Metabolic and Poisoning
Acute Renal Failure
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ABC
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Catheterize to monitor fluid output. Consider central
venous pressure line
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Treat hyperkalaemia (below)
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Fluid challenge if dehydrated and suspect pre-renal
failure. Can repeat if non-responsive.
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Investigations: Urine m+c (white cells, red cells)
ECG (hyperkalaemia)
Bloods: FBC, U+E, ESR, clotting, LFTs
CXR, ultrasound renal tract
Consider biopsy
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If fluid overloaded consider dialysis
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Correct acidosis with bicarbonate
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Correct sepsis with antibiotics
Urgent Dialysis if:
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Potassium remains high despite treatment
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Acidosis
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Pulmonary oedema and no substantial diuresis
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Pericarditis
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Uraemic encephalopathy
Hyperkalaemia
Often occurs in association with acute renal failure. Treat when the
potassium > 6.
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Calcium gluconate IV 10% of 10ml
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20 units of soluble insulin and glucose 50ml of 50%
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Nebulized salbutamol 2.5mg
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Calcium resonium
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Dialysis
Diagnosis
Tall tented T waves, flat P waves, raised PR, widened QRS
Diabetic Ketoacidosis
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IV access and start fluid (0.9% saline)
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Check plasma glucose
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If >20mmol/L give soluble insulin
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Replace potassium
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Ix: Glucose, U+E, HCO3, osmolality, ABG, FBC, blood
culture Urine tests: ketones, MSU, CXR
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Insulin sliding scale
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Monitor glucose, U+E, HCO3 regularly
Poisoning
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ABC, clear airway
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Consider ventilation (if RR < 8, or PaO2
< 8kPa on 60% oxygen), or the airway is at risk
(GCS < 8)
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Treat shock
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If unconscious nurse semi-prone
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Assess the patient Hx from patient, friends, family
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Ix:
Bloods: glucose, U+E (renal excretion), FBC, LFT,
INR (an important marker of liver function in these circumstances),
ABC, ECG, paracetamol/alicylate levels, ABG,
Urine/serum toxicology, specific assays as appropriate
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Monitor: temperature , pulse, RR,
BP, saturation, urine output, ECG
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Rx: supportive: may need catheterization. Consider
activated charcoal
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Specific antidotes Consider naloxone if ↓conscious level,
pin-point pupils
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Contact the poisons information service if unfamiliar
Clues
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Tachycardia
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Salbutamol, TCAs
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Respiratory depression
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Opiate or benzodiazepine toxicity
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Hypothermia
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Barbiturates
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Hyperthermia
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Stimulants like amphetamines, cocaine
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Constricted pupils
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Opiates
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Dilated pupils
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Amphetamines
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Renal failure
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Salicylate, paracetamol
Treatment of specific poisons
Paracetamol
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Symptoms
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None initially, or vomitingÂħRUQ pain. Later: jaundice and
encephalopathy from liver damage + renal failure.
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Overdose
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4g max daily. 12g may be fatal. Measure at 4h past
overdose, otherwise levels will be too low. Consult the
plama-paracetamol/time graph.
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Investigation
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Glucose, U+E (hepatorenal, and excretion), INR
(monitoring), LFT (monitoring, but may be deceptive once liver fails),
ABG, FBC, HCO3, salicylate
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Treatment
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IV acetylcysteine. Activated charcoal if < 8h. If
deterioration consult liver team. Criteria (encephalopathy,
INR>2 at <48h, renal impairment, lactic acidosis ie
hypoxia, BP
sys
<80)
Salicylate
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Symptoms
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Vomiting, dehydration, hyperventilation (stimulates resp
centre), tinnitus, vertigo, sweating.
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Investigation
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Paracetamol, salicylate, glucose, U+E, LFT, INR, ABG
(metabolic acidosis), HCO2, FBC. Monitor urine output (renaly excreted)
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Treatment
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Lavage if < 2h. Charcoal. Correct met acidosis with
bicarbonate. Consider dialysis if plasma high.
Benzodiazepines
Respiratory arrest. Flumazenil (may provoke fits so be careful)
Opiates
Naloxone IV, repeat until breathing adequate.
Sx:
reduced cognition, yellow-green visual halos,
arrhythmia, nausea, anorexia. If serious arrhythmia give digibind
CO
Symptoms:
cherry red appearance, eadache,
vomiting, ↑pulse, tachypnoea.
Treatment:
Remove the source, give 100% O
2
.
Beta-blockers
Symptoms:
severe hypotension or bradycardia.
Rx:
atropine, glucagon
Iron
Desferioxamine