An Unidentified Poisoning.ppt

An Unidentified Poisoning Department of Clinical Toxicology and Pharmacology Hunter Area Health Service 43 yo woman Last seen at 4pm Found by sons at 6.30pm Drowsy, confused speech Teary and smelling of alcohol Unable to confirm nature of tablets Behcet’s Disease NMMH ED T 34.9, HR 80 reg, BP 130/84, Sats 99% R/A pH 7.52 pCO2 19.8 pO2 138.4 BSL 4.8 HCO3 16.2 BE -6.0 SaO2 99.2 Should she have gut decontamination? Became agitated Physically restrained Orogastric tube - patient removed Nasogastric tube - polyethylene glycol NaHCO3 Multiple dose Activated Charcoal Family friend later finds an empty bottle of sulfasalazine and another nearly empty bottle of unknown tablets (90 missing). Date of prescription unknown for both Normal FBC Normal coags Na 130 Normal LFTs K 3.2 urea 2.4 creatinine 71 Anion Gap 16 Salicylate level 0.1 Paracetamol 7 Blood Alcohol 0.22 NMMH ICU Uncooperative, disoriented Pupils mid-size and reactive Normal tone, normal reflexes HS normal, chest clear Active bowel sounds UO 100mls/hr Overnight Nauseated Vomiting T 38.0°C At 12 hours T 38°C Examination NAD ECG SR, normal axis, no acute changes Hb 140, WCC 19.1, Plt 196 PT 14, APTT 28 UEC normal alb 42, bili 8, GGT 19, ALP 237, ALT 30, AST 124, LD 958, CK 326 At 12 hours R/A pH 7.42 pCO2 33.9 pO2 81.5 HCO3 21.4 BE -2.4 SaO2 99.0 At 18 hours T 38.1°C ? triple antibiotics Cramping abdominal pain RUQ tenderness Scanty bowel sounds Poor urine output U/A large blood, large protein Day 2 PT 23, APTT 59, TT 24 urea 7.2, creatinine 136 alb 35, LD 4123, CK 1286 (troponin 4.6) Hb 125, WCC 24.7 (myelo 7.4, metamyelo 7.9, bands 3.0, n. 4.4), Plt 118 fibrinogen 0.7 XDP 1.6 Day 3 Belly pain settled Ileus Dyspnoeic Myalgic UO ~50mls/hr HS normal, JVP ?1cm, mild sacral oedema, scanty bibasal crackles Day 3 CXR - small bilateral pleural effusions, no interstitial fluid 4L O2 pH 7.30 pCO2 28.1 pO2 90.8 HCO3 14.1 BE -10.8 SaO2 96 % Day 3 Hb 100