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Metabolic and Poisoning

Acute Renal Failure

  1. ABC
  2. Catheterize to monitor fluid output. Consider central venous pressure line
  3. Treat hyperkalaemia (below)
  4. Fluid challenge if dehydrated and suspect pre-renal failure. Can repeat if non-responsive.
  5. Investigations: Urine m+c (white cells, red cells)
    ECG (hyperkalaemia)
    Bloods: FBC, U+E, ESR, clotting, LFTs
    CXR, ultrasound renal tract
    Consider biopsy
  6. If fluid overloaded consider dialysis
  7. Correct acidosis with bicarbonate
  8. Correct sepsis with antibiotics

Urgent Dialysis if:

Hyperkalaemia

Often occurs in association with acute renal failure. Treat when the potassium > 6.
  1. Calcium gluconate IV 10% of 10ml
  2. 20 units of soluble insulin and glucose 50ml of 50%
  3. Nebulized salbutamol 2.5mg
  4. Calcium resonium
  5. Dialysis

Diagnosis

Tall tented T waves, flat P waves, raised PR, widened QRS

Diabetic Ketoacidosis

  1. IV access and start fluid (0.9% saline)
  2. Check plasma glucose
  3. If >20mmol/L give soluble insulin
  4. Replace potassium
  5. Ix: Glucose, U+E, HCO3, osmolality, ABG, FBC, blood culture Urine tests: ketones, MSU, CXR
  6. Insulin sliding scale
  7. Monitor glucose, U+E, HCO3 regularly

Poisoning

  1. ABC, clear airway
  2. Consider ventilation (if RR < 8, or PaO2 < 8kPa on 60% oxygen), or the airway is at risk (GCS < 8)
  3. Treat shock
  4. If unconscious nurse semi-prone
  5. Assess the patient Hx from patient, friends, family
  6. 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
  7. Monitor: temperature , pulse, RR, BP, saturation, urine output, ECG
  8. Rx: supportive: may need catheterization. Consider activated charcoal
  9. Specific antidotes Consider naloxone if ↓conscious level, pin-point pupils
  10. Contact the poisons information service if unfamiliar

Clues

Tachycardia
Salbutamol, TCAs
Respiratory depression
Opiate or benzodiazepine toxicity
Hypothermia
Barbiturates
Hyperthermia
Stimulants like amphetamines, cocaine
Constricted pupils
Opiates
Dilated pupils
Amphetamines
Renal failure
Salicylate, paracetamol

Treatment of specific poisons

Paracetamol

Symptoms
None initially, or vomitingÂħRUQ pain. Later: jaundice and encephalopathy from liver damage + renal failure.
Overdose
4g max daily. 12g may be fatal. Measure at 4h past overdose, otherwise levels will be too low. Consult the plama-paracetamol/time graph.
Investigation
Glucose, U+E (hepatorenal, and excretion), INR (monitoring), LFT (monitoring, but may be deceptive once liver fails), ABG, FBC, HCO3, salicylate
Treatment
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

Symptoms
Vomiting, dehydration, hyperventilation (stimulates resp centre), tinnitus, vertigo, sweating.
Investigation
Paracetamol, salicylate, glucose, U+E, LFT, INR, ABG (metabolic acidosis), HCO2, FBC. Monitor urine output (renaly excreted)
Treatment
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
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