Transcript 4th international toxicological conference

Dr.P.Sampath Kumar
Professor & Police Surgeon
Head of Department of Forensic Medicine &
Toxicology
Sri Ramachandra Medical College & RI
Vice Principal , Sri Ramachandra University,
Chennai, India
PRINCIPLES OF MANAGEMENT
IN A CASE OF MULTIDRUG
OVERDOSE
 Alcohol interacts with a number of drugs thereby
resulting in adverse health effects for the drinker.
 Alteration can occur either in the metabolism or
effects of alcohol and/or the medication.
 Alcohol and drug interaction can be of two types
Pharmacokinetic interaction
Pharmacodynamic interaction
 Antihypertensive drugs constitute leading form of
cardiovascular drug overdose
 Implicated in 48% deaths resulting from such
overdose
 Most common among these- Calcium channel
blockers and Beta blockers
 Treating patients with such overdose can be a
challenge for even experienced physicians
College student- quarrels at home
Consumes ethyl alcohol
Comes home and takes 20-25
antihypertensive tablets
Gets up at midnight with severe headache
Takes few tablets of aspirin for relief from
headache
Stays awake for the next two hours after
which he falls asleep again
Next day morning family leaves for a
function leaving the boy at home
Boy gets up , manages to reach the college
Friends find him drowsy and unable to walk
Narrates the incident to them
Wheel him into the casualty of a tertiary
care hospital
Medical officer seeing him in a wheelchair
delays attending to him, thinking its not an
emergency
Collapses in the wheeler, on examining
pulse feeble, BP not recordable
Intubated – put on ventilator, I.V line secured
and fluids ionotropes started
Grave prognosis explained to the relatives
Other investigations were conducted
Despite the fluid management and
ionotropes , his urine output was nil.
Intensivist suggested to start ECMO
Shifted to MDCCU
Specific antidotes were given in the MDCCU
After about half an hour , 15ml of
urine is collected
After 3 days of ECMO, boy regains
consciousness
However he developed swelling and immobility
of the leg in which catheter was placed
Investigations revealed- leg ischemia, that
would have necessitated amputation
However appropriate management by a
plastic surgeon in a rural centre saved the boy,
his leg.
 Alcohol & a number of medications interact with each
other resulting in potentially serious medical
consequences.
 Interactions alter
A)the metabolism or activity of the medication
B)alcohol metabolism.
 Medications and alcohol compete in the body for
absorption
potency of the medication and/or
alcohol is often increased/ decreased.
 No set formula
 Each person is different
 Results of this type of potentially fatal cocktail vary
based on
 type and quantity of medication and alcohol
ingested
 the time frame involved
 individual's tolerance (medication/alcohol)
 Studies focus on the effects of chronic heavy drinking.
 Relatively limited information available on
medication interactions resulting from moderate
alcohol consumption
ALCOHOL
ANTIHYPERTENSIVE
DRUGS
profound hypotension
 refractory bradycardia
 cardiogenic or non cardiogenic pulmonary oedema
 For these reasons it is difficult to treat even for an
experienced physician
• increase stomach irritation
• impair thinking and motor skills
• lead to breathing problems.
 Calcium Therapy: as calcium gluconate or calcium




chloride
Calcium gluconate , 30 mL of 10% solution, can be
administered IV over 10-15 minutes in adults
Glucagon Therapy :promotes calcium entry into cells via
stimulation of a receptor that is considered to be separate
from adrenergic receptors
Administer glucagon 5-10 mg IV bolus up to 15 mg,
followed by an infusion
Insulin Therapy : Hyperglycaemia may occur in CCB
toxicity, as calcium channel blockade inhibits insulin
release. To counter act this Hyperinsulinemia- Euglycemia
 Extracorporeal Membrane Oxygenation
 Oxygen for the body when someone’s lungs and/or
heart are not able to supply oxygen on their own
VEIN
VEIN
DEOXYGENATED
BLOOD
OXYGENATED
BLOOD
ARTERY
ECMO
 A known side effect of this therapy is
risk of low blood flow to the distal part of the limb in
which catheter is placed
risk of causing clots
 However this wasn’t given a keen eye to by the
treating physician in the MDCCU.
 Resulted in leg ischemia
NEGLIGENCE????????
 Carelessness on part of the physician
 Inadequate staffing
 Lack of proper communication
 Not foreseeing the known complications
 Improper diagnostic techniques
 Lack of immediate treatment
 Insensitivity to patients needs
 Incompetence of the physician – washing hands off
 Buckley N, Dawson AH, Howarth D, Whyte IM. Slow-
release verapamil poisoning. Use of polyethylene glycol
whole-bowel lavage and high-dose calcium. Med J Aust.
1993 Feb 1. 158(3):202-4. [Medline].
 Hung YM, Olson KR. Acute amlodipine overdose treated by
high dose intravenous calcium in a patient with severe
renal insufficiency. Clin Toxicol (Phila). 2007. 45(3):3013. [Medline].
 Haddad LM. Resuscitation after nifedipine overdose
exclusively with intravenous calcium chloride. Am J Emerg
Med. 1996 Oct. 14(6):602-3. [Medline].
 Levine M, Boyer EW, Pozner CN, Geib AJ, Thomsen T, Mick
N, et al. Assessment of hyperglycemia after calcium
channel blocker overdoses involving diltiazem or
verapamil. Crit Care Med. 2007 Sep. 35(9):2071-5.[Medline].
 Mycyk MB, Bryant SM. Is simple bedside glucose
assessment prognostic in calcium channel blocker
overdose?. Crit Care Med. 2007 Sep. 35(9):22167. [Medline].
 http://emedicine.medscape.com/article/2184611-
treatment#d17