44
General- evaluationGeneral- evaluation
Rcognition of poisoningRcognition of poisoning
Identification of agents involved Identification of agents involved
Assessment of severity Assessment of severity
Prediction of toxicity Prediction of toxicity
55
General- managementGeneral- management
provision of supportive careprovision of supportive care
prevention of poison absorptionprevention of poison absorption
Enhancement of elimination of Enhancement of elimination of
poisonpoison
Administration of antidotes Administration of antidotes
66
Supportive careSupportive care
A: A: First, the airway should be cleared First, the airway should be cleared of vomitus or any other obstruction and of vomitus or any other obstruction and an oral airway or endotracheal tube an oral airway or endotracheal tube inserted if needed.inserted if needed.
B: B: Breathing should be assessed by Breathing should be assessed by observation and oximetry and, if in observation and oximetry and, if in doubt by measuring arterial blood doubt by measuring arterial blood gases patients with respiratory gases patients with respiratory insufficiency should be intubated and insufficiency should be intubated and mechanically ventilatedmechanically ventilated
77
Supportive careSupportive care
• C:C: Circulation should be assessed by continuous Circulation should be assessed by continuous monitoring of:monitoring of:
• - pulse rate- pulse rate• - blood pressure- blood pressure• -urinary output-urinary output
• An An intravenousintravenous line should be placed and blood line should be placed and blood drawn fro serum glucose and other routine drawn fro serum glucose and other routine determinationsdeterminations
• Dextrose to treat hypoglycemia (0.5gm/kg)Dextrose to treat hypoglycemia (0.5gm/kg)
88
Supportive careSupportive care
Vital signs, mental status, and pupil size Vital signs, mental status, and pupil size
Pulse oximetry, cardiac monitoring, ECGPulse oximetry, cardiac monitoring, ECG
Protect airwayProtect airway
Intravenous access Intravenous access
cervical immobilization if suspect traumacervical immobilization if suspect trauma
Rule out hypoglycaemiaRule out hypoglycaemia
Naloxone for suspected opiate poisoningNaloxone for suspected opiate poisoning
99
HistoryHistory
Pill bottlesPill bottles AlcoholAlcohol Drug history including accessDrug history including access Remember OTC drugsRemember OTC drugs Suicide noteSuicide note National Poisons Information National Poisons Information
Centre (09694)Centre (09694)
1010
ExaminationsExaminations Drug Physiologic excitation :Drug Physiologic excitation : anticholinergicanticholinergic sympathomimeticsympathomimetic central hallucinogenic agentscentral hallucinogenic agents drug withdrawaldrug withdrawal
Physiologic depressionPhysiologic depression cholinergic (parasympathomimetic)cholinergic (parasympathomimetic) sympatholyticsympatholytic opiate, or sedative-hypnotic agents, or alcohols opiate, or sedative-hypnotic agents, or alcohols
Mixed state –Mixed state – polydrugs, polydrugs, hypoglycemic agents, tricyclic hypoglycemic agents, tricyclic
antidepressants, salicylates, cyanideantidepressants, salicylates, cyanide
1313
Preventing absorptionPreventing absorption
Gastric lavageGastric lavage Not in unconscious patient unless intubated (risk Not in unconscious patient unless intubated (risk
aspiration)aspiration)
Flexible tube is inserted through the nose into the Flexible tube is inserted through the nose into the
stomach stomach
Stomach contents are then suctioned via the tubeStomach contents are then suctioned via the tube
A solution of saline is injected into the tube A solution of saline is injected into the tube
Recommended for up to 2 hrs in TCA & up to 4hrs in Recommended for up to 2 hrs in TCA & up to 4hrs in
Salicylate ODSalicylate OD
Induced VomitingInduced Vomiting Ipecac - Not routinely recommended Ipecac - Not routinely recommended Risk of aspirationRisk of aspiration
1414
CONTRAINDICATION CONTRAINDICATION OF EMESISOF EMESIS
Corrosives and volatile poisonsCorrosives and volatile poisons Comatose patientsComatose patients Heart disease patientsHeart disease patients Pregnant womenPregnant women Kerosene : may cause Kerosene : may cause
aspiration pneumoniaaspiration pneumonia Convulsant patientsConvulsant patients
1515
Preventing absorptionPreventing absorption
Activated charcoalActivated charcoal Adsorbs toxic substances or irritants, thus Adsorbs toxic substances or irritants, thus
inhibiting GI absorption inhibiting GI absorption
Addition of sorbitol Addition of sorbitol →→laxative effectlaxative effect
Oral: 25-100 g as a single dose Oral: 25-100 g as a single dose Repetitive doses useful to enhance the Repetitive doses useful to enhance the
elimination of certain drugs:elimination of certain drugs: -theophylline-theophylline -phenobarbital-phenobarbital - carbamazepine- carbamazepine - aspirin- aspirin -sustained-release products-sustained-release products
1616
Preventing absorptionPreventing absorption
not effective for:not effective for:- cyanide- cyanide-mineral acids-mineral acids-caustic alkalis-caustic alkalis- organic solvents- organic solvents-iron, ethanol, methanol poisoning, -iron, ethanol, methanol poisoning, lithium lithium
1717
Elimination of poisonsElimination of poisons
Renal eliminationRenal elimination Medication to stimulate urination or Medication to stimulate urination or
defecation may be given to try to flush the defecation may be given to try to flush the excess drug out of the body fasterexcess drug out of the body faster
Forced alkaline diuresisForced alkaline diuresis Infusion of large amount of NS+NAHCO3Infusion of large amount of NS+NAHCO3 Used to eliminate acidic drug that mainly Used to eliminate acidic drug that mainly
excreted by the kidney eg salicylatesexcreted by the kidney eg salicylates CAUTIONSCAUTIONS Serious fluid and electrolytes disturbance Serious fluid and electrolytes disturbance
may occurmay occur Need expert monitoringNeed expert monitoring
1818
Elimination of poisonsElimination of poisons
Hemodialysis or haemoperfusionHemodialysis or haemoperfusion: : Reserved for severe poisoning Reserved for severe poisoning
Drug should be dialyzable i.e. protein Drug should be dialyzable i.e. protein bound with low volume of distributionbound with low volume of distribution
may also be used temporarily or as may also be used temporarily or as long term if the kidneys are damaged long term if the kidneys are damaged due to the overdose. due to the overdose.
2020
Antidotes Antidotes
Does an antidote exist?Does an antidote exist?
Does actual or predicted severity Does actual or predicted severity of poisoning warrant its use?of poisoning warrant its use?
Do expected benefits of therapy Do expected benefits of therapy outweigh its associated risk?outweigh its associated risk?
Are there contraindications? Are there contraindications?
2222
OpiatesOpiates
Opiat poisoningOpiat poisoning Antidote – naloxoneAntidote – naloxone MoA: Pure opioid antagonist MoA: Pure opioid antagonist
competes and displaces narcotics competes and displaces narcotics at opioid receptor sites at opioid receptor sites
I.V. (preferred), I.M., I.V. (preferred), I.M., intratracheal, SubQ: 0.4-2 mg intratracheal, SubQ: 0.4-2 mg every 2-3 minutes as needed every 2-3 minutes as needed
Lower doses in opiate dependenceLower doses in opiate dependence
2323
OpiatesOpiates
Elimination half-life of naloxone is Elimination half-life of naloxone is only 60 to 90 minutes only 60 to 90 minutes
Repeated administration/infusion Repeated administration/infusion may be necessarymay be necessary
Side EffectsSide Effects BP changes; arrhythmias; BP changes; arrhythmias;
seizures; seizures; withdrawal syndromewithdrawal syndrome
2424
BenzodiazepinesBenzodiazepines
Benzodiazepine poisoning Benzodiazepine poisoning
Antidote – flumazenilAntidote – flumazenil MoA: Benzodiazepine antagonist MoA: Benzodiazepine antagonist IV administration 0.2 mg over 15 sec to max IV administration 0.2 mg over 15 sec to max
3mg3mg S/E : arrhythmias; convulsionsS/E : arrhythmias; convulsions C/I concomitant TCAD; status epilepticusC/I concomitant TCAD; status epilepticus Should not be used for making the diagnosisShould not be used for making the diagnosis Benzodiazepines may be masking/protecting Benzodiazepines may be masking/protecting
against other drug effectsagainst other drug effects
2525
Tricyclic Tricyclic antidepressantsantidepressants PHARMACOLOGY — PHARMACOLOGY — TCAs have several important cellular effects, including TCAs have several important cellular effects, including
inhibition of:inhibition of:
-Presynaptic neurotransmitter reuptake-Presynaptic neurotransmitter reuptake
-Cardiac fast sodium channels -Cardiac fast sodium channels
-Central and peripheral muscarinic acetylcholine -Central and peripheral muscarinic acetylcholine receptorsreceptors
-Peripheral alpha-1 adrenergic receptors -Peripheral alpha-1 adrenergic receptors
-Histamine (H1) receptors -Histamine (H1) receptors
-CNS GABA-A receptors -CNS GABA-A receptors
2626
TCAD overdoseTCAD overdoseclinical featuresclinical features
Arrhythmias Arrhythmias
- widening of PR, QRS, and QT intervals; - widening of PR, QRS, and QT intervals;
- heart block- heart block
HypotensionHypotension
Anticholinergic toxicityAnticholinergic toxicity
- - hyperthermiahyperthermia
- flushing- flushing
-dilated pupils-dilated pupils
-intestinal ileus-intestinal ileus
-urinary retention-urinary retention
- sinus tachycardia- sinus tachycardia
Confusion, delirium, hallucinationsConfusion, delirium, hallucinations
Seizures Seizures
2727
TCAD overdoseTCAD overdose DiagnosisDiagnosis
HistoryHistory
Blood/urine toxicology screenBlood/urine toxicology screen
2828
TCAD overdose -TreatmentTCAD overdose -Treatment
many require intubationmany require intubation
Consider gastric lavage if taken < 2hrsConsider gastric lavage if taken < 2hrs
Activated charcoalActivated charcoal
Treatment of hypotension with isotonic salineTreatment of hypotension with isotonic saline
Sodium bicarbonate for cardiovascular toxicity for cardiovascular toxicity Alpha adrenergic vasopressors Alpha adrenergic vasopressors ((norepinephrine
) ) Benzodiazepines for seizuresBenzodiazepines for seizures
2929
Sodium Bicarbonate Sodium Bicarbonate in TCA in TCA overdoseoverdose
Hypertonic sodium bicarbonate Hypertonic sodium bicarbonate
(NaHCO3) (NaHCO3)
- QRS widening >100 msec - QRS widening >100 msec
-ventricular arrhythmias -ventricular arrhythmias
-refractory hypotension -refractory hypotension
↑↑ serum pH promotes protein serum pH promotes protein
binding and binding and ↓↓ free drug free drug
concentrationsconcentrations
3030
Sodium Bicarbonate Sodium Bicarbonate in TCA in TCA overdoseoverdose
reasonable goal pH is 7.50 to 7.55 reasonable goal pH is 7.50 to 7.55
then taper dosethen taper dose
S/E:S/E:
Volume overload Volume overload
hypernatreamiahypernatreamia
metabolic alkalosis metabolic alkalosis
3131
Special Cautions in TCAD Special Cautions in TCAD overdoseoverdose
Class IA and IC antiarrhythmic agents are Class IA and IC antiarrhythmic agents are
contraindicated eg:contraindicated eg:
quinidinequinidine
DisopyramideDisopyramide
FlecainideFlecainide
propafenonepropafenone
Class IB Lignocaine, phenytoin usedClass IB Lignocaine, phenytoin used
Phenytoin may precipitate arrhythmiasPhenytoin may precipitate arrhythmias
Magnesium may be usefulMagnesium may be useful
Flumazenil must Flumazenil must notnot be given be given
3232
Salicylate overdoseSalicylate overdose
Aspirin (Aspirin (acetylsalicylic acid)acetylsalicylic acid) Methyl salicylate (Oil of Methyl salicylate (Oil of
Wintergreen)Wintergreen) 5 ml = 7g salicylic acid5 ml = 7g salicylic acid Herbal remediesHerbal remedies
Fatal intoxication can occur after Fatal intoxication can occur after the ingestion of 10 to 30 g by adults the ingestion of 10 to 30 g by adults and as little as 3 g by childrenand as little as 3 g by children
3333
Salicylate levelsSalicylate levels
-Rapidly absorbed-Rapidly absorbed
-peak blood levels usually occur within -peak blood levels usually occur within
one hourone hour but delayed in overdose 6-35 but delayed in overdose 6-35
hrs plasma salicylate concentrationhrs plasma salicylate concentration
Measure @ 4 hrs post ingestion & every Measure @ 4 hrs post ingestion & every
2 hrs until they are clearly falling2 hrs until they are clearly falling
Most patients show signs of intoxication Most patients show signs of intoxication
when the plasma level exceeds 40 to 50 when the plasma level exceeds 40 to 50
mg/dL (2.9 to 3.6 mmol/L) mg/dL (2.9 to 3.6 mmol/L)
3434
Salicylate overdoseSalicylate overdose 1- Inhibition of cyclooxygenase results in decreased 1- Inhibition of cyclooxygenase results in decreased
synthesis of prostaglandins, prostacyclin, and synthesis of prostaglandins, prostacyclin, and
thromboxanesthromboxanes 2- Stimulation of the chemoreceptor trigger zone in the 2- Stimulation of the chemoreceptor trigger zone in the
medulla causes:medulla causes: nausea and vomitingnausea and vomiting 3- Activation of the respiratory center of the medulla 3- Activation of the respiratory center of the medulla
results in:results in: tachypnea, hyperventilation, respiratory alkalosistachypnea, hyperventilation, respiratory alkalosis 4- Uncoupled oxidative phosphorylation in the 4- Uncoupled oxidative phosphorylation in the
mitochondria generates heat and may increase body mitochondria generates heat and may increase body
temperaturetemperature 5- Interference with cellular metabolism leads to 5- Interference with cellular metabolism leads to
metabolic acidosismetabolic acidosis
3535
Clinical featuresClinical features
Early symptoms of aspirin toxicity includeEarly symptoms of aspirin toxicity include::
tinnitustinnitus
FeverFever
VertigoVertigo
NauseaNausea
HyperventilationHyperventilation
VomitingVomiting
diarrhoeadiarrhoea
More severe intoxication can cause:More severe intoxication can cause:
altered mental status, comaaltered mental status, coma
non-cardiac pulmonary edema and deathnon-cardiac pulmonary edema and death
3636
Metabolic Metabolic abnormalitiesabnormalities
Stimulate the respiratory center directly, early fall in the Stimulate the respiratory center directly, early fall in the
PCO2 and respiratory alkalosis PCO2 and respiratory alkalosis
An anion-gap metabolic acidosis then follows, due to the An anion-gap metabolic acidosis then follows, due to the
accumulation of organic acids, including lactic acid and accumulation of organic acids, including lactic acid and
ketoacidsketoacids
Mixed Mixed respiratory alkalosis and metabolic acidosis with respiratory alkalosis and metabolic acidosis with ↑ ↑
anion gapanion gap
Arterial Ph variable depending on severityArterial Ph variable depending on severity
3737
Metabolic Metabolic abnormalitiesabnormalities
Metabolic acidosis Metabolic acidosis increases the increases the plasma concentration of plasma concentration of protonated salicylate protonated salicylate
thus worsening toxicity by thus worsening toxicity by allowing easy diffusion of the drug allowing easy diffusion of the drug across cell membranesacross cell membranes
3838
Salicylate overdose - Salicylate overdose - treatmenttreatment
directed toward increasing systemic pH directed toward increasing systemic pH by the administration of sodium by the administration of sodium bicarbonate bicarbonate
IV fluids +/- vasopressorsIV fluids +/- vasopressors
Supplemental glucose (100 mL of 50 Supplemental glucose (100 mL of 50 percent dextrose in adults) to patients percent dextrose in adults) to patients with altered mental status regardless of with altered mental status regardless of serum glucose concentration to:serum glucose concentration to:
overcome neuroglycopaeniaovercome neuroglycopaenia HemodialysisHemodialysis
3939
Alkalinization of plasma and Alkalinization of plasma and
urineurine Alkalemia from a respiratory alkalosis is not a Alkalemia from a respiratory alkalosis is not a
contraindication to sodium bicarbonate therapy contraindication to sodium bicarbonate therapy
A urine pH of 7.5 to 8.0 is desirableA urine pH of 7.5 to 8.0 is desirable
Blood gas analysis every two hours Blood gas analysis every two hours
Avoid severe alkalemia (arterial pH >7.60)Avoid severe alkalemia (arterial pH >7.60)
4040
Haemodialysis - indicationsHaemodialysis - indications
Altered mental statusAltered mental status
Pulmonary or cerebral edemaPulmonary or cerebral edema
Renal insufficiency that interferes with salicylate Renal insufficiency that interferes with salicylate excretionexcretion
Fluid overload that prevents the administration of Fluid overload that prevents the administration of sodium bicarbonatesodium bicarbonate
A plasma salicylate concentration >100 mg/dLA plasma salicylate concentration >100 mg/dL
Clinical deterioration despite aggressive and Clinical deterioration despite aggressive and appropriate supportive careappropriate supportive care
4141
ParacetamolParacetamol
Widely availableWidely available
Potential toxicity underestimatedPotential toxicity underestimated
Toxicity unlikely to result from a single dose of less Toxicity unlikely to result from a single dose of less
than 150 mg/kg in child or 7.5 to 10 g for adult than 150 mg/kg in child or 7.5 to 10 g for adult
Toxicity is likely with single ingestions greater than Toxicity is likely with single ingestions greater than
250 mg/kg or those greater than 12 g over a 24-hour 250 mg/kg or those greater than 12 g over a 24-hour
period period
Virtually all patients who ingest doses in excess of Virtually all patients who ingest doses in excess of
350 mg/kg develop severe liver toxicity unless 350 mg/kg develop severe liver toxicity unless
appropriately treatedappropriately treated
4343
Factors influencing Factors influencing toxicitytoxicity Dose ingestedDose ingested
Excessive cytochrome P450 activity due to Excessive cytochrome P450 activity due to
induction by chronic alcohol or other drug use eg induction by chronic alcohol or other drug use eg
carbamazepine, phenytoin, isoniazid, rifampin carbamazepine, phenytoin, isoniazid, rifampin
Decreased capacity for glucuronidation or sulfationDecreased capacity for glucuronidation or sulfation
Depletion of glutathione stores due to malnutrition Depletion of glutathione stores due to malnutrition
or or chronicchronic alcohol ingestion alcohol ingestion
Acute alcohol ingestion is not a risk factor for Acute alcohol ingestion is not a risk factor for
hepatotoxicity and may even be protective by hepatotoxicity and may even be protective by
competing with acetaminophen for CYP2E1 competing with acetaminophen for CYP2E1
4444
Clinical featuresClinical features Stage I (0.5 to 24 hours) Stage I (0.5 to 24 hours)
No symptomsNo symptoms
Stage II (24 to 72 hours) Stage II (24 to 72 hours)
Subclinical elevations of hepatic aminotransferases Subclinical elevations of hepatic aminotransferases (AST, ALT) (AST, ALT)
-right upper quadrant pain-right upper quadrant pain
-liver enlargement and tenderness-liver enlargement and tenderness
-Elevations of prothrombin time (PT)-Elevations of prothrombin time (PT)
-oliguria and renal function abnormalities may become -oliguria and renal function abnormalities may become evident evident
4545
Clinical featuresClinical features
Stage III (72 to 96 hours) Stage III (72 to 96 hours)
-Jaundice-Jaundice
-confusion (hepatic encephalopathy)-confusion (hepatic encephalopathy)
-marked elevation in hepatic enzymes-marked elevation in hepatic enzymes
-hyperammonemia-hyperammonemia
lactic acidosis-lactic acidosis-
- renal failure 25%- renal failure 25%
- death- death Stage IV (4 days to 2 weeks)Stage IV (4 days to 2 weeks)
Recovery phaseRecovery phase that usually begins by day 4 that usually begins by day 4 and is complete by 7 days after overdose and is complete by 7 days after overdose
4646
Paracetamol overdoseParacetamol overdose
The risk of toxicity is best predicted by relating the The risk of toxicity is best predicted by relating the time of ingestion to the serum time of ingestion to the serum paracetamolparacetamol concentration concentration
Peak serum concentrations reached within 4 hrs Peak serum concentrations reached within 4 hrs following overdose of immediate-release preparationsfollowing overdose of immediate-release preparations
May be delayed with extended releases preparations May be delayed with extended releases preparations or drugs that delay gastric emptying (eg, opiates, or drugs that delay gastric emptying (eg, opiates, anticholinergic agents) are coingestedanticholinergic agents) are coingested
Check level at >= 4 hrsCheck level at >= 4 hrs
4747
Paracetamol overdose Paracetamol overdose treatmenttreatment
Activated charcoal within four hours of Activated charcoal within four hours of
ingestion ingestion
May reduce absorption by 50 to 90 May reduce absorption by 50 to 90
percent percent
Single oral dose of one gram per Single oral dose of one gram per
kilogram kilogram
Inhibits absorption of oral methionineInhibits absorption of oral methionine
4949
N-acetylcysteine N-acetylcysteine
Antidote – MOA: Antidote – MOA: a glutathione precursor a glutathione precursor
Limits the formation and accumulation of NAPQI Limits the formation and accumulation of NAPQI
Powerful anti-inflammatory and antioxidant effects Powerful anti-inflammatory and antioxidant effects
IV infusion or oral tablets (also oral methionine)IV infusion or oral tablets (also oral methionine)
150mg/Kg over 15 min; 50mg/Kg over next 4 hrs; 150mg/Kg over 15 min; 50mg/Kg over next 4 hrs;
100mg/kg over next 16 hrs up to 36hrs100mg/kg over next 16 hrs up to 36hrs
Beyond 8 hours, NAC efficacy progressively decreases Beyond 8 hours, NAC efficacy progressively decreases
S/Es nausea, flushing, urticaria, bronchospasm, S/Es nausea, flushing, urticaria, bronchospasm,
angioedema, fever, chills, hypotension, hemolysis and angioedema, fever, chills, hypotension, hemolysis and
rarely, cardiovascular collapse rarely, cardiovascular collapse
5050
Paracetamol overdose Paracetamol overdose treatmenttreatment
At the end of NAC infusion, a blood sample should be At the end of NAC infusion, a blood sample should be
taken for determination of the INR, plasma creatinine taken for determination of the INR, plasma creatinine
and ALT.and ALT.
If any is abnormal or the patient is symptomatic, If any is abnormal or the patient is symptomatic,
further monitoring is required and advice sought from further monitoring is required and advice sought from
the NPIS the NPIS
Patients with normal INR, plasma creatinine and ALT Patients with normal INR, plasma creatinine and ALT
and who are asymptomatic may be discharged from and who are asymptomatic may be discharged from
medical care. medical care.
They should be advised to return to hospital if vomiting They should be advised to return to hospital if vomiting
or abdominal pain develop or recuror abdominal pain develop or recur
5151
Indications for liver Indications for liver transplantationtransplantation
Liver transplantation is life-saving for fulminant Liver transplantation is life-saving for fulminant hepatic necrosis hepatic necrosis
The indications for liver transplantation are:The indications for liver transplantation are:
1 - Acidosis (pH < 7.3), or 1 - Acidosis (pH < 7.3), or
2 - PT > 100 sec 2 - PT > 100 sec
3 - Creatinine > 300 mcg/l 3 - Creatinine > 300 mcg/l
4 - Grade 3 encephalopathy (or worse)4 - Grade 3 encephalopathy (or worse) It is better to contact the local liver transplant centre It is better to contact the local liver transplant centre
earlier than this. earlier than this. Grossly abnormal prothrombin times should trigger Grossly abnormal prothrombin times should trigger
referral:referral: PT > 20 sec at 24 hr PT > 20 sec at 24 hr PT > 40 sec at 48 hr PT > 40 sec at 48 hr
5252
Alcohol poisoningAlcohol poisoning
Clinical features of acute alcohol poisoning include:Clinical features of acute alcohol poisoning include:
Ataxia and anaesthesia leading to accidental injury Ataxia and anaesthesia leading to accidental injury
Dysarthria and nystagmus Dysarthria and nystagmus
Drowsiness which may progress to coma Drowsiness which may progress to coma
Inhalation of vomit which can be fatal & should be Inhalation of vomit which can be fatal & should be
prevented prevented
Hypoglycaemia in children and some adults Hypoglycaemia in children and some adults
Check BG TEST and give 50% glucose i.v. if requiredCheck BG TEST and give 50% glucose i.v. if required
5353
Coma (alcohol induced)Coma (alcohol induced) In cases of alcohol induced coma exclude:In cases of alcohol induced coma exclude:
1.1. Coincident head injuryCoincident head injury
2.2. Hepatic failure Hepatic failure
3.3. MeningitisMeningitis
4.4. Wernicke’s encephalopathy Wernicke’s encephalopathy
5.5. Other associated drug ingestionOther associated drug ingestion A blood test will confirm substantial levels of A blood test will confirm substantial levels of
alcohol alcohol Rule out alcoholic hypoglycaemiaRule out alcoholic hypoglycaemia The airway and circulation must be maintainedThe airway and circulation must be maintained But glucose- containing fluids may precipitate But glucose- containing fluids may precipitate
Wernicke's encephalopathyWernicke's encephalopathy Thiamine should given to allThiamine should given to all Intravenous naloxone has reversed coma in a Intravenous naloxone has reversed coma in a
proportion of casesproportion of cases
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