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1. PARACETAMOL & SEDATIVE
OVERDOSAGE

2. OVERVIEW
• Considered to be a safe and cheap
analgesic/anti-pyretic
• OTC
• One of the most common overdosed drugs
worldwide
• Most common cause of acute hepatic failure
in the UK & US

3. OVERVIEW
• Leading indication for hepatic transplantation
in patients with drug induced liver disease
• Single dose of 10- 15 G can produce clinical
evidence of liver injury
• Fatal fulminant liver failure is usually
associated with a dosage of > 25 G

4. OVERVIEW
• Blood levels of > 30 micg/ml 4 hours after
ingestion are predictive of severe hepatic
disease
• Levels < 15 micg/ ml are predictive of low risk
• More risk of damage if liver is already
damaged by infection (virus), alcohol or other
illness

5. OVERVIEW
• Available as suppositories- 120,125,325 & 650
mg
• Chewtabs- 8 mg
• Pedtabs - 16 mg
• Regular tabs- 325 mg
• Extra strong tabs- 500, 650, 1000 mg
• Drops, suspension

6. OVERVIEW
• Maximum permissible daily dose : 4 g
• Now has been reduced to 3 g

7. CLINICAL FEATURES
• Nausea, vomiting, diarrhoea, abdo minal pain,
shock- first 24 to 48 hours
• Once these symptoms abate, features of
hepatic injury appears.
• Maximum derangement & hepatic failure
occurs around day 6
• SGOT/PT maybe raised around 10000

8. CLINICAL FEATURES
• Coma, convulsions, irritability, seizures
• Renal failure
• myocarditis

9. PROGNOSIS
• Depends on
• Quantity ingested
• Timing of initiation of treatment
• Pre-morbid health

10. TREATMENT
• Supportive measures
• Airway
• Breathing circulation
• Gastric lavage- oral administration of activated
charcoal/ cholestyramine to prevent the
absorbtion of the residual drug
• Not useful if given > 3 min after ingestion

11. TREATMENT
• Levels> 200 micg/ml after 4h
• Or 100 micg/ml after 8 hours are indications
• Administration of sulfhydril compounds(
cystamine, cysteine or NAC) reduces the
severity of hepatic necrosis.
• They work by acting as a reservoir of – SH
groups that bind to the toxic metabolytes or
stimulate the synthesis/ repletion of hepatic
glutathione

12. TREATMENT
• Must be given within 8 hours and maybe
effective upto as late as 24 to 36 hours
• Dose of NAC- 140 mg/kg stat followed by 70
mg/kg Q4h for 15 to 20 doses
• If evidence of hepatic failure occurs while on
treatment with NAC, consider LT
• Lactate levels > 3.5 mmol/L is a fair indicator
of the need for LT

13. PREVENTION
• Keep all medications out of reach of children
• Know the correct dosage
• Never mix medicines containing
acetaminophen with other drugs
• Remove all medications out of reach of adults
if there is a past/ family history of
suicide/attempt
• Avoid PCM in those who consume > 3 units of
alcohol/day

14. BARBITURATE OVERDOSAGE
• Earliest class of hypnotic-sedatives to be
developed
• Marilyn Monroe & Judy Garland famous victims
• Lethal dose varies according to individual
tolerance (2-10 G is potentially fatal)
• With other CNS depressants like alcohol,opiates
or BZD, the severity of barbiturate overdosage is
amplified.
• Depresses CNS & respiration

15. BARBITURATE OVERDOSAGE
• SIGNS & SYMPTOMS
• Sluggishness, incoordination
• Difficulty in thinking, slow speech
• Faulty judgement, drowsiness
• Shallow breathing, staggering
• Apnea, hypoxia

16. BARBITURATE OVERDOSAGE
• ARDS
• Paranoia
• Combativeness
• Tachycardia, bradycardia, hypotension, Shock
• Coma, death

17. BARBITURATE OVERDOSAGE
• SIGNS
• Hypothermia
• Depressed pupillary reflex
• Nystagmus
• Squint
• Supressed DTR

18. BARBITURATE OVERDOSAGE
TREATMENT
Supportive care/ decontamination/Accelerate
elimination
Secure airway
Endotracheal intubation- if depressed sensorium,
respiratory failure, hypoxia, raised ICT
O2
Venous access

19. BARBITURATE OVERDOSAGE
• Naloxone 2 mg. IV to all with depressed
sensorium
• Measure rectal temperature- rewarming
measures
• Pressors- noradrenaline, dopamine, fluids
• Decontamination- activated charcoal 1G/kg
Q6H
• Cathartics, gastric lavage

20. BARBITURATE OVERDOSAGE
Alkalinise urine
Sodabicarb 1 meq/kg folowed by continuous
infuson
Add 100- 150 meq of NaHco3 to 850 ml of D5 %
Dialysis- hemofiltration preferred over HD
Intravenous lipid emulsion (ILE) is emerging as
an antidote

21. TRICYCLIC ANTIDEPRESSANTS
• One of the most dangerous drugs
• Anti-cholinergic and cardiac depressant
properties(Quinidine like NA+ channel
blockade)
• Newer anti-depressants like sertraline,
fluoxetine, fluvoxamine, citalopram,
bupropion, trazodone, venlaflaxine etc. are
structurally unrelated to TCAD and produce
less cardiotoxicity

22. TRICYCLIC ANTIDEPRESSANTS
• They can produce seizures & serotonin
syndrome
• S & S may occur abruptly in around 30-60
minutes
• Anti-cholinergic effects- dilated pupils,
tachycardia, dry mouth, flushed skin,
fasciculations & reduced peristalsis

23. TRICYCLIC ANTIDEPRESSANTS
• Cardiotoxicity- widens QRSc leading to
ventricular arrhythmias, AV block, and
hypotension
• Prolonged QT – Venlaflaxine, Citalopram
• Severe intoxication- coma, seizures especially
Venlaflaxine & Bupropion
• Hyperthermia- due to anticholinergic induced
reduced sweating

24. TRICYCLIC ANTIDEPRESSANTS
• Diagnosed by the combination of
anticholinergic side effects & prolonged QRSc
with seizures
• Degree of widening of the QRSc corelates
directly with the severity of intoxication rather
than the drug levels
• Serotonin syndrome- agitation, delirium,
muscular hyperactivity, fever

25. TRICYCLIC ANTIDEPRESSANTS
• TREATMENT
• Observe all cases for atleast 6 hours
• Admit all patients with anti-cholinergic effects
or cardiotoxicity
• Activated charcoal, gastric lavage
• Cannot be removed by dialysis as they are
highly tissue bound

26. TRICYCLIC ANTIDEPRESSANTS
• SPECIFIC TREATMENT
• NAHCO3 50 to 10 meq IV- alleviates the NA –
channel depressing effect
• Maintain pH between 7.45- 7.50
• IV MG or overdrive pacing for long QT sy
ndrome/Torsades de pointes
• Serotonin syndrome- Benzodiazepines,
cyproheptadine 4 mg P/O 3 to 4 doses

27. TRICYCLIC ANTIDEPRESSANTS
• Severe hyperthermia
• neuromuscular paralysis
• External cooling
• intubation