Aspirine (Salicylate), tshiamu tshia tshiamu tshia mitaku, ne manga a tshinyangu tshia mashi.¶

Mu tshibombi tshionso tshia manga a mu dîku, mu tshibuta tshia mu tshikuku, anyi mu mesa a butuku a bankambua, mudi mishindu itanu ya manga a mu nzubu ne bintu bikuabu mudi dimina anu 1 anyi 5 (anyi lupongo lumue lua mâyi) mua kushipa muana mutekete ("One-Pill Killers"), ne mudi dikuatshika dia manga a bungi didi mua kufikisha ku disama dia mutshima ne dia mashi adi anyanguka lukasa Dikuatshisha dia patupu kadiena mua kupingana padiku kakuyi manga masunguluke to:

1. Salicylates (Aspirin, Pepto-Bismol / Bismuth Subsalicylate, ne Methyl Salicylate / Oil of Wintergreen): Bidi bishipa mitochondrial oxidative phosphorylation, bifikisha ku dienza dia mutoyi mu matshi (tinnitus), dipuekesha dia luya lua bungi, luya lua bungi, lufu lua mu mikolo ne lua mu buongo anyi lua mu lungenyi edema.
2. Elemental Iron Supplements (Adult Ferrous Sulfate tablets and Prenatal Vitamins): Bidi bifuanangana bikole ne M&Ms anyi Skittles ya chocolat mibuikila ne bonbon kudi bana batekete, bidi binyanga tshitupa tshia munda tshia tshifu ne disama dia mashi kumpala kua kubuela mu **6 too ne ku 24-heures ** "ditalala dia tshimpitshimpi" didi dilonda kudi "phase" ya tshimpitshimpi. dipanga dia tshiadi ne tshipupu tshia mutshima.
3. Tricyclic Antidepressants (TCAs: Amitriptyline, Nortriptyline, Doxepin, Imipramine): Batu batamba kufunda ki nganu bua dibungama to, kadi kabidi mu bungi bukese bua dikuba dia mutu, disama dia fibromyalgie, disama dia mijilu, dipanga tulu, ne disama dia tshiadi dia ku buana, didi dikanga njila wa sodium mu muoyo bua kukola lukasa, ** koma, ne wide-QRS ventricular arrhythmias** mu minite 60 too ne ku 120.
4. Bintu bidi bipangisha njila ya calcium (CCBs: Amlodipine, Nifedipine, Verapamil, Diltiazem): Bidi bipangisha njila ya calcium ya mushindu wa L mu mutshima ne mu mishipa ya mashi eku bipangisha dipatuka dia insuline wa mu tshifu, bienza tshipupu tshikole tshia vasodilatory ne tshia cardiogenic tshisangisha ne hyperglycémie.
5. Beta-Blockers (BBs: Propranolol, Metoprolol, Atenolol, Carvedilol, Sotalol): Bidi bifikisha ku bradycardia mukole (mutshima udi wenda bitekete), hypotension, bronchospasm, ne hypoglycemia (kusangisha ne disama dia sodium-channel ne divulangana dia QRS ne propranolol anyi Torololes ne desolutes).

Mukanda ewu udi uleja malu a tshimpitshimpi udi ufila malu adibu ne bua kuenza diakamue, tshipiminu tshia buanga tshia miligrame ku kilograme, tshikondo tshia luondapu, ne mishindu ya diondapangana dia mu ICU (IV Sodium Bicarbonate urinary alkalinization, Deferoxamine chelation, High-Dose Insulin Euglycemic Therapy [HIET], Intravenous Lipiid, [] ne Glucagon) mu buobumue ne tshisumbu tshia bena Amerike tshia nzubu ya diluisha buanga (AAPCC), tshilongelu tshia bena Amerike tshia malu a buanga (ACMT), kasumbu ka mudimu ka EXTRIP, ne tshibambalu tshia malu a buanga tshia mu ditunga dia UK (NPIS).

Enza nunku mpindieu¶

Shi mwana nansha muntu mukulumpe mumine manga a bungi a aspirine, mafuta a wintergreen, manga a tshiamu tshia mitaku, manga a tension (beta-blockers anyi calcium channel blockers), anyi manga a tricyclic antidepressants:

1. Bikila 911 / 112 / 999 diakamue bua muana udi udia mafuta a wintergreen, manga a tension, tricyclics, anyi tshiamu tshia mitaku, anyi pikala mubedi ne bimanyinu: Enza mudimu wetu nomba ya tshimpitshimpi tshilaminu. Bua muntu mukulumpe anyi muana udi kayi ne bimanyinu udi dijinga ne dibala dia lukasa dia milligram-ku-kilograme, bikila Poison Control (1-800-222-1222 mu États-Unis; NHS 111 / 999 mu UK; 13 11 26 mu Australie) paudi udilongolola bua kuya ku tshibambalu tshia malu a njiwu.
2. Komba mukana mua muana bua kupeta manga adiye kayi muanji kumina ne wangate mulondo wonso ne tshibombi tshionso: Bikala muana mutekete anu muele manga mukana muende, enza mudimu ne tshiamu tshia kukomba natshi munu bua kumbusha manga onso adi kaayi manyanguke ku matama, bala manga adi mashale mu mulondo, ne ulue ne bibombi menemene ku lupitadi.
3. KUENJI KUENZA LUMU ku njibo ne KUKENJI KUFILA bicarbonate de soude anyi mabele kakuyi buludiki bua Poison Control: Kuenzeja mubedi uvua mumine maluvu a tricyclic antidepressants, propranolol, anyi calcium channel blockers kudi ne njiwu mikole bualu mubedi udi mua kujimija lungenyi mu tshimpitshimpi anyi kupeta disama dia nsukadi mu minite 30, mu mikolo yende.
4. Umvua mukenji wa "Makala a tshiamu kaena alamakaja tshiamu tshia mitaku to: Padi makala a tshiamu a mu lupitadi alamakaja aspirine, manga a tricyclic antidepressants, beta-blockers, ne calcium channel blockers (ne adi ne bua kufidibua mu mêba 1 anyi 2, anyi mu bungi bua misangu ne misangu bua makala a tshiamu tshia mitaku adi alamakaja tshiamu tshia mitaku) kulamakaja tshiamu tshia tshiamu. Ma tablette a tshiamu tshia radiopaque adi mu tshifu adi akengela lupitadi Dilengeja dia mala onso (WBI) ne tshiamu tshia polyethylene glycol electrolyte solution (GoLYTELY) ne Deferoxamine mu mishipa.
5. Keba Extended-Release ("XL", "XR", "SR", "CD", "LA") anyi Enteric-Coated ("EC") pa mulondo: Dikuatshika dia bungi dia **extended-release verapamil, diltiazem, nifedipine, metoprolol, anyi enteric-coated aspirine didi mua kuikala ne **bimanyinu bia kumpala bia mêba 6 kumpala kua kupatula mu tshimpitshimpi tshintu tshidi tshishipa bantu mu mashi. Didia dionso dia calcium channel blocker anyi beta-blocker didi dilomba mêba 24 a dilonda dia muoyo wa mu lupitadi, nansha mudi mubedi umueneka bimpe menemene ku dîba dia 4.
6. Didimuija baminganga ne baminganga ba mu nzubu wa lupitadi bua "Salicylate Intubation Trap": Shi mubedi udi ne disama dikole dia aspirine (salicylate) udi upuya lubilu ne mu buondoke (30 to 40 breaths per minute), hyperventilation adi udi ubalama ne muoyo pa kupuekesha dioxide de carbone (\(COte) {\)2} mu mashi ende bua kulama pH yende kupueka. Shi mubedi udi mupuwe ne mufuishe bua kumuela tshiamu tshia endotracheal intubation ne muteka pa tshiamu tshia ventilateur tshidi tshienda bitekete bitekete, dikisha dia tshimpitshimpi dia mupuya didi difikisha mashi \(\text{pH}\) ku dikuluka, dienza bua aside wa salicylic unionized apita buludiludi mu tshibuelelu tshia mashi ne buongo ne dienza bua **dijika dia mutshima dia lukasa ne minite 25 too ne ku 25 ya dibueja dia mupuya.

Disungula dia tshimpitshimpi ne tshimfuanyi tshia manga a diondapangana bua manga a mu nzubu adi ne njiwu mikole¶

flowchart TD
    Start["Dikuatshika dia manga a mu nzubu<br/>(Aspirine, Iron, Tricyclic Antidepressant, Beta-Blocker, anyi Calcium Channel Blocker)"] --> Call["Bikila 911 / 112 / 999 anyi Poison Control (1-800-222-1222)<br/>Tangila bukole (mg) + Extended-Release (XR/XL/SR/EC) Status"]

    Call --> ClassCheck{"Mmunganga kayi uvuabu banue?"}

    ClassCheck -->|Salicylates: Aspirin, Enteric-Coated Aspirin,<br/>Pepto-Bismol, or Oil of Wintergreen| SalRule["SALICYLATE PROTOCOL (Tinnitus + Hyperventilation + Fever)<br/>1. Multi-Dose Activated Charcoal (binds aspirine concrements/bezoars)<br/>2. IV Sodium Bicarbonate (NaHCO3) bua kulama Blood pH 7.45-7.55 & Urine pH 7.5-8.0<br/>+ aggressive IV Potassium (K+ > 4.0) bua mifuba ikale mua kupatula salicylate<br/>3. EPUKA KUTUA MU MUTU pikalaku mushindu; Dipanda dia mashi mu tshimpitshimpi pikala >100 mg/dL anyi bimanyinu bia neuro/pulm"]

    ClassCheck -->|Elemental Iron: Adult Ferrous Sulfate/Gluconate/Fumarate<br/>or Prenatal Vitamins (Calculate Elemental Iron mg/kg)| IronRule["MUKENDE WA MUTU (Makala a tshiamu kaena alamakaja tshiamu to)<br/>1. X-Ray wa mu tshifu (KUB) bua kumona mapilu a tshiamu tshia radiopaque mu tshifu<br/>2. Dilengeja dia mala onso (PEG-ELS / GoLYTELY) pikala manga a radiopaque adiku<br/>3. Kuangata tshitupa tshia tshiamu tshia mitaku tshia mu mashi tshia mêba 4 too ne ku 6 + Gaz/Lactate mu mashi<br/>4. IV Deferoxamine Chelation if Serum Iron > 500 mcg/dL, Shock, or Acidosis"]

    ClassCheck -->|Tricyclic Antidepressants (TCAs): Amitriptyline,<br/>Nortriptyline, Doxepin, Imipramine| TCARule["TRICYCLIC ANTIDEPRESSANT (TCA) PROTOCOL (Fast Na+ Channel Blockade)<br/>1. 12-Lead ECG diakamue: Tangila ni QRS > 100 ms anyi Terminal R wave mu aVR > 3 mm<br/>2. IV Sodium Bicarbonate Boluses (1-2 mEq/kg) too ne padi QRS ukepela < 100 ms & pH 7.50-7.55<br/>3. Kuondopa disama dia tshiadi ANYI ne Benzodiazepines (KENA Phenytoin); IV Lipid Emulsion if refractory"]

    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/>Tangila Glucose mu mashi: CCB Overdose = HYPERGLYCEMIA vs BB Overdose = HYPOGLYCEMIA<br/>1. IV Calcium Chloride/Gluconate + IV Glucagon (5-10 mg bolus, bypasses beta receptor)<br/>2. Vasopressors (Norepinephrine / Epinephrine) bua MAP > 65 mmHg<br/>3. Buondapi bua bungi bua insuline (HIET: 1 to 10 Units/kg/hr Regular Insuline + Dextrose)<br/>4. VA-ECMO anyi IV Lipid Emulsion (Intralipid) bua tshipupu tshia mutshima tshidi katshiyi tshijika"]

Difuanyikija dinene dia manga 5 a lufu a bungi a mu nzubu¶

Deep Dive 1: Salicylate (Aspirin & Wintergreen Oil) Poisoning¶

1. Kujingulula Salicylate Toxidrome (Acute vs. Chronic)¶

Disama dia salicylate didi dienzeka mu bisumbu bibidi bishilangane: (a) Dipitshisha dia bungi kudi bansonga, bansongalume, anyi bana batekete badi banaya mulondo wa aspirine, Excedrin, anyi mafuta a Wintergreen, ne (b) **Disama dia salicylate dia kashidi ("dia buanga") kudi bantu bakulumpe badi banua aspirine anyi bisin wa bungi ku dituku subsalicylate (Pepto-Bismol) bua disama dia tshiadi anyi dia tshifu mu matuku anyi mbingu ya bungi bualu mudimu wa mifuba yabu udi wenda ukepela. Disama dia salicylisme dia kashidi didi ne lufu lua bungi kupita dikuatshika dia maluvu makole bualu batu misangu ya bungi badimona bu sepsis, pneumonie, diabète ketoacidose, anyi stroke/dementia.

• Tshimanyinu tshia didimuija dia ku matshi: Tinnitus (kuteleja anyi kuteleja mupuya): Salicylates udi unyangakaja selile ya nsuki ya ku matshi ne neurons ya ganglion spiral. Padi bungi bua salicylate mu mashi bupita 20 too ne ku 30 mg/dL, babedi badi bumvua mutoyi mukole mu matshi (tinnitus) anyi badila ne: mêyi adi umvuika bu adi kaayi umvuika bimpe, pamue ne disama dia muoyo, disama dia nsukadi ne diaphoresis (dipatuka dia tuishi).
• Tshimanyinu tshia tshianza tshia acide-base:
• Tshia kumpala, salicylate udi usaka buludiludi tshitupa tshia mupuya tshia mu buongo, wenza bua mubedi apuekesha mupuya mukole ne lukasa (hyperpnée ne tachypnée), bidi bipuekesha \(\text{CO}_2\) ne bipatuisha Primary Respiratory Alkalosis (pH mubandile mu mashi ku ntuadijilu).
• Tshibidi, salicylate udi uncouples mitochondrial oxidative phosphorylation mu selile yonso ya mubidi (anu bu dinitrophenol): selile idi idia oxygène bikole, ipatula kapia ka bungi ka mubidi (hyperthermie) pamutu pa ATP, ne idi isangisha acide lactique, ketoacids, ne salicylic acid, idi yenza P musangu umue High-Anion-Gap Metabolic Acidosis.

2. Bua tshinyi dilengeja dia mashi (IV sodium bicarbonate) ne potassium rescue bidi bienza mudimu ("Ion Trapping")¶

Salicylic acid i acid mutekete (\(\text{pK}_a = 3.0\)). Anu molecule udi kayi ne bukole (udi kayi ne ion) (\(\text{HA}\)) ke udi mua kusabuka membrane ya selile ya mafuta bua kubuela mu buongo anyi kupingana mu mashi afumina ku tubules ya mfyo, kadi ion wa salicylate udi ne bukole (udi ne ion) (\(\text{A}^-\)) udi mukuatshike pambelu pa selile:

• Bua tshinyi dipueka dia pH wa mashi didi dishipa mubedi: Shi mashi a mubedi \(\text{pH}\) apueka ku 7.45 too ne ku 7.20 .
• Mushindu kayi udi IV Sodium Bicarbonate (\(\text{NaHCO}_3\)) ulama salicylate mu mashi ne mu mashi:
• Baminganga ba mu lupitadi lua lukasa badi bafila tshiayi tshia 1 too ne ku 2 mEq/kg IV Sodium Bicarbonate, pashishe badi bafila tshiamu tshia nzembu (3 ampules [150 mEq] ya 8.4% Sodium Bicarbonate mixed in 1 Litre of D5W infusioned at 1.5 to 2 times maintenance fluid).
• Kubandisha pH wa mashi a mu mishipa too ne ku 7.45 too ne ku 7.55 kudi kukoka salicylate *mu buongo bua kupingana mu mashi.
• Kubandisha pH wa mashi too ne ku 7.5 too ne ku 8.0 kudi kuenza bua salicylate munda mua tubules ya mu tshifu ikale ion bua kayi mua kupingajibua, kuvudija dipatuka dia aspirine mu tshifu misangu 10 too ne ku 20.
• Mukenji wa potassium (\(K^+\)): Kuena mua kuenza alkali mu mashi a mubedi pikala potassium mu mashi a mubedi mukese (\(\text{K}^+ < 4.0\text{ mEq/L}\))**. Padi potassium wa mu mashi mukese, tubules ya kule ya mu tshifu idi ilama ions ya potassium (\(K^+\)) pa kuela ions ya hydrogène (\(H^+\)) mu mashi (paradoxical aciduria), bienza bua mashi ikale ne acide nansha wewe muele bicarbonate bungi kayi. Nunku, baminganga batu basakidila 40 too ne ku 60 mEq/L ya Potassium Chloride mu mayi a mu tshifu bua kulama serum \(\text{K}^+\) pankatshi pa 4.0 ne 5.0 mEq/L.
• Kulongolola nzala misokoka ya mu buongo ("CNS Neuroglycopenia"): Bualu bua salicylates idi ikolesha glycolyse ya mu buongo eku inyanga dienda dia glucose mu tshitupa tshia mashi ne buongo, mubedi udi ne disama dia salicylate udi mua kuikala ne tshitupa tshia glucose tshia mu buongo tshidi tshikese menemene nansha mudi tshianza tshiende tshibala glucose wa mu mashi 190 anyi 000 mg/dL. Mubedi yense udi ne disama dia salicylate udi ne dipanga dia lungenyi, dipanga dia lungenyi, dipanga dia lungenyi, anyi disama dia tshimpitshimpi udi upeta diakamue IV Dextrose bolus (D50W anyi D10W) nansha mudi sukadi mu mashi ende kayi.

3. Padibu ne bua kuenza hemodialyse wa lukasa¶

Bu mudi aspirine muikale ne tshitupa tshikese tshia diabanya, hemodialyse udi wenzeka pa tshibidilu udi umbusha lukasa salicylate mu mashi eku ulongolola acidose ne divulangana dia mâyi. Bilondeshile mikenji ya EXTRIP, dipanda dia mashi dia lukasa didi dileja diakamue bua:

1. Nsombelu wa lungenyi mushintuluke (dipanga dia lungenyi, dipanga dia lungenyi, dipanga dia lungenyi, dipanga dia lungenyi, anyi disama dia tshiadi), NANSHA
2. Disama dia disama dia mupuya (ARDS) / Disama dia mu mikolo didi kadiyi difumina ku muoyo didi dilomba oxygène wa pa mutu, OR
3. Disama dia tshimpitshimpi anyi dia tshiendelele (didi dipangisha dienza dia alkali mu mashi bua kuenza mudimu), NANSHA
4. Serum Salicylate concentration \(> 100\text{ mg/dL}\) (\(> 7.2\text{ mmol/L}\)) in an acute overdose (anyi \(> 90\text{ mg/dL}\) with impaired kidney function), anyi **\(> 60\text{mg/dL}\) mu chronic salicylism, anyi tshipiminu tshidi tshienda tshivula nansha mudibu bafila makala a bungi ne IV bicarbonate.

Deep Dive 2: Dikuatshika dia tshiamu tshia mitaku ne bikondo 5 bia luondapu¶

1. Kubala bungi bua tshiamu tshia mitaku bilondeshile mishindu ya mukele¶

Padibu babikila bena mudimu ba Poison Control anyi bafika ku tshibambalu tshia malu a mpukapuka kunyima kua didia dia tshiamu tshia mitaku, baminganga batu babala bubi bilondeshile milligrame ya ELEMENTAL IRON ku kilograme wa bujitu bua mubidi, ki mbujitu buonso bua miligrame ya tshiamu tshia mitaku to:

2. Bitupa 5 bia disama dia tshiamu tshia mitaku (Ikala mudimuke tshitupa 2)¶

1. Tshitupa 1: Tshitupa tshia tshifu tshidi tshinyanguka (mêba 0,5 too ne ku 6 panyima pa didia):
2. Difua dia mu tshifu ne dia mu mucosa wa duodenal didi difikisha ku disama dia mu tshifu dia tshimpitshimpi, dikola dia tshifu misangu ne misangu (misangu ya bungi didi ne mashi makunzubile anyi emesis wa "kafe" mufike), ne disama dia mashi anyi difiike dia goudron.
3. Mukenji wa mushinga wa disungula: Shi muana nansha muntu mukulumpe mupeta difu dia tshianana, disama dia tshiadi, ne disama dia mu difu munkatshi mua meba 6 kunyima kua yeye mumane kudia tshiamu tshia mitaku, disama dia tshiamu tshia mitaku didi mua kujimijibua.
4. Tshitupa 2: Tshikondo tshia dishima tshisokoka / tshia ditalala (mêba 6 too ne ku 24 panyima pa didia):
5. Disama didi dijika ne muana udi umueneka mupole anyi mulale tulu, bienza bua mêku (ne baminganga badi kabayi ne dimanya dia bungi) bela meji ne: muana udi wenda ukola. Mu bulelela, tshiamu tshia tshiamu tshia tshianana tshidi tshipatuka mu mala tshibuela mu mashi, tshipita bukole bua transferrin bua kulamakaja ne tshibuela mu selile ya endothélium ya mu mishipa, mu myocytes ya muoyo, ne mu hepatocytes ya periportal (Zone 1) ya mu tshifu.
6. Tshitupa 3: Tshipupu tshia mubidi ne tshitupa tshia acidose wa mubidi (mêba 12 too ne ku 48 panyima pa didia):
7. Ditapuluka dia tshitupa tshisatu tshia mayi, divulangana dia mashi, dinyanguka dia mutshima, ne dishintuluka dia tshiamu tshia mitaku (\(\text{Fe}^{2+}\)) ku ferric (\(\text{Fe}^{3+}\)) ions ne dipatuka dia protons (\(H^+\)) ne mitochondrial unup proound hypovolemic/distributive/cardiogenic shock, severe high-anion-gap lactic acidosis, coagulopathy, lethargy, and coma.
8. Tshitupa 4: Hepatotoxicity / Fulminant Liver Failure Phase (2 to 5 Days Post-Ingestion):
9. Dinyanguka dia mafuta mu Hepatic Zone 1 (periportal hepatocytes, selile ya kumpala ya tshifu idi mikuate kudi mashi a mu tshifu adi ne tshiamu tshia mitaku) didi dijula necrose hepatique acute, jaunisse, elevated transaminases, hypoglycemie, ne bleeding.
10. Tshitupa 5: Dipangisha dia tshifu / Tshitupa tshia dipanga (Mbingu 2 too ne ku 6 panyima pa didia):
11. Bu mudi mputa mikole idi munda mua tshifu ikola ku diambuluisha dia fibrose ne scarring, babedi badi mua kupeta pyloric stenosis / gastric outlet obstruction mbingu mikese kunyima kua bamane kupanduka ku dikuatshika dia manga makole, ne kuleja ne disama dia projectile non-bilious vomiting panyima pa biakudia.

3. Dilengeja dia bukoya mu lupitadi (KUB X-Ray + Whole Bowel Irrigation) ne Deferoxamine Chelation¶

• X-Ray wa mu difu (KUB): Ma tablette a tshiamu tshia mitaku tshia bantu bakole adi ne radiopaque (adi akenka mutoke bikole pa X-ray wa mu difu kumpala kua kunyanguka). Shi mapilu adi kaayi manyanguke anyi pharmacobezoar wa tshiamu (tshisumbu tshia mapilu adi makuate) adi amueneka ku tshiamu tshia X, ba munganga badi batuadija Whole Bowel Irrigation (WBI) pa kuenza mudimu ne Polyethylene Glycol Electrolyte Lavage Solution (PEG-ELS / GoLYTELY) ku diambuluisha dia tshiamu tshia gaz 500 mL/hr mu bana bakese anyi 1,500 to 2,000 mL/hr mu bantu bakole too ne padi mayi a mu tshifu alua matoke ne tshiamu tshia X tshidi tshileja ne: kakuena manga adi mashale to.
• Tshipimu tshia tshiamu tshia mitaku tshia mu mashi (tshiangatshila mu mêba 4 too ne ku 6 panyima pa didia):
• < 300 mcg/dL: Bubi bua pa tshibidilu / bukese.
• 300 to 500 mcg/dL: Bubi bua pa tshibidilu (budi bulomba dipingaja dia mashi mu IV ne ditangila dia pabuipi).
• > 500 mcg/dL: Disama dikole dia mubidi didi dilomba diakamue Intravenous Deferoxamine Chelation.
• IV Deferoxamine Protocol: Deferoxamine udi ulamakaja tshiamu tshia ferric tshia tshianana (\(\text{Fe}^{3+}\)) mu mashi bua kuenza ferrioxamine udi mua kunyanguka mu mayi, udi upatuka ku mifuba ne wenza bua mashi a mubedi ikale **"vin rosé" (pinkish-orange) /**mutoyi mutoke. Badi bafila mu mishipa ku 15 mg/kg/dîba (kutangila bimpe bua kumanya ni udi ne disama dia hypotension anyi disama dia mu mikolo padibu bamuela mu mashi munkatshi mua mêba mapite pa 24).

Deep Dive 3: Tricyclic Antidepressant (TCA) Overdose (The 100-Millisecond QRS Rule)¶

Amitriptyline, nortriptyline, doxepin, imipramine, clomipramine, ne desipramine badi bashala bafunda bikole bua disama dia mijilu dia kashidi, dikuba dia mutu, dipanga tulu, ne disama dia tshiadi. Padibu bapita bungi, mubedi udi mua kumbuka ku diakula bimpe mu ambulanse too ne ku disama dia tonic-clonic, koma, ne disama dia mutshima mu minite mikese menemene ya 30.

1. ECG wa 12-Lead ke tshiamu tshia kumpala tshia diagnostic:
2. Bu mudi bungi bua TCA mu mashi buangata matuku bua kupingana ku laboratware ya tshikebelu, baminganga ba malu a mpukapuka badi batangila disama dia TCA buludiludi ku 12-lead ECG:
   • Sinus tachycardia (ku diambuluisha dia anticholinergic muscarinic blockade).
   • Dishintuluka dia ku dia balume dia ndekelu 40 milliseconds ya frontal plane QRS axis: Bidi bimueneka diakamue pa ECG bu prominent terminal R wave \(> 3\text{ mm}\) mu lead aVR (ne an \(\text{R/S ratio} > 0.7\) mu lead a lead aVR) pamue ne terminal deep SVL wave ne I leads.
   • QRS Duration Widening:
   • \(\text{QRS} < 100\text{ ms}\): Njiwu mikese ya disama dia tshimpumpu anyi dia disama dia tshiadi.
   • \(\text{QRS} \ge 100\text{ ms}\): 33 percent risk of generalized seizures (Tshimanyinu tshia kutuadija IV Sodium Bicarbonate diakamue).
   • \(\text{QRS} \ge 160\text{ ms}\): 50 pa lukama ya njiwu ya lufu lua tachycardia anyi ventricular fibrillation.
3. Tshiamu tshia lukasa: Bicarbonate de sodium intravenous (\(\text{NaHCO}_3\)) Boluses:
4. Dîba dionso didi bule bua QRS bufika anyi bupita 100 milliseconds, anyi padi mubedi upeta disama dia hypotension anyi dia ventricule arrhythmie, baminganga batu bamupesha 8,4% Sodium Bicarbonate (1 to 2 mEq/kg ku bolus) mu minite yonso 3 anyi 5 too ne padi QRS ** muinshi mua 100 ms \(\text{pH}\) udi ufika ku 7.50 too ne ku 7.55.
5. Mushindu kayi udiwu wenza mudimu: Divulangana dinene dia sodium ions (\(\text{Na}^+\)) (udi utshimuna dikanga dia njila ya sodium ya lukasa ya mu muoyo) ne pH wa serum alkaline (udi uvudija dilamakaja dia proteyine ne upuekesha tshitupa tshia ion tshia TCA bua kupingaja njila wa muoyo mu minite mikese.
6. Malu adi kaayi makane mu dienza dia TCA mu bungi:
7. KUPEDI Physostigmine bua disama dia anticholinergic delirium mu dikuatshika dia bungi dia TCA (didi difikisha ku dijika dia mutshima dia bradycardic/asystolic).
8. KUPEDI muntu wa mulongo wa IA (procainamide), wa mulongo wa IC (flecainide), anyi wa mulongo wa III (amiodarone) bua kukandamena disama dia tshiadi to (badi banyanga dikanga dia njila wa sodium anyi dilengeja dia QT; enza mudimu ne IV Sodium Bicarbonate kumpala, ne IV Lidocaine [Class IB] anyi 20% Lidocaine wa mu mishipa [I] tshikole).
9. KUPEDI Phenytoin bua TCA-induced seizures (phenytoin udi kabidi tshintu tshidi tshipangisha sodium-channel; ondapa TCA seizures anu ne IV Benzodiazepines [lorazepam, diazepam, anyi midazolam] ne IV Sodium Bicarbonate).

Deep Dive 4: Calcium Channel Blocker (CCB) ne Beta-Blocker (BB) Overdose¶

1. Mushindu udi sukadi mu mashi utapulula diakamue CCB ne Beta-Blocker Overdose¶

Shi mubedi udi kayi wandamuna udi ne bradycardie (tshitupa tshia mutshima 30 too ne ku 40 bpm) ne hypotension mukole (tension 60/30 mmHg), tshikebelu tshia sukadi mu mashi tshia ku munu tshidi tshifila tshijadiki tshia lukasa:

• Calcium Channel Blocker (CCB) Overdose causes HYPERGLYCEMIA: Bu mudi selile beta ya pancrea idi dijinga ne L-type calcium channel influx bua kupatula insuline granules mu mashi, dipitshisha dia bungi dia CCB didi difikisha ku acute hypoinsulinemie ne hyperglycemie (misangu ya bungi 20 to 50 mL/40 md) babedi badi kabayi ne disama dia diabete. Mu bulelela, bungi bua hyperglycémie budi bupetangana buludiludi ne bunene bua dikuatshika dia bungi dia CCB.
• Beta-Blocker (BB) Overdose causes HYPOGLYCEMIA or Normoglycemia: Beta-2 adrenergic blockade is inhibits hepatic glycogenolysis and pancreatic glucagon mediated release glucose, causes low blood sugar (especially kudi bana).

2. Bua tshinyi diondapangana dia bungi dia insuline (HIET) didi buanga buimpe bua disama dia mutshima¶

Mu nsombelu muimpe, mishipa ya mutshima idi ikisha idi yosha acides gras libres bua kupeta mafuta. Mu tshikondo tshia dikuata dia calcium channel blocker anyi beta-blocker overdose, myocardium udi ne kanyinganyinga udi uteta bua kushintulula muaba udiye ufila mafuta kumbukila ku glucose, eku musangu umue muikale ne nzala ya insuline (ku diambuluisha dia pancreatic L-type calcium channel blockade) ne calcium wa munda mua selile:

• Mushindu kayi udi buanga bua bungi bua insuline (HIET) busungila mutshima udi unyanguka:
• Baminganga ba mu tshimpitshimpi batu bafila Insuline IV wa pa tshibidilu wa 1 Unit/kg (misangu 10 ya dose wa ketoacidose wa diabete), pashishe batu bafila 1 too ne ku 10 Units/kg/hour ya Insuline wa pa tshibidilu, pamue ne IV Dextrose wa pa tshibidilu (150 D W WW mulongo) bua kulama sukadi mu mashi mu mushindu muimpe (euglycémie: 100 to 200 mg/dL) ne dikumbaja dia potassium bua kulama serum \(\text{K}^+\) ku 2.8 to 3.5 mEq/L.
• Insuline wa bungi udi wenza mudimu bu inotrope muimpe wa bukole: udi wenzeja glucose ne lactate buludiludi mu myocytes ya muoyo idi ne nzala ku diambuluisha dia tshimanyinu tshia PI3K/Akt, udi upingaja dilama dia calcium munda mua selile, ne udi uvudija dipatuka dia muoyo ne tension mu minite 30 too ne ku 45 (ke bualu kayi ET udi ne bua kuikala mutuadije IV Calcium, IV Glucagon [5 to 10 mg bolus for beta-blockers], ne Norepinephrine/Epinephrine, pamutu pa kuindila too ne padi mubedi mumane kuikala ne disama dia mutshima).

Nkonko itubu bela misangu ya bungi¶

Muananyi wa bidimu 2 wakamina manga anyi a bungi a tshiamu tshia mitaku kukadi mêba abidi. Bua tshinyi munganga wa mu nzubu wa lupitadi wakamba ne: kabena mua kufila makala a mudimu bu mudibu benza bua bantu bakuabu badi ne buanga?¶

Makala a mudimu adi enza mudimu padiye ubueja bintu binene bia manga bidi ne karbone mu bipese biende bia muinshi mua buloba, kadi ions mikese ya tshiamu tshia mitaku (nangananga tshiamu tshia mitaku, lithium, plomb, potassium, ne sodium) kayena ilamakaja makala a mudimu nansha kakese to. Kupesha muana uvua mumine tshiamu tshia mitaku makala mafiike kudi ne dikuatshisha nansha dimue ne kudi kunyanga dilama dia mubidi padiye usokoka tshimuenekelu tshia endoscopie ne wenza bua se: kabikadi mua kusunguluja makala adi kaayi ne njiwu ne mashi adi afumina ku tshiamu tshia mitaku adi afumina mu tshifu. Pamutu pa nanku, baminganga batu bangata tshimfuanyi tshia mu difu bua kumona mapilu a tshiamu tshia radiopaque, baasukula mu bitupa bia munda ne Whole Bowel Irrigation (diluisha dia polyethylene glycol), ne bafila Deferoxamine chelation mu mushipa bikala bungi bua tshiamu tshia fer mu mashi mu mêba 4 too ne ku 6 bubi.

Bua tshinyi bidi ne njiwu ya bungi bua kuela mubedi udi ne disama dikole dia aspirine (salicylate) mu tshiamu tshia kuela natshi luya?¶

Mubedi udi ne disama dikole dia aspirine udi upuyakana misangu 30 too ne ku 45 ku minite ne mupuya mukole (hyperpnée) bua kumbusha kapepe ka karbone ne kulama pH wa mashi ende muikale ne alkaline (7,45 too ne ku 7,52), udi ulama aside wa salicylique mu mashi ne pambelu pa buongo. Padi munganga ufila manga a ditalala ne a tshilema bua kubueja tshiamu tshia kupuyakana natshi, mubedi udi ulekela kupuyakana munkatshi mua sekonde 60 too ne ku 90, ne tshiamu tshia kupuya natshi katshiena mua kukumbaja tshipiminu tshinene tshia luya lua 25 too ne ku 35-litre ku minite tshivua mubedi wenza nkayende to. Mu minite mikese, CO2 udi mulama udi wenza bua pH wa mashi apueke muinshi mua 7.20, ukudimuna ionized salicylate mu salicylic acid udi kayi ne charge udi uya buludiludi mu buongo ne mu mutshima, wenza bua mutshima wimane diakamue. Nunku, bamanyi ba malu a buanga badi bepuka diela dia babedi badi ne salicylate mu tshiadi padiku mushindu ne badi batamba kuenza hemodialyse diakamue.

Shi muana mutyetye umina anu tshiamu tshimue tshia mashi tshidi tshipatuka mutantshi mule (bu mudi Verapamil SR anyi Nifedipine XL) ne umueneka ne disanka ne makanda 100% kunyima kua mêba abidi, tudiku mua kushala kumbelu anyi?¶

Tòo: bikila 911 ne uye ku lupitadi diakamue. Biamu bidi bipangisha njila wa calcium ne beta-blockers bidi munkatshi mua "One-Pill Killers" mu malu a bana. Bu mudi tshiamu etshi tshienza mu tshiamu tshia polymère tshidi tshipatuka bitekete bitekete anyi mu tshiamu tshia pompe wa osmotic, katshiena tshipatula manga nansha amue mu mêba 2 anyi 6 a kumpala to, nunku muana udi umueneka bimpe menemene. Pashishe, kunyima kua meba 8 to ne ku 18, misangu ya bungi munkatshi mua butuku padi muana mulale, manga adi afika ku tshipiminu tshia toxique mu mashi ne adi asaka mutshima wa muoyo mu tshimpitshimpi udi mua kushipa ne kuimana kua mutshima. Muana yense udi umina nansha tshiamu tshimue tshia calcium tshidi tshipatuka mutantshi mule udi dijinga ne mêba 24 onso a dilonda dia mutshima wa mu lupitadi.

*Mukanda ewu udi bua kufila ngumu ne kawena upingana pa muaba wa luondapu lua bamanyi anyi diyukidilangana dia malu a tshinyangu to. Bu mudi manga a bungi a mu nzubu kudi bana ne bantu bakole mua kufikisha ku disama dia tshimpitshimpi, dijimija dia njila wa luya, ne dijika dia mutshima, tudi tunulomba bikole bua kulonga tulasa tua diambuluisha dia bana ne bantu bakole ne tua CPR ku diambuluisha dia International Federation of International Croix-Rouge ne Sociétés de la Croix-Rouge (IFRC), société wa Croix-Rouge wa mu ditunga dienu, St John Ambulance, anyi mufidi wa dilongesha dia muaba unudi.

Miaba mifumina¶

• Tshilongelu tshia bena Amerike tshia malu a buanga (ACMT) ne tshisumbu tshia bena Amerike tshia malu a buanga (AAPCC): Malu adibu ne bua kuenza bua Salicylate, Iron, Tricyclic Antidepressant, Beta-Blocker, ne Calcium Channel Blocker Poisoning.
• EXTRIP (Extracorporeal Treatments in Poisoning) Workgroup: Evidence-Based Recommendations for Extracorporeal Treatment in Salicylate and Tricyclic Antidepressant Poisoning (Annals of Emergency Medicine).
• Tshisumbu tshia bamanyi badi bumvuangana pa bidi bitangila disama dia calcium channel blocker (Critical Care Medicine): Malu adibu bafila bua kuondopa disama dia calcium channel blocker ne diondapangana dia bungi dia insuline (HIET).
• Tshibambalu tshia dimanyisha dia malu a buanga (NPIS, Royaume-Uni): TOXBASE Mikenji ya dilama dia Salicylates, Ferrous Salts, Tricyclic Antidepressants, ne Cardiovascular Drugs.

Malu adi apetangana¶

• Acetaminophen (paracetamol / Tylenol) mupita bungi ne tshikondo tshia 8-hour antidote
• Diambuluisha dia kumpala dia poison ne disungula dia diluisha poison
• Disama dia serotonine, dia neuroleptic malignant syndrome, ne dipetangana dia manga
• CPR wa bana ne wa bana batekete ne dikuma dia mishiku
• Nomba ya njiwu bilondeshile ditunga