Alcohol (ethanol) toxicity, 980.0
Antiarrhythmic drug overdose, 972.0
Anticoagulant overdose, 964.2
Antidepressant toxicity, 969.0
Antipsychotic toxicity, 969.3
Barbiturate overdose, 967.0
Benzodiazepine overdose, 969.4
Beta blocker overdose, 972.0
Calcium channel blocker overdose, 972.0
Carbon monoxide poisoning, 986.
Digoxin toxicity, 972.1
Lithium toxicity, 985.8
Organophosphate (insecticide) poisoning, 989.3
Salicylate toxicity, 976.4
Stimulant toxicity, 970.9
Theophylline toxicity, 974.1
ACETAMINOPHEN TOXICITY
I. Examples: Anacin-3, Liquiprin, Panadol, Tylenol
II. Subjective findings
A. Usually asymptomatic early
B. Nausea and vomiting at 24 to 48 hours
C. Right upper quadrant pain
D. Hypotension, hypothermia
III. Physical examination findings
A. Hepatotoxicity, including jaundice, prolonged bleeding time, and hepatic encephalopathy (altered mental status, stupor, delirium, coma, asterixis, flapping tremor)
IV. Laboratory/diagnostic findings
A. Draw for blood levels at 4 hours after ingestion; toxicity and liver injury seen with doses greater than 7.5 g (adult) or 140 mg/kg (children); increased risk for hepatic injury at lower doses in the chronic alcoholic, those with preexisting liver disease, or those taking hepatotoxic medications
C. Prolonged prothrombin time (PT), elevated bilirubin, metabolic acidosis
D. Monitor lactic acid, alkaline phosphatase, phosphate, and blood pH every 24 hours until treatment is complete
V. Management
A. Supportive measures and induced emesis or gastric lavage should be first-line management
1. To induce emesis, use 30 ml of syrup of ipecac PO followed by 500 ml of water. Note: Ipecac is always contraindicated for ingestion when the patient has neurologic deficits because of the risk for aspiration.
2. Gastric lavage should be done with a large-bore orogastric tube (36-40 French).
3. Lavage the stomach with boluses of 300 ml of body temperature normal saline until the return is clear
B. Activated charcoal given in a dose of 25-100 g diluted in water if patient presents within 4 hours of ingestion
1. Use 10 g activated charcoal per 1 g acetaminophen ingested (or 1 g per kg body weight)
2. Charcoal should be removed by gastric lavage prior to acetylcysteine administration, as this may prevent its absorbance
C. N-Acetylcysteine (Mucomyst), 140 mg/kg loading dose given PO within 8 to 10 hours of overdose; maintenance doses of 70 mg/kg every 4 hours for a total of 17 doses are indicated for as many doses as the acetaminophen stays in the toxic range (above 20 mcg/ml); check blood levels every 4 hours
D. Acetylcysteine may also be given IV as Acetadote; in this form, it is diluted in 5% dextrose and is given as 3 doses; the first dose is 150 mg/kg in 200 ml 5% dextrose infused over 15 minutes to 1 hour; the second dose is 50 mg/kg in 500 ml 5% dextrose infused over 4 hours; the third dose is 100 mg/kg in 100 ml 5% dextrose infused over 16 hours; monitor the patient for allergic reactions (reduce these by slowing the infusion rate)
ALCOHOL (ETHANOL) TOXICITY
I. Subjective findings
A. Emotional lability
B. Impaired coordination
C. Nausea, vomiting, facial flushing, diaphoresis
II. Physical examination findings
A. Respiratory depression, electrolyte and acid-base imbalances
B. Stupor, mydriasis, nystagmus, diplopia, seizures, coma
C. Tachycardia, hypotension, hypoglycemia
IV. Management
A. ABCs (Airway, Breathing, Circulation)
B. Hemodialysis may be used to reduce ethanol levels in severe toxicity
C. IV glucose, 200-500 mg/kg/dose as 25% dextrose; alcoholics require pretreatment with thiamine (40 mg PO, or 5 to 100 mg IM or IV) and fluids, multivitamins (MVIs), and electrolytes as needed
ANTIARRHYTHMIC DRUG OVERDOSE
I. Examples: Class I antiarrhythmics: flecainide, lidocaine, procainamide, quinidine
II. Subjective/physical examination findings
A. Nausea, vomiting, diarrhea, dizziness, blurred vision
B. Bradycardia, hypotension, cardiovascular collapse
C. Tinnitus, hearing loss, confusion, delirium, psychosis, seizures, coma
III. Laboratory/diagnostic findings
A. Serum levels may confirm overdose and the need for monitoring.
B. Bradycardia with atrioventricular (AV) block
C. Prolonged QRS complex, PR interval, and QT interval
D. Ventricular arrhythmias, torsade de pointes
E. Hypotension, respiratory depression, acute lung injury
F. Thrombocytopenia, leukopenia, hemolytic anemia, and hepatotoxicity
G. Drug-induced lupus with procainamide overdose
IV. Management
A. 12-lead ECG, electrolytes, and continuous ECG monitoring
B. Charcoal administration (30 g charcoal in 240 ml water; 25-100 g total in adults); whole bowel irrigation if sustained-release preparations are involved
C. Gastric lavage with 300 ml boluses of body temperature saline until return runs clear with use of a 36 to 40 orogastric French tube
D. For bradycardia: atropine/overdrive pacing/isoproterenol
BARBITURATE OVERDOSE
I. Examples: amobarbital, meprobamate, pentobarbital, phenobarbital, secobarbital
II. Subjective findings
A. Confusion, slurred speech, ataxia, impaired coordination
B. CNS depression, stupor
III. Physical examination findings
A. CNS depression, drowsiness, confusion, coma, hypothermia
B. Respiratory depression, respiratory acidosis
D. Miosis
IV. Management
A. Maintenance of airway and ventilation is essential
B. Activated charcoal, 1 g/kg PO via gastric tube every 2 to 6 hours
C. Hemodynamic support, including administration of dopamine or norepinephrine, may be necessary to correct hypotension
BENZODIAZEPINE OVERDOSE
I. Examples: clonazepam, clorazepate, diazepam, flurazepam, prazepam
II. Subjective findings
A. Drowsiness, ataxia, confusion
B. Slurred speech
C. Unsteady gait
III. Physical examination findings
A. Respiratory depression
B. Hypoactive reflexes
IV. Management
A. Monitor blood pressure and support respiration
B. Flumazenil (Romazicon)
1. Initial dose 0.2 mg IV over 30 seconds
2. Then, 0.3 mg over 30 seconds
3. Then, 0.5 mg over 30 seconds at 1-minute intervals for a total of 3 mg
C. Gastric lavage with 0.9% sodium chloride or activated charcoal, 1 g/kg PO via 36 to 40 French tube every 2 to 6 hours, may also be used
BETA BLOCKER OVERDOSE
I. Examples: propranolol, timolol, atenolol, labetalol, metoprolol, nadolol, pindolol
II. Subjective findings
A. Nausea
B. Vomiting
C. Diarrhea
III. Physical examination findings
A. Bradycardia, hypotension
B. CNS depression, including delirium, coma, or seizures depending on the agent
C. Bronchospasm, respiratory depression
D. Myocardial depression, cardiogenic shock, heart failure
IV. Laboratory/diagnostic findings
A. Blood levels not very helpful or available
B. Hyperkalemia, hypoglycemia
V. Management
A. Assess ABCs
B. Activated charcoal, 1 g/kg PO repeated every 2 to 6 hours; may consider whole bowel irrigation if sustained-release preparations were used
C. Glucagon, 3-5 mg IV or in saline
D. Calcium (10% calcium chloride at a dose of 0.2 ml/kg body weight IV over 5 minutes) to reverse negative inotropic effects
E. Monitor patient for hyperkalemia and seizure activity; treat these symptoms should they occur with insulin and glucose therapy
F. Vasopressors (e.g., norepinephrine) for hypotension
G. May consider temporary transvenous pacing, intra-aortic balloon pump, or cardiopulmonary bypass
CALCIUM CHANNEL BLOCKER OVERDOSE
I. Examples: amlodipine, bepredil, diltiazem, felodipine, nicardipine, nifedipine, nisoldipine, verapamil
II. Subjective findings
A. Mental status changes (confusion)
B. Light-headedness, headache
III. Physical examination findings
A. Bradycardia, conduction disturbances
B. Hypotension
C. Cyanosis
D. Seizures, coma, death
IV. Laboratory/diagnostic findings
A. AV block, prolonged QRS complex, asystole
B. Metabolic acidosis, hyperglycemia
V. Management
A. IV calcium chloride or gluconate (10%) at 0.2 ml/kg up to 10 ml over 5 minutes
B. Atropine, 0.5-1 mg IV; repeat as needed every 5 minutes
C. Aggressive GI decontamination with polyethylene glycol solution (1-2 liters/hour via orogastric or nasogastric tube until clear) when sustained-release medications are suspected
D. Activated charcoal 1 g/kg, then multiple doses of 0.5 g/kg
E. Continuous cardiac monitoring, 12-lead ECG every 1-2 hours for the first 6 hours
CARBON MONOXIDE POISONING
I. Subjective findings
A. Shortness of breath, headache, confusion, clumsiness, mental status changes
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