gastroesophageal reflux

Diagnosis: Hyperacidity or burning pain related to sternum and increased after meals.
Treatment:
1- As gastritis.
2- Prokinetics : control stomach motility.
To regulate gastric motility by trimebutine.
- Gast-reg tablets, ampoule, supp. and susp.
for tablets 1X3 (every 8 hours) 1/2 before meals.
- G-regular tablets and susp.   

Gastroenteritis

Diagnosis:
Nausea and vomiting - colic and tenderness (mild) around umbilicus - may be fever, diarrhea, distension, dysentry or constipation.
NB: In gastroenteritis nausea and vomiting precede pain but in surgical conditions pain precedes nausea and vomiting.
Treatment:
1- Symptomatic treatment. 2- Specific treatment. 3- Instructions.
1- Symptomatic treatment:
For colic: Buscopan tablets 1X3 (one tablet every 8 hours) before meals , Spasmo-cibalgin tablets or Buscopan compositum tablets.
For diarrhea: Antinal capsules 1X3 (one tablet every 8 hours)  1/2 hour before meals or streptoquine tablets.
For costipation: Abilaxine suppositories (adult) 1X1 at bedtime or glycerine adult suppositories 1X1 at bedtime.
For distension: Disflatyl tablets 1X3 before meals or flatidyl tablets 1X3 before meals.
2- Specific treatment: (according to cause).
A- Amoebic gastroenteritis: Yellowish diarrhea - mild or no fever - may be dysentry - stool analysis.
Treatment: Metronidazole dose 50 mg/kg/day for 10 days : Flagyl, Amrizole, Entophar or Flagicure: one tablet 3 times per day after meals (every 8 hours).
B- Giardiasis gastroenteritis: persistent early watery but turns to soft diarrhea - offensive odour.
Treatment: Metronidazole dose 25 mg/kg/day for 7 days.
C- Bacterial gastroenteritis: High fever above 38.5°C - (E. coli : severe watery diarrhea) - (Shigella - Salmonella - Campylobacter : bloody diarrhea) - stool analysis : pus and RBCs.
Treatment: Antibiotics as ciprofar, ciprofloxacin or rancif.
D- Viral gastroenteritis: 
Most common in winter - fever below 38.5°C - mild - good general condition - no pus in stool analysis.
3- Instructions: 
Bed rest - light food.
Plenty of fluids - advise rehydration if patient is dehydrated : ringer lactate or dextrose 5%.   

Minor Tranquilizer Poisoning

Minor tranquilizers include:
Diazepam: Neuril - Valpam - Valinil - Valium - Farcozepam.
Bromazepam: Calmepam - Lexotanil - Bropam.
Alprazolam: Zolam - Xanax - Prazolam - Alprax - Restolam.
Lorazepam: Ativan.
Treatment:
1- Gastric lavage.
2- Na Sulphate as cathartic.
3- Specific antidote of benzodiazepines: Anexate IV infusion.
4- Symptomatic treatment.

Major Tranquilizer Poisoning

Major tranquilizers include:
Chlorpromazine: Neurazine - Promacid - Largactil.
Promazine: Sparine vial.
Trifluoperazine: Stelazine - Stellasil.
Flupenthixol: Fluanxol.
Thioridazine: Melleril - Thiozin.
Haloperidol: Safinace - Serenace - Haldol Decanoas.
Fluphenazine: Motival - Modicate.
Pimozide: Orap Forte (4 mg).
Sulpiride: Dogmatil.
Lithium Carbonate: Prianil C.R. tablets.
Treatment:
- Gastric lavage with activated charcoal.
- Antihistaminic: R/Diphenhydramine 10 - 25 mg slow IV. R/Sultan capsule.
- Symptomatic treatment. 

Anticoagulants Poisoning

As Heparin & Warfarin.
Treatment:
1- Gastric lavage with activated charcoal.
2- Konakion ampoule 10 mg (vitamin K) IM and repeated till prothrombin time reaches normal level.
3- Blood transfusion may be needed.

 

Cocaine Bugs

Clinical picture:
Sensation of insects creeping under the skin - found in addicts.
Addicts also suffer anorexia, loss of weight, perforated nasal septum and moral deterioration.
Treatment:
1- Acticarb tablets (3X4): 3 tablets taken per oral 4 times a day (every 6 hours).
2- Gastric lavage: of little value due to extreme action duration.
3- Symptomatic:
Diazepam for convulsions as R/ farcozepam or R/ valpam.
Control hypertension.
 

Cocaine Toxicity

Clinical picture:
Sense of great power - over concentration.
Dilated reactive pupil.
Convulsions - tremors - tachycardia - increased blood pressure.
Euphoria.
Treatment:
1- No value of gastric lavage.
2- Beta blockers to control tachycardia (Propranolol).
R/ Inderal ampoule (1mg).
3- Diazepam for convulsions.
R/ valpam. or R/ farcozepam. (amp.)
- Phenytoin may be added.
R/ Phenytoin. or R/ Epanutin. or R/ Phenytin. (amp.)

Morphine Or Other Opioids as Heroin or Codeine Poisoning

Clinical picture: 
Pin point pupil.
Gradual loss of consiousness.
Subnormal temperature.
Stertorous breathing.
Cyanotic cold calm skin.
Treatment:
1- Antidote (Naloxone) as R/ Naloxone or Narcan.
Repeate the dose to awake the patient.
2- Gastric lavage with activated charcoal.
3- Clear air way.
4- Symptomatic treatment.
NB: Never give 100% oxygen, why?
As hypoxia is the only way to stimulate respiratory center.

Cannabis

Clinical picture:
- Red eye.
- Reactive dilated pupil.
- Increased appetite.
- Visual hallucinations.
- Slow harsh voice.
- Sense of forgetting of expression before finishing.
Treatment:
1- Gastric lavage with activated charcoal.
2- Open air current.
3- Symptomatic treatment.

Strychnine Poisoning

Usually not suicidal but commonly accidentaly ingestion of rat poisons or overdose of aphrodisiacs.
Clinical picture: (no loss of consciousness).
- lag of 15 minutes inbetween tetanus like attacks  
- restlessness  
- irritability  
- trismus (contracture of facial muscles as smile) and opisthotonus (arched back) - muscles twitches - convulsions (symmetrical, spontaneous or due to external stimuli and non coordinated) - respiratory arrest - death.
Treatment:
1- Isolation of the patient alone in dark quiet room + anticonvulsive therapy.
2- respiratory care is very important.
3- acid diuresis as vit. C.
4- NB: gastric lavage is done with K permanganate 1/5000 solution only after complete control of convulsions.
  

CO2 Poisoning

Causes: Inhalation of smoke and fumes produced by complete combustion.
Clinical picture: according to amount of CO2 inhaled (headache - drowsiness - depression - coma - death).
Treatment:
1- Fresh air.
2- Oxygen therapy.
3- Solucortef vial IV to decrease laryngeal oedema.

CO1 Poisoning

Causes: Incomplete oxidation.  e.g. car smoke in a closed garage.  
(varying according to degree).
Clinical picture:
May be: Dyspnea - headache - drowsy - incoordination - drunken gate - slurred speech - coma - peaceful death.
Treatment:
1- Fresh air.
2- Oxygen 100% (the only antidote).
3- Blood Transfusion in severe cases.
4- Symptomatic for convulsions, hypotension, headache........
NB: The patient can not escape from the area of toxicity due to malaise, confusion, incoordination, drunken gate,  vomiting and muscle aches and fatigue  

Paracetamol Toxicity

NB:
Paracetamol toxicity may lead to :
1- Renal failure (analgesic nephropathy).
2- Liver necrosis and damage.
3- Haemolytic anemia & methemoglobinemia.
Treatment:
1- Gastric lavage. 2- Specific antidote. 3- Supportive care for hepatic injury.

1- Gastric lavage with activated charcoal.
2- Specific antidote (Acetylcysteine):
Acetylcistein pack = Mucomyst.
Dose: 140 mg/kg oral, then 70 mg/kg/4 hours for 17 doses or until serum paracetamol level is zero.
3- Supportive care for hepatic injury.
NB: Hepatic transplantation may be required in massive liver damage.

Salicylate Poisoning

Clinical picture:

* Poisoning by Aspirin is common as Aspirin is abundant in many homes.

* The patient should swallow at least more than 40 Aspirin tablets to reach intoxication level.

* CNS stimulation: Fever - sweeting - burning pain in stomach - bloody vomiting - delirium - hypercapnia.

* Followed by CNS depression: Drowsiness - coma - respiratory failure and cardiovascular failure.

Treatment:

1- Gastric lavage. 2- Purgatives. 3- Fluids and electrolytes. 4- Cardio-respiratory care. 5- Alkalinization of

urine.  6- Forced alkaline diuretics.

1- Gastric lavage (repeated):

Using activated charcoal or milk.

Do not use Sodium bicarbonate as it increases Salicylate absorption.

2- Purgatives: Na sulphate 5 - 10 gm oral.

3- Fluids and electrolytes:

* (Glucose 10% + Saline 0.9%  → 2 : 1)   up to 15 mg/kg/hour.

* In shocked patient: blood or plasma transfusion.

4- Cardiac and respiratory care: 

* Oxygen inhalation + 5% CO2.

* May be artificial respiration.

5- Alkalinization of urine.

6- Forced alkaline diuretics:

* Used only to reduce duration of coma when salicylate level is more than 50 mg% or to decrease

complications.

* Contraindicated in shock, heart failure, renal failure or history of respiratory failure.

* (500 ml 0.9% saline + 1000 ml glucose 5% + 20 ml NaHCO3 + 25 mEq K to each liter of IV solution +

KCl  3 gm) :

This Cocktail is given over a complete hour.

Give another similar Cocktail over the second hour.

And another similar one over the next hour.

* But in children give 30 ml/kg/hour.