Aspirin (Salicylate), Iron Pill, ne Mogya Nhyɛso Nnuru a Wɔnom Boro So¶

Ɛkame ayɛ sɛ abusua nnuru dan biara mu, adididan mu drawer, anaa nana ne nananom anadwo pon mu no, ofie nnuru ne nnuru a wɔde ka ho akuw anum te baabi a sɛ obi mene aduru 1 kosi 5 pɛ (anaasɛ nsu teaspoon biako) a, ebetumi akum abofra a ɔretu mmirika ("One-Pill Killers"), ne baabi a ɔpanyin a ɔnom boro so no kanyan nipadua mu nneɛma ne koma ne ntini mu ntini a ɛhwe ase ntɛmntɛm, a ɛyɛ den sɛ ɔhwɛ a ɛboa no ntumi nsan n’akyi a nnuru pɔtee bi a wɔde kum ɔyare mmoawa nka ho:

1. Salicylates (Aspirin, Pepto-Bismol / Bismuth Subsalicylate, ne Methyl Salicylate / Oil of Wintergreen): Ɛno na ɛma mitochondrial oxidative phosphorylation no yɛ biako, na ɛma aso mu nnyigyei bɔ (tinnitus), mframa a ɛboro so a ennyae, ɔhyew a ɛboro so, amemene mu ntini mu glycopenia, ne ahurututu anaa amemene mu edema a ɛyɛ owuyare.
2. Elemental Iron Supplements (Adult Ferrous Sulfate tablets and Prenatal Vitamins): Nea ɛte sɛ chocolate M&M anaa Skittles a wɔde ahwiesa akata so yiye ma mmofra nkumaa, a ɛde mogya a ɛtɔ kɔ yafunu no mu no sɛe ansa na akɔhyɛn nnaadaa ** nnɔnhwerew 6 kosi 24 "latent quiescent phase"** a ɛno akyi no, hepatorenal mpofirim huammɔdi ne koma ne ntini mu ahodwiriw.
3. Tricyclic Antidepressants (TCAs: Amitriptyline, Nortriptyline, Doxepin, Imipramine): Ɛnyɛ adwenemhaw nko na wɔtaa kyerɛw ma na mmom wɔ dodow a ɛba fam nso de siw atiridiinini ano, fibromyalgia, ntini mu yaw, nna a wontumi nna, ne mmofra mpa so nsu, a esiw koma mu sodium akwan a ɛkɔ ntɛmntɛm no kwan ma ɛde mpofirim akisikuru, koma, . ne wide-QRS ventricular arrhythmias wɔ simma 60 kosi 120 mu.
4. Calcium Channel Blockers (CCBs: Amlodipine, Nifedipine, Verapamil, Diltiazem): Ɛma L-type calcium akwan a ɛwɔ koma ne mogya ntini mu no yɛ mmerɛw bere a esiw insulin a ɛba dwensɔtwaa mu no kwan, na ɛde ntini a emu dɔ trɛw ne koma mu ahodwiriw a ɛne hyperglycemia a wɔahyɛ no agyirae ba.
5. Beta-Blockers (BBs: Propranolol, Metoprolol, Atenolol, Carvedilol, Sotalol): Nea ɛde bradycardia a emu yɛ den (koma a ɛbɔ brɛoo), mogya mmoroso, ahurututu mu akisikuru, ne asikre a ɛba fam (ne sodium-channel akisikuru ne QRS a ɛtrɛw a wɔde propranolol, anaa Torsades de Pointes a wɔde sotalol ka ho) ba.

Saa awuduru ho akwankyerɛ a ɛkɔ akyiri yi de afuw mu nneyɛe a wɔyɛ no ntɛm ara, awuduru a ɛwɔ miligram biara mu pɛpɛɛpɛ, ayaresabea gyinabea, ne ICU nnuru a wɔde ko tia ɔyare mmoawa a ɛyɛ pintinn (IV Sodium Bicarbonate urinary alkalinization, Deferoxamine chelation, High-Dose Insulin Euglycemic Therapy [HIET], Intravenous Lipid Emulsion [Intralipid], . ne Glucagon) ne Amerika Fekuw a Ɛhwɛ Awuduru So (AAPCC), Amerika Aduruyɛ mu Awduru Ho Adesua Sukuu (ACMT), EXTRIP Adwumayɛkuw, ne UK Ɔman Awuduru Ho Amanneɛbɔ Dwumadibea (NPIS) yɛɛ biako.

Yɛ eyi mprempren¶

Sɛ abofra anaa ɔpanyin bi amene aspirin, wintergreen oil, iron tablets, mogya mmoroso nnuru (beta-blockers anaa calcium channel blockers), anaa tricyclic nnuru a ekum adwenemhaw a ɛboro so a:

1. Frɛ 911 / 112 / 999 ntɛm ara sɛ abofra biara bɛnom wintergreen oil, mogya mmoroso nnuru, tricyclics, anaa iron, anaasɛ sɛ ɔyarefo biara wɔ sɛnkyerɛnne ahorow a: Fa yɛn nɔma ahorow a egye ntɛmpɛ directory a wɔde kyerɛw nsɛm. Sɛ wopɛ ɔpanyin anaa abofra a onni sɛnkyerɛnne biara a wuhia sɛ wobu miligram kilogram biara mu nhwehwɛmu ntɛm ara a, frɛ Poison Control (1-800-222-1222 wɔ United States; NHS 111 / 999 wɔ UK; 13 11 26 wɔ Australia) bere a woresiesie wo ho sɛ wobɛkɔ dwumadibea a wɔhwɛ ntɛmpɛ so no.
2. Pora abofra no ano ma hwehwɛ nnuru a wɔamene na boaboa toa ne akisikuru biara ano: Sɛ abofra ketewa bi de nnuru a wɔde hyɛ n’anom kɛkɛ a, fa nsateaa popa yi nnuru a enni dɛm biara fi n’afono mu, kan nnuru a aka a ɛwɔ toa no mu, na fa nkuku pɔtee no bra ayaresabea.
3. MMMA ɔfe wɔ fie DA na MMFA baking soda anaa nufusu mma a Poison Control akwankyerɛ nka ho: Sɛ wɔma ɔfe wɔ ɔyarefo a ɔmenee tricyclic antidepressants, propranolol, anaa calcium channel blockers mu no yɛ asiane kɛse efisɛ ɔyarefo no betumi ahwere n’adwene mpofirim anaasɛ ne ho akyere no wɔ simma 30 mu, na wahome ɔfe akɔ n’ahurututu mu.
4. Te "Activated Charcoal Does NOT Bind Iron" mmara no ase: Bere a ayaresabea activated charcoal kyekyere aspirin, tricyclic antidepressants, beta-blockers, ne calcium channel blockers (na ɛsɛ sɛ wɔde ma wɔ nnɔnhwerew 1 kosi 2 mu, anaasɛ wɔ dodow a wɔsan de ma mu ma aspirin a wɔde enteric-coated aspirin) no, fango a wɔde yɛ adwuma no Nkyekyere elemental iron. Dade aduru a ɛnyɛ radiopaque a ɛbata yafunu mu no hia ayaresabea Whole Bowel Irrigation (WBI) a wɔde polyethylene glycol electrolyte solution (GoLYTELY) ne Deferoxamine a wɔde fa ntini mu.
5. Hwɛ Extended-Release ("XL", "XR", "SR", "CD", "LA") anaa Enteric-Coated ("EC") nkyerɛwde wɔ toa no so: extended-release verapamil, diltiazem, nifedipine, metoprolol, anaa aspirin a wɔde enteric-coated a wɔnom boro so no betumi anya zero sɛnkyerɛnne biara wɔ 6 kosi 18 a edi kan no mu nnɔnhwerew ansa na nnubɔne a edi awu a ɛretu akɔ mogya no mu mpofirim. Calcium channel blocker anaa beta-blocker a wɔde bere tenten anom biara hwehwɛ sɛ wɔde wɔkɔ so hwɛ koma no so kɔ ayaresabea nnɔnhwerew 24, sɛ mpo ɔyarefo no hwɛ sɛ ne ho ye koraa wɔ dɔnhwerew 4 mu a.
6. Bɔ Paramedics ne ER Doctors kɔkɔ wɔ "Salicylate Intubation Trap" ho: Sɛ ɔyarefo bi a ɔwɔ aspirin (salicylate) awuduru a emu yɛ den rehome ntɛmntɛm na emu dɔ (home 30 kosi 40 simma biara), sɛ mframa a ɛboro so no rema wɔakɔ so atra ase denam carbon dioxide (\(\text{CO}_2\)) a wɔbɔ no so na ama wɔn mogya pH akɔ fam. Sɛ wɔma ɔyarefo no dwo na ɔyɛ obubuafo ma endotracheal intubation na wɔde no si ventilator rate a ɛyɛ brɛoo a ɛfata so a, home tiawa a wɔde home bere tiaa mpofirim no ma mogya \(\text{pH}\) kɔ fam kɛse, na ɛma salicylic acid a wɔaka abom no fa mogya-amemene akwanside no so tẽẽ na ɛkanyan koma no gyaee ntɛm ara wɔ simma 2 kosi 5 akyi wɔ simma 2 kosi 5 akyi.

Emergency triage ne antidote flowchart a wɔde yɛ ofie nnuru a asiane kɛse wom¶

flowchart TD
    Start["Wosusuw sɛ Wɔnom Ofie Nnuru a Wɔnom boro So<br/>(Aspirin, Iron, Tricyclic Antidepressant, Beta-Blocker, anaa Calcium Channel Blocker)"] --> Call["Frɛ 911 / 112 / 999 anaa Poison Control (1-800-222-1222)<br/>Hwɛ Toa no mu sɛ Ahoɔden (mg) + Extended-Release (XR/XL/SR/EC) Gyinabea"]

    Call --> ClassCheck{"Nnuru kuw bɛn na wɔnom?"}

    ClassCheck -->|Salicylates: Aspirin, Enteric-Coated Aspirin,<br/>Pepto-Bismol, or Oil of Wintergreen| SalRule["SALICYLATE PROTOCOL (Aso a ɛyɛ den + Mframa a ɛkɔ soro + Atiridiinini)<br/>1. Multi-Dose Activated Charcoal (ɛkyekyere aspirin concrements/bezoars)<br/>2. IV Sodium Bicarbonate (NaHCO3) na ama Mogya pH ayɛ 7.45-7.55 & Nsu pH 7.5-8.0<br/>+ aggressive IV Potassium (K+ > 4.0) sɛnea ɛbɛyɛ a asaabo betumi ayi salicylate<br/>3. KWATI INTUBATION sɛ ɛbɛyɛ yiye a; Emergency Hemodialysis sɛ >100 mg/dL anaa neuro/pulm sɛnkyerɛnne ahorow a"]

    ClassCheck -->|Elemental Iron: Adult Ferrous Sulfate/Gluconate/Fumarate<br/>or Prenatal Vitamins (Calculate Elemental Iron mg/kg)| IronRule["DADEƐ PROTOCOL (Activated Charcoal Nkyekyere Dadeɛ)<br/>1. Yafunu mu X-Ray (KUB) de hu dade nnuru a ɛnyɛ radiopaque wɔ yafunu mu<br/>2. Nsuo a wɔde gugu dwensɔtwaa mu nyinaa so (PEG-ELS / GoLYTELY) sɛ radiopaque pills ba a<br/>3. Twe Nnɔnhwerew 4 kosi 6 Peak Serum Iron Level + Mogya Mframa/Lactate<br/>4. IV Deferoxamine Chelation sɛ Serum Iron > 500 mcg/dL, Ahodwiriw, anaa Acidosis a"]

    ClassCheck -->|Tricyclic Antidepressants (TCAs): Amitriptyline,<br/>Nortriptyline, Doxepin, Imipramine| TCARule["TRICYCLIC ANTIDEPRESSANT (TCA) PROTOCOL (Nna+ Nsuo a Wɔde Siw Ntɛmntɛm)<br/>1. 12-Lead ECG ntɛm ara: Hwɛ sɛ QRS > 100 ms anaa Terminal R asorɔkye wɔ aVR mu > 3 mm<br/>2. IV Sodium Bicarbonate Boluses (1-2 mEq/kg) kosi sɛ QRS bɛtew < 100 ms & pH 7.50-7.55<br/>3. Fa Benzodiazepines NKUTOO Sa Akisikuru (MENNI Phenytoin DA); IV Lipid Emulsion sɛ ɛyɛ nea ɛyɛ den a"]

    ClassCheck -->|Calcium Channel Blockers (CCBs: Verapamil, Diltiazem, Amlodipine)<br/>OR Beta-Blockers (BBs: Propranolol, Metoprolol, Sotalol)| CCBBBRule["CARDIOVASCULAR BLOCKADE PROTOCOL (24-Hr Monitoring for XR/SR Pills)<br/>Hwɛ Mogya mu Glucose: CCB dodow a ɛboro so = HYPERGLYCEMIA vs BB Dodo a ɛboro so = HYPOGLYCEMIA<br/>1. IV Calcium Chloride/Gluconate + IV Glucagon (5-10 mg bolus, ɛtwa beta agyefo ho)<br/>2. Nnuru a ɛma mogya tu (Norepinephrine / Epinephrine) ma MAP > 65 mmHg<br/>3. Insulin a Wɔde Di Dwuma Kɛse Euglycemic Ayaresa (HIET: 1 kosi 10 Units/kg/hr Insulin a Wɔyɛ Daa + Dextrose)<br/>4. VA-ECMO anaa IV Lipid Emulsion (Intralipid) a wɔde yɛ komayare a ɛnyɛ den"]

Master Ntotoho a Wɔde Toto Ofie Nnuru a Wɔde Di Dwuma boro So 5 a Ekum Nnipa Kɛse no Ho¶

Deep Dive 1: Salicylate (Aspirin & Wintergreen Oil) Awuduru a Wɔde Ma¶

1. Salicylate Toxidrome a Wohu (Ade a Ɛyɛ Den ne Nea Enni sabea) .¶

Salicylate awuduru ba wɔ nnipa ahorow abien a ɛsono emu biara mu: (a) Aduru a wɔnom boro so denneennen wɔ mmabun, mpanyimfo nkumaa, anaa mmofra nkumaa a wɔmene aspirin, Excedrin, anaa Oil of Wintergreen toa biako mu, ne (b) **Salicylate awuduru a enni sabea ("ayaresa") ** wɔ mpanyimfo a wɔn mfe akɔ anim a wɔnom aspirin anaa bismuth subsalicylate dodow a ɛkɔ soro da biara da no mu (Pepto-Bismol) ma ntini mu yare anaa atiridiinini wɔ nna anaa adapɛn pii mu bere a wɔn asaabo dwumadi so tew wɔ anifere kwan so no. Salicylism a enni sabea no de owu dodow kɔ soro sen nnuru a wɔde di dwuma boro so a emu yɛ den efisɛ wɔtaa hu sɛ ɛyɛ sepsis, ahurututu mu yare, asikreyare ketoacidosis, anaa ɔyare a ɛma obi hwe ase/adwene mu yare.

• Atesɛm mu Kɔkɔbɔ Nsɛnkyerɛnne a Edi Kan: Tinnitus (Ringing anaa Muffled Hearing): Salicylates nya cochlear hair cells ne spiral ganglion neurons so nkɛntɛnso wɔ ɔkwan a ɛdannan so. Sɛ serum salicylate dodow boro 20 kosi 30 mg/dL a, ayarefo no nya aso mu nnyigyei a ano yɛ den (tinnitus) anaasɛ wonwiinwii sɛ nne ahorow no te sɛ nea wɔayɛ no den, a akisikuru, ɔfe, ne diaphoresis (fifiri) ka ho.
• Nsateaa a ɛyɛ Acid-Base Nsateaa Nkyerɛwee:
• Nea edi kan no, salicylate kanyan medullary respiratory center a ɛwɔ amemene no dua mu no tẽẽ, na ɛma ɔyarefo no home kɔ akyiri na ɛyɛ ntɛmntɛm (hyperpnea ne tachypnea), a ɛbɔ \(\text{CO}_2\) na ɛma Primary Respiratory Alkalosis (mogya pH a ɛkɔ soro ntɛm).
• Nea ɛto so abien no, salicylate yi mitochondrial oxidative phosphorylation fi nipadua no mu nkwammoaa biara mu (te sɛ dinitrophenol ara pɛ): nkwammoaa no di oxygen abufuw so, ɛma nipadua mu ɔhyew kɛse (hyperthermia) ba sen ATP, na ɛboaboa lactic acid, ketoacids, ne salicylic acid ankasa ano, na ɛyɛ bere koro mu Acidosis a Ɛyɛ Anion-Gap a Ɛkorɔn a Ɛho Hia.

2. Nea enti a Nsuo mu Alkalinization (IV Sodium Bicarbonate) ne Potassium Gye Adwuma ("Ion Trapping") .¶

Salicylic acid yɛ acid a ɛyɛ mmerɛw (\(\text{pK}_a = 3.0\)). molekyule a enni ahoɔden (a ɛnyɛ ionized) (\(\text{HA}\)) nkutoo na ebetumi atwa lipid nkwammoaa ntini mu akɔ amemene no mu anaasɛ asan akɔ mogya no mu afi asaabo mu ntini no mu, bere a a ahoɔden wom (ionized) salicylate ion (\(\text{A}^-\)) no akɔda nkwammoaa akyi:

• Nea enti a mogya mu pH a ɛrekɔ fam kum ɔyarefo no: Sɛ ɔyarefo no mogya \(\text{pH}\) kɔ fam fi 7.45 down to 7.20 (acidemia), kari pɛ no dan kɔ benkum so denneennen (\(\text{HA}\)), na ɛma salicylic acid a enni ahoɔden fi mogya no mu tẽẽ fa mogya-amemene akwanside no mu kɔ amemene no mu ntini no mu, na ɛde amemene mu akisikuru, akisikuru, komayare, ne owu ba.
• Sɛnea IV Sodium Bicarbonate (\(\text{NaHCO}_3\)) kyere salicylate wɔ mogya ne nsu mu:
• Nnuruyɛfo a wɔhwɛ ntɛmpɛ so de bolus a ɛyɛ 1 kosi 2 mEq/kg IV Sodium Bicarbonate ma, na wɔde kɔ so de gu nipadua no mu (3 ampules [150 mEq] a ɛyɛ 8.4% Sodium Bicarbonate a wɔde afra D5W Lita 1 mu a wɔde ahyɛ mu wɔ nsu a wɔde siesie no mmɔho 1.5 kosi 2 mu).
• Sɛ wɔma ntini mu mogya pH kɔ soro kodu 7.45 kosi 7.55 a, ɛtwe salicylate fi amemene no mu san kɔ mogya no mu.
• Sɛ wɔma nsuo mu pH kɔ soro kɔ 7.5 kɔsi 8.0 a, ɛma salicylate no yɛ ionize wɔ renal tubules no mu ma enti ɛntumi nsan nnye bio, ɛma aspirin a ɛfiri asaabo mu no kɔ soro mpɛn 10 kɔsi 20.
• Potassium (\(K^+\)) Mmara: Wo ntumi nyɛ alkalinize nsuo no sɛ ɔyarefoɔ no mogya mu potassium sua (\(\text{K}^+ < 4.0\text{ mEq/L}\)). Sɛ serum potassium sua a, asaabo no akyirikyiri ntini no kura potassium ions (\(K^+\)) mu denam hydrogen ions (\(H^+\)) a wɔtow gu nsu no mu (paradoxical aciduria) so, na ɛma nsu no kɔ so yɛ acid ɛmfa ho sɛ bicarbonate dodow a wode bɛhyɛ mu no. Enti, nnuruyɛfo de ahoɔhare de Potassium Chloride** **40 kosi 60 mEq/L ka IV nsu no ho na ama serum \(\text{K}^+\) akɔ so ayɛ 4.0 ne 5.0 mEq/L.
• Amemene mu Ɔkɔm a Ahintaw a Wɔteɛteɛ ("CNS Neuroglycopenia"): Esiane sɛ salicylates ma amemene mu glycolysis yɛ ntɛmntɛm bere a ɛmma glucose a wɔde fa mogya-amemene akwanside no so no sɛe nti, ɔyarefo a ɔwɔ salicylate awuduru betumi anya amemene mu glucose dodow a ɛba fam kɛse bere mpo a wɔn nsateaa mu mogya mu glucose kenkan 90 anaa 100 a ɛfata koraa no mg/dL. Ɔyarefo biara a wɔde salicylate awuduru ayɛ no a n’adwene atu afra, n’adwene mu yɛ no naa, n’ayɛ basaa, anaasɛ n’adwene mu yɛ no naa no nya IV Dextrose bolus (D50W anaa D10W) ntɛm ara a wɔn nsateaa mu asikre a ɛwɔ mogya mu mfa ho.

3. Bere a Ɛsɛ sɛ Wɔyɛ Hemodialysis Ntɛmntɛm¶

Esiane sɛ aspirin kyekyɛ kakraa bi nti, hemodialysis a wɔyɛ no bere ne bere mu no yi salicylate fi mogya no mu ntɛmntɛm bere a ɛteɛ acidosis ne nsu a ɛboro so no so no. Sɛnea EXTRIP akwankyerɛ kyerɛ no, wɔkyerɛ sɛ wɔnyɛ hemodialysis ntɛm ara ma:

1. Adwene mu tebea a ɛsakra (adwene mu naayɛ, adwenemhaw, adwenemhaw, komayare, anaasɛ akisikuru), ANAA
2. Acute Respiratory Distress Syndrome (ARDS) / Non-cardiogenic pulmonary edema a ɛhwehwɛ sɛ wɔde oxygen foforo ma, OR
3. Asaabo mu opira a emu yɛ den anaa enni sabea (a ɛmma nsuo mu alkalinization ntumi nyɛ adwuma), ANAA
4. Serum Salicylate dodow \(> 100\text{ mg/dL}\) (\(> 7.2\text{ mmol/L}\)) wɔ dodow a ɛboro so a emu yɛ den (anaasɛ \(> 90\text{ mg/dL}\) a asaabo dwumadi asɛe), anaasɛ \(> 60\text{ mg/dL}\) wɔ salicylism a enni sabea mu, anaasɛ dodow a ɛkɔ soro ɛmfa ho sɛ wɔde nnuru pii di dwuma fango a wɔde yɛ adwuma ne IV bicarbonate.

Deep Dive 2: Iron Supplement Overdose ne Ayaresa mu Nneɛma 5 no¶

1. Elemental Iron Dose a Wobu ho akontaa denam Nkyene Su so¶

Sɛ nnuruyɛfo frɛ Poison Control anaasɛ wodu dwumadibea a wɔhwɛ ntɛmpɛ so bere a wɔanom dade aduru bi akyi a, egyina ELEMENTAL IRON miligram wɔ nipadua mu duru kilogram biara mu so bu awuduru ho akontaa, na ɛnyɛ dade nkyene aduru no mu duru nyinaa miligram:

2. Ayaresabea Akwan 5 a Ɛfa Dade a Ɛma Awuduru Ho (Hwɛ Yiw Ɔfã 2) .¶

1. Stage 1: Corrosive Gastrointestinal Fase (Nnɔnhwerew 0.5 kosi 6 wɔ anom akyi):
2. Direct corrosive necrosis of the stomach and duodenal mucosa de yafunu mu yaw a emu yɛ den mpofirim, ɔfe mpɛn pii (a mpɛn pii no mogya kɔkɔɔ a ɛhyerɛn anaasɛ "kɔfe a wɔayam" a ɛyɛ tumm a ɛtwetwe), ne mogya anaa tuntum tarry diarrhea.
3. Mmara a Ɛho Hia a Wɔde Di Dwuma: Sɛ abofra anaa ɔpanyin bi nya fefe biara, atiridiinini biara, ne yafunu mu yaw biara nni hɔ nnɔnhwerew 6 a edi mũ wɔ dade a wosusuw sɛ wanom akyi a, wɔpow dade awuduru kɛse a ɛwɔ nipadua no mu no yiye.
4. Stage 2: Nnaadaa Latent / Quiescent Phase (Nnɔnhwerew 6 kosi 24 wɔ Ingestion akyi):
5. Ɔfe gyae na ɛte sɛ nea abofra no ho adwo no anaasɛ ɔda, na ɛma mmusua (ne ayaresabea adwumayɛfo a wonni osuahu) susuw sɛ abofra no ho retɔ no. Nokwarem no, wɔretwe dade a enni mu afi awotwaa no mu akɔ mogya no mu, a ɛboro transferrin tumi a ɛkyekyere no so na ɛreyiri akɔ ntini mu endothelial nkwammoaa, koma mu nkwammoaa, ne hepatic periportal (Zone 1) hepatocytes mu.
6. Ɔfã 3: Systemic Shock ne Metabolic Acidosis Phase (Nnɔnhwerew 12 kosi 48 wɔ anom akyi):
7. Nsuo a ɛto so abiɛsa ntam kwan kɛse, ntini a ɛtrɛw tẽẽ, koma no mu adwenemhaw, ne dade a ɛma ferrous (\(\text{Fe}^{2+}\)) dannan kɔ ferric (\(\text{Fe}^{3+}\)) ions a protons (\(H^+\)) ne mitochondrial uncoupling fi mu ba no ma hypovolemic/distributive/cardiogenic a emu dɔ ahodwiriw, lactic acidosis a emu yɛ den a anion-gap pii wom, coagulopathy, ɔbrɛ, ne coma.
8. Ɔfã 4: Hepatotoxicity / Fulminant Liver Failure Phase (Nnafua 2 kosi 5 wɔ anom akyi):
9. Free radical lipid peroxidation a ɛwɔ Hepatic Zone 1 (periportal hepatocytes, mmerɛbo mu nkwammoaa a edi kan a portal vein mogya a dade ahyɛ mu ma a efi awotwaa mu bɔ no) kanyan aduru a ɛyɛ mmerɛbo mu akisikuru a emu yɛ den, jaundice, transaminases a ɛkɔ soro, asikre a ɛba fam, ne mogya a ɛtɔ.
10. Ɔfã 5: Yafunu mu Outlet Obstruction / Stricture Phase (Adapɛn 2 kosi 6 wɔ anom akyi):
11. Bere a ɔhyew a emu dɔ a ɛporɔw a ɛwɔ yafunu no mu no sa denam fibrosis ne akuru so no, ayarefo betumi anya pyloric stenosis / gastric outlet obstruction adapɛn bi akyi a wɔanya nkwa wɔ dodow a ɛboro so a emu yɛ den no mu, na ɛde projectile non-bilious fe a ɛba bere a wɔadi akyi.

3. Ayaresabea a Wɔde Fi Efĩ Ho (KUB X-Ray + Nsu a Wɔde Gu Nsu Mu Nyinaa So) ne Deferoxamine Chelation¶

• Yafunu X-Ray (KUB): Mpanyimfo dade aduru a ɛyɛ den no yɛ radiopaque kɛse (ɛhyerɛn fitaa a ɛhyerɛn wɔ yafunu X-ray a ɛnyɛ den so ansa na apete). Sɛ wohu nnuru a enni dɛm anaa dade pharmacobezoar (aduru a akyea akuwakuw) wɔ X-ray no so a, nnuruyɛfo fi ase Whole Bowel Irrigation (WBI) denam Polyethylene Glycol Electrolyte Lavage Solution (PEG-ELS / GoLYTELY) a wɔde tu mmirika fa nasogastric tube mu wɔ 500 mL/hr wɔ mmofra nkumaa mu anaa 1,500 to 2,000 mL/hr wɔ mpanyimfo mu kosi sɛ nsu a ɛkɔ akyi berɛmo mu no bɛtew te sɛ ahwehwɛ na sɛ wɔyɛ X-ray mpɛn pii a, ɛbɛkyerɛ sɛ nnuru biara nkae.
• Peak Serum Iron Level (Wɔtwe wɔ Nnɔnhwerew 4 kosi 6 wɔ Wɔnom Akyi):
• < 300 mcg/dL: awuduru a ɛyɛ daa / a ɛba fam koraa.
• 300 to 500 mcg/dL: Awduru a ɛkɔ fam (ɛhwehwɛ sɛ wɔsan de nsu a wɔde fa IV mu ma obi nya nkwa na wɔhwɛ no yiye).
• ** > 500 mcg/dL: awuduru a emu yɛ den a ɛba nipadua no mu a ɛhwehwɛ sɛ wɔde Intravenous Deferoxamine Chelation ntɛm ara.
• IV Deferoxamine Protocol: Deferoxamine kyekyere ferric iron a enni mu (\(\text{Fe}^{3+}\)) wɔ mogya no mu ma ɛyɛ ferrioxamine a ɛtumi nwura nsuo mu, a asaabo no yi fi mu na ɛma ɔyarefoɔ no nsuo dane kɔla soronko "vin rosé" (pinkish-orange / salmon-red). Wɔde fa ntini mu 15 mg/kg/dɔnhwerew (wɔhwɛ yiye sɛ ebia mogya mmoroso a ɛba fam a ɛfa sɛnea ɛkɔ soro anaa ahurututu mu awuduru ho sɛ wɔde bɛboro nnɔnhwerew 24 a).

Deep Dive 3: Tricyclic Antidepressant (TCA) a wɔde di dwuma boro so (QRS Mmara a Ɛyɛ Millisecond 100) .¶

Wɔda so ara kyerɛw amitriptyline, nortriptyline, doxepin, imipramine, clomipramine, ne desipramine kɛse ma ntini mu ɛyaw a enni sabea, atiridiinini a wɔde siw ano, nna a wontumi nna, ne ɔfe a ɛkɔ so kyinhyia. Wɔ nnuru a wɔde di dwuma boro so mu no, ɔyarefo betumi afi ɔkasa a ɛne ne ho hyia wɔ ambulance mu so akɔ generalized tonic-clonic seizures, coma, ne komayare wɔ nea ennu simma 30 mu.

1. ECG a ɛwɔ 12-Lead no ne Adwinnade titiriw a wɔde hu yare:
2. Esiane sɛ TCA mogya mu dodow gye nna pii ansa na afi nhwehwɛmu dan ahorow mu aba nti, nnuruyɛfo a wɔhwɛ ntɛmpɛ so di TCA awuduru ho dwuma tẽẽ fi 12-lead ECG no so:
   • Sinus tachycardia (efi anticholinergic muscarinic blockade mu).
   • Nifa so nsakraeɛ a ɛba terminal no so milisekɔn 40 wɔ anim wimhyɛn QRS axis no so: Wohu no ntɛm ara wɔ ECG no so sɛ asorɔkye R a ɛda nsow \(> 3\text{ mm}\) wɔ lead aVR mu (ne \(\text{R/S ratio} > 0.7\) wɔ lead aVR mu) a wɔde terminal S asorɔkye a emu dɔ ka ho wɔ leads I ne aVL mu.
   • QRS Bere Tenten Ntrɛwmu:
   • \(\text{QRS} < 100\text{ ms}\): Asiane a ɛnyɛ hwee sɛ wobɛnya akisikuru anaasɛ ventricular arrhythmias.
   • \(\text{QRS} \ge 100\text{ ms}\): asiane a ɛwɔ hɔ sɛ obi betumi anya akisikuru a ɛkɔ so wɔ ɔkwan a ɛkɔ akyiri so ɔha biara mu nkyem 33 (Ɛkyerɛ sɛ ɛsɛ sɛ wofi ase IV Sodium Bicarbonate ntɛm ara).
   • \(\text{QRS} \ge 160\text{ ms}\): asiane ɔha biara mu nkyem 50 a ɛbɛma obi anya ventricular tachycardia anaa ventricular fibrillation a ɛde nkwa to asiane mu.
3. Aduru a Wɔde Ko Tia Ntɛm ara: Sodium Bicarbonate (\(\text{NaHCO}_3\)) a wɔde fa ntini mu Boluses:
4. Bere biara a QRS bere tenten no du anaasɛ ɛboro milisekɔn 100, anaasɛ sɛ ɔyarefo no nya mogya mmoroso anaasɛ ventricular arrhythmia a, nnuruyɛfo ma IV pushes ntɛmntɛm a ɛyɛ 8.4% Sodium Bicarbonate (1 kosi 2 mEq/kg wɔ bolus biara mu) simma 3 kosi 5 biara kosi sɛ QRS no bɛtew akɔ fam 100 ms ne mogya \(\text{pH}\) du 7.50 kosi 7.55.
5. Sɛnea ɛyɛ adwuma: Nkwammoaa akyi sodium ions (\(\text{Na}^+\)) (a edi akansi a esiw koma sodium akwan a ɛkɔ ntɛmntɛm so nkonim) ne alkaline serum pH (a ɛma protein a ɛkyekyere no yɛ kɛse na ɛtew TCA fã a ɛyɛ ionized a ɛkyekyere channel receptor no so) a ɛkɔ soro kɛse no nyinaa san ma koma no kwan a ɛfata no san ba wɔ simma kakraa bi mu.
6. Nneɛma a Ɛho Hia a Ɛko Tia TCA Overdose:
7. MMMA Physostigmine DA mma anticholinergic delirium wɔ TCA dodow a ɛboro so mu (ɛma bradycardic/asystolic koma gyaee a edi awu).
8. MMFA Class IA (procainamide), Class IC (flecainide), anaa Class III (amiodarone) antiarrhythmics DA (ɛma sodium channel blockade anaa QT kyɛ yɛ kɛse; fa IV Sodium Bicarbonate di kan, ne IV Lidocaine [Class IB] anaa 20% Intravenous Lipid Emulsion [Intralipid] sɛ ɛyɛ refractory a).
9. MMFA Phenytoin mma DA mma akisikuru a TCA de ba (phenytoin nso yɛ sodium-channel blocker; fa IV Benzodiazepines [lorazepam, diazepam, anaa midazolam] ne IV Sodium Bicarbonate sa TCA akisikuru no katee).

Deep Dive 4: Calcium Channel Blocker (CCB) ne Beta-Blocker (BB) a wɔde di dwuma boro so¶

1. Sɛnea Mogya mu Asikre Ma Nsonsonoe a Ɛwɔ CCB ne Beta-Blocker Dodow a Ɛboro So Mu Ntɛm ara¶

Sɛ ɔyarefo a ontumi nyɛ hwee de bradycardia a emu dɔ (koma a ɛbɔ 30 kosi 40 bpm) ne mogya mmoroso a emu yɛ den (mogya mmoroso 60/30 mmHg) ba a, mpa ho nsateaa a wɔde hwɛ mogya mu glucose mu no ma yehu ntɛm ara sɛ:

• Calcium Channel Blocker (CCB) a wɔnom boro so no ma HYPERGLYCEMIA: Esiane sɛ pancreatic beta nkwammoaa hia L-type calcium channel influx na ama insulin granules akɔ mogya no mu nti, CCB dodow a ɛboro so a emu yɛ den ma acute hypoinsulinemia ne marked hyperglycemia (ɛtaa yɛ 200 kosi 450 mg/dL) wɔ ayarefo a wonni asikreyare mpo mu. Nokwarem no, sɛnea asikre dodow a ɛkɔ soro no ne sɛnea CCB a wɔnom boro so no mu yɛ den no wɔ abusuabɔ tẽẽ.
• Beta-Blocker (BB) a wɔnom boro so no ma HYPOGLYCEMIA anaa Normoglycemia: Beta-2 adrenergic blockade siw hepatic glycogenolysis ne pancreatic glucagon mediated glucose release ano, na ɛma mogya mu asikre a ɛba fam (titiriw wɔ mmofra mu).

2. Nea Enti a Insulin a Wɔde Di Dwuma Euglycemic Therapy (HIET) Yɛ Aduru a Ɛyɛ Pɛ a Wɔde Ko Tia Koma ne Ntini Mu Ahodwiriw¶

Wɔ tebea horow a ɛfata mu no, koma ntini a ɛregye n’ahome no hyew srade a enni mu titiriw de yɛ pɛtro. Wɔ calcium channel blocker anaa beta-blocker overdose a emu yɛ den mu no, myocardium a ayɛ basaa no bɔ mmɔden sɛ ɛbɛsakra ne pɛtro fibea afi srade acid so akɔ glucose, bere a bere koro no ara mu no, ɔkɔm de no insulin (a efi pancreatic L-type calcium channel blockade) ne intracellular calcium:

• Sɛnea High-Dose Insulin Euglycemic Therapy (HIET) gye koma a ɛredi nkogu no:
• Nnuruyɛfo a wɔhwɛ ntɛmpɛ so de Regular Insulin IV bolus kɛse a ɛyɛ 1 Unit/kg (asikreyare ketoacidosis dodow a wɔtaa de ma no mmɔho 10), na ɛno akyi no, wɔde Regular Insulin** **1 kosi 10 Units/kg/dɔnhwerew **1 kosi 10/dɔnhwerew biara, a wɔde IV Dextrose a wɔahyɛ no den (D10W anaa D50W via central) ka ho line) na ama asikre a ɛwɔ mogya mu akɔ so ayɛ nea ɛfata (euglycemia: 100 to 200 mg/dL) ne potassium a wɔde ma a wɔde ma serum \(\text{K}^+\) wɔ 2.8 to 3.5 mEq/L.
• Insulin a wɔde di dwuma kɛse yɛ adwuma sɛ inotrope a ɛyɛ papa a tumi wom: ɛhyɛ glucose ne lactate tẽẽ kɔ koma mu myocytes a ɔkɔm de wɔn mu denam PI3K/Akt sɛnkyerɛnne so, ɛsan de calcium a ɛwɔ nkwammoaa mu no di dwuma, na ɛma koma no mu nsu a ɛba ne mogya mmoroso kɔ soro wɔ simma 30 kosi 45 mu (ɛno nti na ɛsɛ sɛ wofi ase HIET nkyɛ ka IV ho Calcium, IV Glucagon [5 kosi 10 mg bolus ma beta-blockers], ne Norepinephrine/Epinephrine, sen sɛ wɔbɛtwɛn kosi sɛ ɔyarefo no koma ayɛ basaa dedaw).

Nsɛm a wɔtaa bisa¶

Me ba a wadi mfe 2 no menee me dade a wɔde hyɛ me ansa na wɔawo no pii nnɔnhwerew abien a atwam ni. Dɛn nti na oduruyɛfo a ɔhwɛ ayaresabea a wɔhwɛ wɔn a wɔwɔ yare a egye ntɛmpɛ mu no kae sɛ WONTUMI mma fango a wɔde yɛ adwuma te sɛ nea wɔyɛ wɔ awuduru afoforo ho no?¶

Fango a wɔde yɛ adwuma no yɛ adwuma denam nnuru akɛse a egyina organic carbon so a ɛtwetwe kɔ ne ntini nketenkete mu no so, nanso elemental metal ions nketewa a ahoɔden wom (titiriw Iron, Lithium, Lead, Potassium, ne Sodium) nkyekyere fango a wɔayɛ no adwuma koraa. Fango tuntum a wɔde ma abofra a ɔmenee dade aduru no nyɛ papa biara na epira ɔhwɛ ankasa denam endoscopic adwene a ɛkata so na ɛmma wontumi nhu nsonsonoe a ɛda fango nsu a asiane biara nni ho ne mogya a ɛyɛ hu a dade de ba ne yafunu mu mogya a ɛba no ntam. Mmom no, nnuruyɛfo yɛ yafunu mu X-ray de hu dade aduru a radiopaque wom no, de Whole Bowel Irrigation (polyethylene glycol solution) hohoro fa awotwaa no mu, na sɛ dade dodow a ɛwɔ mogya mu nnɔnhwerew 4 kosi 6 no yɛ awuduru a, wɔde Deferoxamine chelation fa ntini mu.

Dɛn nti na asiane wom saa sɛ wɔbɛma ɔyarefo a aspirin (salicylate) awuduru a emu yɛ den ahyɛ no afiri mu na wɔde ahyɛ afiri a wɔde home mframa mu?¶

Ɔyarefo a aspirin awuduru a emu yɛ den wom no home mpɛn 30 kosi 45 simma biara denam ahome a emu dɔ a ɛyɛ hu (hyperpnea) so de bɔ carbon dioxide na ɛma ne mogya mu pH yɛ alkaline kakra (7.45 kosi 7.52), a ɛma salicylic acid kɔ so yɛ ion wɔ mogya no mu na efi amemene no mu. Sɛ oduruyɛfo ma nnuru a ɛma obi dwo na ɛma obubuafo de hyɛ afiri a wɔde home mu a, ɔyarefo no gyae home simma 60 kosi 90, na mfiri a wɔde home mframa a wɔtaa de di dwuma no ntumi nhyia mframa kɛse a ɛyɛ lita 25 kosi 35 simma biara a na ɔyarefo no ankasa reyɛ no. Wɔ simma kakraa bi mu no, CO2 a wɔkora so no ma mogya no pH so tew kɛse sen 7.20, na ɛdan salicylate a wɔde ion ayɛ no ma ɛbɛyɛ salicylic acid a enni ahoɔden a ɛde ahopere kɔ amemene ne koma no mu tẽẽ, na ɛma koma no gyaw mpofirim. Enti, awuduru ho animdefo kwati sɛ wɔde salicylate bɛhyɛ ayarefo mu bere biara a ɛbɛyɛ yiye na wɔde mogya mu nhwehwɛmu a wɔbɛyɛ ntɛm ara di kan mmom.

Sɛ abofra ketewaa bi mene mogya mmoroso aduru BIAKO pɛ a ɛtrɛw (te sɛ Verapamil SR anaa Nifedipine XL) na ɛte sɛ nea n’ani agye na ɔwɔ ahoɔden 100% wɔ nnɔnhwerew abien akyi a, so yebetumi atra fie?¶

Dabi: frɛ 911 na kɔ ayaresabea ntɛm ara. Nnuru a wɔde siw calcium kwan a wɔde ma bere tenten (SR, XL, XR, CD) ne beta-blockers ka "One-Pill Killers" a agye dimmɔne sen biara wɔ mmofra ayaresa mu no ho. Esiane sɛ wɔayɛ tablet no wɔ polymer matrix a ɛyi brɛoo anaa osmotic pump shell mu nti, ɛkame ayɛ sɛ ɛmma aduru biara mfi mu wɔ nnɔnhwerew 2 kosi 6 a edi kan no mu, enti abofra no te sɛ nea ɔte ase koraa. Afei, nnɔnhwerew 8 kosi 18 akyi, mpɛn pii no anadwo fã bere a abofra no ada no, aduru no du mogya mu awuduru dodow mu na ɛkanyan koma a ɛyɛ mmerɛw mpofirim a edi awu na ɛma koma no gyaee. Abofra biara a ɔbɛmene calcium channel blocker biako mpo a ɛtrɛw bere tenten no hia sɛ wɔde nnɔnhwerew 24 nyinaa hwɛ koma so wɔ ayaresabea bere nyinaa.

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Akwankyerɛ yi yɛ nsɛm a wɔde ma na ɛnsi aduruyɛ a wɔde hwɛ adwumayɛfoɔ anaa Poison Control anim. Esiane sɛ nnuru a wɔnom boro so wɔ fie wɔ mmofra ne mpanyimfo mu no betumi ama obi anya akisikuru mpofirim, mframa kwan asɛe, na koma atɔ so nti, yɛhyɛ nyansa denneennen sɛ fa mmoa a edi kan a wɔde ma mmofra ne mpanyimfo ne CPR adesua a wɔagye atom denam Amanaman Ntam Mmeamudua Kɔkɔɔ ne Ɔsram Kɔkɔɔ Fekuw (IFRC), wo man Red Cross fekuw, St John Ambulance, anaa mpɔtam hɔ nteteefo a ɔwɔ adansedi krataa so.

Sources a wɔhwɛɛ mu¶

• Amerika Aduruyɛ mu Awduru Ho Adesuabea (ACMT) & Amerika Fekuw a Ɛhwɛ Awuduru So (AAPCC): Adeyɛ ho Akwankyerɛ a ɛfa Salicylate, Dade, Tricyclic Antidepressant, Beta-Blocker, ne Calcium Channel Blocker Awuduru ho.
• EXTRIP (Ayaresa a Wɔde Ma Wɔ Aduru a Wɔde Di Dwuma Mu) Adwumakuo: Nkamfo a Egyina Adanse So a Ɛfa Ayaresa a Ɛfa Nipadua Ho a Wɔde Salicylate ne Tricyclic Antidepressant Poisoning (Annals of Emergency Medicine).
• Abenfoɔ a Wɔpene so wɔ Calcium Channel Blocker Poisoning (Critical Care Medicine): Adwene a Wɔagye atom Nkamfo a ɛfa Calcium Channel Blocker Poisoning ne High-Dose Insulin Euglycemic Therapy (HIET) ho dwumadie ho.
• Ɔman Awuduru Ho Amanneɛbɔ Dwumadibea (NPIS, United Kingdom): TOXBASE Ayaresa mu Nnuru a Wɔde Di Dwuma a Ɛfa Salicylates, Ferrous Salts, Tricyclic Antidepressants, ne Koma ne Ntini Ho Nnuru ho.

Akwankyerɛ ahorow a ɛfa ho¶

• Acetaminophen (paracetamol / Tylenol) a wɔde di dwuma boro so ne nnɔnhwerew 8 aduru a wɔde kum ɔyare mmoawa mfɛnsere
• Mmoa a edi kan a wɔde ma awuduru ne awuduru a wɔde siw ano triage
• Serotonin yare, neuroleptic malignant syndrome, ne nnuru a ɛne ne ho di nkitaho
• Mmofra ne nkokoaa CPR ne wɔn a wɔmene wɔn
• Nnɔmba a egye ntɛmpɛ sɛnea ɔman biara te