Chapter 14 Overdose and self harm
Primary survey positive patient
The objectives of this chapter are listed in Box 14.1. Poisoning and self-inflicted trauma are two of the commonest causes of death and life-threatening emergencies in patients less than 40 years of age. These will present as primary positive patients for the reasons listed in Box 14.2. However be aware that these can be compounded by major trauma as part of the suicide attempt (e.g. falls, hanging and shootings). Recognition and management of these associated injuries are described elsewhere.
Management
The airway
The care of the airway is discussed in Chapter 2. Usually good basic techniques, such as airway opening procedures and patient positioning will be sufficient. Do the least to ensure a clear airway as in some types of drug overdose over aggressive intervention might induce vomiting or extreme bradycardia.
Breathing
Opiate overdose is the commonest cause of drug-induced hypoventilation. The initial management is to open the airway and ventilate using bag/valve mask techniques. Naloxone is a very effective antidote but can wear off before the opiate has been removed from the body. Consequently if the patient wakes up and then refuses to go to hospital, there is a risk that respiratory depression may re-occur once the naloxone is metabolised. As this has led to patients dying JRCALC recommends the titration of the naloxone to keep the patient in a ‘groggy state’. In such circumstances we recommend that naloxone is given slowly to bring the respiratory rate above 10 breaths per minute.
Circulation
Many drugs can cause hypotension; Box 14.3 lists the commonest. The initial management is to obtain IV access, to give fluids and arrange transport to hospital. Simple measures such as raising the legs are also effective. The commonest drugs causing arrhythmia are listed in Box 14.4.