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Okay. Back to myself. All right. So I am going to do a stent on tac syndromes employees, and there's no way In 20 minutes, they give you all of this, but I'm going to give you some. There's a few nights four times in the background just to keep you awake at this time, the evening and you're recognize that one muscle. Then if you haven't seen, Do go. Okay. Okay. So what are we gonna cover today? We'll talk split into two. Like I say first, most Oxytrols, we'll talk about some basic principles of management. We look at a few vacatur on. That's for me, Really. When we look at the risk of what comes through cause really, somebody's around here and serotonin syndrome only because in many cases, I After Ghanikheil, we have a I'm going to play and hard happens. And our patients, we need to be more mindful over the second one. Look at Saturdays because that's a most common presentation off overdose is that we get because I cholinergic anti cholinergics are parasympathetic have fallen off of this. Only Julie Constraints of time. Maybe if I behave needle invite me back. We'll give you a moment and second have the talk will be poisoning. We're gonna talk a little bit of a paracetamol, the most common one of the most deadly overdoses within the UK A little bit. But it's not critical calcium channel blockers and be the blockers. Only because we have very good treatment modalities. We see them, they are sick, but they are salvageable. And then I was really king. They include some off the junk. So we have so activated charcoal on intralipid. So and why am I giving you this talk today? Well, you saw my expertise with the defense earlier on, but I cannot say that I'm on expert by no other fact that I have made all them stakes that Artemis extra. You can hopefully dodge the mistakes. I mean it and you'll be in their obvious mistake on the screen. You can spot it. Carl's jumping up with nine actually going left after all, right, Carl, it's not just it's not just the my child. It could be a woman who's an expert. Absolutely. In fact, most experts are feeling okay. I just thought it would have to show you this because the surface is pumping on east on west on poor bone trail White rocks today on course, dear Johnny tells me is, well, the surface happening. So I just, you know, I love you guys so much. I'm giving up surfing. Okay, here we are. Principles off management when it comes to toxic. Very simple. Very basic. Highly effective. You find yourself stand on the bile of a mixed overdose. This is what your human for. Okay. I don't expect you to know the ends of nights of malignant your elastic syndrome. Do you expect all our staff to be under provide this level of care serotonin syndrome that started off to try out okay on. There's a recurrent thing when we come to sedation here, but see and ask disturbance. These patients are agitated. They they have acute behavioral disturbance. It's autonomic dysfunction. They're sweaty. They're talking, Kartik, they're people. A rechange is two left more last degree. We'll talk about that Saturdays. They tend to be hyper stimulating it on the also in your muscular excitability. Okay. Clonus of agitation on, um, levels of clonus that will feed into that will Kachemak lungs particular syndrome in a minute. If you see serotonin syndrome. And I would put it to you that everybody in this department has seen it. My question is how we recognized it. Because when you look at the kids report, so you look at the literature about high Sierra told them, Single comes a bite. It's two or more agents. Think about your last evening shift. Did you see a patient with potential cocaine with amphetamines? He was taking an SSRI Or and I says, and I where there's some recreational, other recreational drugs on board that they have left them where the anti ch that's quite a large proportion of our patients will be on one or other of those. And then when they arrive with us in the what we often give them well, some of the clip the typical drugs would be on dansetron Met Phantom. No, not a clue. Promide sumatriptan, tramadol thes in the big head er items off second agents in relation to serotonin syndrome. So please be mindful about the medication. Both your cation your patients are taking as a baseline before you see them on. Also in conjunction with what medications are you going to give them in the evening? because these are the people that are going to run the serotonin syndrome, the two or more agents, and often that second engine is given by one of us in the in the evening. And there's a lot, but it is a nice little better worked on, and there's references of the end if you want to look it where this comes from. But it's a great couple of papers done looking to see her tone in syndrome and put it on spectrum. Really? So for my moderate to severe like threatening and these are some of the things that come up, you'll notice there that Clonus appears twice on the serotonin syndrome spectrum. Really, when you look at that differentiation between moderate to severe or for mild a life threatening, the clonus is really where you make a difference. And there's some really good diagnostic sensitivity and specificity on by a guy called Hunter. When he looks at a certain clinical features of put not into serotonin syndrome, essentially, it goes along the lines off are you on one arm? Or agents that are susceptible to call serotonin syndrome have one of them either being recently started or increased in the last 24 hours on. Do you have inducible calmness or do you have sustained clonus I you could test for clueless. That's inducible. But if it's sustained, I it's prolonged clonus either the ankle or other joint. Then that's where you have a life threatening or severe serotonin toxicity. And the reference is in the show notes, I don't have time to go into more detail than up, but just be aware you can start a fight that feeds in the prognosis. So you have someone in resource that they've been night on a vander and they've had some ecstasy. They've had some kooky, and they've taken some fentanyl or sometime with all off the street. Number one, stop the offending Agent IE. Have we given, um, fentanyl for sedation? Have we given them on down to drawn? Let's not give them anymore. Let's stop any infusions that are going. The tricky one here becomes free oxidant because of the half life of 1 to 2 weeks. So you can see that if you find the opposite in the last two weeks and come in the US for a rest that needs filled with fentanyl, you might be in trouble there. The goal is supportive. Care will go into what we treat it with, um, about minute. But really, it's taken those preventive measures, stopping the patient getting really worse. On a nutshell. If this patient is hyper thermic, your temperature greater than 40 or 41 there's a high risk of death. One of the basic principles are one of the basic things we can do for serotonin syndrome in the e. D. We stopped the medication we moved into. Resource will recognize that which is half the battle with any of the cooler temperature. Dive fans, water sprays, ice packs, cool fluids or are optional on included. If you have a patient that has sustained clonus, you're going to be looking more at a critical care paralysis, intubation of bed delicious on the cooling side of the hosts. Paracetamol will not get better deal on this one. Antipyretic. Six. Your fans will not help you to jail. It's the temperature is due to muscle excitability. It's not a pirox origin, so personable won't help you, but the agitation bands is where we start on large doses were talking obsessively 25 30 mg lorazepam in small aliquot, so you'll have a consultant at the end of the bed. You have critical care on board when we're doing this. Tox face does recommend talapia Haloperidol Academy all the it critical Karen eat and put there. And I would say a consultant at the end of the bed is the most. If you have cardiac changes, there's indications for bicarb. But if you have an elevated C k, you're going to get fluids. But a lot of these guys get cold, Cool IV fluids anyway, So one of the parents about just be mindful of the Poly Pharmacy. We are on the Poly Poly Pharmacy. Sometimes for these guys Lawrence, he associated with the antidepressant know being use. Uh huh. A rapid onset with an increase in the serotonin agent or the addition of a second agent is highly productive or of a serotonin syndrome. You have to know the drugs. You have to know their past drug history and put it together, and it comes on fast. But it also results fast. And once you stop the vending agent, usually patients will resolve symptoms within 24 hours if we support them adequately. For those that are severe. I've talked about your system and clonus. But then you've got hypothermia seasons and rhabdo. Supportive treatment is the key. Okay, little better by Saturday again. It works in the triad on the take home For this the difference of how to tell tell the difference is this people early change. So when we think about their Saturday is often bans. Oh, well, we know that bans was will cause a CNS depression low GCS We know that they cause cardiovascular Risperdal compression. They don't pan to change your peoples. Yes, If you've got a city, it'd patient. These are very different than the serotonin agitated, flighty patients. These is this the flat patients with a normal responsive pupillary change that will be more in keeping with the bands. Oh, overdose. Obviously there are other medications I don't from a side of the point of you know, bits will tend to give me the pin point people's And then there are other sort of stimulant. The agents, less common here saw the more in London the likes of, uh, DHEA or gamma hydroxybutyrate. It would give you that dietician of people still a sedative. They're very flat, but the papillary changes are taking when it comes to bands is when it comes to these guys that are city, it'd that are flat with an overdose. Really a thorough history and exam is the key. The more times than not? No, I asked the numbers. Cream will have answers for you. What medication was lying around the heist? What do they usually take? What did you see them with last week? A collateral history. I want whether there may consider with them with a girlfriend, the wives, their partners, your husband's. What have they said? What have they done on also the exam? Because you'll find patches. These guys have either applying as fentanyl patches or sometimes on Lupron orphan patches on these other medications. So you don't do a thorough history exam. You can't mess it again as a sad, supportive care is the key. Consider charcoal in these patients and they are flat. They are low, but if you can get them early enough on they have a piece of a B C, the getting there a way of protecting early, then consider it. I'm gonna go into charcoal. The more data I did do a search around in preparation for the stock of white flumazenil in the setting of bands of overdose on. It's still fairly conclusive. When I look at the literature, there is no role for Flumazenil and Mexico overdoses and that come in from the community, and I have heard a little bit more talking critical care. I've seen it used critical care for these patients coming in from the community. Suspected Banzel's and Flumazenil has been administered. There's nothing to support that meant in the literature. There's no change in any guidelines from talks, Bs or anybody else on I. I certainly would not take it for it and cause a D. It'll be interesting to see you, my consulting college, that they feel differently than not. But there is no role fruitful as well, and these community based overdoses they're often next, and it only causes more home. All right, on the poisonings in eso a little bit to start with piracy more and snap, so not going to go into how it works. But essentially everybody's got a protective mechanism within their liver and the napkin I I, which can give you by your Fiore's off paracetamol toxicity treatment. It's it's glutathione that is in the liver that can be metabolized. We know that if we can get not the antidote onboard within about 10 R's, there's only 3% of those patients will be liver toxic, liver toxic on Most of them are a treatable, so my liver toxicity need to find it as an a L T great on the thighs. And But even then, if we could get knock on board in the right, patients in a timely fashion, we can see of a lot of lives. There are boy 150 deaths from paracetamol in the UK every year, so this is significant mortality since utilities. It's not protocol. Essentially, if you haven't used it, please do. It's the only protocol that were subscribed to hear nine calls or any D. It's on the Resource Resources folder, and it's very quick, and it's very simple. 12 or protocol. Multiple Externally validated studies show and reduce adverse drug reactions, including any of the edge rash on the factory reactions. It reduces the length of stay. It's a 12 hour protocol, and 95% of patients will only need the trail bars as opposed to previously. When you're on the 21 or protocol that acquits that over 50 thirties and acute medical admissions a year in the UK, if we can reduce any portion about lead to stay, that will massively genes floating through our meetings on for the hospital, the only contraindications snap is true. Anaphylaxis the back. I've never seen true anaphylaxis to knock on my career thus far. Peace reports are minuscule. And so I would say there's very few people that you're going to not give snap protocol to for privacy, the more toxicity. It's all on the share drive. Have a look at it if you haven't already. Okay, Calcium channels on beta blockers. We've been my constant channel. First of all, it acts in three different areas of the body. You may have heard me is going on about this a little bit in the board runs, but this is our fresher so cardiac. My insights reduces contractility, reduces cardiac output, reduces dropping ability of the heart. Hence you get a bloody cardiologists cardiac output, hypertension. You get vascular smooth muscle, told me. Changes again works in the vascular smooth muscle you get. You can get pressure a little tissue that's going to cause reduction in blood pressure. Vascularity. Centrally, perfectly interestingly, it also has a fact in the pancreas. The island be the cells. So you will get reduction. Instant release of the hyperglycemia. Okay, this is important. We're gonna come back to this hyperglycemia idea in a minute. The treatment again. As I said, it's all supportive, but essentially revolves around the basic things IV fluids or, after paying initially, one up to 3 mg about dropping calcium. This is that This is a heart that a starved off calcium. We need to give it some. We carry calcium, gluconate it in the department. 30 mills of blocking it is to see Ms 10 mills off chloride house into all right. But the gluconate is much safer, Preferably so. You can give up to 40 mills of 10% calcium gluconate IV on dots. Just defend that. Overwhelmed the calcium receptors. They're quite that. Block it and try and get counseling back to just the action potential Heart Luca Goal has mentioned a zipper toxic waste, but you will need walking dose is okay. There is only about 10 mg of glucagon in our department at any one time. If you feel you need to do this, their their consultant at the end of the bed, there be an emergency pharmacist probably getting woken up from the bed on. The bad manager will be in the emergency drug store, trying to get you some more. It's walking doses, so it's a 5 to 10 mg IV bolus, plus the see him again for infusion. These patients will vomit. There's no doubt about it. They will vomit everywhere. All the amount of the, um, attics in the world won't stop them, so be prepared for that one. Hypertension is obviously going to be there because of the cardiac contractility Of the preferably is a donation IV adrenaline piercing a junk. Your IV fluid there filling is also in there, and you had an accident. Talk on Pearson before about it intralipid, and we'll talk to you in a bit more detail about it. And then there's the hyper insulin in here. You'd like cement thoroughly. There's a link to that in the show notes. You're gonna have a consultant on the critical care person at the end of the bed. It has been shown to be highly effective with very few adverse. It comes on there. Some case reports off really making the difference in patients. Young patients get turned around with the high insurance therapy on having a good neurological. It comes. What gives the per prognosis. You have a high, persistently hypertensive patient, despite the previous life you have. New onset hyperglycemia is a very per productive advocator for these patients on the rising. Blocked it on the cereal venous blood classes. These patients will not be well. This is critical care on, I would say to you, if they don't survive, there's options here for organs to be considered. But please be mindful of this this new hyperglycemia as again, a really important point when it comes to calcium channel on. I'll speak about that again when we do the the blockers because it's high. We definitely get calcium put Your blood was up blockers right on to be the blockers. So, um, to receptors some or cardiac on. Some are preferable. Cardioselective ones will reduce your contractility on your heart rate. It'll also act in the lungs and arteries. You tend to get the skull little muscle dilatation. You also get this ways of Bronchospasm very unhelpful and being mindful that thespian a blocker patients are often not taking whopping dose is of the the blocker in a self harm fashion. But they may just hep over to be toxic because they've had New York said liver or renal metabolism issues a year. A K toxic step rather than any increase in dose, is so just be mindful when you're on the shop floor under the present. Well, in many cases, this is back next, very similar to counseling channel blocker over those, but you can see of highlight in Boulder. It's the hypoglycemia that that we'll steer you more towards the the blockage. Okay, hopefully your old back with me So activated charcoal. Interesting love the data. This on a prescription basis? Really late nineties early two thousands were using loads of it. There's a case to say, actually, member um, usually too often, and I really as we come into the leader that the 20 tens and the words we've under used it. So it's really about bringing this back, and they're happy medium right now. We still continue to under use it on a second, something body we would see this is well, we were coming into review. Case is remove the night we go through. We better, but I really it's tough. It's zero rough stuff to drink. It's 50 g for a novel. It's a ground turkey low in a child on the only real contra indication is someone who's got an obstruction either. Obstructed are unprotected our way on also boil obstruction you wouldn't want to get into those Everybody else is four again. How does it work? Reduces drug absorption and that increases the drug. 11 year shouldn't still different drugs? Well, the mechanism of action will be appropriate for different drugs. We'll talk about when which drugs is suitable for what's or no, really, the sooner the better. Because as time goes on post digestion, it becomes less effective. Toxicities will say it must be given within the Are So um really that's been hammered home. But a lot of the resources on this would be from the M Doc. Stocks cards or from resource resources are resource room podcast. And actually this would fit with current practice in the UK and to do surveys, we can give an extended time steal in the modified release or sustained release preparations. Most of us would consider it up there by four hours in a modified or sustained release. Patient thinking about you for a pound. A little ass are for anxiety. Tends to be any milligrams. S are the day. Take that. And enough overdose. It's really gonna put you harm up to four hours post in Destin. I would advocate for the administration off Charcot with no contraindications. Okay, this is where it's not indicated. This is what? You can't give it to you. So no, alcohol is nowhere. No. Left him anything else? Absolutely. For game, if you're unsure. Ask Like a toxic last few minutes on intralipid. Okay. Really useful socks off the drug. Moves it into the liver on the muscle on away from the MRI. In those two things, it's got a positive ANA treatment effect. But it also gives the heart few source to, uh, toe work with because these patients are often attempted when it comes to Internet producing. It's on the screen mg and has done a better work for the lipid with us in the resource cover it. It's gonna prove a call about grinding in the resource drug covered. So it's all there and write note for you. In the setting of a persistent cardiovascular collapse or a systole, you can repeat the bonuses. You can titrate the response, but talks. Peace would say, Once it's administered your commitment to resource for a least one are on, it's really important that we keep that going. In that case of it, CPR would be auto pulses. Well, these are the drugs that Internet but is most successful for. When you look at the literature, you're quite a few. There we talked about the Prepontine law was obviously the SSRI. So calcium channels are there, and but also, as some others were considered with the little Perles, it tends to work less well in those patients with with small muscle mass. Because you think about the mechanism of action the leopard binds to the drug drug moves it into the muscles. We don't have a lot of muscle. You're very coccyx, anorexic or just small body Avonex. That might not work so well. The key is still doing basic life support. If you don't get the heart pumping with the cardiac, you're not going to absorb the drug you're not gonna move it into the muscle and then just mine for a lot of these patients will get dialysis afterwards because the kidneys are not good or they need filtration for other ones. Intralipid on dialysis aren't always ask me. It's because it clogs up there at dialysis. Chief of the members, Any questions at all? Didn't think so. So there's a few references. The little be on that off. Thanks very much. Okay? No right, John Complex. I think maybe it's a combination of the questions in no eso I have seen. If you couldn't see me that I was frantically having a cold start talking so right when we don't have a very last full people into Well, guys were trying three tops and I was just reading