1. Paracetamol toxicity results from formation of a reactive metabolite that binds to cellular proteins, causing cell death and hepatic or renal failure. Acetylcysteine replenishes glutathione stores and is highly effective if given within 8 hours of overdose.
2. Salicylate poisoning causes respiratory alkalosis, metabolic acidosis, and organ damage. Treatment involves correcting dehydration and acidosis with sodium bicarbonate. Hemodialysis is effective for removing salicylates from the body.
3. Tricyclic antidepressant overdose can cause arrhythmias, hypotension, and seizures due to sodium channel blockade. Treatment involves sodium bicarbonate to correct
Diuretic and Urinary alkalizes-Dr.Jibachha Sah,M.V.ScDr. Jibachha Sah
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Dr.Jibachha Sah,M.V.Sc (Veterinary pharmacology),Lecture,College of Veterinary science,NPI,Bhojard,Chitwan,Nepal.This is part of lecture note on veterinary pharmacologyAUTONOMIC AND SYSTEMIC PHARMACOLOGY, Sixth Semester, B.V.Sc & A.H 6th semester.
Dr.Jibachha sah,Email: jibachhashah@gmail.com,Mobile:00977-9845024121
Diuretic and Urinary alkalizes-Dr.Jibachha Sah,M.V.ScDr. Jibachha Sah
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Dr.Jibachha Sah,M.V.Sc (Veterinary pharmacology),Lecture,College of Veterinary science,NPI,Bhojard,Chitwan,Nepal.This is part of lecture note on veterinary pharmacologyAUTONOMIC AND SYSTEMIC PHARMACOLOGY, Sixth Semester, B.V.Sc & A.H 6th semester.
Dr.Jibachha sah,Email: jibachhashah@gmail.com,Mobile:00977-9845024121
diagnosis & complication of Diabetes mellitus including Diabetic ketoacidosis & HHS
anaesthesia managment for patient with DM posted for surgery both emergency and elective surgery
gestational diabetes mellitus
The urinary system, also known as the renal system or urinary tract, consists of the kidneys, ureters, bladder, and the urethra. The purpose of the urinary system is to eliminate waste from the body, regulate blood volume and blood pressure, control levels of electrolytes and metabolites, and regulate blood pH.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Perioperative management of a patient with diabetes mellitusrajkumarsrihari
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Anesthetic implications in a patient with Diabetes Mellitis with latest updates taken from british journal of anesthesia on perioperative glycemic control (2013)
diagnosis & complication of Diabetes mellitus including Diabetic ketoacidosis & HHS
anaesthesia managment for patient with DM posted for surgery both emergency and elective surgery
gestational diabetes mellitus
The urinary system, also known as the renal system or urinary tract, consists of the kidneys, ureters, bladder, and the urethra. The purpose of the urinary system is to eliminate waste from the body, regulate blood volume and blood pressure, control levels of electrolytes and metabolites, and regulate blood pH.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Perioperative management of a patient with diabetes mellitusrajkumarsrihari
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Anesthetic implications in a patient with Diabetes Mellitis with latest updates taken from british journal of anesthesia on perioperative glycemic control (2013)
Alcoholic liver disease is a result of over-consuming alcohol that damages the liver, leading to a buildup of fats, inflammation, and scarring. It can be fatal.
Recomendaçþes da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS â Objetivos do Desenvolvimento SustentĂĄvel e a EstratĂŠgia Global para a SaĂşde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pĂłs-natais devem expandir-se para alĂŠm da cobertura e da simples sobrevivĂŞncia, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pĂłs-natais essenciais e de rotina prestados Ă s mulheres e aos recĂŠm-nascidos, com o objetivo final de melhorar a saĂşde e o bem-estar materno e neonatal.
Uma âexperiĂŞncia pĂłs-natal positivaâ ĂŠ um resultado importante para todas as mulheres que dĂŁo Ă luz e para os seus recĂŠm-nascidos, estabelecendo as bases para a melhoria da saĂşde e do bem-estar a curto e longo prazo. Uma experiĂŞncia pĂłs-natal positiva ĂŠ definida como aquela em que as mulheres, pessoas que gestam, os recĂŠm-nascidos, os casais, os pais, os cuidadores e as famĂlias recebem informação consistente, garantia e apoio de profissionais de saĂşde motivados; e onde um sistema de saĂşde flexĂvel e com recursos reconheça as necessidades das mulheres e dos bebĂŞs e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendaçþes novas e jĂĄ bem fundamentadas sobre cuidados pĂłs-natais de rotina para mulheres e neonatos que recebem cuidados no pĂłs-parto em unidades de saĂşde ou na comunidade, independentemente dos recursos disponĂveis.
Ă fornecido um conjunto abrangente de recomendaçþes para cuidados durante o perĂodo puerperal, com ĂŞnfase nos cuidados essenciais que todas as mulheres e recĂŠm-nascidos devem receber, e com a devida atenção Ă qualidade dos cuidados; isto ĂŠ, a entrega e a experiĂŞncia do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendaçþes da OMS de 2014 sobre cuidados pĂłs-natais da mĂŁe e do recĂŠm-nascido e complementam as atuais diretrizes da OMS sobre a gestĂŁo de complicaçþes pĂłs-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências Ê contemplada.
Recomendamos muito.
Vamos discutir essas recomendaçþes no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação sĂł estĂĄ disponĂvel em inglĂŞs atĂŠ o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Tom Selleck Health: A Comprehensive Look at the Iconic Actorâs Wellness Journeygreendigital
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Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on:Â Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
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June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMENâS HEALTH: FERTILITY PRESERVATION
- WHATâS NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
New Drug Discovery and Development .....NEHA GUPTA
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The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
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Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
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NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2â3 criteria; moderate AUD: 4â5 criteria; severe AUD: 6â11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
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As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Departmentâs official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganongâs Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganongâs Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
2. Paracetamol
⢠Acetaminophen) is the drug most commonly used in overdose.
⢠Toxicity results from formation of an intermediate reactive
metabolite which binds covalently to cellular proteins, causing cell
death , results in hepatic& occasionally renal failure.
⢠In therapeutic doses, the toxic intermediate metabolite is
detoxified in reactions requiring glutathione, but in overdose,
glutathione reserves become exhausted.
3. Management
⢠Activated charcoal used in patients presenting within 1 hour.
⢠Antidotes act by replenishing hepatic glutathione.
⢠Acetylcysteine IV (or orally in some countries) is highly
efficacious if administered within 8 hours of the overdose.
⢠The efficacy declines thereafter, administration should not be
delayed in patients presenting after 8 hours to await a
paracetamol blood concentration result.
⢠The antidote can be stopped if the paracetamol concentration is
shown to be below the appropriate treatment line.
⢠The most important adverse effect is related to dose-related
histamine release, the âanaphy-actoidâ reaction, with itching /
urticaria,in severe cases, bronchospasm/ hypotension,managed by
temporary discontinuation & an antihistamine.
⢠An alternative antidote is methionine 2.5 g orally 4-hourly to a
total of four doses, less effective, especially if delayed.
4. Management
⢠If a patient presents >15 hours after ingestion, liver function
tests, PT(or INR), renal function tests& a venous bicarbonate
should be measured, the antidote started& a poisons information
centre or local liver unit contacted for advice if results are
abnormal.
⢠ABG should be taken in patients with severe liver function
abnormalities; as metabolic acidosis indicates severe poisoning.
⢠Liver transplantation should be considered in individuals who
develop life- threatening liver failure.
⢠If multiple ingestions of paracetamol have taken place over several
hours or days (i.e. a staggered overdose), acetylcysteine should
be given when the paracetamol dose exceeds 150 mg/kg /any
one 24-hour period or 75 mg/kg in âhigh-risk groupsâ
5.
6.
7. (Salicylates (aspirin
⢠Commonly causes nausea, vomiting, sweating, tinnitus ,
deafness.
⢠Direct stimulation of the respiratory centre produces
hyperventilation &respiratory alkalosis.
⢠Peripheral vasodilatation with bounding pulses& profuse sweating
occurs in moderately severe poisoning.
⢠Serious salicylate poisoning is associated with metabolic acidosis,
hypoprothrombinaemia, hyperglycaemia, hyperpyrexia, renal
failure, pulmonary oedema, shock &cerebral oedema.
⢠Agitation, confusion, coma&fits may occur, especially in children.
⢠Toxicity is enhanced by acidosis, which increases salicylate transfer
across the BBB.
8. Management
⢠Activated charcoal should be administered if presents early.
⢠Multiple doses of activated charcoal may enhance salicylate
elimination but currently are not routinely recommended.
⢠The plasma salicylate concentration should be measured at
least 2 (in symptomatic patients) or 4 hours (asymptomatic
patients) after overdose&repeated in patients with suspected
serious poisoning, since it may continue to rise some hours after .
⢠In adults, concentrations >500 -700 mg/L suggest serious & life-
threatening poisoning respectively, but clinical status is more
important assessing severity.
⢠Dehydration should be corrected carefully, as there is a risk of
pulmonary oedema.
⢠Metabolic acidosis should be identified and treated with iv sodium
bicarbonate (8.4%), once plasma potassium has been corrected.
⢠Urinary alkalinisation is indicated for adults if salicylate >500 mg/L.
9. Management
⢠Haemodialysis is very effective at removing salicylate
&correcting acidâbase & fluid balance abnormalities& should be
considered when :
⢠Serum concentrations >700 mg/L in adult patients with severe
toxic features
⢠Or when there is renal failure
⢠Pulmonary oedema,
⢠Coma
⢠Convulsions
⢠Refractory acidosis
10. (Tricyclic antidepressants (TCAs
⢠TCAs used frequently in overdose
⢠It carries a high morbidity/mortality relating to their sodium
channel-blocking, anticholinergic &Îą-adrenoceptor-blocking effects
11. Clinical features
⢠Anticholinergic effects are common .
⢠Life-threatening complications are frequent, including convulsions,
coma, arrhythmias (ventricular tachycardia, ventricular fibrillation
, less commonly, heart block) & hypotension, which results from
inappropriate vasodilatation or impaired myocardial contractility.
⢠Serious complications appear to occur more commonly with
dosulepin &amitriptyline.
12. Management
⢠Activated charcoal should be given if presents sufficiently early.
⢠All patients with possible TCAD overdose should have a 12-lead ECG
& ongoing cardiac monitoring for at least 6 hours.
⢠Prolongation of the QRS interval (especially if > 0.16 s) indicates
severe sodium channel blockade associated with an increased
risk of arrhythmia .
⢠ABGs be measured in patients with suspected severe poisoning.
⢠In patients with arrhythmias, severe ECG effects or acidosis, IV
sodium bicarbonate (50 mL of 8.4% solution) should be
administered &repeated to correct pH.
⢠The correction of the acidosis &sodium loading that result is
often associated with rapid improvement in ECG & arrhythmias.
⢠Hypoxia &electrolyte abnormalities should also be corrected.
⢠Anti-arrhythmic drugs should only be given on specialist advice.
â˘
15. Clinical features
⢠Drowsiness, tachycardia,hypotension are frequently found.
⢠Anticholinergic features& acute dystonias (e.g. oculogyric crisis,
torticollis &trismus) may occur after overdose with typical
antipsychot-ics such as haloperidol or chlorpromazine.
⢠QT interval prolongation &torsades de pointes may occur with
some antipsychotics, either typical (e.g. thioridazine,
haloperidol) or atypical (e.g. quetiapine, ziprasidone).
⢠Convulsions may occur.
16. Management
⢠Activated charcoal may be of benefit if given sufficiently early.
⢠Cardiac monitoring should be undertaken for at least 6 hours.
⢠Management is largely supportive, with treatment directed at
complications
17. Antidiabetic agents
⢠Commonly causing toxicity in over-dose include the sulphonylureas
(chlorpropamide, glibenclamide, gliclazide, glipizide, tolbutamide),
biguanides (metformin and phenformin)& insulins.
18. Clinical features
⢠Sulphonylureas &parenteral insulin cause hypoglycaemia when
taken in overdose, but insulin is non-toxic if ingested.
⢠The duration of hypoglycaemia depends on the half-life or release
characteristics of the preparation& may be prolonged over
several days with long-acting agents such as chlorpropamide,
insulin zinc suspension or insulin glargine.
⢠Features of hypoglycaemia include nausea, agitation, sweating,
aggression, behavioural disturbances, confusion, tachycardia,
hypothermia, drowsiness, coma or convulsions .
⢠Permanent neurological damage can occur if hypoglycaemia is
prolonged.
⢠Hypoglycaemia can be diagnosed using bedside glucose strips but
venous blood should also be sent for laboratory confirmation.
19. Clinical features
⢠Metformin is uncommonly associated with hypoglycaemia.
⢠Its major toxic effect in overdose is lactic acidosis, which can be
associated with a high mortality, particularly common in elder
&those with renal or hepatic impairment, or ethanol
coingestion.
⢠Other featuresare nausea ,vomiting, diarrhoea, abdominal pain,
drowsiness, coma, hypotension &CV collapse.
20. Management
⢠Activated charcoal should be considered for all patients who
present within 1 hour of ingestion of a substantial overdose of an
oral hypoglycaemic agent.
⢠Venous blood glucose, urea, electrolytes should be measured
&repeated regularly.
⢠Hypoglycaemia should be corrected using oral or IV glucose (50
mL of 50% dextrose); an infusion of 10â20% dextrose may be
required to prevent recurrence.
⢠Intramuscular glucagon can be used as an alternative, especially if
IV access is unavailable.
⢠Failure to regain consciousness within a few minutes of
normalisation of the blood glucose can indicate (CNS) depressant
has also been ingested, the hypoglycaemia has been prolonged,
or there is another cause for the coma (e.g. cerebral haem-orrhage
or oedema).
21. :Management
⢠ABG should be taken after metformin overdose to assess the
extent of acidosis.
⢠If present, plasma lactate should be measured &acidosis should be
corrected with intravenous sodium bicarbonate (e.g. 250 mL 1.26%
solution or 50 mL 8.4% solution, repeated as necessary).
⢠In severe cases haemodialysis or haemo-diafiltration is used.
22. Organophosphorus (op) insecticides/ nerve agents
⢠Widely used as pesticides, especially in developing countries.
⢠The case fatality rate following deliberate ingestion of OP pesticides
in devel-oping countries in Asia is 5â20%.
⢠Nerve agents developed for chemical warfare are derived from
OP insecticides but are much more toxic.
⢠âGâ agents are volatile, are absorbed by inhalation or via the
skin&dissipate rapidly after use.
⢠âVâ agents are contact poisons unless aerosolised,contaminate
ground for weeks or months.
⢠The toxicology and management of nerve agent&pesticide
poisoning are similar.
23. Mechanism of toxicity
⢠OP compounds phosphonylate the active site of
acetylcholinesterase (AChE), inactivating the enzyme,leading to the
accumulation of acetylcholine (ACh) in cholinergic synapses.
⢠Spontaneous hydrolysis of the OP-enzyme complex allows
reactivation of the enzyme.
⢠Loss of a chemical group from the OP-enzyme complex prevents
further enzyme reactivationâageingâ),after which,
praladoxime(enzyme reactivator will not be effective) & new
enzyme needs to be synthesised before function can be restored.
The rate of ageing is is more rapid with dimethyl compounds (3.7
hours) than diethyl compounds (31 hours),especially rapid after
exposure to nerve agents (soman in particular), which cause
ageing within minutes.
24. Clinical features
⢠OP poisoning causes an acute cholinergic phase, occasionally
followed by the intermediate syndrome or organophosphate-
induced delayed polyneuropathy (OPIDN).
⢠The onset, severity and duration of poisoning depend on the
route of exposure & agent involved.
25. Clinical features
⢠Acute cholinergic syndrome
⢠Usually starts within a few minutes of exposure.
⢠Nicotinic or muscarinic features may be present.
⢠Vomiting ,profuse diarrhoea are typical following oral ingestion.
⢠Bronchoconstriction, bronchorrhoea and salivation may cause
severe respiratory compromise.
⢠Miosis is characteristic &muscle fasciculations strongly suggests
the diagnosis, although often absent, even in serious poisoning.
⢠Subsequently, generalised flaccid paralysis which can affect
respiratory & ocular muscles &result in respiratory failure.
⢠Ataxia, coma,convulsions may occur.
⢠In severe poisoning, cardiac repolarisation abnormalities& torsades
de pointes may occur.
⢠Other early complications include extrapyramidal features,
26. Management
⢠If external contamination, further exposure should be prevented,
contaminated clothing&contact lenses removed, the skin washed
with soap and water& the eyes irrigated.
⢠The airway should be cleared of excessive secretions & high-flow
oxygen administered.
⢠Intravenous access should be obtained.
⢠Gastric lavage or activated charcoal may be considered within 1
hour of ingestion.
⢠Convulsions should be treated
⢠The ECG, oxygen saturation, blood gases, temperature, urea ,
electrolytes, amylase, glucose should be monitored closely.
⢠Early use of sufficient doses of atropine is potentially lifesaving in
patients with severe toxicity.
⢠Atropine reverses ACh-induced bronchospasm
27. Management
⢠Atropine reverses ACh-induced bronchospasm,bronchorhea,
bradycardia ,hypotension.
⢠A marked increase in heart rate associated with skin flushing
after a 1 mg intravenous dose makes OP poisoning unlikely.
⢠In OP poisoning, atropine should be administered in doses of 0.6â2
mg i.v., repeated every 10â25 mins until secretions are
controlled, the skin is dry and there is a sinus tachycardia.
⢠Large doses may be needed but excessive doses may cause
anticholinergic effects.
⢠In patients requiring atropine, an oxime such as pralidoxime
chloride (or obidoxime), if available, should also be administered,
as this may reverse or prevent muscle weakness, convulsions or
coma, especially if administered rapidly after exposure.
⢠The dose for an adult is 2 g i.v. over 4 mins, repeated 4â6-hourly.
28. Management
⢠Oximes re-activating AChE that has not undergone âageingâ &are
less effective with dimethyl compounds &nerve agents,
especially soman.
⢠Oximes may provoke hypotension, especially if rapidly.
⢠Ventilatory support should be instituted before the patient
develops respiratory failure .
⢠Benzodiazepines may be used to reduce agitation,fasciculations,
&treat convulsions&sedate patients during mechanical ventilation.
⢠Exposure is confirmed by measurement of plasma
(butyrylcholinesterase) or red blood cell cholinesterase activity.
,correlate poorly with the severity of clinical features, although
values are usually less than 10% in severe poisoning, 20â50% in
moderate poisoning ,> 50% in subclinical poisoning.
⢠The acute cholinergic phase usually lasts 48â72 hours, with most
patients requiring intensive cardiorespiratory support& monitoring.
29. Ethylene glycol/Methanol
⢠Found in antifreeze, brake fluids and, in lower concentrations,
windscreen washes.
⢠Methanol is present in some antifreeze products& commercially
available industrial solvents, methylated spirits,illi-citly produced
alcohol.
⢠Both are rapidly absorbed after ingestion.
⢠They are converted via alcohol dehydrogenase to toxic metabolites
largely responsible for their clinical effects.
⢠are no longer detectable.
30. Clinical features
⢠Early feature: ataxia, drowsiness, dysarthria and nystagmus, often
associated with vomiting.
⢠As the toxic metabolites are formed, metabolic acidosis,
tachypnoea, coma,seizures may develop.
⢠Toxic effects of ethylene glycol toxicity include :
⢠ophthalmoplegia, cranial nerve palsies, hyporeflexia ,myoclonus.
⢠Renal pain / acute tubular necrosis occur because of renal
precipitation of calcium oxalate .
⢠Hypocalcaemia, hypomagnesaemia,hyperkalaemia are common.
⢠Methanol poisoning features:
⢠headache, confusion , vertigo.
⢠Visual impairment & photophobia develop.
⢠Blindness may be permanent, although some recovery may occur
⢠Pancreatitis & abnormal liver function reported.
31. Management
⢠Urea, electrolytes, chloride, bicarbonate, glucose, calcium,
magnesium, albumin&plasma osmolarity,ABG, should be measured
in all patients.
⢠The osmolal & anion gaps should be calculated.
⢠Initially, poisoning is associated with an increased osmolar gap, but
as toxic metabolites are produced, an increased anion gap
associated with metabolic acidosis will develop.
⢠The diagnosis can be confirmed by measurement of ethylene glycol
or methanol concentrations,but not widely available.
⢠An antidote, either ethanol or fomepizole, should be
administered to all patients with suspected significant exposure
while awaiting the results of laboratory investigations.
⢠These block alcohol dehydrogenase&delay the formation of toxic
metabolites until the drug is eliminated naturally or by dialysis.
32. Management
⢠The antidote should be continued until ethylene glycol or methanol
concentrations are undetectable.
⢠Metabolic acidosis should be corrected with sodium bicarbonate
⢠(e.g. 250 mL of 1.26% solution, repeated as necessary).
⢠Convulsions should be treated with an IV benzodiazepine.
⢠In ethylene glycol poisoning, hypocalcaemia should only be
corrected if there are severe ECG features or seizures occur, since
this may increase calcium oxalate crystal formation.
⢠Haemodialysis or haemodiafiltration should be used in severe
poisoning, especially if renal failure is present or there is visual
loss in the context of methanol poisoning.
⢠It should be continued until acute toxic features are no longer
present and ethylene glycol or methanol concentrations are not
detectable.
33. CO poisoning
⢠CO is a colourless / odourless gas produced by faulty appliances
burning organic fuelsvehicle exhaust fumes,house fires smoke.
⢠It causes toxicity by binding with haemoglobin &cytochrome
oxidase, which reduces tissue oxygen delivery&inhibits cellular
respiration.
⢠It is a common cause of death by poisoning& most patients who die
before reaching hospital.
34. CO poisoning: Clinical features
⢠Early clinical features : headache, nausea, irritability, weakness&
tachypnoea, are non- specific, so correct diagnosis will not be
obvious if the exposure is occult, e.g. faulty domestic appliance.
⢠Subsequently, ataxia, nystagmus, drowsiness and hyperreflexia
may develop, progressing to coma, convulsions, hypotension,
respiratory depression, cardiovascular collapse &death.
⢠Myocardial ischaemia may result in arrhythmias or AMI.
⢠Cerebral oedema is common &rhabdomyolysis may lead to
myoglobinuria &renal failure.
⢠In those who recover from acute toxicity, longer-term
neuropsychiatric effects are common,as personality change,
memory loss , concentration impairment,extrapyramidal effects,
urinary or faecal incontinence, gait disturbance.
⢠Poisoning during pregnancy may cause fetal hypoxia& intrauterine
death.
35. CO poisoning: Management
⢠Patients should be removed from exposure as soon as possible
&resuscitated as necessary.
⢠Oxygen should be administered in as high a concentration as
possible via a tightly fitting facemask, as this reduces the half-
life of carboxyhaemoglobin from 4â6 hours to about 40
minutes.
⢠Measurement of carb-oxyhaemoglobin is useful for confirming
exposure, but results do not correlate well with the severity of
poisoning, partly because concentrations fall rapidly after removal
of the patient from exposure, especially if supplemental oxygen has
been given.
⢠An ECG should be performed in all patients with acute
poisoning, especially those with pre-existing heart disease.
⢠Arterial blood gas analysis should be checked in those with serious
poisoning.
36. CO poisoning: Management
⢠Oxygen saturation readings by pulse oximetry are misleading
since both carboxyhaemoglobin &oxyhaemoglobin are measured.
⢠Excessive IVF should be avoided, particularly in the elderly,
because of the risk of pulmonary & cerebral oedema.
⢠Convulsions should be controlled with diazepam.
⢠Hyperbaric oxygen therapy is controversial.
⢠In theory, at 2.5 atmospheres, it reduces the half-life of
carboxyhae-moglobin to 20 minutes& increases the amount of
dissolved oxygen by a factor of 10.
37. Single-best choice MCQs:
⢠1.The antidote of paracetamol can be only be given:
⢠A.Oraly alone.
⢠B. IV alone.
⢠C.Rectally.
⢠D.IM.
⢠E. IV / or orally.
38. Single-best choice MCQs:
⢠2. The antidote of paracetamol:
⢠A.Replenishes glutathione liver stores.
⢠B. Activates drug metabolizing enzymes.
⢠C. Inhibits drug metabolizing enzyme.
⢠D.All.
⢠E.None.
39. Single-best choice MCQs:
⢠3. The paracetamol antidote should be given within:
⢠A. 16 hours.
⢠B. 4 hours.
⢠C. 8 hours.
⢠D. 24 hours.
⢠E.35 hours.
40. Single-best choice MCQs:
⢠4.Paracetamol drug level in paracetamol poisoning is best
measured after ingestion of:
⢠A. 16 hours.
⢠B. 4 hours.
⢠C. 8 hours.
⢠D. 24 hours.
⢠E.35 hours.
41. Single-best choice MCQs:
⢠5.Paracetamol poisoning causes:
⢠A.Heopatic failure alone.
⢠B. Renal failure.
⢠C. Both.
⢠D. Neither.
⢠E. Respiratory failure.
42. Single-best choice MCQs:
⢠6.High risk for paracetamol poisoning with lower doses include all
the following except:
⢠A. Chronic alcoholics.
⢠B. Eating disorders patients.
⢠C. Epileptics on treatment.
⢠D. Asthmatics.
⢠E. Maluarished persons.
43. Single-best choice MCQs:
⢠7. In symptomatic aspirin poisoning patients drug level is best taken
after ingestion of:
⢠A. 2 HOURS.
⢠B.4 hours.
⢠C.6 hours.
⢠D.8 hours.
⢠E.10 hours.
44. Single-best choice MCQs:
⢠8. In symptomatic aspirin poisoning patients, hemodialysis is
indicated if blood level is above:
⢠A. 400 mgm/l.
⢠B. 300 mgm/l.
⢠C 200 mgm/l.
⢠D. 600 mgm/l.
⢠E. 700 mgm/l.
45. Single-best choice MCQs:
⢠9. The most serious effects of aspirin poisoning is:
⢠A. Hypoglycemia.
⢠B.Hypocalcemia.
⢠C. Metabolic acidosis.
⢠D. Respiratory alkalosis.
⢠E.Bleeding tendencies.
46. Single-best choice MCQs:
⢠10.All these drugs are cardiotoxic if taken in overdose except:
⢠A.Trcyclic antidepressants.
⢠B.Antipsychotics.
⢠C. CO.
⢠D.Paracetamol.
⢠E.SSRI.
47. Single-best choice MCQs:
⢠11.Oximes are least effects in organophosphorous poisoning with:
⢠A. Soman.
⢠B.Dimethyl compounds.
⢠C. Diethyl compounds.
⢠D. All.
⢠E.None.
48. Single-best choice MCQs:
⢠12.CO poisoning is best diagnosed by:
⢠A.Pulseoximetry.
⢠B. Carboxyhemoglobin blood level.
⢠C. Clinical features.
⢠D.All.
⢠E.Neither.
49. Single-best choice MCQs:
⢠13. CO poisoning is best treated by:
⢠A. Usual ward oxygen.
⢠B. Hyperbaric oxygen.
⢠C. Only supportive measures.
⢠D. All.
⢠E. None.
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