4TH INTERNATIONALTOXICOLOGICAL 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

INTRODUCTION:

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

After about half an hour , 15ml of urine is collected

After 3 days of ECMO, boy regains consciousness

Specific antidotes were given in the MDCCU

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.

DISCUSSION

Medications and alcohol compete in the body for absorption potency of the medication and/or alcohol is often increased/ decreased.

No set formulaEach person is differentResults 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

For these reasons it is difficult to treat even for an experienced physician

ALCOHOL AND CARDIAC DRUGS

ALCOHOL

ANTIHYPERTENSIVEDRUGS

profound hypotension refractory bradycardia cardiogenic or non cardiogenic pulmonary oedema

ALCOHOL and PAIN KILLERS

• 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

TREATMENT OF CCB TOXICITY

Extracorporeal Membrane OxygenationOxygen for the body when someone’s lungs

and/or heart are not able to supply oxygen on their own

ECMO

VEIN

ECMO

VEIN

ARTERY

DEOXYGENATED BLOOD

OXYGENATED BLOOD

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 physicianInadequate staffingLack of proper communicationNot foreseeing the known complicationsImproper diagnostic techniquesLack of immediate treatmentInsensitivity to patients needs Incompetence of the physician – washing

hands off

REASONS

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):301-3. [Medline].

Haddad LM. Resuscitation after nifedipine overdose exclusively with intravenous calcium chloride. Am J Emerg Med. 1996 Oct. 14(6):602-3. [Medline].

REFERENCES:

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):2216-7. [Medline].

http://emedicine.medscape.com/article/2184611-treatment#d17