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VAQ 8 - Paracetamol

VAQ 8 - Paracetamol. Jon Dowling Andre Vanzyl. Question. A 22 year old male presents with abdominal pain and vomiting. He states that it all started the preceding day with a headache in the morning. He has been taking 2 paracetamol tablets every 2 hours to attempt to control his symptoms

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VAQ 8 - Paracetamol

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  1. VAQ 8 - Paracetamol Jon Dowling Andre Vanzyl

  2. Question • A 22 year old male presents with abdominal pain and vomiting. He states that it all started the preceding day with a headache in the morning. He has been taking 2 paracetamol tablets every 2 hours to attempt to control his symptoms • Temp 36.7 • PR 110 • BP 130/80 • RR 22 • Sats 99% on room air

  3. Distribution of marksOverall pass rate 40% 1 1 2 (%) 2 0 0 (%) 3 3 6 (%) 4 28 52 (%) 5 9 17 (%) 6 8 15 (%) 7 4 8 (%)

  4. Question • A 22 year old male presents with abdominal pain and vomiting. He states that it all started the preceding day with a headache in the morning. He has been taking 2 paracetamol tablets every 2 hours to attempt to control his symptoms • Temp 36.7 • PR 110 • BP 130/80 • RR 22 • Sats 99% on room air

  5. Salient points • Patient was unwell before commencing paracetamol • The amount of paracetamol ingested is not stated, nor is the patients weight • The vital signs are abnormal

  6. Describe and interpret his pathology results • Abnormal: • K 3.3 • Chloride 90 • Urea 14 • Creat120 • ALT 58 • AST 72 • Relevant normals • Albumin 40 • INR 1.0 • Unhelpful • Paracetamol level 120umol/L

  7. Description • Mildly low K and Chloride, probably due to vomiting • Deranged renal function with urea>cr, suggestive of pre renal impairment • Deranged ALT and AST with normal remainder LFTs suggestive hepatitis picture • Normal INR and albumin, suggestive of normal synthetic function • Elevated paracetamol level but time of ingestion not stated and staggered ingestion so nomogram not useful

  8. Interpretation • Likely staggered ingestion paracetamol with early toxicity • Needs treatment with NAC • Pre-renal impairment and deranged electrolytes, in clinical picture (HR 110, RR 22) suggestive of dehydration • Cause of original symptoms not yet determined

  9. A “Pass” mark ie a 5/10 • Description as above (not just a list) • Recognition of early paracetamol toxicity, plus 2 differentials (or mention assessment for primary cause of illness) • State patient needs NAC • Recognise renal impairment

  10. Better questions • Describe what a toxic dose paracetamol in staggered ingestion is • Describe that patient needs iv fluids • Outline a suitable NAC protocol (not just state “as per local protocol”) • Outline a plan for monitoring the LFTs/NAC and when to stop

  11. Poor questions • No mention of NAC or not appreciating this is paracetamol toxicity with LFT changes = fail.  Only a few people mentioned the NAC dose. • No mention of dDX or mention of assessment for primary cause of illness in quite a few answers • Just listing abnormal results without interpreting them.  • Failed to describe all the results. • Failed to appreciate renal impairment (and need for IV fluids) • Some candidates appeared to run out of time - very basic, non consultant level answers = 3.  • Failed to appreciate that abnormal LFT in setting of staggered OD = hepatotoxicity

  12. Learning points • This was the last question, but it is worth the same amount as the first – TIMING IS IMPORTANT • Don’t write a generic answer • Always bring the answer back to the patient • Don’t make stuff up • There is no point writing an equation eg anion gap if you don’t have all the info, its just wasting time

  13. Learning points • Make sure you label exam booklet correctly and don’t write in the wrong book • The college reserves the right to give you a zero if you are at fault • Paracetamol ingestion is COMMON and requires EXPERT knowledge

  14. Toxicology questions last 5 yrs • SAQ • Local anesthetic • Recreational drug in a colleague • Valproate • Charcoal • NAC • ETOH withdrawal • Bradycardia with multiple cardiac drugs • Discharge planning post OD • Organophosphate • Hydrofluoric acid • CO poisoning in an explosion • Paediatric mixed oral hypoglycaemic and Beta blocker

  15. Toxicology questions last 5 yrs • VAQ • Seizure with abnormal ECG, ?Na channel (twice) • Digoxin (chronic) • Bradycardic ECG ?cardiac meds • Paediatricparacetamol • Opiate (iatrogenic poisoning) • Paediatric extended release paracetamol • Collapse with metabolic acidosis • Venlafaxine with abnormal ECG

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