TCA OVERDOSE

Remember the actions of TCAs:

• SNRI
• Anticholinergic: All D's (Dry Mouth, Dry skin and hyperthermia, DIlated pupils, Depressin of Respiration, Disorder Heart Rhythm,  Delayed Gastric Emptying, Distended Bladder) and Agitation (Remember the atropine psychosis in OPC Poisoning)
• Alpha 1 Blocker: Hypotension
• Na+ Channel Blocker: Wide PR, QRS, QT

Fatal Dose: 15 mg/kg

Management:

Approach in ABCDE Method:

Airway: Nasal Oxygen

Breathing: Assisted Ventilation

Circulation: IV Access (Lab workup: Venous blood Gas for Acidosis, FBC, U & Es, Renal Functions, Acetaminophen levels), EKG, Vitals, Monitoring, 

IV Fluids

Antidotes:

If taken within 2 hours: Give Oral Charcoal 50 gms

Correct Acidosis: With NaHCO3

50 ml of 8.4% over 15 minutes, then 500 ml of 1.8% over 4 hours (Give HCO3, even if pH is normal, try to keep pH > 7.5, if QRS > 100, monitor hypokalemia)

IV benzodiazepines for convulsions (Avoid phenytoin -- Na+ Channel blocker)

Treat Arrythmia with fluids and NaHCO3, avoid Antiarrythmic Class 1a and 1c -- Na+ Channel Blockers

HD if required,

Refer TOXBASE

Refer ITU

ACETAMINOPHEN (PARACETAMOL) OVERDOSE

A very common OSCE scenario presented as:

• Obtaining History
• Management
• Psychiatric Assessment
• Assessing Capacity
• Assessing Mental Status

OBTAINING HISTORY:

Hi, My Name is Dr ABC, one of the ED Registrars who will be taking care of you today. May I know you name please? How old are you? And what do you do for your living?

Are you having any discomfort or pain? I want to assure you that I would provide you with every assistance, including pain killers to make you more comfortable.

If attendant is present, ask her name and relationship?

Ask the patient if she wants him/her to be present or can they wait outside in the Lobby?

If unstable, begin resuscitation.

I would like to ask you what brought you here today?

 Current Symptoms:

 Do you have any pain in abdomen? Vomiting? 

Event:

What have you taken? Do you have any packets or labels? Exactly when did you take it? How many tablets? Did you take anything else along with it,.... like any other medications or drugs, or alcohol?

Psychiatry:

Why did you take the overdose? Did you want to kill yourself or was it a cry for help?

Did you plan about doing it? Like trying not to be found? Closure of bank accounts? Suicide note?

How do you feel now?

Did you come here by yourself or under duress?

Did you try hurting yourself before too?

Assess risk of severe depression by asking about Sleep, Loss of interest, Guilt feeling, memory and concentration, appetite, psychomotor symptoms.

Assess Suicidal risk by asking SAD PERSONS Score: (Male 1945, single without social support and feeling hopeless and has a plan)

Social History:

Smoking, drugs, alcohol, Social support, Schooling, Stress at work or home

Medical illness:

Do you have any other medical illnesses? like liver disease, kidney disease or infections

Do you take any medications routinely? 

Are you allergic to any medications?

Have you been diagnosed of any psychiatric illnesses like depressions?

Management:

Bloods for CBC, U & Es, glucose, Coagulations Panel, group and type, LFTs, Serum Acetaminophen level, VBGs, lactate. Urine Toxicology screen

Ask for a nomogram

If less than one hour of intake, 50 gm of Charcoal PO

IV NAC

Hospitalize

Psychiatric referral

If denies NAC/treatment:

• Assess Capacity : Understand what is proposed, retain, weigh the benefits and risks involved, make a decision and communicate it
• If capacitated and no risk of repetition discharge (0 - 4 SAD PERSONS)
• If Capacitated, but risk of repetition of self harm (4+ SAD PERSONS), use section under Mental Capacity Act and hold.
• Explore Needle phobia
• Offer Oral Methionine

Depression Cases: Assessment

Use the following 2 Mnemonics for assessment in any case of suspected depression and/or Suicidal attempt. Widely applicable and used in most EDs, and is often tested in the MCEM OSCE Part C.

SIGMECAPS

1. Sleep
2. Interest
3. Guilt Feelings
4. Mood lately/Memory
5. Energy Level (Tired or fatigued)
6. Concentration
7. Appetite loss (Weight Loss/Gain)
8. Psychomotor symptoms
9. Suicidal ideations

5 out of 9 indicates depression

SADPERSONS

1. S – Sex:  1 if male; 0 if female; (more females attempt, more males succeed)
2. A – Age: 1 if < 20 or > 44 (Remember 1945)
3. D – Depression: 1 if depression is present
4. P – Previous attempt: 1 if present
5. E –Ethanol abuse: 1 if present
6. R – Rational thinking loss: 1 if present
7. S – Social Supports Lacking: 1 if present
8. O – Organized Plan: 1 if plan is made and lethal
9. N – No Spouse: 1 if divorced, widowed, separated, or single
10. S – Sickness: 1 if chronic, debilitating, and severe

0 - 2   Discharge with follow up
3 - 4   Discharge with close monitoring
5 - 6   Consider Admission
7 +    Definite admission (Can hold the patient under mental health act, even if Normal Capacity)

(Source: Univ of North Carolina, 2013)