Rosen & Barkin's 5-Minute Emergency Medicine Consult (559 page)

TREATMENT

• Search for clues at scene:
  
  • Pills/pill bottles
    
  • Drug paraphernalia
    
  • Witnesses
    
  • Transport all drugs and pill bottles for identification.
    
• Restrain uncooperative patients for patient and health care giver protection.
  
• Consider comorbid conditions:
  
  • Trauma
    
  • Medical illness
    
  • Environmental exposure
    
• Pre-hospital administration of activated charcoal may optimize decontamination if prolonged transport time.
  

• ABCs:
  
  • Endotracheal intubation as needed for airway protection, oxygenation, ventilation, and orogastric lavage
    
  • Supplemental oxygen for hypoxia
    
  • Pulse oximetry
    
  • Cardiac monitor
    
  • IV access
    
• Hypotension:
  
  • Administer 0.9% normal saline IV fluid bolus.
    
  • Trendelenburg
    
  • Vasopressors for persistent hypotension
    
• Bradycardia:
  
  • Atropine
    
  • Cardiac pacing
    
• If altered mental status, administer coma cocktail: Thiamine, D50W (or Accu-Chek), naloxone
  

• Decontamination:
  
  • See Poisoning, Gastric Decontamination.
    
  • Prevents systemic absorption of ingested toxin
    
• Orogastric lavage:
  
  • Consider in potentially lethal ingestions without known antidote within 1 hr of ingestion.
    
  • Protected airway
    essential
    prior to lavage
    
• Activated charcoal:
  
  • Most effective within a few hours of most toxic ingestions
    
  • Contraindicated if caustic ingestion, unprotected airway, or bowel obstruction
    
  • Drugs not effectively bound to charcoal: Metals (borates, bromide, iron, lithium), alcohols, potassium
    
• Whole-bowel irrigation:
  
  • Polyethylene glycol (Colyte, GoLytely) evacuates bowel without causing electrolyte disturbances.
    
  • Consider in toxins not well adsorbed by charcoal (e.g., iron and lithium), body packers/stuffers, sustained-release ingestions.
    
  • Contraindicated if bowel obstruction, perforation, or hypotension
    
• Enhanced elimination:
  
  • Enhances removal of systemically absorbed toxin
    
• Multiple-dose activated charcoal:
  
  • Theophylline
    
  • Carbamazepine
    
  • Phenobarbital
    
• Urinary alkalinization:
  
  • Salicylates
    
  • Phenobarbital
    
• Hemodialysis/hemoperfusion:
  
  • Lithium
    
  • Salicylates
    
  • Theophylline
    
  • Toxic alcohols
    
  • Valproate
    
• Seizures
  
  • Treat initially with diazepam or lorazepam.
    
  • For persistent seizures, consider phenobarbital.
    
  • Phenytoin
    not
    indicated in toxicologic seizures:
    
    • Indicated only if seizures secondary to idiopathic epilepsy, post-traumatic, or status epilepticus
      
• Antidotes:
  
  • Acetaminophen:
    N
    -acetylcysteine
    
  • Anticholinergic: Physostigmine
    
  • Benzodiazepines: Flumazenil
    
  • β-blockers: Glucagon
    
  • Calcium-channel blockers: Calcium chloride/gluconate, insulin
    
  • Carbon monoxide: Oxygen, hyperbaric oxygen
    
  • Coumadin: Vitamin K
    ₁
    
  • Cyanide: Cyanide antidote kit, hydroxocobalamin
    
  • Digoxin: Digibind
    
  • Ethylene glycol: Ethanol, 4-methylpyrazole
    
  • Iron: Deferoxamine
    
  • Isoniazid: Pyridoxine (vitamin B
    ₆
    )
    
  • Methanol: Ethanol, 4-methylpyrazole
    
  • Methemoglobinemia: Methylene blue
    
  • Opiates: Naloxone
    
  • Organophosphates: Atropine, pralidoxime
    
  • Tricyclic antidepressants: NaHCO
    ₃
    

• Activated charcoal slurry: 1–2 g/kg PO
  
• Dextrose: D50W 1 amp: 50 mL or 25 g (peds: D25W 2–4 mL/kg) IV
  
• Diazepam: 5–10 mg (peds: 0.2–0.5 mg/kg) IV every 10–15 min
  
• Lorazepam: 2–6 mg (peds: 0.05–0.1 mg/kg) IV every 10–15 min
  
• Naloxone (Narcan): 0.4–2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  
• Thiamine (vitamin B
  ₁
  ): 100 mg (peds: 50 mg) IV or IM
  

FOLLOW-UP

• Altered mental status
  
• Cardiopulmonary instability
  
• Suicidal
  
• Lab abnormalities
  
• Potential for decompensation from delayed acting substance
  

• Psychiatrically clear
  
• Detoxified
  
• Hemodynamically stable
  

• Patients with unintentional (accidental) poisoning require poison prevention counseling.
  
• Patients with intentional (e.g., suicide) poisoning require psychiatric evaluation.
  
• Consider substance abuse referral for patients.
  

In general, treating the mother is also the best treatment strategy for the fetus.

• Consider substance abuse referral for patients with recreational drug abuse.
  
• Patients with unintentional (accidental) poisoning require poison prevention counseling.
  
• Patients with intentional (e.g., suicide) poisoning require psychiatric evaluation.
  

• Do not forget to consider nontoxicologic etiologies for altered mental status.
  
• Do not rely on the urine drug screen to make a diagnosis: It only provides screening tests for a limited number of drugs.
  
• Call a toxicologist or a poison center for help: 800-222-1222.
  

• Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose.
  Emerg Med Clin North Am
  . 2007;25(2):249–281.
  
• Levine M, Brooks DE, Truitt CA, et al. Toxicology in the ICU: Part 1: General overview and approach to treatment.
  Chest
  . 2011;140(3):795–806.
  
• Mycyk MB. Poisoning and drug overdose. In: Longo D, Fauci A, Kasper D, et al., eds.
  Harrison’s Principles of Internal Medicine.
  18th ed. New York, NY: McGraw Hill; 2012:e50.1–e50.16.
  
• Wills B, Erickson T. Drug- and toxin-associated seizures.
  Med Clin North Am
  . 2005;89:1297–1321.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Poisoning, Antidotes
  
• Poisoning, Gastric Decontamination
  
• Poisoning, Toxidromes
  

CODES

• 971.1 Poisoning by parasympatholytics (anticholinergics and antimuscarinics) and spasmolytics
  
• 977.9 Poisoning by unspecified drug or medicinal substance
  
• 977.9 Poisoning by unspecified drug or medicinal substance
  

TREATMENT

• Indications: Acetaminophen overdose
  
• Warnings:
  
  • Unpleasant odor, nausea, vomiting
    
  • Most effective if given in 1st 8 hr postingestion
    
• Dose:
  
  • PO: 140 mg/kg, then 70 mg/kg q4h for 17 doses
    
  • IV (consult poison center): 150 mg/kg in 200 mL D
    ₅
    W over 60 min, then 50 mg/kg in 500 mL D
    ₅
    W over 4 hr, then 100 mg/kg in 1,000 mL D
    ₅
    W over 16 hr