Courtesy of Steven Chan, one of the excellent Pediatric Emergency Medicine fellows at CCHMC, are some highlights from a toxicology talk given to the residents on the ED rotation.
- Activated charcoal is part of decontamination, but it doesn’t work well for drugs like Iron, and it should never be given to the obtunded patient.
- Remember to remove the clothes of the patient who spilled something on themselves (like gasoline).
- Don’t forget oxygen (hypoxia) and glucose!
- If patients are agitated after an ingestion benzodiazepines (like lorazepam) are your best choice
Beta Blockers hypotension, bradycardia and obtundation. Hypoglycemia! May worsen asthma symptoms, but less relevant clinically in the single pill ingestion.Treat with supportive care including fluids. Consider atropine for refractory bradycardia and vasopressors if hypotension is refractory to fluids (epinephrine). Glucagon can block activity – only if very symptomatic (shock) and you have discussed with toxicologist.
Calcium Channel Blockers Hypotension, bradycardia, obtundation. verapamil and diltiazem have more specific activity on heart, nifedipine has more activity on vascular smooth muscle (the latter leads to reflex tachycardia due to the hypotension brought on by decreased peripheral vascular resistance). Hyperglycemia! Treat with supportive measures, fluids, atropine if refractory bradycardia. The #1 treatment is calcium. The en vogue treatment is insulin and glucose. The insulin may have inotropic benefit in patients with cariogenic shock.
Clonidine Bradycardia, hypotension, miosis. Similar to beta blockers and CCB. Can also be confused with opiates. Alpha-2 agonist puts the brakes on central sympathetic output. CNS depression leads to secondary respiratory depression. Treat with fluids and other supportive measures. Naloxone may help in refractory cases – especially if you’re considering protecting the airway. Not definitive however – and YMMV.
Sulfonylureas A single pill can lead to hypoglycemia. Increases insulin release from the pancreas. Toxidrome is the symptoms of hypoglycemia. Give a bolus of dextrose – but continuous infusions may stimulate more insulin release. Instead treat with octreotide which inhibits secretion of GI hormones including insulin.
TCAs fever, tachycardia, hypertension. Effect so many receptors it’s not even funny… Cause QRS prolongation – look for wide complex QRS (>100 msec) on the EKG. Treat with 1-2 mEq/kg Sodium Bicarb. Anticholinergic toxindrome. Alkalinize urine to enhance elimination. Hypertonic saline may overload the sodium blockade as well – by bicarb is preferred.
Opiates Depressed respiratory drive, miosis, obtundation. Peak activity may vary depending on sustained release. Treat with naloxone. Onset <2 min, duration 20-90min – but in massive ingestions/overdoses it can wear off quickly. 0.1 mg/kg max 2mg every 3-5minutes. If no effect you need to consider other ingestions/co-ingestions.
Lomitil Agitation, tachycardia, hypertension – then in 2-3 hours become somnolent and lethargic. Has atropine anticholinergic effect first, second phase is opiod like. The half life is up to 14 hours. Should admit on telemetry. Slows GI transit. Consider naloxone.
Camphor Abrupt onset of seizures – distinctive menthol odor (Vick’s VapoRub). Delirium and hallucinations are also seen. Also can lead to GI symptoms.
Salicylate Agitation, vomiting, tachypnea. mixed metabolic anion gap acidosis and respiratory alkalosis. Oil of wintergreen has the highest concentration. Tinnitus is seen early at serum level >30 mg/dL. Life threatening at >100 mg/dL. Can lead to coma and death. Treat with urinary alkalinization with sodium bicarb. urine pH >7.5 but serum pH <7.6. Dialysis in the most severe cases.