What is shock?

Shock is a life-threatening medical condition whereby the body suffers from insufficient blood flow throughout the body. Shock often accompanies severe injury or illness. Medical shock is a medical emergency and can lead to other conditions such as lack of oxygen in the body's tissues (hypoxia), heart attack (cardiac arrest) or organ damage. It requires immediate treatment as symptoms can worsen rapidly. Medical shock is different than emotional, or psychological, shock that can occur following a traumatic or frightening emotional event.

What are the types of shock?

Septic shock results from bacteria multiplying in the blood and releasing toxins. Common causes of this are pneumonia, intra-abdominal infections (such as a ruptured appendix) and meningitis. Anaphylactic shock is a type of severe hypersensitivity or allergic reaction. Causes include allergy to insect stings, medicines or foods (nuts, berries, seafood) etc. Cardiogenic shock happens when the heart is damaged and unable to supply sufficient blood to the body. This can be the end result of a heart attack or congestive heart failure. Hypovolemic shock is caused by severe blood and fluid loss, such as from traumatic bodily injury, which makes the heart unable to pump enough blood to the body. Neurogenic shock is caused by spinal cord injury, usually as a result of a traumatic accident or injury. There are several main causes of shock:

Heart conditions (heart attack, heart failure) Heavy internal or external bleeding, such as from a serious injury Dehydration Infection Severe allergic reaction Spinal injuries Burns Persistent vomiting or diarrhea

What are the signs and symptoms of shock?

Low blood pressure is the key sign of shock. Symptoms of all types of shock include:

Rapid, shallow breathing Cold, clammy skin Rapid, weak pulse Dizziness or fainting Weakness

Depending on the type of shock the following symptoms may also be observed:

Eyes appear to stare Anxiety or agitation Confusion or unresponsiveness Low or no urine output Bluish lips and fingernails Sweating Chest pain

When should I seek medical care for shock?

If you suspect shock after an injury, even if the person seems alright, call 911 or get them to an emergency department immediately. Prompt treatment can save a person's life. The sooner shock is treated, the better. When treated quickly there is less risk of damage to a person's vital organs.

What is the treatment for shock?

Depending on the type or the cause of the shock, treatments will differ. In general, fluid resuscitation (giving a large amount of fluid to raise blood pressure quickly) with an IV in the ambulance or emergency room is the first-line treatment for all types of shock. The doctor will also administer medications such as epinephrine, norepinephrine or dopamine to the fluids to try to raise a patient's blood pressure to ensure blood flow to the vital organs.

Tests (for example, x-rays, blood tests, EKGs) will determine the underlying cause of the shock and uncover the severity of the patient's illness. Septic shock is treated with prompt administration of antibiotics depending on the source and type of underlying infection. These patients are often dehydrated and require large amounts of fluids to increase and maintain blood pressure. Anaphylactic shock is treated with diphenhydramine (Benadryl), epinephrine (an "Epi-pen"), steroid medications methylprednisolone (Solu-Medrol) and sometimes a H2-Blocker medication [for example, famotidine (Pepcid), cimetidine (Tagamet), etc.]. Cardiogenic shock is treated by identifying and treating the underlying cause. A patient with a heart attack may require a surgical procedure called a cardiac catheterization to unblock an artery. A patient with congestive heart failure may need medications to support and increase the force of the heart's beat. In severe or prolonged cases, a heart transplant may be the only treatment. Hypovolemic shock is treated with fluids (saline) in minor cases, but may require multiple blood transfusions in severe cases. The underlying cause of the bleeding must also be identified and corrected. Neurogenic shock is the most difficult to treat. Damage to the spinal cord is often irreversible and causes problems with the natural regulatory functions of the body. Besides fluids and monitoring, immobilization (keeping the spine from moving), anti-inflammatory medicine such as steroids, and sometimes surgery are the main parts of treatment. Self-Care at Home

Call 911 for immediate medical attention any time a person has symptoms of shock. Do not wait for symptoms to worsen before calling for help. Stay with the person until help arrives. While waiting for help or on the way to the emergency room, check the person's airway, breathing and circulation (the ABCs). Administer CPR if you are trained. If the person is breathing on his or her own, continue to check breathing every five minutes until help arrives. Have the person lie down on his or her back with the feet elevated above the head (if raising the legs causes pain or injury, keep the person flat) to increase blood flow to vital organs. Do not raise the head. Do NOT move a person who has a known or suspected spinal injury. Keep the person warm and comfortable. Loosen tight clothing and cover them with a blanket.

Do not give fluids by mouth, even if the person complains of thirst. There is a choking risk in the event of sudden loss of consciousness. Give appropriate first aid for any injuries.

When things go wrong If cells are deprived of oxygen, instead of aerobic (with oxygen) metabolism, the cells use the anaerobic (without oxygen) pathway to produce energy. Unfortunately, lactic acid is formed as the by product of anaerobic metabolism. This acid changes the acid-base balance in the blood and leads to a downward spiral where cells start to leak toxic chemicals into the bloodstream, cause blood vessel walls to become damaged, and this process ultimately leads to the death of the cell. If enough cells die, then organs start to fail, and the body dies. Think of the cardiovascular system of the body as similar to the oil pump in your car. For efficient functioning, the electrical pump needs to work to pump the oil, there needs to be enough oil, and the oil lines need to be intact. If any of these components fail, oil pressure falls and the engine may be damaged. In the body, if the heart, blood vessels, or bloodstream (circulation) fail, then the body fails. Where things go wrong The oxygen delivery system to the body's cells can fail in a variety of ways.

The amount of oxygen in the air that is inhaled can be decreased. Examples include breathing at high altitude or carbon monoxide poisoning.

The lung may be injured and not be able to transfer oxygen to the blood stream. Causes of this may include, among others:

pneumonia (an infection of the lung), congestive heart failure where the lung fills with fluid, or trauma with collapse or bruising of the lung.

The heart may not be able to adequately pump the blood to the tissues of the body. Cases of this may include, among others:

In the case of a heart attack, where muscle tissue is lost, or by a rhythm disturbance of the heart, when the heart can't beat in a coordinated way. It may also occur because of heart inflammation due to infection or other causes, again where the effective beating capabilities of the heart are lost.

There may not be enough red blood cells in the blood. If there aren't enough red blood cells (anemia), then not enough oxygen can be delivered to the tissues with each heart beat. Causes may include:

acute or chronic bleeding, inability of the bone marrow to make red blood cells, or the increased destruction of red blood cells by the body (an example includes sickle cell disease).

There may not be enough other fluids in the blood vessels. The blood stream contains the blood cells (red, white, and platelets), plasma (which is more than 90% water), and many important proteins and chemicals. Loss of body water or dehydration can cause shock. The blood vessels may not be able to maintain enough pressure within their walls to allow blood to be pumped to the rest of the body. Normally, blood vessel walls have tension on them to allow blood to be pumped against gravity to areas above the level of the heart. This tension is under the control of the unconscious central nervous system, balanced between the action of two chemicals, adrenaline (epinephrine) and acetylcholine. If the adrenaline system fails, then the blood vessel walls dilate and blood pools in the parts of the body closest to the ground and may have a difficult time returning to heart to be pumped around the body. Since one of the steps in the cascade of events causing shock is damage to blood vessel walls, this loss of integrity can cause blood vessels to leak fluid, leading to dehydration which initiates a vicious circle of worsening shock.

Medical Treatment

EMS personnel are well trained in the initial assessment of the patient in shock. The first course of action is to make certain that the ABCs have been assessed. The so-called ABCs are:

Airway: assessment of whether the patient is awake enough to try to take their own breaths and/or if there is there anything blocking the mouth or nose. Breathing: assessment of the adequacy of breathing and whether it may need to be assisted with mouth-to-mouth resuscitation or more aggressive interventions like a bag and mask or intubation with an endotracheal tube. Circulation: assessment of the adequacy of the blood pressure adequate and determination of whether intravenous lines are needed for delivery of fluid or medications to support the blood pressure.

If there is bleeding that is obvious, attempts to control it with direct pressure will be attempted.

A fingerstick blood sugar will be checked to make certain that hypoglycemia (low blood sugar) does not exist. Many people can appear to be on death's door, but wake up and remain normal when given sugar. In the Emergency Department, diagnosis and treatment will happen at the same time. Patients will be treated with oxygen supplementation through nasal cannulae, a face mask, or endotracheal intubation. The method and amount of oxygen will be titrated to make certain enough oxygen is available for the body to use. Again, the goal will be to pack each hemoglobin molecule with oxygen. Blood may be transfused if bleeding (hemorrhage) is the cause of the shock state. If bleeding is not the case, intravenous fluids will be given to bolster the volume of fluids within the blood vessels. Intravenous drugs can be used to try to bolster blood pressure (vasopressors). They work by stimulating the heart to beat stronger and by squeezing blood vessels to increase the flow within them.

Exams and Tests

The approach to the patient in shock requires that treatment occur at the same time as the diagnosis occurs. The source of the underlying disease needs to be found. Sometimes it is obvious, for example, a trauma victim bleeding from a wound. Other times, the diagnosis is elusive. The type of tests will depend upon the underlying condition. That said, the diagnosis is most often found through the medical history. A thorough physical examination will be undertaken and the patients vital signs monitored.

Patient vital signs monitored might include continual blood pressure, heart rate, and oxygen measurement. Special catheters may be inserted into the large veins in the neck, chest, arm, or groin and threaded near the heart or into the pulmonary artery, to measure central pressures, which may be a better indicator of the body's fluid status. Other catheters may be inserted into arteries (arterial lines) to measure blood pressures more directly. Tubes may be placed in the bladder (Foley catheter) to measure urine output. Blood laboratory tests will be performed (the type dependent on the underlying disease or condition). Radiologic tests may be performed, again dependent on the underlying illness.

Shock Symptoms
Shock is defined as abnormal metabolism at the cellular level. Since it is not easy to directly measure cellular problems, the symptoms of shock are indirect measurements of cellular function. Shock is the end stage of all diseases, and symptoms will often be dependant on the underlying cause.

Vital signs As the patient goes through the various stages of shock, vital signs change. In the early stages, the body tries to compensate by moving fluids around from within cells to the blood stream with an attempt to maintain blood pressure in a normal range. However, there may be a slight rise in the heart rate (tachycardia = tachy or fast + cardia or heart). Think of donating blood. A unit of blood (or about 10% of your blood volume) is removed, yet the body compensates well, except for a little lightheadedness, which is often resolved by drinking fluids. Another example is exercising and forgetting to drink enough fluids and feeling a little tired at the end of the day. As the body loses the ability to compensate, the breathing rate gets faster and the tachycardia increases as the body tries to pack as much oxygen onto the remaining red blood cells as possible and deliver them to the cells. Unfortunately, blood pressure starts to fall (hypotension=hypo or low + tension= pressure) as compensation mechanisms fail. Body function Cells don't get enough oxygen and the organs that they comprise start to fail. All organs may be affected.

As the brain is affected, the patient may become confused or lose consciousness (coma). There may be chest pain as the heart itself doesn't get an adequate oxygen supply. Diarrhea often occurs as the large intestine becomes irritated due to hypotension. Kidneys may fail and the body may stop making urine. The skin becomes clammy and pale.

Burns Most burns are minor injuries that occur at home or work. It is common to get a minor burn from hot water, a curling iron, or touching a hot stove. Home treatment is usually all that is needed for healing and to prevent other problems, such as infection. There are many types of burns.

Heat burns (thermal burns) are caused by fire, steam, hot objects, or hot liquids. Scald burns from hot liquids are the most common burns to children and older adults. Cold temperature burns are caused by skin exposure to wet, windy, or cold conditions. Electrical burns are caused by contact with electrical sources or by lightning. Chemical burns are caused by contact with household or industrial chemicals in a liquid, solid, or gas form. Natural foods such as chili peppers, which contain a substance irritating to the skin, can cause a burning sensation. Radiation burns are caused by the sun, tanning booths, sunlamps, X-rays, or radiation therapy for cancer treatment. Friction burns are caused by contact with any hard surface such as roads ("road rash"), carpets, or gym floor surfaces. They are usually both a scrape (abrasion) and a heat burn. Athletes who

fall on floors, courts, or tracks may get friction burns to the skin. Motorcycle or bicycle riders who have road accidents while not wearing protective clothing also may get friction burns. For information on treatment for friction burns, see the topic Scrapes.

Breathing in hot air or gases can injure your lungs (inhalation injuries). Breathing in toxic gases, such as carbon monoxide, can cause poisoning. Burns injure the skin layers and can also injure other parts of the body, such as muscles, blood vessels, nerves, lungs, and eyes. Burns are defined as first-, second-, third-, or fourth-degree, depending on how many layers of skin and tissue are burned. The deeper the burn and the larger the burned area, the more serious the burn is.

First-degree burns are burns of the first layer of skin. See a picture of a first-degree burn . There are two types of second-degree burns: o Superficial partial-thickness burns injure the first and second layers of skin. See a picture of this type of second-degree burn . o Deep partial-thickness burns injure deeper skin layers. See a picture of this type of deep second-degree burn . Third-degree burns (full-thickness burns) injure all the skin layers and tissue under the skin. See a picture of a third-degree burn . These burns always require medical treatment. Fourth-degree burns extend through the skin to injure muscle, ligaments, tendons, nerves, blood vessels, and bones. These burns always require medical treatment.

The seriousness of a burn is determined by several things, including:

The depth, size, cause, affected body area, age, and health of the burn victim. Any other injuries that occurred, and the need for follow-up care.

Burns affect people of all ages, though some are at higher risk than others.

Most burns that occur in children younger than age 5 are scald burns from hot liquids. Over half of all burns occur in the 18- to 64-year-old age group. Older adults are at a higher risk for burns, mostly scald burns from hot liquids. Men are twice as likely to have burn injuries as women.

Burns in children

Babies and young children may have a more severe reaction from a burn than an adult. A burn in an adult may cause a minor loss of fluids from the body, but in a baby or young child, the same size and depth of a burn may cause a severe fluid loss. A child's age determines how safe his or her environment needs to be, as well as how much the child needs to be supervised. At each stage of a child's life, look for burn hazards and use appropriate safety measures. Since most burns happen in the home, simple safety measures decrease the chance of anyone getting burned. See the Prevention section of this topic.

When a child or vulnerable adult is burned, it is important to find out how the burn happened. If the reported cause of the burn does not match how the burn looks, abuse must be considered. Self-inflicted burns will require treatment as well as an evaluation of the person's emotional health. Infection is a concern with all burns. Watch for signs of infection during the healing process. Home treatment for a minor burn will reduce the risk of infection. Deep burns with open blisters are more likely to become infected and need medical treatment. Use the Check Your Symptoms section to decide if and when you should see a doctor.

Home Treatment
Most minor burns will heal on their own, and home treatment is usually all that is needed to relieve your symptoms and promote healing. But if you suspect you may have a more severe injury, use first-aid measures while you arrange for an evaluation by your doctor.
Immediate first aid for burns

First, stop the burning to prevent a more severe burn. o Heat burns (thermal burns): Smother any flames by covering them with a blanket or water. If your clothing catches fire, do not run: stop, drop, and roll on the ground to smother the flames. o Cold temperature burns: Try first aid measures to warm the areas. Small areas of your body (ears, face, nose, fingers, toes) that are really cold or frozen can be warmed by blowing warm air on them, tucking them inside your clothing or putting them in warm water. o Liquid scald burns (thermal burns): Run cool tap water over the burn for 10 to 20 minutes. Do not use ice. o Electrical burns: After the person has been separated from the electrical source, check for breathing and a heartbeat. If the person is not breathing or does not have a heartbeat, see Dealing With Emergencies. o Chemical burns: Natural foods such as chili peppers, which contain a substance irritating to the skin, can cause a burning sensation. When a chemical burn occurs, find out what chemical caused the burn. Call your local Poison Control Center or the National Poison Control Hotline (1-800-222-1222) for more information about how to treat the burn. o Tar or hot plastic burns: Immediately run cold water over the hot tar or hot plastic to cool the tar or plastic. Next, look for other injuries. The burn may not be the only injury. Remove any jewelry or clothing at the site of the burn. If clothing is stuck to the burn, do not remove it. Carefully cut around the stuck fabric to remove loose fabric. Remove all jewelry because it may be hard to remove it later if swelling occurs.

Prepare for an evaluation by a doctor

If you are going to see your doctor soon:

Cover the burn with a clean, dry cloth to reduce the risk of infection. Do not put any salve or medicine on the burned area, so your doctor can properly assess your burn. Do not put ice or butter on the burned area, because these measures do not help and can damage the skin tissue.

Home treatment for minor burns

For home treatment of first-degree burns and sunburns: o Use cool cloths on burned areas. o Take frequent cool showers or baths. o Apply soothing lotions that contain aloe vera to burned areas to relieve pain and swelling. Applying 0.5% hydrocortisone cream to the burned area also may help. Note: Do not use the cream on children younger than age 2 unless your doctor tells you to. Do not use in the rectal or vaginal area of children younger than age 12 unless your doctor tells you to. There isn't much you can do to stop skin from peeling after a sunburnit is part of the healing process. Lotion may help relieve the itching. Other home treatment measures, such as chamomile, may help relieve your sunburn symptoms.

For home treatment of second-degree burns, see home treatment for second-degree burns. First-degree burns and minor second-degree burns can be painful. Try the following to help relieve your pain:
Medicine you can buy without a prescription Try a nonprescription medicine to help treat your fever or pain:

Acetaminophen, such as Tylenol Nonsteroidal anti-inflammatory drugs (NSAIDs): o Ibuprofen, such as Advil or Motrin o Naproxen, such as Aleve or Naprosyn Aspirin (also a nonsteroidal anti-inflammatory drug), such as Bayer or Bufferin

Talk to your child's doctor before switching back and forth between doses of acetaminophen and ibuprofen. When you switch between two medicines, there is a chance your child will get too much medicine.
Safety tips Be sure to follow these safety tips when you use a nonprescription medicine:

Carefully read and follow all directions on the medicine bottle and box. Do not take more than the recommended dose.

Do not take a medicine if you have had an allergic reaction to it in the past. If you have been told to avoid a medicine, call your doctor before you take it. If you are or could be pregnant, do not take any medicine other than acetaminophen unless your doctor has told you to. Do not give aspirin to anyone younger than age 20 unless your doctor tells you to.

Lotions

Some doctors suggest using skin lotions, such as Vaseline Intensive Care or Lubriderm, on firstdegree burns or second-degree burns that have unbroken healing skin. These skin lotions can be used to relieve itching but should not be used if the burns have fluid weeping from them or have fresh scabs. An antihistamine, such as Benadryl or Chlor-Trimeton, can also help stop the itching. Read and follow any warning on the label. When a first-degree burn or minor second-degree burn is 2 to 3 days old, using the juice from an aloe leaf can help the burn heal and feel better. Applying the aloe juice may sting at first contact. It is important to protect a burn while it is healing.

Newly healed burns can be sensitive to temperature. Healing burns need to be protected from the cold, because the burned area is more likely to develop frostbite. A newly burned area can sunburn easily. Sunscreen with a high sun protective factor (SPF at least 30) should be used for the first year after a burn to protect the new skin.

Do not smoke. Smoking slows healing because it decreases blood supply and delays tissue repair. For more information, see the topic Quitting Smoking.
Symptoms to Watch For During Home Treatment

Use the Check Your Symptoms section to evaluate your symptoms if any of the following occur during home treatment.

Pain, limited movement, or numbness develops. Difficulty breathing develops. Signs of infection develop. Symptoms become more severe or frequent.

Prevention
Most burns happen in the home. Simple safety measures decrease the chances of anyone getting burned.
Home safety measures

Do not smoke in bed.

Place smoke alarms and other fire safety devices in strategic locations in your home, such as in the kitchen and bedrooms and near fireplaces or stoves. Smoke detectors need to be checked and to have the batteries replaced regularly. A good way to remember to do this is to check smoke detectors twice a year when daylight savings and standard time change. Make a fire escape plan, and make sure the family knows it (babysitters, too). Keep a fire extinguisher near the kitchen and have it checked yearly. Learn how to use it. Put out food or grease fires in a pan with a lid or another pot. Set your water heater at 120F (50C) or lower. Always test the temperature of bathwater. Store cleaning solutions and paints in containers in well-ventilated areas. Use proper fuses in electrical boxes, do not overload outlets, and use insulated and grounded electrical cords. Keep trash cleaned up in attics, basements, and garages. Be careful with gas equipment such as lawn mowers, snow blowers, and chain saws. Be careful with any flammable substances used to start fires, such as lighter fluid. Avoid fireworks. Think of safety first when dealing with fireworks.

Your local fire department is a good resource for more information on how to prevent fires, make a fire escape plan, use fire safety devices, and provide first-aid treatment for burns.
Child safety

Teach children safety rules for matches, fires, electrical outlets, electrical cords, stoves, and chemicals. Keep in mind child safety considerations. Prevention tips for children include the following:

Keep matches and flames, such as candles or lanterns, out of the reach of children. Keep small children away from stoves and ovens when you are cooking, and do not place pot handles where a child can reach them. Do not let children play with any small appliances such as curling irons, hair dryers, toasters, or heating pads. Never hold a child while smoking or drinking a hot liquid, because any sudden movement by the child could cause a burn. Never leave hot foods or liquids within reach of children, such as on the edges of tables or counters. Also, be cautious about leaving hot liquids on a table with a tablecloth that young children can reach and pull down. Prevent electrical burns in young children. Keep electrical cords away from a child's reach. A child chewing on a cord could cause an electrical burn of the mouth. Cover electrical outlets so children will not stick items in the outlet. Prevent heat burns in young children. Do not allow children to remove hot items from the oven or microwave. Use caution whenever heating baby bottles in the microwave so that the liquid does not get too hot. A liner may burst or a lid may not be secure, and when the bottle is tipped for feeding, the hot contents may burn the baby. For this reason, most doctors recommend that bottles not be heated in the microwave. Teach children who are old enough to understand to stop, drop, and roll if their clothing catches on fire so they can help put out the flame and prevent getting burned more. Buy children's sleepwear made of flame-retardant fabric. Dress children in flame- and fireretardant clothing. Older adults need to be careful about wearing clothing with loose material that could catch on fire.

Keep woodstoves and fireplaces in good working condition, and use screens to keep children a safe distance away. Keep portable heaters, furnaces, water heaters, and small appliances in good working condition. Prevent chemical burns in young children. Store cleaning solutions and chemicals out of the reach of children. Prevent friction burns in young children. Friction burns can cause small cuts and scrapes. Don't pull or drag your child across carpet while playing.

Reduce the risk of a lightning strike

In general, avoid placing camping tents under tall trees, near bodies of water, or on the highest hill in an area. Seek shelter in a covered area, such as a car, if you get caught outdoors in bad weather. If no shelter is available, lie on the ground in a ditch or take cover in a thick grove of trees, where lightning striking a single tree is unlikely.

Avoid handling metal or electrical objects. Avoid or stop using any machines outdoors. Get out of water and off of boats

Dka What is diabetic ketoacidosis (DKA)?

Diabetic ketoacidosis (DKA) is a life-threatening condition that develops when cells in the body are unable to get the sugar (glucose) they need for energy, such as when you have diabetes and do not take enough insulin. Without insulin, the body cannot use sugar for energy. When the cells do not receive sugar, the body begins to break down fat and muscle for energy. When this happens, ketones, or fatty acids, are produced and enter the bloodstream, causing the chemical imbalance (metabolic acidosis) called diabetic ketoacidosis.
What causes DKA?

Ketoacidosis can be caused by not taking enough insulin, having a severe infection or other illness, becoming severely dehydrated, or some combination of these things. It can occur in people who have little or no insulin in their bodies (mostly people with type 1 diabetes but it can happen with type 2 diabetes) when their blood sugar levels are high.
What are the symptoms?

Your blood sugar may be quite high before you notice symptoms, which include:

Flushed, hot, dry skin. Blurred vision. Feeling thirsty. Drowsiness or difficulty waking up. Young children may lack interest in their normal activities. Rapid, deep breathing. A strong, fruity breath odor.

Loss of appetite, belly pain, and vomiting. Confusion.

When diabetic ketoacidosis is severe, you may have a hard time breathing, your brain may swell (cerebral edema), and there is a risk of coma and even death.
How is DKA diagnosed?

Laboratory tests, including blood and urine tests, are used to confirm a diagnosis of diabetic ketoacidosis. Urine dipstick tests for ketones are available for home use. Keep some nearby in case your blood sugar level becomes high.
How is it treated?

When ketoacidosis is severe, it must be treated in the hospital, often in an intensive care unit. Treatment involves giving insulin and fluids through a vein and closely watching certain chemicals in the blood (electrolytes). It can take several days for your blood sugar level to return to a target range.
Who is at risk for DKA?

If you have type 1 diabetes, you are at risk for DKA if you do not take enough insulin, have a severe infection or other illness, or become severely dehydrated. In some cases DKA can be the first sign of diabetes.

Diabetic Ketoacidosis Overview

Diabetic ketoacidosis (DKA) results from dehydration during a state of relative insulin deficiency, associated with high blood levels of sugar level and organic acids called ketones. Diabetic ketoacidosis is associated with significant disturbances of the body's chemistry, which resolve with proper therapy. Diabetic ketoacidosis usually occurs in people with type 1 (juvenile) diabetes mellitus (T1DM), but diabetic ketoacidosis can develop in any person with diabetes. Since type 1 diabetes typically starts before age 25 years, diabetic ketoacidosis is most common in this age group, but it may occur at any age. Males and females are equally affected.

Diabetic Ketoacidosis Causes

Diabetic ketoacidosis occurs when a person with diabetes becomes dehydrated. As the body produces a stress response, hormones (unopposed by insulin due to the insulin deficiency) begin to break down muscle, fat, and liver cells into glucose (sugar) and fatty acids for use as fuel. These hormones include glucagon, growth hormone, and adrenaline. These fatty acids are converted to ketones by a process called oxidation. The body consumes its own muscle, fat, and liver cells for fuel.

In diabetic ketoacidosis, the body shifts from its normal fed metabolism (using carbohydrates for fuel) to a fasting state (using fat for fuel). The resulting increase in blood sugar occurs, because insulin is unavailable to transport sugar into cells for future use. As blood sugar levels rise, the kidneys cannot retain the extra sugar, which is dumped into the urine, thereby increasing urination and causing dehydration. Commonly, about 10% of total body fluids are lost as the patient slips into diabetic ketoacidosis. Significant loss of potassium and other salts in the excessive urination is also common. The most common events that cause a person with diabetes to develop diabetic ketoacidosis are:

infection such as diarrhea, vomiting, and/or high fever (40%), missed or inadequate insulin (25%), and newly diagnosed or previously unknown diabetes (15%).

Various other causes may include a heart attack, stroke, trauma, stress, alcohol abuse, drug abuse, and surgery. Approximately 5% to 10% of cases have no identifiable cause.

Exams and Tests

The diagnosis of diabetic ketoacidosis is typically made after the health care practitioner obtains a history, performs a physical examination, and reviews the laboratory tests.

Blood tests will be ordered to document the levels of sugar, potassium, sodium, and other electrolytes. Ketone level and kidney function tests along with a blood gas sample (to assess the blood acid level, or pH) are also commonly performed. Other tests may be used to check for conditions that may have triggered the diabetic ketoacidosis, based on the history and physical examination findings. These may include chest X-ray, electrocardiogram (ECG), urine analysis, and possibly a CT scan of the brain.

Diabetic Ketoacidosis Treatment Self-Care at Home

Home care is generally directed toward preventing diabetic ketoacidosis and treating moderately to elevated to high levels of blood sugar.

If you have type 1 diabetes, you should monitor your blood sugars as instructed by your health care practitioner. Check these levels more often if you feel ill, if you are fighting an infection, or if you have had a recent illness or injury. Your health care practitioner may recommend treating moderate elevations in blood sugar with additional injections of a short-acting form of insulin. Working with their

health care practitioner, people with diabetes should have previously arranged a regimen of extra insulin injections and more frequent blood glucose and urinary ketone monitoring for home treatment as blood sugar levels begin to rise.

Be alert for signs of infection and keep yourself well hydrated by drinking sugar free fluids throughout the day.

Medical Treatment

Fluid replacement and insulin administration intravenously (IV) are the primary and most critical initial treatments for diabetic ketoacidosis. These therapies together reverse dehydration, lower blood acid levels, and restore normal sugar and electrolyte balance. Fluids must be administered wisely - not at an excessive rate or total volume due to the risk of brain swelling (cerebral edema). Potassium is typically added to IV fluids to correct total body depletion of this important electrolyte. Insulin must not be delayed and must be given promptly as a continuous infusion (not as a bolus - a large dose given rapidly) to stop further ketone formation and to stabilize tissue function by driving available potassium back inside the body's cells. Once blood glucose levels have fallen below 300mg/dL, glucose may be co-administered with ongoing insulin administration to avoid the development of hypoglycemia (low blood sugar). People diagnosed with diabetic ketoacidosis are usually admitted into the hospital for treatment and may be admitted to the intensive care unit. Some people with mild acidosis with modest fluid and electrolyte losses, and who can reliably drink fluid and follow medical instructions can be safely treated and sent home. Follow-up must be available with a health care practitioner. Individuals with diabetes who are vomiting should be admitted to the hospital or urgent care center for further observation and treatmen

Diabetic Ketoacidosis Symptoms

A person developing diabetic ketoacidosis may have one or more of these symptoms:

excessive thirst or drinking lots of fluid, frequent urination, general weakness, vomiting, loss of appetite,

confusion, abdominal pain, shortness of breath, a generally ill appearance, dry skin, dry mouth, increased heart rate, low blood pressure, increased rate of breathing, and a distinctive fruity odor on the breath.

Self-Care at Home
Home care is generally directed toward preventing diabetic ketoacidosis and treating moderately to elevated to high levels of blood sugar.

If you have type 1 diabetes, you should monitor your blood sugars as instructed by your health care practitioner. Check these levels more often if you feel ill, if you are fighting an infection, or if you have had a recent illness or injury. Your health care practitioner may recommend treating moderate elevations in blood sugar with additional injections of a short-acting form of insulin. Working with their health care practitioner, people with diabetes should have previously arranged a regimen of extra insulin injections and more frequent blood glucose and urinary ketone monitoring for home treatment as blood sugar levels begin to rise. Be alert for signs of infection and keep yourself well hydrated by drinking sugar free fluids throughout the day.

Hepatic

Encephalopathy Overview
Encephalopathy is a broad term used to describe abnormal brain function or structure. (Encephalo= brain +pathy= disorder). The abnormality may be transient, recurrent, or permanent. The loss of brain function may be reversible, static and stable, or progressive with increasing loss of brain activity.

Normal brain function

Brain cells are linked together with neurons called axons and dendrites covered in myelin sheaths. The electrical impulses work together with chemical receptors to allow brain activity to translate in to thought and action. Different locations in the brain specialize with respect to function, for example, vision function is located in the occipital lobes, speech production in Broca's area in the lower part of the frontal lobe, speech recognition is located in Wernicke's area of the temporal lobe, and the motor strip in the parietal lobes of each hemisphere. The brain also requires blood flow to provide oxygen and glucose to function. Other chemicals, nutrients and vitamins are needed for long term normal function.

Abnormalities and conditions that affect brain function

The brain develops quickly in a fetus as it grows in a mother's uterus; and any disruption in this growth and development may lead to encephalopathy. Abnormalities in anatomic structure, electrical, and chemical function may lead to altered mental function and encephalopathy. Poisoning of brain tissue and cells may also affect function. This poison may be produced within the body, for example from liver or kidney failure, or it may be ingested intentionally or unintentionally. Examples of intentional ingestion include alcohol intoxication or drug abuse. Examples of unintentional ingestion include carbon monoxide poisoning, medications, or toxic substances such as lead paint. It may be due to a birth defect (a genetic abnormality causing abnormal brain structure or chemical activity with symptoms being found at birth), or it may be evident towards the end of life due to disease, such as dementia or Alzheimer's disease.

Depending upon the cause, encephalopathy can occur at any age. Symptoms may present as a form of altered mental status including confusion and loss of memory, or a physical problem such as weakness or numbness of a body part, loss of muscle, uncoordinated movements, seizure, or any combination of the above. The symptoms depend on what part of the brain is being affected, and how much or how little it continues to function.

Encephalopathy Causes
Abnormal brain function may occur because of many different conditions; for example, lack of nutrients, poisoning, infection, structural changes, or anoxia.

Alcoholic Encephalopathy
Alcohol is a classic example of an acute and chronic ingestion that causes brain function changes. When a person drinks alcohol to excess, it alters brain activity. An acutely intoxicated person demonstrates lack of judgment, decreased reflexes, and coordination. If enough alcohol is

ingested, the parts of the brain that control wakefulness and breathing can be depressed to the point that the person can become comatose. These effects are short lived and transient as the liver metabolizes the alcohol and removes it from the body. When the alcohol is gone, the individual returns to normal functioning. When alcohol is repeatedly abused, it can cause liver disease or direct damage to the brain with loss of brain tissue. Wernecke- Korsakoff syndrome is one type of alcoholic encephalopathy that is caused by thiamine (vitamin B1) deficiency due to malnutrition. The malnutrition occurs because most of the dietary calories are derived from alcohol, decreased appetite from a regular diet, and possibly malabsorption of nutrients from the intestine. There may be memory loss and confusion, loss of coordination and ataxia with a wobbling gait (walk), and confusion. Non alcohol related causes can include AIDS, cancer, renal (kidney) dialysis, and hyperthyroidism (thyrotoxicosis).

Anoxic/hypoxic Encephalopathy
Anoxic (an= no + oxia= oxygen) or hypoxic (hypo=less +oxia=oxygen) encephalopathy is a condition in which brain tissue is deprived of oxygen and there is global loss of function. The longer brain cells lack oxygen, the more damage occurs. In pregnancy, the fetus may develop hypoxic encephalopathy if blood supply from the placenta is compromised. Placenta abruptio and placenta previa are two situations that occur in the third trimester leading to fetal distress. Difficulties during the delivery, for example when the umbilical cord is wrapped around the fetus' neck, may cause distress and compromise oxygen delivery to its brain. Anoxic or hypoxic encephalopathy may occur at any time in life. When the heart stops oxygen isn't pumped to the brain. The purpose of starting CPR (cardiopulmonary resuscitation) immediately is to try to continue blood flow and oxygen delivery. Delays in this process may result in brain cell damage and death.

Hepatic Encephalopathy
Hepatic encephalopathy often is associated with alcohol abuse, though any illness that leads to liver failure can cause a build up of ammonia in the blood stream. The ammonia levels, in effect are an internal "poisoning." Ammonia is produced when the liver cannot adequately metabolize urea in the blood stream. The ammonia is able to cross from the bloodstream into the brain cells causing them to swell and malfunction. Treatment to remove the ammonia from the blood stream will reverse the encephalopathy and brain function will return to normal. Other causes of hepatic encephalopathy and liver failure include Tylenol (acetaminophen) overdose, infectious hepatitis (A, B, and C), and other chemical exposures such as carbon tetrachloride, historically a compound no longer used in dry cleaning.

Hypertensive Encephalopathy

Hypertensive encephalopathy occurs when blood pressure rises to levels that cause brain function to be affected. Headache, nausea and vomiting, changes in vision, and decreased level of consciousness may be due to markedly elevated pressure. This condition is also known as a hypertensive crisis (hypertensive emergency), where high blood pressure readings are associated with organ failure. In addition to encephalopathy, there can also be symptoms of chest pain, shortness of breath and kidney failure. Hypotension (low blood pressure) due to many factors (for example, blood loss and blood pressure medications) may result in encephalopathy with symptoms of fainting, weakness and altered mental status.

Infectious Encephalopathy
Infections are a cause of encephalopathy. Many types of bacteria, viruses, and fungi can cause encephalitis by infection and inflammation of the brain tissue or of the meninges (meningitis) that line the brain and spinal cord. Prions are the cause of rare infections like Jacob-Creutzfeldt disease, which is related to bovine spongiform encephalopathy (BSE) or mad cow disease. The prions invade brain tissue and begin to form abnormal protein deposits between brain cells, disrupting tissue structure. The disease is progressive and untreatable leading ultimately to death. Kuru is another type of human prion brain infection.

Ischemic encephalopathy
Ischemic encephalopathy occurs because the small blood vessels that supply blood to brain tissue gradually narrow and cause a generalized decrease in blood flow to the brain. This causes progressive loss of brain tissue with associated loss of function.

Metabolic Encephalopathy
Metabolic encephalopathy (toxic metabolic encephalopathy) is a broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function. In addition to liver and kidney waste products, it may include abnormally high or low blood sugar (hyperglycemia, hypoglycemia), thyroid problems, and sodium levels in the blood (hyponatremia, low sodium). Other causes of metabolic encephalopathy include carbon monoxide or cyanide poisoning, which prevents hemoglobin from carrying oxygen in the blood stream and results in tissue anoxia. Toxic metabolic encephalopathy can also include medication side effects or drug ingestions affecting the chemical transmitters in the brain. Called neurotransmitters, dopamine, GABA, serotonin, acetylcholine, and glutamine help nerve endings pass electrical signals between brain cells. Alterations in these transmitters can decrease brain function. Concentrations of neurotransmitters and abnormal function can be seen in seizure disorders and Alzheimer's disease.

Structural Encephalopathy

Head trauma can cause brain damage due to bleeding in and around the brain. This can cause increased pressure within the skull that presses on brain tissue and cause abnormal brain function. Shear injuries to brain tissue can disrupt the neurons that connect brain cells together. Aside from the direct brain tissue injury, increased pressure build-up within the skull can decrease the amount of blood flow to the brain causing anoxic or hypoxic damage. Blood supply to the brain may be compromised because of stroke, where one of the arteries to the brain becomes blocked and that part of the brain is replaced with scar tissue. If enough cells are injured, there can be permanent damage. Alternatively, hemorrhagic stroke occurs when bleeding occurs into the brain itself causing damage.

Uremic Encephalopathy
Acute or chronic kidney failure can lead to uremic encephalopathy. When the kidneys fail to adequately cleanse the blood stream, a variety of toxins can gradually build and cause brain function to decrease. If kidney function is not restored or if dialysis is not instituted, permanent brain tissue damage can occur leading to death.

Encephalopathy Symptoms
Encephalopathy describes abnormal brain function due to problems with the brain tissue. Symptoms of encephalopathy can be generalized causing decreased level of consciousness from minimal lethargy to coma. Encephalopathy can cause abnormal thought processes including confusion, poor memory, hallucinations, and even psychotic thinking. The abnormalities may be evident because the parts of the body that the brain controls may not work appropriately. There may be incoordination and difficulty walking (ataxia) or there may be abnormalities with vision and eye movement. The encephalopathy may mimic stroke with weakness of one side of the body. The abnormalities may not only affect motor function but also sensation. It all depends upon what part of the brain is not functioning. In some patients, the encephalopathy is so profound that it affects basic brain functions that control wakefulness, breathing, heart beat, and temperature. The symptoms depend on the basic cause of encephalopathy and the potential for reversal of the cause. Symptoms may be present and remain constant, or they may wax and wane. The symptoms may present once and never recur, or they can be progressive and lead to death. For example, low blood glucose (hypoglycemia) may be easily reversed with no brain damage, while profound anoxia may be partially reversible or result in disability or death.

Exams and Tests

The diagnosis of encephalopathy begins with the history provided by the patient, family, or friends. The health care practitioner will be given direction based upon information about the symptoms, for example, how quickly they appeared, how long they have been present, whether they wax and wane, or whether there is a progressive downward course. Past history of medical

illness, intentional or unintentional ingestions, prescribed medications, chemical exposure, and infections may provide clues as to why the patient has encephalopathy. Testing will depend upon the patient's history and symptoms and/or the information the health care practitioner has gathered as to likely potential diagnoses. Routine blood tests such as a complete blood count (CBC) may provide information about possible infection, anemia, or vitamin deficiency. Chemistry tests can evaluate electrolytes, glucose levels, kidney function, and liver function. Other tests may be ordered to access for different types of vitamin deficiencies. If appropriate, drug and alcohol screening may be suggested. Imaging studies such as X-rays, computerized tomography (CT), and magnetic resonance imaging (MRI) may be useful depending upon the clinical situation. Lumbar puncture (spinal tap) may be helpful in evaluating for infection, bleeding, and inflammation. The cerebrospinal fluid can also be analyzed for abnormal proteins, chemicals, and cells. Other testing may be appropriate depending upon the clinical situation and the suspicions of the health care practitioner.

Medical Treatment
Treatment for encephalopathy varies according to the basic cause; for example, short-term anoxia may only require oxygen therapy, while uremic poisoning may require dialysis and a kidney transplant. Consequently, specific mediations and treatment programs will be prescribed based upon the underlying disease. The first episode of encephalopathy should be evaluated immediately by a physician to potentially diagnose and treat the basic cause; such action may reverse or limit the symptoms and prognosis of encephalopathy. Other treatment scenarios include:

When patients present for the first time with confusion, lethargy, or other symptoms suggestive of decreased brain function, an initial cocktail of naloxone (Narcan) and glucose may be injected intravenously to treat quickly reversible narcotic drug overdose and low blood sugar (hypoglycemia) - if these are the causes of the patient's encephalopathy. The ABCs of resuscitation are always evaluated (Airway, Breathing, Circulation). If the airway is compromised and the patient is unable to breathe adequately, endotracheal intubation may be considered. A tube is placed through the mouth into the trachea and a ventilator is used to breathe for the patient. The patient is usually unconscious or nearly so (obtunded) when this situation arises.

Prevention

Some encephalopathies are preventable by positive lifestyle choices and others cannot be foreseen. For example, hepatic encephalopathy from liver failure due to alcoholism may be prevented with a patient's commitment to abstinence from alcohol and use of medical care and community support to prevent or minimize the risk of relapse. Liver failure from other illnesses and congenital or accidental trauma that result in encephalopathy may not be preventable.
Myxedema

Myxedema Coma Overview

The thyroid gland, located at the front part of the neck, is responsible for making substances called thyroid hormones that are important for all body cells to work properly. In certain conditions, the thyroid becomes underactive and produces fewer amounts of its hormones, a situation called hypothyroidism. People with hypothyroidism have problems that reflect underactivity of the organs of the body, resulting in symptoms such as fatigue, feeling cold, weight gain, dry skin, and sleepiness. When the levels of thyroid hormones become very low, the symptoms get worse and can result in a serious condition called myxedema coma. Myxedema coma is a rare but life-threatening condition. People with hypothyroidism who are in or near a coma should be taken to an emergency department immediately.

Myxedema Coma Causes

If you have hypothyroidism, then any of the following can contribute to myxedema coma:

Infections, especially lung and urine infections Heart failure Stroke Trauma Surgery Drugs, such as phenothiazines, amiodarone, lithium, and tranquilizers, and prolonged iodide use Not taking prescribed thyroid medications

Myxedema Coma Symptoms

Symptoms of hypothyroidism may include the following:

Weakness Confusion

Feeling cold Low body temperature Swelling of the body Difficulty breathing

People who have myxedema coma are in or near a coma and not able to function normally. They require emergency care.

Exams and Tests

Blood tests are performed to check blood cell count, electrolytes, sugar, and thyroid hormone levels. Tests are also performed to evaluate how the liver and adrenal glands are functioning. Blood gases are evaluated to check for oxygen and carbon dioxide levels. An ECG of the heart is performed to check for disturbances in the activity of the heart. Additional tests are performed at the discretion of the treating doctor.

Myxedema Coma Treatment Self-Care at Home

If you have hypothyroidism, be alert to your condition.

Call your doctor if you are concerned. Check your blood sugar level if you are diabetic. Warm yourself up with a warm blanket and seek help. Take your prescribed thyroid medication if you missed them earlier.

People with myxedema coma are in a coma or nearly in a coma. They are not able to function normally. Friends or family members should take them to an emergency department immediately. Friends or family members should not give the person in myxedema coma any thyroid medication before taking him or her to the emergency department. If adrenal insufficiency is present, then administration of thyroxin (in the thyroid medication) will provoke an adrenal crisis.

Medical Treatment

Intravenous fluids

Electrolytes replacement as necessary Thyroid hormones are usually administered through a vein (intravenously or IV) to quickly correct the low thyroid hormone blood level. (Oral thyroid hormone is usually not used for severe myxedema because it may take days or weeks to obtain the proper blood level.) Cortisol or other adrenal cortical hormone intravenously Warming blanket if body temperature is low Glucose supplements if the blood sugar level is low Antibiotics if an infection is present

Thyroid

Topic Overview
Thyroid storm (thyroid crisis) is a potentially life-threatening condition for people with hyperthyroidism. Thyroid storm happens when your thyroid gland suddenly releases large amounts of thyroid hormone in a short period of time. If you have thyroid storm, you will need emergency medical treatment. Thyroid storm is more likely to develop when a person has a serious health problem in addition to hyperthyroidism or in people who have untreated or undertreated Graves' disease. The problem usually happens after a stressful event or a serious illness, such as a major infection. It may also be triggered by surgery or by using iodine for a CT scan or in radioactive iodine therapy. Symptoms of thyroid storm include:

Feeling extremely irritable or grumpy. High systolic blood pressure, low diastolic blood pressure, and fast heartbeat. Nausea, vomiting, or diarrhea. High fever. Shock and delirium. Feeling confused. Feeling sleepy. Yellow skin or eyes. Symptoms of heart failure, such as breathing problems or feeling very tired.

Thyroid storm can lead to coma, heart failure, or death.

Thyroid Storm Overview

The thyroid gland, located at the front part of the neck, is responsible for making substances (thyroid hormones) that are important for all body cells to work properly. In certain conditions, the thyroid becomes over-active and produces too much of its hormones, a situation called hyperthyroidism. People with hyperthyroidism have problems that reflect overactivity of the organs of the body, resulting in symptoms such as sweating, feeling hot, rapid heartbeats, weight loss, and sometimes eye problems. When the levels of thyroid hormones become very high in a patient who has hyperthyroidism, the symptoms get worse and can result in a serious condition called thyroid storm. One major sign of thyroid storm that differentiates it from plain hyperthyroidism is a marked elevation of body temperature, which may be as high as 105-106 F. Thyroid storm is unusual, but when it occurs, it is a life-threatening emergency. People experiencing symptoms of thyroid storm should be taken to an emergency department.

Thyroid Storm Causes

Infections, especially of the lung Thyroid surgery in patients with overactive thyroid gland Stopping medications given for hyperthyroidism Too high of thyroid dose Treatment with radioactive iodine Pregnancy Heart attack or heart emergencie

Thyroid Storm Symptoms

Rapid heart beats Greatly increased body temperature Chest pain Shortness of breath Anxiety and irritability Disorientation Increased sweating Weakness Heart failure

Exams and Tests

The following tests are usually performed: blood tests to check blood cell count, electrolyte levels, sugar level, and thyroid hormone levels. Liver function tests are also usually performed.

Medical Treatment

A complete evaluation to determine the cause of thyroid storm Intravenous fluids and electrolytes Oxygen if needed Fever control with antipyretics (fever-reducing medications) and if needed cooling blankets Intravenous corticosteroids such as hydrocortisone Medications to block the production of thyroid hormones, such as propylthiouracil (PTU) or methimazole Iodide to block thyroid hormone release Block the action of thyroid hormones on the cells by drugs called beta-blockers, such as propranolol (Inderal) Treatment of heart failure if present

Pulmo

Pulmonary Edema Overview

Pulmonary edema literally means an excess collection of watery fluid in the lungs. (pulmonary=lung +edema=excess fluid). However, the lung is a complex organ, and there are many causes of this excess fluid accumulation. Regardless of the cause, fluid makes it difficult for the lungs to function (to exchange oxygen and carbon dioxide with cells in the bloodstream). Air enters the lungs through the mouth and nose, traveling through the trachea (windpipe) into the bronchial tubes. These tubes branch into progressively smaller segments until they reach blind sacs called alveoli. Here, air is separated from red blood cells in the capillary blood vessels by the microscopically thin walls of the alveolus and the equally thin wall of the blood vessels. The walls are so thin that oxygen molecules can leave air and transfer onto the hemoglobin molecule in the red blood cell, in exchange for a carbon dioxide molecule. This allows oxygen to be carried to the body to be used for aerobic metabolism and also allows the waste product, carbon dioxide, to be removed from the body.

If excess fluid enters the alveolus or if fluid builds up in the space between the alveolar wall and the capillary wall, the oxygen and carbon dioxide molecules have a greater distance to travel and may not be able to be transferred between the lung and bloodstream. This lack of oxygen in the bloodstream causes the primary symptom of pulmonary edema, which is shortness of breath.

Pulmonary Edema Causes

Pulmonary edema is often classified as cardiogenic or non-cardiogenic [due to a heart (cardiac) problem or due to a non-heart related issue respectively].

Cardiogenic Pulmonary Edema

Cardiogenic pulmonary edema is the most common type and is sometimes referred to as heart failure or congestive heart failure. It may be helpful to understand how blood flows in the body to appreciate why fluid would "back up" into the lungs. The function of the right side of the heart is to receive blood from the body and pump it to the lungs where carbon dioxide is removed, and oxygen is deposited. This freshly oxygenated blood then returns to the left side of the heart which pumps it to the tissues in the body, and the cycle starts again. Pulmonary edema is a common complication of atherosclerotic (coronary artery) disease. As the blood vessels that supply nutrients to the heart tissue progressively narrow, the heart muscle may not receive enough oxygen and nutrients to pump efficiently and adequately. This can limit the heart's ability to pump the blood it receives from the lungs to the rest of the body. If a heart attack occurs, portions of the heart muscle die and is replaced by scar tissue, further limiting the heart's pumping capability leaving it unable to meet its work requirements.

When the heart muscle is not able to pump effectively there is a back-up of blood returning from the lungs to the heart; this backup causes an increase in pressure within the blood vessels of the lung, resulting in excess fluid leaking from the blood vessels into lung tissue. Examples of other conditions in which heart muscle may not function adequately include (this list is not all inclusive):

cardiomyopathy (abnormally functioning heart muscle); previous viral infection; thyroid problems, and alcohol or drug abuse.

Two of the most common cardiomyopathies are ischemic (due to poor blood supply to the heart muscle as described above) and hypertensive. In hypertensive cardiomyopathy, poorly treated high blood pressure results in thickening of the heart muscle - so the heart is able to pump blood against that increased pressure. After a period of time, the heart may no longer be able to compensate and fails to keep up with the work load; as a result, fluid leaks out of the blood vessels into the lung tissue. Another cause of pulmonary edema are mitral and aortic heart valve conditions. Normally, heart valves open and close at the appropriate time when the heart pumps, allowing blood to flow in the appropriate direction. In valvular insufficiency or regurgitation, blood leaks in the wrong direction. In stenosis of the heart valves, the valve becomes narrowed and doesn't allow enough blood to be pumped out of the heart chamber, causing pressure behind it. Failure of the mitral and aortic valves located in the left side of the heart can result in pulmonary edema.

Non-cardiogenic Pulmonary Edema

Non-cardiogenic pulmonary edema is less common and occurs because of damage to the lung tissue and subsequent inflammation of lung tissue. This can cause the tissue that lines the structures of the lung to swell and leak fluid into the alveoli and the surrounding lung tissue. Again, this increases the distance necessary for oxygen to travel to reach the bloodstream. The following are some examples of causes of non-cardiogenic pulmonary edema.

Kidney failure: In this situation the kidneys do not remove excess fluid and waste products from the body, and the excess fluid accumulates in the lungs. Inhaled toxins: Inhaled toxins (for example, ammonia or chlorine gas, and smoke inhalation) can cause direct damage to lung tissue. High altitude pulmonary edema (HAPE): HAPE is a condition that occurs in people who exercise at altitudes above 8,000ft without having first acclimated to the high

altitude. It commonly affects recreational hikers and skiers, but it can also be observed in well-conditioned athletes.

Medication side effects: These may occur as a complication of aspirin overdose or with the use of some chemotherapy drug treatments. Illicit drug use: Non-cardiogenic pulmonary edema is seen in patients who abuse illicit drugs, especially cocaine and heroin. Adult respiratory distress syndrome (ARDS): ARDS is a major complication observed in trauma victims, in patients with sepsis, and shock. As part of the body's attempt to respond to a crisis, the antiinflammatory response attacks the lungs with white blood cells and other chemicals of the inflammatory response causing fluid to fill the air spaces of the lungs. Pneumonia: Bacterial or viral pneumonia infections are quite common; however, occasionally become complicated as a collection of fluid develops in the section of the lung that is infected.

Pulmonary Edema Symptoms

Shortness of breath is the most common symptom of pulmonary edema and is due to the failure of the lungs to provide adequate oxygen to the body. In most cases the shortness of breath or dyspnea (dys=abnormal +pnea=breathing) has a gradual onset. However, depending on the cause, it may occur acutely. For example, flash pulmonary edema, which has an abrupt onset, is often associated with a heart attack. The shortness of breath may initially be manifested by difficulty doing activities that once were routine. There may be a gradual decrease in exercise tolerance, where it takes less activity to bring on symptoms. In addition to shortness of breath, some patients with pulmonary edema will also wheeze. Orthopnea and paroxysmal nocturnal dyspnea are two variants of shortness of breath seen in association with pulmonary edema.

Orthopnea describes shortness of breath while lying flat. Some patients with orthopnea may use two or three pillows to prop themselves up at night or resort to sleeping in a recliner. Symptoms of paroxysmal nocturnal dyspnea are generally described by the patient as wakening in the middle of the night, short of breath, with a need to walk around and perhaps stand by a window.

The lack of oxygen in the body can cause significant distress, leading to a respiratory crisis, gasping for air, and feeling unable to breathe. In effect, if there is enough fluid in the lungs, it can feel like a drowning. The patient may begin coughing up frothy sputum, become markedly sweaty and cool and clammy. The lack of oxygen can also affect other organs. Confusion and

lethargy from lack of oxygen delivery to the brain; and angina (chest pain) from the heart, can both be associated with massive pulmonary edema and respiratory failure. Pulmonary edema is due to left heart failure, in which pressure backs up into the blood vessels of the lungs, but some patients also have associated right heart failure. In right heart failure, the pressure backs up in the veins of the body, and fluid accumulation can occur in the feet, ankles, and legs as well as any other dependent areas like the sacrum, if the patient sits for prolonged periods of time. Patients with high altitude pulmonary edema may also develop high altitude cerebral edema (inflammation and swelling of the brain). This may be associated with headache, vomiting, and poor decision making.

Exams and Tests

Should the patient present in respiratory distress, initial stabilization of the ABCs (airway, breathing, and circulation) may occur at the same time as, or take priority over, any diagnostic testing or examination. However, if there is time, history and physical examination are important first steps in making the diagnosis and establishing the cause of pulmonary edema.

Patient History
With the history taken from the patient or family, the health care practitioner will try to determine the cause of the shortness of breath that brings the patient in for care. Symptoms of shortness of breath on exertion, chest pain, orthopnea, and paroxysmal nocturnal dyspnea (waking from sleep due to respiratory distress) may be the clue to make the diagnosis of pulmonary edema. Past medical history may provide direction as to the cause. Patients at risk for cardiogenic pulmonary edema may have risk factors for heart disease, including high blood pressure, high cholesterol, diabetes, family history of heart disease, and smoking. Questions about signs of infection, medications and other complaints may be asked to access for reasons other than pulmonary edema that may be causing the shortness of breath. Non-cardiogenic causes of pulmonary edema are also considered, especially in patients with no previous history of heart disease.

Physical Examination
Physical examination often concentrates on the heart and lungs. Listening to the lungs may reveal abnormal lung sounds consistent with fluid accumulation. Wheezing may be heard, and while may people equate wheezing with asthma or chronic obstructive pulmonary disease (COPD), this is not always the case and may be due to pulmonary edema. Listening to the heart may reveal abnormal heart sounds or murmurs associated with valvular heart disease. If right heart failure exists, there may be swelling of the feet, ankles, and legs as

well as jugular venous distention (a prominence of the veins in the neck associated with fluid overload).

Imaging and Other Tests

Often a chest X-ray is taken to assess the status of the lungs. It may reveal obvious fluid, or there may be subtle changes that give direction to the diagnosis. An electrocardiogram (EKG) may be helpful in diagnosing heart rhythm disturbances, previous heart attack, and ventricular hypertrophy (thickening of the heart ventricle muscle) associated with hypertension. If there is concern about the structure and pumping capabilities of the heart, an echocardiogram may be considered. This uses ultrasound images which can help identify valve abnormalities, pumping efficiency of the heart, motion of the heart wall, and heart muscle thickness. The pericardium, the lining of the heart, can also be evaluated.

Blood Tests
Screening blood tests may be considered to look for any underlying medical issues. A complete blood count (CBC) may find an elevated white blood cell count associated with infection or stress. Blood chemistries can screen for diabetes and kidney disease. An arterial blood gas can assess lung function by assessing the oxygen and carbon dioxide levels in the blood; measuring pH and helping determine the acid-base balance of the body.

Medical Treatment
When a patient is in respiratory distress, the initial treatment will occur at the same time or even before the diagnosis is made. The health care practitioner will assess whether the airway is open and whether breathing is adequate; otherwise there may be a need to breathe for the patient until treatment becomes effective. The blood pressure may need to be supported with medications until the breathing status improves. In situations in which there is the luxury of time to evaluate the patient, such as in an office or outpatient clinic, the treatment of pulmonary edema may involve minimizing risk factors that may have caused it. In cardiogenic pulmonary edema, efforts to maximize heart function and decrease the amount of work the heart has to do are attempted to try to decrease the amount of fluid that the heart has to pump. This should decrease the amount of fluid build-up in the lungs and relieve symptoms.

Medication
In the acute situation, oxygen is the first drug that may help reduce dyspnea, or shortness of breath.

Intravenous diuretics [furosemide (Lasix), bumetanide (Bumex)] are first-line medications to help the kidneys remove excess fluid from the body. Even in kidney failure, these drugs may help shift fluid out of the lung for a short period of time. Reducing the work effort of the heart may be helpful in the acute situation. Nitroglycerin (Nitrolingual, Nitrolingual Duo Pack, Nitroquick, Nitrostat) can be used to reduce the workload of the heart by dilating blood vessels and reducing the amount of blood returning to the heart. Enalapril (Vasotec) and captopril (Capoten) are examples of medications that dilate peripheral arteries and decrease the resistance against which the heart muscle must pump. Morphine may be considered to ease anxiety and help with the feeling of shortness of breath. If the patient is in respiratory failure, positive airway pressure breathing machines (CPAP, BiPAP) may be used to force air into the lungs. This is a short-term solution (used for up to a few hours) until the medications work. In patients who become somnolent (sleepy) or who are no longer able to breathe adequately on their own, intubation (putting a tube into the airway) and using a ventilator may be required. In non-cardiogenic pulmonary edema, the focus will be on decreasing lung inflammation. While the above medications may be considered, the short-term use of mechanical ventilation with CPAP, BiPAP, or a ventilator may be indicated. The underlying cause of pulmonary edema needs to be diagnosed, and this will direct further therapy.
Arf

Topic Overview
Is this topic for you?

This topic provides information about sudden kidney failure. If you are looking for information about long-term kidney disease, see the topic Chronic Kidney Disease.
What is acute renal failure?

Acute renal failure (also called acute kidney injury) means that your kidneys have suddenly stopped working. Your kidneys remove waste products and help balance water and salt and other minerals (electrolytes) in your blood. When your kidneys stop working, waste products, fluids, and electrolytes build up in your body. This can cause problems that can be deadly.
What causes acute renal failure?

Acute renal failure has three main causes:

A sudden, serious drop in blood flow to the kidneys. Heavy blood loss, an injury, or a bad infection called sepsis can reduce blood flow to the kidneys. Not enough fluid in the body (dehydration) also can harm the kidneys. Damage from some medicines, poisons, or infections. Most people don't have any kidney problems from taking medicines. But people who have serious, long-term health problems are more likely than other people to have a kidney problem from medicines. Examples of medicines that can sometimes harm the kidneys include: o Antibiotics, such as gentamicin and streptomycin. o Pain medicines, such as aspirin and ibuprofen. o Some blood pressure medicines, such as ACE inhibitors. o The dyes used in some X-ray tests. A sudden blockage that stops urine from flowing out of the kidneys. Kidney stones, a tumor, an injury, or an enlarged prostate gland can cause a blockage.

You have a greater chance of getting acute renal failure if:

You are an older adult. You have a long-term health problem such as kidney or liver disease, diabetes, high blood pressure, heart failure, or obesity. You are already very ill and are in the hospital or intensive care (ICU). Heart or belly surgery or a bone marrow transplant can make you more likely to have kidney failure.

What are the symptoms?

Symptoms of acute renal failure may include:

Little or no urine when you urinate. Swelling, especially in your legs and feet. Not feeling like eating. Nausea and vomiting. Feeling confused, anxious and restless, or sleepy. Pain in the back just below the rib cage. This is called flank pain.

Some people may not have any symptoms. And for people who are already quite ill, the problem that's causing the kidney failure may be causing other symptoms.
How is acute renal failure diagnosed?

Acute renal failure is most often diagnosed during a hospital stay for another cause. If you are already in the hospital, tests done for other problems may find your kidney failure. If you're not in the hospital but have symptoms of kidney failure, your doctor will ask about your symptoms, what medicines you take, and what tests you have had. Your symptoms can help point to the cause of your kidney problem.

Blood and urine tests can check how well your kidneys are working. A chemistry screen can show if you have normal levels of sodium (salt), potassium, and calcium. You may also have an ultrasound. This imaging test lets your doctor see a picture of your kidneys.
How is it treated?

Your doctor or a kidney specialist (nephrologist) will try to treat the problem that is causing your kidneys to fail. Treatment can vary widely, depending on the cause. For example, your doctor may need to restore blood flow to the kidneys, stop any medicines that may be causing the problem, or remove or bypass a blockage in the urinary tract. At the same time, the doctor will try to:

Stop wastes from building up in your body. You may have dialysis. This treatment uses a machine to do the work of your kidneys until they recover. It will help you feel better. Prevent other problems. You may take antibiotics to prevent or treat infections. You also may take other medicines to get rid of extra fluid and keep your body's minerals in balance.

You can help yourself heal by taking your medicines as your doctor tells you to. You also may need to follow a special diet to keep your kidneys from working too hard. You may need to limit sodium, potassium, and phosphorus. A dietitian can help you plan meals.
Does acute renal failure cause lasting problems?

About half the time, doctors can fix the problems that cause kidney failure, and the treatment takes a few days or weeks. These people's kidneys will work well enough for them to live normal lives. But other people may have permanent kidney damage that leads to chronic kidney disease. A small number of them will need to have regular dialysis or a kidney transplant. Older people and those who are very sick from other health problems may not get better. People who die usually do so because of the health problem that caused their kidneys to fail.
Ards

Topic Overview
Is this topic for you?

This topic provides information about sudden kidney failure. If you are looking for information about long-term kidney disease, see the topic Chronic Kidney Disease.

What is acute renal failure?

Acute renal failure (also called acute kidney injury) means that your kidneys have suddenly stopped working. Your kidneys remove waste products and help balance water and salt and other minerals (electrolytes) in your blood. When your kidneys stop working, waste products, fluids, and electrolytes build up in your body. This can cause problems that can be deadly.
What causes acute renal failure?

Acute renal failure has three main causes:

A sudden, serious drop in blood flow to the kidneys. Heavy blood loss, an injury, or a bad infection called sepsis can reduce blood flow to the kidneys. Not enough fluid in the body (dehydration) also can harm the kidneys. Damage from some medicines, poisons, or infections. Most people don't have any kidney problems from taking medicines. But people who have serious, long-term health problems are more likely than other people to have a kidney problem from medicines. Examples of medicines that can sometimes harm the kidneys include: o Antibiotics, such as gentamicin and streptomycin. o Pain medicines, such as aspirin and ibuprofen. o Some blood pressure medicines, such as ACE inhibitors. o The dyes used in some X-ray tests. A sudden blockage that stops urine from flowing out of the kidneys. Kidney stones, a tumor, an injury, or an enlarged prostate gland can cause a blockage.

You have a greater chance of getting acute renal failure if:

You are an older adult. You have a long-term health problem such as kidney or liver disease, diabetes, high blood pressure, heart failure, or obesity. You are already very ill and are in the hospital or intensive care (ICU). Heart or belly surgery or a bone marrow transplant can make you more likely to have kidney failure.

What are the symptoms?

Symptoms of acute renal failure may include:

Little or no urine when you urinate. Swelling, especially in your legs and feet. Not feeling like eating. Nausea and vomiting. Feeling confused, anxious and restless, or sleepy. Pain in the back just below the rib cage. This is called flank pain.

Some people may not have any symptoms. And for people who are already quite ill, the problem that's causing the kidney failure may be causing other symptoms.

How is acute renal failure diagnosed?

Acute renal failure is most often diagnosed during a hospital stay for another cause. If you are already in the hospital, tests done for other problems may find your kidney failure. If you're not in the hospital but have symptoms of kidney failure, your doctor will ask about your symptoms, what medicines you take, and what tests you have had. Your symptoms can help point to the cause of your kidney problem. Blood and urine tests can check how well your kidneys are working. A chemistry screen can show if you have normal levels of sodium (salt), potassium, and calcium. You may also have an ultrasound. This imaging test lets your doctor see a picture of your kidneys.
How is it treated?

Your doctor or a kidney specialist (nephrologist) will try to treat the problem that is causing your kidneys to fail. Treatment can vary widely, depending on the cause. For example, your doctor may need to restore blood flow to the kidneys, stop any medicines that may be causing the problem, or remove or bypass a blockage in the urinary tract. At the same time, the doctor will try to:

Stop wastes from building up in your body. You may have dialysis. This treatment uses a machine to do the work of your kidneys until they recover. It will help you feel better. Prevent other problems. You may take antibiotics to prevent or treat infections. You also may take other medicines to get rid of extra fluid and keep your body's minerals in balance.

You can help yourself heal by taking your medicines as your doctor tells you to. You also may need to follow a special diet to keep your kidneys from working too hard. You may need to limit sodium, potassium, and phosphorus. A dietitian can help you plan meals.
Does acute renal failure cause lasting problems?

About half the time, doctors can fix the problems that cause kidney failure, and the treatment takes a few days or weeks. These people's kidneys will work well enough for them to live normal lives. But other people may have permanent kidney damage that leads to chronic kidney disease. A small number of them will need to have regular dialysis or a kidney transplant. Older people and those who are very sick from other health problems may not get better. People who die usually do so because of the health problem that caused their kidneys to fail.
Next Page: FAQs

ARDS Causes
A number of risk factors are associated with the development of ARDS.

Sepsis (presence of various pathogenic microorganisms, or their toxins, in the blood or tissues) Severe traumatic injury (especially multiple fractures), severe head injury, and injury to the chest Fracture of the long bones Transfusion of multiple units of blood Acute pancreatitis Drug overdose Aspiration Viral pneumonias Bacterial and fungal pneumonias Near drowning Toxic inhalations

ARDS Symptoms

Severe difficulty in breathing Anxiety Agitation Fever

Exams and Tests for ARDS

Arterial blood gas analysis reveals hypoxemia (reduced levels of oxygen in the blood). A complete blood count may be taken. The number of white blood cells is increased in sepsis. Chest x-ray will show the presence of fluid in the lungs.

CT scan of the chest may be required only in some situations (routine chest x-ray is sufficient in most cases). Echocardiogram (an ultrasound of the heart) may help exclude any heart problems that can cause fluid build-up in the lung. Monitoring with a pulmonary artery catheter may be done to exclude a cardiac cause for the difficulty in breathing. Bronchoscopy (a procedure used to look inside the windpipe and large airways of the lung) may be considered to evaluate the possibility of lung infection.

ARDS Treatment Medical Treatment for ARDS

Persons with ARDS are hospitalized and require treatment in an intensive care unit. No specific therapy for ARDS exists. Treatment is primarily supportive using a mechanical respirator and supplemental oxygen. Intravenous fluids are given to provide nutrition and prevent dehydration, and are carefully monitored to prevent fluid from accumulating in the lungs (pulmonary edema). Because infection is often the underlying cause of ARDS, appropriate antibiotic therapy is administered. Corticosteroids may sometimes be administered in ARDS or if the patient is in shock, but their use is controversial.

Medications for ARDS

The following drugs may be administered:

Antibiotics to treat infection Anti-inflammatory drugs, such as corticosteroids, to reduce inflammation in the lungs in the late phase of ARDS or sometimes if the person is in septic shock Diuretics to eliminate fluid from the lungs Drugs to counteract low blood pressure that may be caused by shock Anti-anxiety drugs to relieve anxiety

Inhaled drugs administered by respiratory therapists to open up the airways (bronchodilators)

Pulmo emboli

Pulmonary Embolism Overview

A pulmonary embolism (PE) is a blood clot in the lung. It usually comes from smaller vessels in the leg, pelvis, arms, or heart. When a clot forms in the legs or arms, it is referred to as a deep venous thrombosis (DVT). The clot travels through the vessels of the lung continuing to reach smaller vessels until it becomes wedged in a vessel that is too small to allow it to continue farther. The clot gets wedged and prevents any further blood from traveling to that section of the lung. When no blood reaches a section of the lung, that portion of the lung suffers an infarct, meaning it dies because no blood or oxygen is reaching it. This is referred to as a pulmonary (or lung) infarct.

Pulmonary Embolism Causes

Several factors can make someone more likely to develop a blood clot that can eventually break loose and travel to the lung.

Immobilization: A stroke, broken bone, or spinal cord injury can result in confinement to bed so that clot formation can occur in either the arms or legs. Travel: Prolonged travel, such as sitting in an airplane or a long car trip, allows the blood to sit in the legs and increases the risk of clot formation. Recent surgery Trauma or injury (especially to the legs) Obesity Heart disease (such as an irregular heartbeat) Burns Previous history of blood clot in the legs (DVT) or PE Conditions that increase clotting of the blood
o o

Pregnancy Cancer

o o

Estrogen therapy Certain protein and enzyme deficiencies

Pulmonary Embolism Symptoms

Not all PEs exhibit the same signs and symptoms. But certain symptoms may indicate that a PE has occurred.

The following signs and symptoms may occur (in the order they are typically seen):
o

Chest pain: Pain is very sharp and stabbing in nature, has a sudden onset, and is worse when taking a deep breath (referred to as pleuritic chest pain). Shortness of breath Anxiety or apprehension Cough: Usually, this cough is dry, but it may be associated with blood. Sweating Passing out

o o o o o

Doctors may suspect a blood clot if any of these symptoms occur in someone who has or recently had a swollen or painful arm or leg or who has any of the risk factors.

Pulmonary Embolism Treatment Medical Treatment

When you go to a hospital's emergency department or your doctor's office with chest pain or other symptoms that may suggest a PE, remember that the diagnosis has not yet been confirmed, and therefore not all treatment will occur from the beginning of an evaluation. If you have chest pain, you will be placed on a heart monitor, and usually an IV will be inserted. Some people with PE are critically ill. They have severe shortness of breath, low blood pressure, and low oxygen concentrations. Much more aggressive treatment is undertaken to support or elevate the blood pressure and increase the oxygen in the blood. The following treatments are the most frequently used for PEs.

Oxygen can be given in several ways. One is through tubing that is inserted at the tip of the nostrils, called a nasal cannula.

If you have severely low oxygen levels, you will be given a higher flow of oxygen through a mask. You may be so sick that you require ventilator treatment. A large tube is placed into your trachea (windpipe) and connected to a ventilator (breathing machine), which assists or does the breathing for you. If a ventilator is required, you will usually be sedated so that you are not aware, which also helps to ease your breathing and make it effortless.

Blood-thinning medication is given through your IV, injected in the skin directly, and also taken by mouth.
o

Heparin is usually the first medication given. This is given in an IV and works to stop further clot formation from occurring. It is administered continuously through the IV. Another medication is called enoxaparin (Lovenox), or a low molecular weight heparin. This medication is given subcutaneously, or just under the skin. It only has to be given every 12 hours, but it does require an injection each time. The current trend is to use low molecular weight heparin for the treatment of PE. The oral blood-thinning medication called warfarin (Coumadin) is usually given shortly after the heparin or a low molecular weight heparin is started. The medications are continued until blood tests show that the warfarin is adequately thinning the blood. Once this is shown, then the heparin or enoxaparin is stopped, and the warfarin is continued as an outpatient.

Blood pressure elevators are IV medications given to critically ill people with low blood pressures. The most commonly used medication is dopamine (Intropin). It works to elevate the blood pressure into an acceptable range. "Clot buster" medications (also called thrombolytics) are given to those who are critically ill. The purpose is to break up the clot that is blocking the blood vessel in the lung. These medications are used only in those with massive PE, blood pressure collapse, or severely low oxygen that does not respond to treatment. Examples of these medications are reteplase (Retavase), TPA, streptokinase, and urokinase.

Poisoning

Poisoning Overview
If you or someone you know has swallowed or breathed in a poison, and you or they have serious signs or symptoms (nausea, vomiting, pain, trouble breathing, seizure, confusion, or

abnormal skin color), then you must either call an ambulance for transport to a hospital emergency department or call a poison control center for guidance. The National Poison Control Center phone number in the U.S. is 1-800-222-1222. If the person has no symptoms but has taken a potentially dangerous poison, you should also call a poison control center or go to the nearest emergency department for an evaluation. Poison is anything that kills or injures through its chemical actions. Most poisons are swallowed (ingested). The word poison comes from the Latin word - potare - meaning to drink. But poisons can also enter the body in other ways:

By breathing Through the skin By IV injection From exposure to radiation Venom from a snake bite

Topic Overview
A poison is a substance that has toxic effects and may injure you or make you sick if you are exposed to it. Poisons can be found everywhere, from simple household cleaners to cosmetics to houseplants to industrial chemicals. Even medicines that are taken in the wrong dose, at the wrong time, or by the wrong person can cause a toxic effect. Poisonous substances can hurt you if they are swallowed, inhaled, spilled on your skin, or splashed in your eyes. In most cases, any product that gives off fumes or is an aerosol that can be inhaled should be considered a possible poison. More than 90% of poisonings occur in the home. Young children have the highest risk of poisoning because of their natural curiosity. More than half of poisonings in children occur in those who are younger than age 6. Some children will swallow just about anything, including unappetizing substances that are poisonous. When in doubt, assume the worst. Always believe a child or a witness, such as another child or a brother or sister, who reports that poison has been swallowed. Many poisonings occur when an adult who is using a poisonous product around children becomes distracted by the doorbell, a telephone, or some other interruption. Teenagers also have an increased risk of poisonings, both accidental and intentional, because of their risk-taking behavior. Some teens experiment with poisonous substances such as by sniffing toxic glues or inhaling aerosol substances to get "high." About half of all poisonings in teens are classified as suicide attempts, which always requires medical evaluation. Adultsespecially older adultsare at risk for accidental and intentional poisonings from:

Alcohol and illegal drugs. For more information, see the topic Alcohol and Drug Problems.

Gas leaks, such as exhaust leaks from heaters and stoves and automobile exhaust. For more information, see the topic Carbon Monoxide Poisoning. Medicines, such as acetaminophen, antibiotics, cough and cold remedies, vitamins, pain relievers, sleeping pills, and tranquilizers. Household cleaning supplies and other substances, such as cosmetics, antifreeze, windshield cleaner, gardening products, and paint thinners. Herbal products.

If a poisoning was intentional, call your local suicide hotline or the national suicide hotline 1800-273-TALK or 1-800-273-8255 for help.
Symptoms of poisonings

The symptoms of a suspected poisoning may vary depending on the person's age, the type of poisonous substance, the amount of poison involved, and how much time has passed since the poisoning occurred. Some common symptoms that might indicate a poisoning include:

Nausea and vomiting. Cramps. Throat pain. Drooling. Sudden sleepiness, confusion, or decreased alertness. Anxiousness, nervousness, irritability, or tremors. Seizures. Substance residue or burn around the mouth, teeth, eyes, or on the skin. Difficulty breathing. Headache.

Poisoning Causes
Poisons include highly toxic chemicals not meant for human ingestion or contact, such as cyanide, paint thinners, or household cleaning products. Many poisons, however, are substances meant for humans to eat, including foods and medicines. Foods

Some mushrooms are poisonous Drinking water contaminated by agricultural or industrial chemicals Food that has not been properly prepared or handled

Drugs Drugs that are helpful in therapeutic doses may be deadly when taken in excess.

Examples include:

Beta blockers: Beta blockers are a class of drugs used to treat heart conditions (for example, angina, abnormal heart rhythms) and other conditions, for example, high blood pressure, migraine headache prevention, social phobia, and certain types of tremors. In excess, they can cause difficulty breathing, coma, and heart failure. Warfarin (Coumadin): Coumadin is a blood thinner used to prevent blood clots. It is the active ingredient in many rat poisons and may cause heavy bleeding and death if too much is taken. Vitamins: Vitamins, especially A and D, if taken in large amounts can cause liver problems and death.

Poisoning Symptoms
The signs and symptoms seen in poisoning are so wide and variable that there is no easy way to classify them.

Some poisons enlarge the pupils, while others shrink them. Some result in excessive drooling, while others dry the mouth and skin. Some speed the heart, while others slow the heart. Some increase the breathing rate, while others slow it. Some cause pain, while others are painless. Some cause hyperactivity, while others cause drowsiness. Confusion is often seen with these symptoms.

When the cause of the poisoning is unknown A big part of figuring out what type of poisoning has occurred is connecting the signs and symptoms to each other, and to additional available information.

Two different poisons, for example, may make the heart beat quickly. However, only one of them may cause the skin and mouth to be very dry. This simple distinction may help narrow the possibilities. If more than one person has the same signs and symptoms, and they have a common exposure source, such as contaminated food, water, or workplace environment, then poisoning would be suspected. When two or more poisons act together, they may cause signs and symptoms not typical of any single poison.

Toxidromes Certain poisons cause what toxicologists call toxidromes - a contraction of the words toxic and syndrome. Toxidromes consist of groups of signs and symptoms found together with a given type of poisoning.

For example: Jimson weed, a plant smoked or ingested for its hallucinogenic properties, produces the anticholinergic toxidrome: Rapid heart rate, large pupils, dry hot skin, retention of urine, mental confusion, hallucinations, and coma. Most poisons either have no associated toxidrome or have only some of the expected features of the toxidrome.

Delayed onset of symptoms A person can be poisoned and not show symptoms for hours, days, or months. Cases of poisoning with a prolonged onset of symptoms are particularly dangerous because there may be a dangerous delay in obtaining medical attention.

Acetaminophen (Tylenol) is considered one of the safest drugs but is toxic to the liver when taken in large quantities. Because it acts so slowly, 7-12 hours may pass before the first symptoms begin (no appetite when normally hungry, nausea, and vomiting). The classic example of a very slow poison is lead. Before 1970, most paints contained lead. Young children would eat paint chips and, after several months, develop abnormalities of the nervous system.

When the illness may be poisoning - or may not be poisoning Some signs and symptoms of poisoning can imitate signs and symptoms of common illnesses.

For example, nausea and vomiting are a sign (vomiting) and symptom (nausea) of poisoning. However, nausea and vomiting can also be found in many illnesses that have nothing to do with poisoning. Examples include:
o o o o o o o

stroke, heart attack, stomach ulcers, gallbladder problems, hepatitis, appendicitis, head injuries, and

many others.

Almost every possible sign or symptom of a poisoning can also be caused by a non poison-related medical problem.

Exams and Tests

A combination of history, physical examination, and laboratory studies will help reveal the cause of most poisonings. Frequently, treatment must begin before all information is available. History: As a family member or friend of a poisoned person, you can greatly assist the doctor and provide valuable clues by telling the doctor about these details:

Everything the person ate or drank recently Names of all prescription and over-the-counter medications the person is taking Exposure to chemicals at home or at work Whether others in the family or at work have been similarly ill or exposed Whether the person has any psychiatric history to suggest an intentional ingestion (suicide attempt)

Testing: Many poisons can be detected in the blood or urine. However, a physician cannot order "every test in the book" when the diagnosis is unclear. The tests ordered will be based on information revealed in the history and physical exam.

A toxicology screen or "tox" screen looks for common drugs of abuse. Most toxicology screens will detect:
o o o o o o o o

acetaminophen, aspirin, marijuana, opioids (heroin, codeine), benzodiazepines (Valium, Librium), amphetamines (uppers), cocaine, and alcohol.

A specific blood test will give serum levels of some drugs, including phenytoin (Dilantin), theophylline (Theo-Dur, Respbid, Slo-Bid, Theo-24, Theolair, Uniphyl, SloPhyllin), digoxin (Lanoxin), lithium (Lithobid), and acetaminophen. Some drugs affect the electrical activity of the heart. An electrocardiogram (ECG) may reveal toxicity. Sometimes a person is unconscious for no obvious reason. A CT scan of the brain will help tell if there has been a structural change in the brain, such as a stroke.

Poisoning Treatment Self-Care at Home

If you or someone you know has swallowed or breathed a poison and you or they have signs or symptoms, such as nausea, vomiting, pain, trouble breathing, seizure, confusion, or abnormal skin color, then you must call either an ambulance or the U.S. National Poison Control Center at 1-800-222-1222 for guidance. This number is routed to the poison control center that serves your area.

Post the telephone number (along with police, fire, and 911 or equivalent) near your home phones. Do not induce vomiting or give syrup of Ipecac.
o

Ipecac was previously used to induce vomiting in poisoned patients where there was a chance to get the toxin out of the body. Several advisory bodies such as the American Association of Poison Control Centers and the American Academy of Pediatrics have recommended that Ipecac NOT be used and that it should not even be kept in the household. For more information on this subject go to: http://www.poison.org/prepared/ipecac.asp

Do not give activated charcoal at home. Allow medical personnel to decide if this treatment is appropriate. The poison control center will instruct you what to do or if an antidote is readily available.

Medical Treatment
Elimination: Get rid of the unabsorbed poison before it can do any harm.

If the person is unconscious, the doctor will put a flexible, soft, plastic tube into the windpipe to protect the person from suffocating in his or her own vomit and to provide artificial breathing (intubation).

Once the poison has moved past the stomach, other methods are needed. o Activated charcoal acts as a "super" absorber of many poisons. Once the poison is stuck to the charcoal in the intestine, the poison cannot get absorbed into the bloodstream. Activated charcoal has no taste, but the gritty texture sometimes causes the person to vomit. To be effective, activated charcoal needs to be given as soon as possible after the poisoning. It does not work with alcohol, caustics, lithium (Lithobid), or petroleum products.
o

Whole bowel irrigation requires drinking a large quantity of a fluid called Golytely. This flushes the entire gastrointestinal tract before the poison gets absorbed.

Antidotes: Some poisons have specific antidotes. Antidotes either prevent the poison from working or reverse the effects of the poison.

Atropine is an antidote for certain nerve gases and insecticides. During Operation Desert Storm, all military personnel were issued atropine injectors when it was feared that the enemy would use nerve gas. A common antidote is N-acetylcysteine (Mucomyst), which is used to neutralize acetaminophen (Tylenol) overdoses. Acetaminophen, in normal doses, is one of the safest medications known, but after a massive overdose, the liver is damaged, and hepatitis and liver failure develop. Mucomyst works as an antidote by bolstering the body's natural detoxification abilities when they are overwhelmed. It may also be possible to reverse the harmful effect of a drug even if no antidote exists. o If a person with diabetes takes too much insulin, a dangerously low blood sugar (hypoglycemia) will cause weakness, unconsciousness, and eventually death. Sugar given by mouth or IV is an effective treatment until the insulin wears off.
o

When the poison is a heavy metal, such as lead, special medicines (chelators) bind the poison in the bloodstream and cause it to be eliminated in the urine. Another "binder" is sodium polystyrene sulfonate (Kayexalate), which can absorb potassium and other electrolytes from the bloodstream.

General supportive measures: When there are no specific treatments, the physician will treat signs and symptoms as needed.

If the person is agitated or hallucinating, a sedative can be given to calm the person until the drug wears off. A ventilator can be used to breathe for anyone who has stopped breathing from a poisoning. Antiseizure medicines can be used to treat or prevent seizures.

Drug overdose

Drug Overdose Overview

Overdoses of drugs or chemicals can be either accidental or intentional. Drug overdoses occur when a person takes more than the medically recommended dose. However, some people may be more sensitive to certain medications so that the high end of the therapeutic range of a drug may be toxic for them. Illicit drugs, used to get high, may be taken in overdose amounts when a person's metabolism cannot detoxify the drug fast enough to avoid unintended side effects. Exposure to chemicals, plants, and other toxic substances that can cause harm are called poisonings. The higher the dose or the longer the exposure, the worse the poisoning. Two examples are carbon monoxide poisoning and mushroom poisoning.

People respond differently to a drug overdose. Treatment is tailored to the individual's needs. Drug overdoses can involve people of any age. It is most common in very young children (from crawling age to about 5 years) and among teenagers to those in their mid-30s.

Drug Overdose Causes

The cause of a drug overdose is either by accidental overuse or by intentional misuse. Accidental overdoses result from either a young child or an adult with impaired mental abilities swallowing a medication left within their grasp. An adult (especially elderly persons or people taking many medications) can mistakenly ingest the incorrect medication or take the wrong dose of a medication. Purposeful overdoses are for a desired effect, either to get high or to harm oneself.

Young children may swallow drugs by accident because of their curiosity about medications they may find. Children younger than 5 years (especially 6 months to 3 years) tend to place everything they find into their mouths. Drug overdoses in this age group are generally caused when someone accidentally leaves a medication within the child's reach. Toddlers, when they find medications, often share them with other children. Therefore, if you suspect an overdose in one child while other children are around, those other children may have taken the medication too. Adolescents and adults are more likely to overdose on one or more drugs in order to harm themselves. Attempting to harm oneself may represent a suicide attempt. People who purposefully overdose on medications frequently suffer from underlying mental health conditions. These conditions may or may not have been diagnosed before.

Next Page: Drug Overdose Symptoms

Drug Overdose Symptoms

Drugs have effects on the entire body. Generally, in an overdose, the effects of the drug may be a heightened level of the therapeutic effects seen with regular use. In overdose, side effects become more pronounced, and other effects can take place, which would not occur with normal use. Large overdoses of some medications cause only minimal effects, while smaller overdoses of other medications can cause severe effects, possibly death. A single dose of some medications can be lethal to a young child. Some overdoses may worsen a person's chronic disease. For example, an asthma attack or chest pains may be triggered.

Problems with vital signs (temperature, pulse rate, respiratory rate, blood pressure) are possible and can be life threatening. Vital sign values can be increased, decreased, or completely absent. Sleepiness, confusion, and coma are common and can be dangerous if the person breathes vomit into the lungs (aspirated). Skin can be cool and sweaty, or hot and dry. Chest pain is possible and can be caused by heart or lung damage. Shortness of breath may occur. Breathing may get rapid, slow, deep, or shallow. Abdominal pain, nausea, vomiting, and diarrhea are possible. Vomiting blood, or blood in bowel movements, can be life threatening. Specific drugs can damage specific organs, depending on the drug.

Next Page: When to Seek Medical Care

Exams and Tests

A history and physical examination to look for evidence of poisoning will be performed. The doctor will order laboratory tests based on the organ systems that can be harmed by the specific drug overdose.

Family members and associates are an important source of information. They can assist in providing the doctor with names of drugs, amounts taken, and timing of overdose. Specific drug levels in the blood may be measured, depending on the drug taken and the reason for the overdose. Drug screening may also be done.

Drug Overdose Treatment

Treatment will be dictated by the specific drug taken in the overdose. Information provided about amount, time, and underlying medical problems will be very helpful.

The stomach may be washed out by gastric lavage (stomach pumping) to mechanically remove unabsorbed drugs from the stomach. Activated charcoal may be given to help bind drugs and keep them in the stomach and intestines. This reduces the amount absorbed into the blood. The drug, bound to the charcoal, is then expelled in the stool. Often, a cathartic is given with the charcoal so that the person more quickly evacuates stool from his or her bowels. Agitated or violent people need physical restraint and sometimes sedating medications in the emergency department until the effects of the drugs wear off. This can be disturbing for a person to experience and for family members to witness. Medical professionals go to great lengths to use only as much force and as much medication as necessary. It is important to remember that whatever the medical staff does, it is to protect the person they are treating. Sometimes the person has to be intubated (have a tube placed in the airway) so that the doctor can protect the lungs or help the person breathe during the detoxification process. For certain overdoses, other medicine may need to be given either to serve as an antidote to reverse the effects of what was taken or to prevent even more harm from the drug that was initially taken. The doctor will decide if treatment needs to include additional medicines.

Self-Care at Home
Home care should not be done without first consulting a doctor or poison expert.

For some accidental drug overdoses, the local poison control center may recommend home therapy and observation. Because of the potential for problems after some overdoses, syrup of ipecac or other therapies should not be given unless directed by a medical professional.
o

Most people have telephone access to a local poison control center. Locate the closest one to you through the American Association of Poison Control Centers. Anyone who has small children at home should have the "poison line" telephone number readily available near the telephone.

People who take a drug overdose in an attempt to harm themselves generally require psychiatric intervention in addition to poison management. People who overdose for this purpose must be taken to a hospital's Emergency Department, even if their overdose seems trivial. These people are at risk for eventually achieving a successful suicide. The sooner you intervene, the better the success of avoiding suicide.

Narcotic Abuse Overview

Pain is one of the most common reasons people seek medical treatment. Doctors can prescribe several different drugs to relieve pain. The most potent pain-relieving drugs are narcotics. In the United States, narcotics are widely prescribed to treat painful conditions. Narcotics are often prescribed in conjunction with other less potent drugs (such as nonsteroidal antiinflammatory medications) or as a pill that has a combination of a narcotic with either acetaminophen (for example, Tylenol) or aspirin (Arthritis Pain, Aspergum Cherry, Aspergum Orginal, Aspir-Low, Aspirin Lite Coat, Aspirin Low Strength, Bayer Aspirin, Bayer Aspirin Regimen, Bayer Childrens Aspirin, Bufferin, Bufferin Arthritis Strength, Easprin, Ecotrin, Empirin, Fasprin, Genacote, Halfprin, Norwich Aspirin, St. Joseph Aspirin, St. Joseph Aspirin Adult Chewable, Stanback Analgesic, Tri-Buffered Aspirin, Zorprin). Acetaminophen is also commonly found in many different products that are available as over-the-counter (OTC) medications. With the public often using OTC products that contain acetaminophen as well as prescription narcotics that might also have acetaminophen, the U.S. Food and Drug Administration (FDA) has become concerned about dangerous interactions from combining these medications. There is not just the potential for narcotic abuse but the concern that patients are accidentally ingesting too much acetaminophen from combining these products with the potential for severe liver damage or even death. The use of prescription pain relievers without a doctor's prescription only for the experience or the feeling it causes is often called "nonmedical" use. Narcotic use is considered abuse when people use narcotics to seek feelings of well-being apart from the narcotic's pain-relief applications. The U.S. Substance Abuse and Mental Health Services (SAMHSA) report that after marijuana, nonmedical use of painkillers is the second most common form of illicit drug use in the United States. According to SAMHSA, 21% of people age 12 and older (5.2 million individuals) reported using prescription pain relievers nonmedically in 2007. The U.S. Drug Enforcement Agency suggests that the number of people abusing any prescription drugs is even higher at 7 million individuals. SAMHSA's Drug Abuse Warning Network reported that approximately 324,000 emergency department visits in 2006 involved the nonmedical use of pain relievers (this includes both prescription and over-the-counter pain medications). According to the U.S. Department of Health and Human Services, there were an estimated 90,232 emergency department visits related to narcotic analgesic abuse in 2001.

Morphine (Avinza, Kadian, Morphine IR, MS Contin, MSIR, Oramorph SR, Roxanol) and codeine are natural derivatives of the opium poppy. Related medications that are semisynthetic include drugs such as heroin, oxycodone (Percocet, Percodan, OxyContin), and hydrocodone and acetaminophen (Vicodin). Synthetic medications in this class include drugs such as methadone (Diskets, Dolophine, Methadose), meperidine (Demerol), and fentanyl. All medications in this group are called opiates or narcotics.

Some chemicals, called endorphins, occur naturally in the body and produce a morphinelike effect.

The most commonly abused illicit narcotic is heroin, but all prescription narcotics have the potential for abuse. In 2008, the Florida Medical Examiners Commission noted that prescription opioid painkillers (such as Vicodin, Percocet, and OxyContin) caused more deaths than illicit substances such as heroin.

Narcotics have many useful pain-relieving applications in medicine. They are used not only to relieve pain for people with chronic diseases such as cancer but also to relieve acute pain after operations. Doctors may also prescribe narcotics for painful acute conditions, such as corneal abrasions, kidney stones, and broken bones. When people use narcotics exclusively to control pain, it is unlikely that they become addicted or dependent on them. A patient is given a dosage of opioids strong enough to reduce their awareness of pain but not normally potent enough to produce a euphoric state. Adequate pain control is the goal for the medical use of narcotics. Thus, patients or health-care professionals should not allow fear of addiction to interfere with using narcotics for effective pain relief. The difference between opioid abuse, dependence, and addiction There is somewhat of a continuum between opioid abuse, opioid dependence, and addiction. Individuals who use narcotics to the extent that they start to interfere with the person's ability to do routine activities or fulfill regular responsibilities at home, at school, or at work would be considered to be abusing opioids. Other signs that individuals are abusing opioids include maladaptive behaviors that impact adversely on relationships, worsening of interpersonal problems, or frequent involvement with legal problems related to opioid use. Individuals who have opioid dependence often will manifest some of the following symptoms.

Ingestion of larger and larger amounts of opioids or for longer periods of time than intended

Desire or compulsion to take the drug with significant amount of time spent trying to obtain opioids

Withdrawal symptoms if the drug is stopped or the amount taken is reduced

The need for increased amounts of drug to achieve the original effects (tolerance)

Social, recreational, occupational, or pleasurable activities are neglected

Persistent use of narcotics even when evidence that is harmful to their body, mood, thinking, or actions

Addiction is elevated narcotic abuse that becomes a craving, with compulsive need to use opioids and often self-destructive behavior

Narcotic Abuse Causes

Narcotic drugs produce their effect by stimulating opioid receptors in the central nervous system and surrounding tissues. The abuse of narcotics occurs as a result of the euphoria and sedation that narcotics produce within the central nervous system. Abusers of intravenously injected heroin describe the effects as a "rush" or orgasmic feeling followed by elation, relaxation, and then sedation or sleep. Narcotics used for short-term medical conditions rarely require weaning since stopping the medication after a brief period rarely produces adverse effects. If circumstances allow, the dose for people using narcotics over an extended period of time for medical purposes is slowly lowered over a few weeks to prevent withdrawal symptoms. The goal is to wean individuals off narcotics so that they are pain-free or able to use a less potent nonnarcotic analgesic.

Narcotic Abuse Symptoms

Narcotics users can develop tolerance, as well as psychological and physical dependence to opioids when they take them over an extended period of time.

Tolerance refers to a decreased response to a drug, with increasing doses required to achieve comparable effects.

Psychological dependence refers to compulsive drug use in which a person uses the drug for personal satisfaction, often in spite of knowing the health risks.

Physical dependence occurs when a person stops using the narcotic but experiences a withdrawal syndrome (or set of symptoms).

Signs and symptoms of narcotic abuse

analgesia (feeling no pain),

sedation,

euphoria,

respiratory depression (shallow breathing),

small pupils, bloodshot eyes,

nausea, vomiting,

itching skin, flushed skin,

constipation,

slurred speech,

confusion, poor judgment, and

needle marks on the skin .

Signs and symptoms of narcotic withdrawal: The withdrawal syndrome from narcotics generally includes signs and symptoms opposite of the drug's intended medical effects. The severity of the withdrawal syndrome increases as the drug dose increases. The longer the duration of the physical dependence to the narcotic increases, the more severe the withdrawal syndrome. Symptoms of heroin withdrawal generally appear 12-14 hours after the last dose. Symptoms of methadone withdrawal appear 24-36 hours after the last dose. Heroin withdrawal peaks within 36-72 hours and may last seven to 14 days. Methadone withdrawal peaks at three to five days and may last three to four weeks. Although uncomfortable, acute narcotic withdrawal for adults is not considered lifethreatening unless the person has a medical condition that compromises their health (for example, if someone has severe heart disease). Some of the signs and symptoms of narcotic withdrawal are listed below:

Anxiety

Irritability

Craving for the drug

Increased respiratory rate (rapid breathing)

Yawning

Runny nose

Salivation

Gooseflesh

Nasal stuffiness

Muscle aches

Nausea or vomiting

Abdominal cramping

Diarrhea

Sweating

Confusion

Enlarged pupils

Tremors

Lack of appetite

Complications of narcotic abuse: Many complications can result from narcotic abuse, the most common being infectious conditions.

Infections of the skin and deeper layers

Abscesses in skin, lungs, and brain

Infection of the heart valves

Pneumonia

Fluid in the lungs

Liver dysfunction

Intestinal slowdown

Seizures

Coma and other neurological complications

Infectious arthritis

Loss of menstrual cycle

Overdose and death

Premature and growth-retarded infants

Neonatal withdrawal: Up to 70% of babies delivered from pregnant women who use narcotics experience neonatal withdrawal, a potentially fatal condition.

Exams and Tests

The initial diagnosis of narcotic overdose in the emergency department is made based on obtaining a history and considering the signs and symptoms that the patient is experiencing. Almost all unconscious people receive a drug called naloxone (Narcan), which is known as a narcotic antagonist because it blocks and reverses the effects of narcotics. After the initial resuscitation, opioids are easy to detect in a routine urine test. Information from friends and family or indicators such as pill bottles or drug paraphernalia may provide important clues to the emergency doctors about the person's drug use and abuse. Information from friends and family or indicators such as pill bottles or drug paraphernalia may provide important clues to the emergency doctors about the person's drug use and abuse.

Narcotic Abuse Treatment

Overdose: An unconscious person suspected of overdosing on narcotics is given naloxone, a narcotic antagonist. When given intravenously, it is effective in one to two minutes in reversing the coma and respiratory depression caused by a narcotic.

Withdrawal: Treating people who are addicted to narcotics is difficult. The most common long-term treatment of the narcotic withdrawal syndrome is substituting methadone for the illicit drug, followed by a slow process of then weaning the abuser off the methadone. Buprenorphine (Buprenex) is another medicine that can be used in the process of detoxification, with the concept being to replace one opioid (for example, heroin) with another and then taper the second opioid slowly.

The drug clonidine (Catapres) has been shown to relieve some of the symptoms of withdrawal, especially salivation, runny nose, sweating, abdominal cramping, and

muscle aches. Clonidine, when used in combination with naltrexone (ReVia), a long-acting narcotic antagonist, produces a more rapid detoxification.

Buprenorphine is also used in the treatment of withdrawal symptoms

Barbiturates

Barbiturate Abuse Overview

Barbiturates are a group of drugs in the class of drugs known as sedative-hypnotics, which generally describes their sleep-inducing and anxiety-decreasing effects.

History of use and abuse

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Barbiturates were first used in medicine in the early 1900s and became popular in the 1960s and 1970s as treatment for anxiety, insomnia, or seizure disorders. With the popularity of barbiturates in the medical population, barbiturates as drugs of abuse evolved as well. Barbiturates were abused to reduce anxiety, decrease inhibitions, and treat unwanted effects of illicit drugs. Barbiturates can be extremely dangerous because the correct dose is difficult to predict. Even a slight overdose can cause coma or death. Barbiturates are also addictive and can cause a life-threatening withdrawal syndrome. Barbiturate use and abuse has declined dramatically since the 1970s, mainly because a safer group of sedative-hypnotics called benzodiazepines are being prescribed. Benzodiazepine use has largely replaced barbiturates in the medical profession, with the exception of a few specific indications. Doctors are prescribing barbiturates less, and the illegal use of barbiturates has also substantially declined,although barbiturate abuse among teenagers may be on the rise compared with the early 1990s. Addiction to barbiturates, however, is uncommon today.

Types of barbiturates
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There are many different barbiturates. The primary difference among them is how long their effects last. The effects of some of the long-acting drugs may last up to 2 days. Others are very short acting. Their effects last only a few minutes. Barbiturates can be injected into the veins or muscles, but they are usually taken in pill form. The street names of commonly abused barbiturates describe the desired effect of the drug or the color and markings on the actual pill. Barbiturate Names

Generic Name Amobarbital Pentobarbital Phenobarbital Secobarbital Tuinal

Street Name Downers, blue heavens, blue velvet, blue devils Nembies, yellow jackets, abbots, Mexican yellows Purple hearts, goof balls Reds, red birds, red devils, lilly, F-40s, pinks, pink ladies, seggy Rainbows, reds and blues, tooies, double trouble, gorilla pills, F-66s

Barbiturate Abuse Causes

Although the medical use of barbiturates has declined since the 1970s, and street abuse was also in decline, high school surveys suggest abuse has been rising over last 10 years. A common reason to abuse barbiturates is to counteract the symptoms of other drugs.

The increase in the abuse of barbiturates may be due to the popularity of stimulating drugs such as cocaine and methamphetamines. The barbiturates ("downers") counteract the excitement and alertness obtained from the stimulating drugs. Today's drug abusers may be too young to remember the death and dangerous effects barbiturates caused in the 1970s, so they underestimate the risks of using them. Barbiturates are also commonly used in suicide attempts.

Barbiturate Abuse Symptoms

In general, barbiturates can be thought of as so-called brain relaxers. Alcohol is also a brain relaxer. The effects of barbiturates and alcohol are very similar. Pain medicines, sleeping pills, and antihistamines also cause symptoms similar to those of barbiturates. People who abuse barbiturates use them to obtain a "high," which is described as being similar to alcohol intoxication, or to counteract the effects of stimulant drugs.

In small doses, the person who abuses barbiturates feels drowsy, disinhibited, and intoxicated.

In higher doses, the user staggers as if drunk, develops slurred speech, and is confused. At even higher doses, the person is unable to be aroused (coma) and may stop breathing. Death is possible.

The difference between the dose causing drowsiness and one causing death may be small. In the medical profession, this difference is called a narrow therapeuticto-toxic range. This is the reason why barbiturates are dangerous. It is also why barbiturates are not often prescribed today. In addition to having a narrow therapeutic range, barbiturates are also addictive. If taken daily for longer than about 1 month, the brain develops a need for the barbiturate, which causes severe symptoms if the drug is withheld. Symptoms of withdrawal or abstinence include tremors, difficulty sleeping, and agitation. These symptoms can become worse, resulting in life-threatening symptoms, including hallucinations, high temperature, and seizures. Pregnant women taking barbiturates can cause their baby to become addicted, and the newborn may have withdrawal symptoms.

Exams and Tests

A urine test can readily identify barbiturate use. Diagnosis in a hospital emergency department, however, concentrates on diagnosing other potential reasons for the person to be drowsy, such as other drugs taken, head injury, stroke, infection, or shock. These diagnostic efforts take place while the person is being treated. In general, the person will have an IV started and blood will be drawn. An ECG (electrocardiogram) will be performed to evaluate the person's heart. Other diagnostic efforts depend on the specific situation.

Barbiturate Abuse Treatment Self-Care at Home

There is no home treatment for barbiturate abuse. If you believe someone has taken barbiturates inappropriately, take him or her to the hospital for evaluation by a doctor.

Barbiturates have a narrow therapeutic index and can cause coma or death if taken inappropriately. This is especially true in children and in elderly persons.

Because children are smaller and weigh less than adults, even small doses of barbiturates could be life threatening. Elderly people can be more sensitive to barbiturates and develop a coma with small doses.

Medical Treatment
The treatment of barbiturate abuse or overdose is generally supportive. The amount of support required depends on the person's symptoms.

If the person is drowsy but awake and can swallow and breathe without difficulty, the treatment may consist ofjust watching the person closely. If the person is not breathing, a breathing machine is used to ensure the person can breathe well until the drugs have worn off. Most people receive a liquid form of activated charcoal to bind to any drugs in their stomach. This may be done by placing a tube into the stomach (through the nose or mouth) or by having the person drink it. Most people are admitted to the hospital or are observed in the emergency department for a number of hours. Other treatments depend on the specific situation.