro P I think I apologize for the spelling wrong is pyridostigmine you OK. Benzodiazepine flumazenil. Now remember flumazenil is not advised if they've taken a co cocktail of drugs. If they've only taken a Benzo fine, if they have taken a cocktail, don't give flumazenil that can cause uh a different effect. Cyanide is, is a, is a really horrible drug. You, you shouldn't be touching it coming in contact. EDTA Dicobalt is the is antidote. Some of you said d digoxin is af fragment the dan uh insulin dextrose. Of course, iron is another common overdose that sometimes we see. Desferrioxamine is the drug to keep in mind. Iron is another drug that blood levels help because and you got to repeat the blood levels to see whether the antidote is working. So lipid is for local anesthetic overdose overdose means you've given it too much in terms of intravenous methylene and ethylene, glycol alcohol. So these are like antifreeze if they have taken, you give alcohol. So we have alcohol in the department. Organophosphate. So these are the pesticides, atropine or flua. We said opioids, naloxone, some of you have said and para n acetylcysteine is a commonly used antidote. But how much you would use? There is a nomogram that you use based on the body weight and you start with a heavy dose and over quickly and then you slow it down with a lesser dose over 24 hours tricyclic antidepressant. They cause a broad complex tachycardia. They cause metabolic acidosis. Sodium bicarb is the 18.4% warfarin Vitamin K You said that OK. And, and again, you know, there are others which we haven't mentioned but we, we, we we haven't got time to go through all. But those are some of the common ones. Now, now some of the drugs, as I said before, the drug levels of the drug in the blood system can help you treat. So any thoughts, I think you've got some idea by now already we've been talking about it. Um which drug blood levels will help any thoughts? I know who will answer probably. But anyone one answer and move on, you're nearly there. Paracetamol. Muhammad Shafi says absolutely spot on. So here you are. What is this line? What is this, this is a treatment line for paracetamol OD. Yeah. And this is universal treatment line and you can see this graph, you need to plot the level and it, uh, and it starts at four hours. So if, if at four hours the, the level is 100 it's on the treatment line. If, if the level is on the treatment line or above, you treat it, if they are below the treatment line, you don't treat it. Now, if it's just below, you've got to have a discussion in your department. Do I treat, do I not treat? Ok. And the longer you take the, the l the bloods lev the blood levels, the lesser the blood level is and less chance of toxicity, of course, because it's wearing off. But that drug, um II that, that chart is so important in paracetamol. Uh and, and then you prescribe the N acetylcysteine. Ok. So that um covers, um I think that's all I have to say with drug. I'll just spend some time on alcohol poisoning or alcohol intoxication. And, and the FMAX we have is either ethanol or methanol or Ethylene Glycol. Ok. Now I'm not gonna touch withdrawal. We do get patients with withdrawal symptoms. It can kill patients about 5%. And the one that we worry about with patients with encephalopathy. Yeah. So these are chronic alcoholics who have suddenly stopped taking alcohol because they want to give it up, but they can't just stop it and they get a withdrawal same if they, if smokers give up, give up smoking suddenly or opiates. Those who are on morphine, they suddenly stop taking morphine, they get withdrawal symptoms as well. Yeah. And, and with all patients have all sorts of symptoms, we have alcohol team who come down and discuss the treatment and management plan with the patient. There are specific treatment, uh, that you can give vitamin, uh, you know, thiamine, for instance. Yeah. Now, ethanol to treat blood level is important. Now, it depends on how much alcohol they have consumed, the patient has consumed and, and the blood level reflects that the symptoms reflect again how much alcohol they have taken. Ok. From uh, your uh, um, um, a happy go lucky type. Um, feeling to uh, drowsiness to lowering of G CS are unconscious, start starting to uh, starting to having seizures and can cause death as well, especially if they vomit with low G CS, unprotected airway and they aspirate. Yeah. One of the things you got to find out what have they co ingested. Have they co ingested anything else? Any drugs, then you have two problems to deal with if they have taken alcohol. Ok. Now, if their gcs is low, then they are prone to develop to, to suffer injuries. Yeah. And w what is a common injury that alcohol intoxication patients can suffer? And that can add to the problem any thought. And we see a lot liver failure with paracetamol. Yes, head trauma. He says that's the one I was looking for. Excellent Now, ii, if you've got a head injury patient, this is something to keep in mind. If you've got a head injury patient who's taking alcohol and a low GC, consider all the symptom signs uh from the head injury, not alcohol, it may be, but the safe will be to consider they are from head trauma. Do a CT brain scan if the CT scan is normal, start treating the alcohol intoxication. Now remember alcohol can kill. So it's a poison, it can be become a poison if taken. You know, it's not a poison, it can become a poison if you take it if you consume too much beyond the, beyond the safe limit and, and, and they need admission sometime observation, they, they can cause liver failure. Yes, Mohammad Shafi, you're right. Just like paracetamol. Ok? And that's why you need the liver function test doing and, and uh monitoring them and then you might have to refer patients to liver units as well, special units and, and not only head trauma, other injuries can happen, you know, they can fall, they can break bones, fractures, you name it, but also alcohol can, you know, facilitate uh fighting and, and and and fights and assaults. So a lot of patients come having been beaten up or assaulted on and sustaining injuries, some minor, some serious. So you've got two prong problem if they've taken another drug, that's two problem. If you, they have sustained an injury, you've got three problems to deal with. Safeguarding is when, uh, alcohol leads to assaults within the domestic situation or in a child. So the child has consumed alcohol left in a bottle where mom and dad or the carers who are looking after a are not looking after them properly. They are supposed to look after they have got drugs around alcohol around so serious safeguarding issues to keep in mind. Yeah. Know that the way they present in terms of signs and symptoms is seen as depression. Ok? And, and I'm coming to the end of my, my, my talk. Um So what I'm going to do is just summarize what we've done is delve into, you know, what is toxicology? What is drug overdose and poisoning? We've discussed uh interactively with you all and thanks for cooperation, how to assess and manage common overdoses. We talked about antidotes and some alcohol intoxication. We talked about decontamination as well, gastric decontamination and that uh so G one says agitation aggregation due to alcohol, of course, of course. So that leaves me to pass on to sue any questions. Thank you so much for listening. Hope you found reduced. So, have we got any questions? Oh Mary says, could you please show the slide on antidotes again? OK. I'll go back. OK. So this is the list, one list is here and the second list, these are the common ones. Oh, that's OK. I'll leave it there. Uh Thank you. Thank you for all the comments. Can you? Ok, dad. Sorry, sue. I'm I'm taking over for you. No, no, you go on ahead. Like I said, you do have a job soon. Carry on. So dad says, can you recommend literature where we can find the treatment of specific poisoning? Yeah, I mean emergency medicine textbooks, emergency medicine textbooks. That's the resource I would recommend or go online. Uh Thank you. Thank you everyone. Thank you so much for your thanks. Anyone else? Any questions? Thank you. I know it's going to be appreciated. Right. Yes, absolutely. Absolutely. Ok. Mohammad Shafi says any treatment for Nova overdose uh What is uh Nova means Nova. Ok. So uh so no a uh are the novel oral anticoagulant agents? Is thean, the Rivaroxaban? They have specific antidotes that you can use. The, the Vitamin K that you use for Warfarin. They won't work. So you've got to speak to your, your in your department to see what has been agreed to keep as an antidote. The product information also talks about antidote. Yes, there is, there is specific antidote. G says it's saddening that there is a rise in the poison cases. Yes, it is sad. It's a sign that the society we live in has to be sorted. It is, it is. So prevention is what we need is to sit and talk to the people who have taken the overdose as to why they have taken. That's why just medical treatment alone is not enough. That's why you need the psychosocial aspect. Now some patients will say sorry, I'm leaving and unfortunately they've got medical capacity, mental capacity, then we can't keep them out of, out of by force. But most of them, they, they wait to speak to a psychiatrist or psychologist to delve into the because they have, they can, then if the patient's medical treatment is sorted, uh they're medically cleared as we so to speak, then they can spend their time talking and hopefully prevent it. Good point. Even any other questions. Has anyone typing away? Um Like I said, as always, your feedback form will be coming to you in eight minutes time and then you can fill it out and you'll get your attendance certificate. Here we go. We've got another question. If York says, uh do we still need induce M SMS means inducing vomiting in certain cases of accidental injection in adults? If you're the only, um we don't use it anymore. The, the two standard gastric decontamination we use is either activated charcoal, which you can use in most of the overdoses or gastric lavage where the gastric ing time is prolonged like salicylate. But um we don't even use vomiting, especially if the GCS is low because you're going to uh you know, risk. Um um uh What shall I say? Um um inhalation. So Mohammed Shafi says, uh oh, thank you, sir. Thank you. Thank you. You're welcome. I think that's us. Ok? I don't think there's um many more questions coming. Anyone, any more questions for us? Thank you for giving this opportunity, sir. Thank you. No, no, we uh we love it, love it and you can catch um Sandra's other events. If you go on to medal, I'm just going to share our med education link for you other um catch up on, on that link there. So by all means, do take a look at his other uh talks, his trauma talks is getting a lot of views. You do get a certificate. It's your feedback form. It'll be in your inbox in about six minutes now. Uh It'll be in your inbox, fill it out and then your um attendance certificate will be on your medical account. You can download it or you can print it what a wonderful opportunity to reach out to the global people, you know, global learners all over the world. Brilliant, brilliant, right? So we're gonna let you go now everyone uh and have a lovely weekend. Ok. Thank you so much and we'll see you at another medical education event. Take care. Thank you.