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Paracetamol

Essentials 1 Paracetamol poisoning is one of the most common toxicological presentations to Australasian emergency departments. 2 The decision to treat patients with antidotal therapy following acute single ingestions should be made using the paracetamol treatment nomogram. 3 Acetylcysteine (NAC) prevents liver toxicity; however, this effect decreases with a delay to treatment. Patients presenting more than 8 hours post-ingestion should have NAC commenced while waiting for…

Lithium

Essentials 1 Chronic lithium toxicity is associated with significant morbidity and mortality, especially where diagnosis and treatment are delayed. a The diagnosis of lithium intoxication needs to be considered in any patient on lithium, and a serum lithium undertaken. b It usually develops due to impaired lithium excretion. The underlying factors must be identified and corrected. c It presents with neurological dysfunction. d Serum lithium levels…

Antidepressant drugs

Essentials 1 Tricyclic antidepressant (TCA) overdose is associated with severe cardiovascular toxicity, seizures, coma and death. 2 Sodium bicarbonate is the specific treatment of TCA cardiotoxicity. 3 Selective serotonin reuptake inhibitors (SSRIs) produce mild clinical effects in overdose; however very large ingestions or co-ingestion with another serotonergic agent can produce clinically significant serotonin toxicity. 4 SSRIs rarely produce cardiovascular toxicity; however, citalopram and escitalopram are associated…

Antipsychotic drugs

Essentials 1 Antipsychotics can cause numerous adverse effects at therapeutic doses, which may limit compliance. 2 Extrapyramidal effects are less pronounced with second-generation antipsychotics. 3 Clozapine is associated with agranulocytosis and myocarditis with therapeutic use and requires strict surveillance. 4 Following overdose, antipsychotics predominantly cause central nervous system (CNS) depression and cardiovascular effects. 5 Amisulpride can cause significant QT prolongation, potentially resulting in torsades de pointes.…

Cardiovascular drugs

Essentials 1 Calcium channel blockers, β-blockers, digoxin and sodium channel blocker poisonings are associated with potentially life-threatening toxicity. 2 The key to the management of calcium channel blocker and β-blocker toxicity rests with aggressive supportive care of the circulation including early use of hyperinsulinaemia euglycaemic therapy. 3 The onset of toxicity following overdose with slow-release formulations of calcium channel blockers may be delayed. 4 Early aggressive…

Approach to the poisoned patient

Essentials 1 Self-poisoning is a manifestation of an underlying psychiatric, drug and alcohol, or social disorder. 2 A wide range of clinical manifestations of toxicity may be observed following drug overdose. 3 An accurate risk assessment predicts the likely clinical course and informs planning for subsequent investigation, management and disposition. 4 The mainstay of management is timely institution of an appropriate level of supportive care. 5…

Altitude illness

Essentials 1 The high-altitude syndromes—acute mountain sickness (AMS), high-altitude cerebral oedema (HACE) and high-altitude pulmonary oedema (HAPE)—are all clinical diagnoses, where management may need to be undertaken without access to diagnostic testing. 2 AMS and HACE represent stages along a continuum owing to cerebral vasodilatation and cerebral oedema, while in HAPE the oedema manifests in the lungs. 3 Descent is the single best treatment for AMS,…

Electric shock and lightning injury

Essentials 1 Death from electric shock is due to ventricular fibrillation, the lethal arrhythmia occurring at the time of the exposure. Routine admission for ECG monitoring is unnecessary. 2 Most deaths are caused by low-voltage (<1000 V) exposures. 3 The amount of current passing through the body is determined mainly by tissue resistance, which is dramatically reduced by moisture. 4 Electrical injury resembles a crush injury…

Drowning

Essentials 1 The incidence of non-fatal drownings requiring medical assessment to fatal drownings is around 2 to 20 times greater than fatal drowning. 2 The highest rates of drowning occur in children from 1 to 4 years of age and young adult males. In adults that die, many are intoxicated. 3 A total of 10% to 20% of fatal drownings have minimal aspiration with asphyxia probably…

Radiation incidents

Essentials 1 Radiation accidents are rare but require well-planned protocols for successful management. The principal challenge will be managing large numbers of people who have concerns about their exposure to radiation, or contamination with radioactive material as a result of an incident. 2 The management of life-threatening illness or injury always takes precedence over the radiation aspects of the patient’s condition. 3 Removing the patient’s clothing…

Dysbarism

Essentials 1 Dysbarism is the term given to medical complications of exposure to gases at higher than normal atmospheric pressure. It includes barotrauma and decompression illness. 2 An understanding of the pathophysiology of dysbarism requires an understanding of the gas laws. 3 Barotrauma occurs as a consequence of excessive expansion or contraction of gas within enclosed body cavities. It principally affects the middle ear, the sinuses…

Hypothermia

Essentials 1 Hypothermia is categorized into mild (32°C to 35°C), moderate (29°C to 32°C) and severe (<29°C) on the basis of a rectal or other core temperature reading. 2 Moderate-to-severe hypothermia produces progressive delirium and coma, hypotension, bradycardia and failure of thermogenesis. 3 The electrocardiograph will often show slow atrial fibrillation and an extra positive deflection in the QRS (the J or Osborn wave) in leads…

Heat-related illness

Essentials 1 Exercise-associated collapse is the most common heat- and exercise-related illness. It is due to an impaired compensation for the drop in blood pressure that occurs when muscle pumping ceases and venous return drops at the cessation of exercise. It responds rapidly to supine posture followed by rest and oral fluids. No other medical interventions are usually required. 2 Heatstroke is a true medical emergency,…

Magnetic resonance imaging in emergency medicine

Essentials 1 Magnetic resonance imaging (MRI) is becoming more readily available in Australian hospitals and is becoming part of many imaging diagnostic algorithms. 2 The most common indication for MRI in the emergency department (ED) is suspected acute spinal cord pathology. 3 MRI is well suited to imaging soft tissues, particularly the central nervous system, musculoskeletal tissues and abdominal organs. 4 Lack of ionizing radiation makes…

Computed tomography scanning in emergency medicine

Essentials 1 Computed tomography (CT) scans are a major diagnostic modality in emergency medicine. 2 Emergency physicians are ordering CTs more frequently than previously for a variety of reasons. 3 Artefacts are occasionally encountered in CT scans, and clinicians should be familiar with these artefacts. 4 Contrast media reactions and carcinogenic effects of radiation are recognized potential adverse effects of CT scanning. Introduction Computed tomography (CT)…

Emergency department ultrasound

Essentials 1 Ultrasound examination, interpretation and clinical correlation should be available in a timely manner 24 hours a day for emergency department patients. 2 Emergency physicians providing emergency ultrasound services should possess appropriate training and hands-on experience to perform and interpret limited bedside ultrasound imaging. 3 Ultrasound imaging by emergency physicians is useful for at least the following indications: major trauma, undifferentiated shock, respiratory distress, pain…

Emergency department procedural sedation

Essentials Emergency physicians and nurses should all be trained to provide effective procedural sedation in the emergency department (ED). Plan and prepare yourself, and assess the risk-benefit of each individual procedure. Assess the timing and nature of recent oral intake, medications, available staff to assist, other simultaneous activity in the ED and patient comorbidities. Determine the safe limit of targeted depth and duration of the sedation.…

Local anaesthesia

Essentials 1 Local anaesthetic infiltration and nerve blocks may be used as a supplement to oral, inhaled or parenteral analgesia. 2 Also, they may be the primary method of achieving analgesia, particularly where pain is localized to a digit or within a peripheral nerve distribution region. 3 Local anaesthetic toxicity may occur with inadvertent bolus intravenous injection or by exceeding the recommended maximum safe dose. Neurological…

General pain management

Essentials 1 Acute pain is the most common symptom in the emergency setting. 2 Pain is a complex, multidimensional, subjective phenomenon. 3 Effective pain management involves both accurate assessment and timely treatment. 4 Patient self-reporting is the most reliable indicator of the presence and intensity of pain. 5 Both pharmacological and non-pharmacological techniques should be employed for the treatment of acute pain. Effective pain relief should…

Organ and tissue donation

Essentials 1 Organ donation should be considered for all patients where death is expected. Suitability for donation should be discussed with an organ donation specialist. 2 A substantial numbers of missed potential organ and tissue donors can be identified in emergency departments (EDs) and intensive care units (ICUs). 3 Clinical triggers have been introduced in Australian EDs to assist with the early identification of potential donors.…