Rosen & Barkin's 5-Minute Emergency Medicine Consult (560 page)

This volume of D
₅
W will need to be reduced in dosing pediatric patients to avoid fluid overload/hyponatremia. Discuss with pharmacy.

• Indications:
  
  • Bradycardia owing to drugs
    
  • Organophosphate insecticides
    
• Warnings:
  
  • Myasthenia gravis, narrow-angle glaucoma, HTN, coronary ischemia, and urinary obstruction
    
• Dose:
  
  • Adult: 1–2 mg IV
    
  • Pediatric: 0.02 mg/kg (min. 0.1 mg) IV
    
  • Large repeated doses needed in organophosphate poisoning
    

• Indications: Acute dystonic reactions
  
• Warnings: Carbamates, myasthenia gravis, narrow-angle glaucoma, HTN, coronary ischemia, and urinary obstruction
  
• Dose:
  
  • Adult: 1–2 mg IV (for acute reaction) or PO (to prevent reaction)
    
  • Pediatric: 0.02 mg/kg IV (for acute reaction) or PO (to prevent reaction)
    

• Indications: Agitation, stimulant drugs, seizures
  
• Warnings: Respiratory/CNS depression
  
• Dose:
  
  • Midazolam:
    
    • Adult: 1 mg IV/IM every 2–3 min PRN
      
    • Pediatric: 0.1 mg/kg IV/IM
      
  • Diazepam:
    
    • Adult: 2–5 mg IV/IM, repeat in 10–15 min
      
    • Pediatrics: 0.1 mg/kg IV/IM
      

• Indications: Cyclic antidepressant poisoning, metabolic acidosis, urinary alkalinization
  
• Warnings: May cause CHF, excessive alkalosis, hypokalemia
  
• Dose:
  
  • Serum alkalinization:
    
    • 1 mEq/kg IVP
      
  • Urine alkalinization:
    
    • 100–150 mEq in 1 L DW at 2–3 mL/kg/h IV, goal urine pH 7—8
      

• Indications: Severe HTN, muscle spasms not alleviated by analgesics and muscle relaxants; consider in extremes of age (<5 or >65 years), pregnant women with threatened abortion
  
• Warnings:
  
  • Equine serum derived: Immediate hypersensitivity, serum sickness 10–14 days
    
  • Premedicate for anaphylaxis if know equine serum hypersensitivity.
    
• Dose: 1–2 vials IM or IV slowly over 15–30 min; dilute 1 vial in 50 mL saline for IV
  

• Indications: Clinical botulism, prior to onset of paralysis
  
• Warnings:
  
  • Binds only free toxins
    
  • Not for infant botulism
    
  • Equine serum derived: Immediate hypersensitivity, serum sickness 10–14 days
    
  • Premedicate for anaphylaxis if know equine serum hypersensitivity.
    
  • Administer slow IV push.
    
• Dose: 1–2 vials IV q4h for 4 or 5 doses; reconstitute 1 vial with 2 mL sterile water. Administer 0.5 mL/kg/h IV. Double rate after 15 min if no ill effects.
  

• Indications:
  
  • Hyperkalemia with cardiac toxicity
    
  • Hydrofluoric acid burn
    
  • Calcium channel blocker overdose
    
  • Citrate, oxalate, phosphate poisoning
    
• Warnings:
  
  • Avoid in digoxin toxicity, hypercalcemia
    
  • Calcium chloride (CaCl) corrosive to skin, SC tissue
    
  • Incompatible with certain IV solutions
    
  • Administer slow IV push.
    
• Dose:
  
  • Adult: 5–10 mL of 10% CaCl, or 10–20 mL of 10% Ca gluconate
    
  • Pediatric: 0.1–0.2 mL/kg of 10% CaCl, or 0.2–0.3 mL/kg of 10% Ca gluconate
    

• Indications: Lead, chromium, nickel, manganese, zinc toxicity
  
• Warnings: Nausea, vomiting, chill, nephrotoxicity, hypercalcemia
  
• Dose: 1 g/m
  ²
  /day IV over 8–12 hr for 5 days, skip 2–4 days, then repeat. Follow lead (Pb) level
  

• Indications: Eastern or Texas coral snake
  
• Warnings:
  
  • Equine serum derived: Immediate hypersensitivity, serum sickness 10–14 days
    
  • Premedicate for anaphylaxis if we know the equine serum hypersensitivity.
    
• Dose: 4–10 vials slow IV push over 15–30 min
  

• Indications: Cyanide poisoning
  
• Warnings: Hypotension, methemoglobinemia
  
• Dose:
  
  • Amyl nitrite: 1–2 amp crushed, inhaled
    
    • Use amyl nitrite only until IV access is established
      
  • Sodium nitrite:
    
    • Adult: 300 mg in 10 mL IV over 5 min
      
    • Pediatric: 0.3 mL/kg of 3% solution IV
      
  • Sodium thiosulfate:
    
    • Adult: 12.5 g IV, may repeat in 1 hr
      
    • Pediatric: 50 mg/kg IV
      

• Indications: Cyanide poisoning
  
• Warnings: Erythema, HTN
  
• Dose:
  
  • Adult: 5 g IV over 15 min; may repeat a 2nd 5 g dose depending on severity of poisoning and clinical response. Max. 10 g. Reconstitiute each 2.5 g vial with 100 mL 0.9% NaCl
    
  • Pediatric: Safety and efficacy have not been established in children. Suggested initial dose: 70 mg/kg IV.
    

• Indications:
  
  • Malignant hyperthermia
    
  • Neuroleptic malignant syndrome
    
  • Serotonin syndrome
    
  • Muscle rigidity
    
• Warnings: Muscle weakness, respiratory depression, hepatitis
  
• Dose: 1–2 mg/kg IV bolus, repeat q10–15 min PRN, max. 10 mg/kg
  

• Indications: Iron toxicity
  
• Warnings:
  
  • Do not treat for >24 hr, risk for delayed adult respiratory distress syndrome (ARDS).
    
  • Hypotension if >15 mg/kg/h, flushing, urticaria
    
• Dose: 10–15 mg/kg/h IV, may increase in severe iron (Fe) poisoning
  

• Indications: Digoxin, digitoxin toxicity
  
• Warnings:
  
  • Falsely elevated digoxin levels after use
    
  • Development of CHF/atrial fibrillation in patients requiring digoxin
    
• Dose:
  
  • 1 vial (40 mg) binds 0.6 mg digoxin.
    
  • Number of vials = digoxin level (ng/mL) × weight (kg)/100
    
  • Dose estimate: Acute overdose 10–20 vials, chronic overdose 4–6 vials
    

• Indications: Arsenic, gold, mercury, lead-induced encephalopathy
  
• Warnings: Renal toxicity, fever, nausea, vomiting, urticaria, cholinergic symptoms
  
• Dose:
  
  • 3 mg/kg deep IM q4h for 2 days, then q12h for 7 days; follow metal levels
    
  • For Pb level >100 μg/dL: 4–5 mg/kg IM q4h until Pb <50 μg/dL, in conjunction with EDTA
    

• Indications: Antihistamine, acute dystonic reaction
  
• Warnings: Sedation, excitation in children, anticholinergic symptoms
  
• Dose:
  
  • Adult: 25–50 mg IV/IM/PO q4–6h
    
  • Pediatric: 0.5–1 mg/kg IV/IM/PO q4–6h
    

• Indications: Pediatric lead poisoning
  
• Warnings:
  
  • Caution in renal impairment—urinary elimination
    
  • Nausea, vomiting diarrhea
    
• Dose: 10 mg/kg PO q8h for 5 days, then q12h for 14 days, then reassess blood lead levels
  

• Indications: Angioedema, anaphylaxis, acute asthma, spinal shock, β-blocker overdose
  
• Warnings: Dysrhythmias, HTN, tremor, anxiety
  
• Dose:
  
  • Hypotension/shock:
    
  • Adult: 1–4 μg/min IV infusion
    
  • Pediatric: Start IV infusion at 0.1 μg/kg/min.
    
  • Anaphylaxis
    
    • Adult: 0.3–0.5 mg IM/SC
      
    • Pediatric: 0.01 mg/kg IM/SC
      

• Indications: Methanol or ethylene glycol toxicity
  
• Warnings:
  
  • Disulfiram reaction, CNS sedation
    
  • Hypoglycemia in pediatric population
    
  • Increase dose during dialysis, for chronic alcoholics.
    
• Dose:
  
  • IV: 10 mL/kg load as 10% solution over 1 hr, then 1 mL/kg/h maintenance
    
  • PO: 1.5 mL/kg as 100-proof solution, then 0.3 mL/kg/h maintenance
    
  • Goal: Ethanol level of 100–150 mg/dL
    

• Indications: Benzodiazepine overdose
  
• Warnings:
  
  • Contraindicated in tricyclic antidepressant (TCA) overdose
    
  • Lowers seizure threshold
    
  • Induces benzodiazepine withdrawal
    
• Dose:
  
  • Adult: 0.2 mg IV slow, repeat q2–3min to 1 mg max.
    
  • Pediatric: 0.01–0.05 mg/kg IV over 30 min–1 hr
    

• Indications: Methanol or ethylene glycol toxicity
  
• Warnings: Nausea, dizziness, headache
  
• Dose: 15 mg/kg load IV, then 10 mg/kg q12h for 4 doses, then 15 mg/kg q12h
  

• Indications:
  
  • β-blocker or calcium channel blocker overdose with bradycardia/hypotension
    
  • Hypoglycemia
    
• Warnings:
  
  • Nausea, vomiting, hyperglycemia
    
  • Hypotension from diluent (phenol containing)
    
• Dose:
  
  • β-blocker or calcium channel blocker overdose:
    
    • Adult: 5–10 mg IV over 1 min
      
    • Pediatric: 0.15 mg/kg IV over 1 min
      
  • Hypoglycemia:
    
    • Adult: 0.5–1 mg IM/IV/SC
      
    • Pediatric: 0.025–0.1 mg/kg IM/IV/SC (max. 1 mg per dose)
      

• Indications:
  
  • Calcium channel blocker overdose with severe hypotension/symptomatic bradycardia refractory to other therapies
    
  • Hyperkalemia
    
• Warnings:
  
  • Experimental therapy: Consult a poison control center/medical toxicologist.
    
  • Follow serum glucose q15min for 1 hr after the 1st bolus or after any increase in dose, then q1h
    
• Dose:
  
  • Bolus:
    
    • 0.5–1 IU/kg regular insulin, followed by 25 g glucose (1 amp D
      ₅₀
      )
      
  • Maintenance:
    
    • Insulin 0.5 IU regular insulin per kg/hr, titrate to 1 IU regular insulin per kg/hr
      
    • Glucose D
      ₁₀
      start at 100 mL/h (10 g/h) and titrate to keep glucose ≥100 mg/dL
      

• Indications:
  
  • Cardiac arrest due to local anesthetic toxicity, most commonly bupivacaine, however may be useful for other lipid-soluble drugs
    
• Warnings:
  
  • Experimental therapy: Consult a poison control center/medical toxicologist.
    
• Dose:
  
  • Intralipid 20% bolus; 1.5 mL/Kg over 1 min followed by infusion 0.25 mL/kg/min.
    
  • Repeat bolus in 3–5 min if circulation not restored.
    

• Indications: Methemoglobinemia with dyspnea or >25%
  
• Warnings: G6-PD deficiency
  
• Dose: 1–2 mg/kg slow IV as 1% solution, repeat in 1 hr
  

• Indications:
  
  • Opiate poisoning, empiric treatment of coma
    
• Warnings:
  
  • Acute opiate withdrawal, severe agitation
    
• Dose:
  
  • Adult: 0.4–2 mg IV or IM, repeat to 10 mg
    
  • Pediatric: 0.1 mg/kg IV or IM
    

• Indications: Sulfonylurea overdose with hypoglycemia
  
• Warnings: Use with caution in diabetic patients.
  
• Dose:
  
  • Adult: 50 μg SC q6h
    
  • Pediatric: 4–5 μg/kg/d SC div. q6h
    

• Indications: Carbon monoxide (CO) poisoning
  
• Warnings:
  
  • Tympanic membrane (TM) perforation, seizures owing to oxygen toxicity
    
  • Difficulty monitoring patient
    
• Dose: 100% oxygen at 2–3 atm