Makindo Medical Notes

⚠️ Many toxins can also cause coma or delirium. Clinical signs can be crucial when the history is unclear.

🩺 General Measures (when diagnosis uncertain)

🧑‍🚒 Protect staff (e.g. organophosphates). 🫁 ABC + Oxygen if SpO₂ <94%. GCS <9 → ITU review. 💧 Irrigate eyes/skin if contaminated. 🩸 Check CBG (>4.0 mmol/L). If unsure → give glucose. 💉 Suspected opioid → give Naloxone. 🔬 IV access + bloods (paracetamol, salicylate levels). 🧪 Activated charcoal 50 g PO if <1 hr (except iron, lithium, methanol, etc.). 🧍‍♂️ Top-to-toe exam: look for trauma, rashes, patches (e.g. fentanyl). 🧠 CT head/neck if cause unclear. 👀 Pupils: unilateral dilated = coning; bilateral small = opioids/GHB/OP; bilateral large = cocaine/TCA/ICH. 🌡️ Rewarm if hypothermic. ⚖️ Calculate anion gap: Na⁺ – (Cl⁻ + HCO₃⁻). High gap → alcohols, CO, salicylates, lactic acidosis, DKA. ✔️ Naloxone + glucose cause little harm if diagnosis unclear. 🧫 If no diagnosis on CT: consider IV cefotaxime + IV aciclovir ± LP. 🌍 Travel? Consider cerebral malaria (blood films). 📈 EEG if non-convulsive status suspected. 💊 Sepsis? Give broad-spectrum antibiotics + escalate to HDU/ITU.

⚠️ Risk Factors for Overdose

• 🧠 Psychiatric illness (depression, schizophrenia)
• 👤 Male sex, Living alone
• 💔 Recent bereavement/divorce
• 📝 Suicide note written
• 🎂 Age >45
• 💼 Unemployment
• 🩺 Chronic physical illness
• 🍷 Drug or alcohol misuse
• 🔄 Previous attempts (esp. violent methods)

🚨 Any septic patient with lactate >4 mmol/L = septic shock until proven otherwise → immediate IV fluids, antibiotics, ± inotropes (per sepsis bundle).

📖 About Lactate

• Normal: <1 mmol/L
• Raised: >2 mmol/L
• Lactic acidosis: >4 mmol/L + pH <7.35

🧾 Classification of Lactic Acidosis

Type	Causes
⚡ Type A (Hypoxia-driven)	Shock, anaemia, hypoxia, bowel ischaemia, seizures, cholera, phaeochromocytoma, tumour lysis
🧪 Type B (Non-hypoxia)	Liver failure, DKA, ethanol abuse, drugs (metformin, methanol, ethylene glycol, salicylates, cyanide)

🤒 Clinical Features

• Hypotension, shock, peri-arrest appearance.
• Respiratory: Kussmaul breathing, tachypnoea.
• Organ failure: renal, hepatic, cardiac involvement.

🔍 Clinical Clues in Toxicology

Finding	Possible Cause
🌸 Pink colour	Cyanide, CO poisoning
💙 Cyanosis	Methaemoglobinaemia
🤢 Nausea/vomiting	Paracetamol, NSAIDs, salicylates, iron
👁️ Small pupils	Opioids, GHB, organophosphates
👁️ Large pupils	Cocaine, TCA, anticholinergics
❤️ Hypertension	Cocaine, amphetamines
💔 Hypotension	TCAs, haloperidol
🐢 Bradycardia	Digoxin, β-blockers, CCBs
🐇 Tachycardia	TCAs, theophylline, digoxin
🍬 Hypoglycaemia	Insulin, sulphonylureas, alcohol
🍭 Hyperglycaemia	Organophosphates, theophylline
😮‍💨 Hyperventilation	Salicylates
🧪 Renal failure	Salicylates, paraquat, ethylene glycol
🔥 Hyperthermia	Serotonin syndrome, cocaine, MDMA
❄️ Hypothermia	CNS depressants, opioids
🟡 Jaundice	Paracetamol, solvents
⚡ Seizures	TCAs, opioids, cocaine
💪 Rhabdomyolysis	Amphetamines
🤯 Myoclonic jerks	GHB
❤️ Chest pain	Cocaine, CO
👄 Oral ulcers	Corrosives, paraquat
🧮 High osmolar gap	Methanol, acetone
➕ High anion gap	Metformin, methanol, iron, INH

💊 Specific Antidotes

Always check local toxicology/NPIS guidance before giving antidotes.

Drug	Antidote
Digoxin	Digibind (Fab)
Iron	Desferrioxamine IV
Opioids	Naloxone IV
Paracetamol	N-acetylcysteine or methionine
Warfarin	Vit K + PCC/FFP
Heparin	Protamine
Methanol, ethylene glycol	Fomepizole or ethanol
Benzodiazepines	Flumazenil (⚠️ seizure risk)
β-blockers	Atropine, glucagon
TCAs	IV sodium bicarbonate
Sulphonylureas	Glucose, octreotide
Organophosphates	Atropine + pralidoxime
Methotrexate	Folinic acid
CO poisoning	100% O₂ ± hyperbaric O₂
Methaemoglobinaemia	Methylene blue
Cyanide	Cyanide kit (amyl nitrite, thiosulfate)
Arsenic	Dimercaprol or succimer
Theophylline, salicylates	Haemodialysis