Life Support |
A) Support respiratory and cardiovascular function.
|
Monitoring |
A) Appropriate laboratory evaluation is determined in part by the clinical condition of the patient. Initial history is often inaccurate and most deliberate ingestions in adults and adolescents involve more than one drug.
1) Serum electrolytes to evaluate for metabolic acidosis and a four hour acetaminophen level should be obtained if there is any possibility of mixed overdose or uncertain history.
2) Tests of hepatic and renal function, arterial blood gases, pulse oximetry, and chest radiographs should be performed if clinically indicated.
3) A 12-lead electrocardiogram should be performed to evaluate for arrhythmia, tachycardia, or interval prolongation.
4) Pregnancy testing should be considered in women of childbearing potential as pregnancy may precipitate suicidal gestures and overdose may complicate the pregnancy.
B) Toxicology screens and drug levels should be performed as indicated by history and clinical signs and symptoms.
1) A variety of tests are available. General toxicology screens rarely provide information that alters the management of the asymptomatic, stable patient (an exception to this is an acetaminophen level).
2) Blood, urine and gastric contents are potential analytical samples and should be saved.
3) Consult the clinical toxicology laboratory early so that the correct specimens are obtained for the suspected poison.
|
Oral Exposure |
6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
A) SUMMARY 1) Goals are to remove, detoxify, or prevent absorption of ingested substances.
2) UNIVERSAL ANTIDOTE - (non-activated or activated charcoal, tannic acid, and magnesium oxide or hydroxide) should NOT be used.
6.5.2) PREVENTION OF ABSORPTION
A) ACTIVATED CHARCOAL 1) There are very few drugs or chemicals which are not adsorbed by activated charcoal (Hayden & Comstock, 1975; Temple & Mancini, 1980). Among them are alkalis and acids, ferrous sulfate, lithium (Linakis et al, 1989), and N-methyl carbamate (Greensher et al, 1979). 2) INDICATIONS - Administered orally or by nasal gastric tube to all patients who have overdosed on medication adsorbed by it. Charcoal is usually given after completion of gastric emptying. 3) CONTRAINDICATIONS - Charcoal should not be administered in cases of simple caustic ingestion because it will obscure endoscopic evaluation or in hydrocarbon ingestion because of the risk of vomiting and aspiration, unless the major toxicologic risk is from another coingestant. 4) CHARCOAL DOSE a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005). 1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
b) ADVERSE EFFECTS/CONTRAINDICATIONS 1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
B) GASTRIC LAVAGE 1) INDICATIONS a) Potentially life threatening amount of a poison recently ingested.
b) In ingestions for which activated charcoal is not effective (Pers Comm, 1991).
2) Advantages of lavage include its ability to potentially remove pills and pill fragments. Lavage must be performed within a short period of time following ingestion or its effectiveness decreases dramatically; some authors speculate that it may force gastric content beyond the pylorus (Saetta et al, 1991). a) Potential complications include vomiting, pulmonary aspiration, epistaxis, and laryngospasm (Pers Comm, 1991).
3) INDICATIONS: Consider gastric lavage with a large-bore orogastric tube (ADULT: 36 to 40 French or 30 English gauge tube {external diameter 12 to 13.3 mm}; CHILD: 24 to 28 French {diameter 7.8 to 9.3 mm}) after a potentially life threatening ingestion if it can be performed soon after ingestion (generally within 60 minutes). a) Consider lavage more than 60 minutes after ingestion of sustained-release formulations and substances known to form bezoars or concretions.
4) PRECAUTIONS: a) SEIZURE CONTROL: Is mandatory prior to gastric lavage.
b) AIRWAY PROTECTION: Place patients in the head down left lateral decubitus position, with suction available. Patients with depressed mental status should be intubated with a cuffed endotracheal tube prior to lavage.
5) LAVAGE FLUID: a) Use small aliquots of liquid. Lavage with 200 to 300 milliliters warm tap water (preferably 38 degrees Celsius) or saline per wash (in older children or adults) and 10 milliliters/kilogram body weight of normal saline in young children(Vale et al, 2004) and repeat until lavage return is clear.
b) The volume of lavage return should approximate amount of fluid given to avoid fluid-electrolyte imbalance.
c) CAUTION: Water should be avoided in young children because of the risk of electrolyte imbalance and water intoxication. Warm fluids avoid the risk of hypothermia in very young children and the elderly.
6) COMPLICATIONS: a) Complications of gastric lavage have included: aspiration pneumonia, hypoxia, hypercapnia, mechanical injury to the throat, esophagus, or stomach, fluid and electrolyte imbalance (Vale, 1997). Combative patients may be at greater risk for complications (Caravati et al, 2001).
b) Gastric lavage can cause significant morbidity; it should NOT be performed routinely in all poisoned patients (Vale, 1997).
7) CONTRAINDICATIONS: a) Loss of airway protective reflexes or decreased level of consciousness if patient is not intubated, following ingestion of corrosive substances, hydrocarbons (high aspiration potential), patients at risk of hemorrhage or gastrointestinal perforation, or trivial or non-toxic ingestion.
8) CONTRAINDICATIONS - Gastric lavage should not be performed in cases of caustic ingestion because of the risk of GI perforation, or in hydrocarbon ingestion because of the risk of aspiration, unless the major toxicologic risk is from another coingestant. C) CATHARTICS 1) NOT indicated in the management of overdose.
2) There has been documented toxicity from overdoses of magnesium sulfate (Outerbridge et al, 1973), sodium phosphate (Fassler et al, 1985; Garcia-Webb et al, 1984; Smilkstein et al, 1988), magnesium citrate (Jones et al, 1986), and sorbitol (Farley, 1986; Caldwell et al, 1987; Geffner & Opas, 1980).
D) MULTIPLE DOSE ACTIVATED CHARCOAL 1) Serial doses of charcoal may be useful for life threatening ingestions of several drugs including phenobarbital, carbamazepine, and dapsone, theophylline and quinine (Levy, 1982) Vale et al, 1999). 2) MULTIPLE DOSE ACTIVATED CHARCOAL a) ADULT DOSE: Optimal dose not established. After an initial dose of 50 to 100 grams of activated charcoal, subsequent doses may be administered every 1, 2 or 4 hours at a dose equivalent to 12.5 grams/hour (Vale et al, 1999), do not exceed: 0.5 g/kg charcoal every 2 hours (Ghannoum & Gosselin, 2013; Mauro et al, 1994). There is some evidence that smaller more frequent doses are more effective at enhancing drug elimination than larger less frequent doses (Park et al, 1983; Ilkhanipour et al, 1992). PEDIATRIC DOSE: Optimal dose not established. After an initial dose of 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) (Chyka & Seger, 1997), subsequent doses may be administered every 1, 2 or 4 hours (Vale et al, 1999) in a dose equivalent to 6.25 grams/hour in children 1 to 12 years old.
b) Activated charcoal should be continued until the patient's clinical and laboratory parameters, including drug concentrations if available, are improving (Vale et al, 1999). The patient should be frequently assessed for the ability to protect the airway and evidence of decreased peristalsis or intestinal obstruction.
c) Use of cathartics has not been shown to increase drug elimination and may increase the likelihood of vomiting. Routine coadministration of a cathartic is NOT recommended (Vale et al, 1999).
d) AGENTS AMENABLE TO MDAC THERAPY: The following properties of a drug that are likely to allow MDAC therapy to be effective include: small volume of distribution, low protein binding, prolonged half-life, low intrinsic clearance, and a nonionized state at physiologic pH (Chyka, 1995; Ghannoum & Gosselin, 2013).
e) Vomiting is a common adverse effect; antiemetics may be necessary.
f) CONTRAINDICATIONS: Absolute contraindications include an unprotected airway, intestinal obstruction, a gastrointestinal tract that is not intact and agents that may increase the risk of aspiration (eg, hydrocarbons). Relative contraindications include decreased peristalsis (eg, decreased bowel sounds, abdominal distention, ileus, severe constipation) (Vale et al, 1999; Mauro et al, 1994).
g) COMPLICATIONS: Include constipation, intestinal bleeding, bowel obstruction, appendicitis, charcoal bezoars, and aspiration which may be complicated by acute respiratory failure, adult respiratory distress syndrome or bronchiolitis obliterans (Ghannoum & Gosselin, 2013; Ray et al, 1988; Atkinson et al, 1992; Gomez et al, 1994; Mizutani et al, 1991; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Mina et al, 2002; Harsch, 1986; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002).
E) WHOLE BOWEL IRRIGATION a) WHOLE BOWEL IRRIGATION/INDICATIONS: Whole bowel irrigation with a polyethylene glycol balanced electrolyte solution appears to be a safe means of gastrointestinal decontamination. It is particularly useful when sustained release or enteric coated formulations, substances not adsorbed by activated charcoal, or substances known to form concretions or bezoars are involved in the overdose. 1) Volunteer studies have shown significant decreases in the bioavailability of ingested drugs after whole bowel irrigation (Tenenbein et al, 1987; Kirshenbaum et al, 1989; Smith et al, 1991). There are no controlled clinical trials evaluating the efficacy of whole bowel irrigation in overdose.
b) CONTRAINDICATIONS: This procedure should not be used in patients who are currently or are at risk for rapidly becoming obtunded, comatose, or seizing until the airway is secured by endotracheal intubation. Whole bowel irrigation should not be used in patients with bowel obstruction, bowel perforation, megacolon, ileus, uncontrolled vomiting, significant gastrointestinal bleeding, hemodynamic instability or inability to protect the airway (Tenenbein et al, 1987). c) ADMINISTRATION: Polyethylene glycol balanced electrolyte solution (e.g. Colyte(R), Golytely(R)) is taken orally or by nasogastric tube. The patient should be seated and/or the head of the bed elevated to at least a 45 degree angle (Tenenbein et al, 1987). Optimum dose not established. ADULT: 2 liters initially followed by 1.5 to 2 liters per hour. CHILDREN 6 to 12 years: 1000 milliliters/hour. CHILDREN 9 months to 6 years: 500 milliliters/hour. Continue until rectal effluent is clear and there is no radiographic evidence of toxin in the gastrointestinal tract. d) ADVERSE EFFECTS: Include nausea, vomiting, abdominal cramping, and bloating. Fluid and electrolyte status should be monitored, although severe fluid and electrolyte abnormalities have not been reported, minor electrolyte abnormalities may develop. Prolonged periods of irrigation may produce a mild metabolic acidosis. Patients with compromised airway protection are at risk for aspiration. INTRAVENOUS-ENVENOMATION EXPOSURES 1) FASCIOTOMY - There is little that can be done to eliminate exposure to toxins administered intravenously or by envenomation. Procedures such as fasciectomy and fasciotomy are ONLY recommended when documented pressure myolysis is function-threatening.
2) EXTRAVASATION - The primary complications of extravasation are cell damage caused by the chemical leaking into the surrounding tissues, vasoconstriction, and vascular collapse.
6.5.3) TREATMENT
A) SUPPORT 1) Establish respiration and create an artificial airway if necessary. Check adequacy of tidal volume.
2) Treat hypotension with fluids - try to avoid vasopressors if possible.
B) COMA 1) Aggressively treat and evaluate coma regardless of suspected cause. Intubate and ventilate as needed. Comatose patients should receive oxygen, naloxone (Narcan(R)), thiamine (adults) and either D50 or rapid determination of glucose level. Check core temperature to evaluate for hypo- or hyperthermia. Consider evaluation for CNS lesion or infection with CT and lumbar puncture.
2) DOSE OF NALOXONE: The single dose method is an intravenous bolus form with the initial adult and pediatric dose of 0.4 to 2 milligrams intravenously (5 ampules) repeated as necessary.
3) CAUTION: The use of naloxone may induce vomiting or WITHDRAWAL SYNDROMES (Nicholson, 1983).
|
Inhalation Exposure |
6.7.1) DECONTAMINATION
A) Move patient from the toxic environment to fresh air. Monitor for respiratory distress. If cough or difficulty in breathing develops, evaluate for hypoxia, respiratory tract irritation, bronchitis, or pneumonitis.
B) OBSERVATION: Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
C) INITIAL TREATMENT: Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta-2 adrenergic agonists, if bronchospasm develops. Consider systemic corticosteroids in patients with significant bronchospasm (National Heart,Lung,and Blood Institute, 2007). Exposed skin and eyes should be flushed with copious amounts of water.
6.7.2) TREATMENT
A) IRRITATION SYMPTOM 1) Respiratory tract irritation, if severe, can progress to noncardiogenic pulmonary edema which may be delayed in onset up to 24 to 72 hours after exposure in some cases. 2) There are no controlled studies indicating that early administration of corticosteroids can prevent the development of noncardiogenic pulmonary edema in patients with inhalation exposure to respiratory irritant substances, and long-term use may cause adverse effects (Boysen & Modell, 1989). a) However, based on anecdotal experience, some clinicians do recommend early administration of corticosteroids (such as methylprednisolone 1 gram intravenously as a single dose) in an attempt to prevent the later development of pulmonary edema. 1) Anecdotal experience with dimethyl sulfate inhalation showed possible benefit of methylprednisolone in the TREATMENT of noncardiogenic pulmonary edema (Ip et al, 1989).
3) Anecdotal experience also indicated that systemic corticosteroids may have possible efficacy in the TREATMENT of drug-induced noncardiogenic pulmonary edema (Zitnik & Cooper, 1990; Stentoft, 1990; Chudnofsky & Otten, 1989) or noncardiogenic pulmonary edema developing after cardiopulmonary bypass (Maggart & Stewart, 1987). 4) It is not clear from the published literature that administration of systemic corticosteroids early following inhalation exposure to respiratory irritant substances can PREVENT the development of noncardiogenic pulmonary edema. The decision to administer or withhold corticosteroids in this setting must currently be made on clinical grounds. B) ACUTE LUNG INJURY 1) ONSET: Onset of acute lung injury after toxic exposure may be delayed up to 24 to 72 hours after exposure in some cases. 2) NON-PHARMACOLOGIC TREATMENT: The treatment of acute lung injury is primarily supportive (Cataletto, 2012). Maintain adequate ventilation and oxygenation with frequent monitoring of arterial blood gases and/or pulse oximetry. If a high FIO2 is required to maintain adequate oxygenation, mechanical ventilation and positive-end-expiratory pressure (PEEP) may be required; ventilation with small tidal volumes (6 mL/kg) is preferred if ARDS develops (Haas, 2011; Stolbach & Hoffman, 2011). a) To minimize barotrauma and other complications, use the lowest amount of PEEP possible while maintaining adequate oxygenation. Use of smaller tidal volumes (6 mL/kg) and lower plateau pressures (30 cm water or less) has been associated with decreased mortality and more rapid weaning from mechanical ventilation in patients with ARDS (Brower et al, 2000). More treatment information may be obtained from ARDS Clinical Network website, NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary, http://www.ardsnet.org/node/77791 (NHLBI ARDS Network, 2008)
3) FLUIDS: Crystalloid solutions must be administered judiciously. Pulmonary artery monitoring may help. In general the pulmonary artery wedge pressure should be kept relatively low while still maintaining adequate cardiac output, blood pressure and urine output (Stolbach & Hoffman, 2011). 4) ANTIBIOTICS: Indicated only when there is evidence of infection (Artigas et al, 1998). 5) EXPERIMENTAL THERAPY: Partial liquid ventilation has shown promise in preliminary studies (Kollef & Schuster, 1995). 6) CALFACTANT: In a multicenter, randomized, blinded trial, endotracheal instillation of 2 doses of 80 mL/m(2) calfactant (35 mg/mL of phospholipid suspension in saline) in infants, children, and adolescents with acute lung injury resulted in acute improvement in oxygenation and lower mortality; however, no significant decrease in the course of respiratory failure measured by duration of ventilator therapy, intensive care unit, or hospital stay was noted. Adverse effects (transient hypoxia and hypotension) were more frequent in calfactant patients, but these effects were mild and did not require withdrawal from the study (Wilson et al, 2005). 7) However, in a multicenter, randomized, controlled, and masked trial, endotracheal instillation of up to 3 doses of calfactant (30 mg) in adults only with acute lung injury/ARDS due to direct lung injury was not associated with improved oxygenation and longer term benefits compared to the placebo group. It was also associated with significant increases in hypoxia and hypotension (Willson et al, 2015). C) BRONCHOSPASM 1) If bronchospasm and wheezing occur, consider treatment with inhaled sympathomimetic agents.
D) OBSERVATION REGIMES 1) Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
E) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate. |
Eye Exposure |
6.8.1) DECONTAMINATION
A) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).
6.8.2) TREATMENT
A) INJURY OF GLOBE OF EYE 1) Irrigate eyelids, etc, thoroughly with isotonic, sterile saline (0.9 percent NaCl) for 10 to 15 minutes. This irrigation reduces local injury and sometimes limits systemic absorption. Test the pH of the eye after irrigation and if possible test the pH of the substance.
2) A VISUAL ACUITY TEST - should be performed on all patients with eye exposures.
3) TO EXAMINE THE EYE - a local anesthetic agent may be required. Examine the eye and periorbital strictures in good light and preferably with a slit lamp.
4) If local ocular signs and symptoms are severe, instill a 2% buffered sterile solution of fluorescein. Greenish areas of stain mark the regions where the conjunctiva, cornea, or sclera is damaged and eroded. If these areas are extensive, a dry sterile patch should be applied to the eye and the patient should be referred to an ophthalmologist (Gosselin et al, 1976).
5) Patients with significant decrease in visual acuity, acid or alkali exposure, or injury to ocular structures require prompt referral to an ophthalmologist.
B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate. |
Dermal Exposure |
6.9.1) DECONTAMINATION
A) DERMAL DECONTAMINATION 1) Many agents, especially pesticides, can be rapidly absorbed through the skin and may continue to cause symptoms with prolonged absorption.
2) Others, such as gasoline, acids, nitriles, and caustics which may cause skin irritation or burns as well, need to be removed from the skin.
3) The safest decontaminant is water with soap. Use copious amounts gently and try not to abrade the skin. If there is any question of exposure, skin decontamination should be thorough.
B) SUMMARY 1) PREHOSPITAL DECONTAMINATION - Should occur outside the medical facility if possible since the wash may contaminate medical personnel and cause them to become poisoned.
2) The person performing the procedure should be protected by wearing rubber gloves, disposable shoe covers, and a rubber apron.
3) Two separate water/detergent washes should be performed. Remove the patient's clothes and place them in specially marked plastic bags.
4) Studies performed with two separate water/detergent washes showed that even 6 hours postexposure the first water/detergent wash removed 50 to 70% of an organophosphate, and a second wash done immediately after the first left a 6 to 9% residue.
5) Any soap that is available can be used for decontamination. Wash all parts of the body including the hair and under the nails. The vomitus of a person who has ingested an organophosphate or carbamate insecticide should also be removed by decontamination if it is on the person's clothes or skin (Kulig et al, 1983).
6.9.2) TREATMENT
A) CONTRAINDICATED TREATMENT 1) NEUTRALIZING AGENTS - The use of NEUTRALIZING AGENTS for acids and alkalis is NOT WARRANTED. The use of emollients such as vaseline or creams will make decontamination more difficult.
B) BURN 1) APPLICATION a) These recommendations apply to patients with MINOR chemical burns (FIRST DEGREE; SECOND DEGREE: less than 15% body surface area in adults; less than 10% body surface area in children; THIRD DEGREE: less than 2% body surface area). Consultation with a clinician experienced in burn therapy or a burn unit should be obtained if larger area or more severe burns are present. Neutralizing agents should NOT be used.
2) DEBRIDEMENT a) After initial flushing with large volumes of water to remove any residual chemical material, clean wounds with a mild disinfectant soap and water.
b) DEVITALIZED SKIN: Loose, nonviable tissue should be removed by gentle cleansing with surgical soap or formal skin debridement (Moylan, 1980; Haynes, 1981). Intravenous analgesia may be required (Roberts, 1988).
c) BLISTERS: Removal and debridement of closed blisters is controversial. Current consensus is that intact blisters prevent pain and dehydration, promote healing, and allow motion; therefore, blisters should be left intact until they rupture spontaneously or healing is well underway, unless they are extremely large or inhibit motion (Roberts, 1988; Carvajal & Stewart, 1987).
3) TREATMENT a) TOPICAL ANTIBIOTICS: Prophylactic topical antibiotic therapy with silver sulfadiazine is recommended for all burns except superficial partial thickness (first-degree) burns (Roberts, 1988). For first-degree burns bacitracin may be used, but effectiveness is not documented (Roberts, 1988). b) SYSTEMIC ANTIBIOTICS: Systemic antibiotics are generally not indicated unless infection is present or the burn involves the hands, feet, or perineum. c) WOUND DRESSING: 1) Depending on the site and area, the burn may be treated open (face, ears, or perineum) or covered with sterile nonstick porous gauze. The gauze dressing should be fluffy and thick enough to absorb all drainage.
2) Alternatively, a petrolatum fine-mesh gauze dressing may be used alone on partial-thickness burns.
d) DRESSING CHANGES: 1) Daily dressing changes are indicated if a burn cream is used; changes every 3 to 4 days are adequate with a dry dressing.
2) If dressing changes are to be done at home, the patient or caregiver should be instructed in proper techniques and given sufficient dressings and other necessary supplies.
e) Analgesics such as acetaminophen with codeine may be used for pain relief if needed. 4) TETANUS PROPHYLAXIS a) The patient's tetanus immunization status should be determined. Tetanus toxoid 0.5 milliliter intramuscularly or other indicated tetanus prophylaxis should be administered if required.
C) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate. |
Enhanced Elimination |
A) SUMMARY
1) Appropriate use of techniques to enhance elimination of toxins depends on specific knowledge of chemical properties (pKa, molecular size), active forms, kinetics (volume of distribution, metabolism and route of elimination), and protein binding. All of these techniques have inherent risks and should not be utilized unless specifically indicated.
B) FORCED DIURESIS
1) May be useful in serious poisonings if the drug is excreted in the urine in active form. The technique should not be used unless it is specifically indicated, as it may increase the problem of pulmonary or cerebral edema, common complications in the poisoned patient. a) Hypertonic or pharmacologic diuretics should be given along with adequate fluids. Usual urine flow is 0.5 to 2 milliliters/kilogram/hour and with forced diuresis should be 3 to 6 milliliters/kilogram/hour.
b) Forced diuresis may enhance the excretion of lithium, bromides, and other drugs excreted primarily by the kidneys.
C) ALKALINE DIURESIS
1) EFFICACY: a) ALKALINE DIURESIS is effective in enhancing the elimination of drugs in which (1) significant amounts of the drug are excreted in the urine, and (2) the drug's Pka is such that urinary alkalinization will trap ionized drug in the tubular lumen and prevent reabsorption.
b) URINARY ALKALINIZATION may enhance the excretion of acidic agents: barbiturates, isoniazid, and salicylates.
2) SODIUM BICARBONATE/INITIAL DOSE a) Administer 1 to 2 milliequivalents/kilogram of sodium bicarbonate as an intravenous bolus. Add 132 milliequivalents (3 ampules) sodium bicarbonate and 20 to 40 milliequivalents potassium chloride (as needed) to one liter of dextrose 5 percent in water and infuse at approximately 1.5 times the maintenance fluid rate. In patients with underlying dehydration additional administration of 0.9% saline may be needed to maintain adequate urine output (1 to 2 milliliters/kilogram/hour). Manipulate bicarbonate infusion to maintain a urine pH of at least 7.5.
3) SODIUM BICARBONATE/REPEAT DOSES a) Additional sodium bicarbonate (1 to 2 milliequivalents per kilogram) and potassium chloride (20 to 40 milliequivalents per liter) may be needed to achieve an alkaline urine.
4) CAUTION a) Obtain hourly intake/output and urine pH. Assure adequate hydration and renal function prior to alkalinization. Do not administer potassium to an oliguric or anuric patient. Monitor fluid and electrolyte balance carefully. Monitor blood pH, especially in intubated patients, to avoid severe alkalemia.
5) Osmotic load is also important and either type of diuretic should be given at intervals. Proximal reabsorption may occur if inadequate osmotic load is not maintained in the tubule. 6) CAUTION: Assure adequate hydration and renal function prior to alkalinization. Never give potassium to an oliguric patient. Follow serum calcium, phosphorus and magnesium during alkalinization. D) ACID FORCED DIURESIS
1) ACID FORCED DIURESIS is NO longer recommended for ANY agent including amphetamines, strychnine, and phencyclidine.
E) DIALYSIS
1) May be considered in those patients not responding to standard therapeutic measures to treat a dialyzable drug. It also may be considered a part of supportive care whether the drug is or is not dialyzable to treat the following: Stage 3 or 4 coma or hyperactivity caused by a dialyzable drug which cannot be treated by conservative means, marked hyperosmolality which is not due to easily corrected fluid problems, severe acid base disturbance not responding to therapy, or severe electrolyte disturbance not responding to therapy. 2) DEFINITE INDICATIONS: a) Dialysis should be initiated, regardless of clinical condition, in the following situations: following heavy metal chelation in patients with renal failure, following significant ethylene glycol or methanol ingestion.
3) PROBABLE INDICATIONS: Dialysis is indicated in patients with severe intoxications with the following agents. The need for dialysis is based more on the patient's clinical condition than on specific drug levels. See specific drug managements for more detailed information. 1) lithium
2) phenobarbital
3) salicylate
4) theophylline
4) POSSIBLE INDICATIONS: 1) alcohols
2) amphetamines
3) anilines
4) antibiotics
5) boric acid
6) barbiturates
7) bromides
8) calcium
9) chlorates
10) chloral hydrate
11) ethanol
12) iodides
13) isopropanol
14) isoniazid
15) meprobamate
16) paraldehyde
17) fluorides
18) potassium
19) quinidine
20) quinine
21) strychnine
22) thiocyanates
a) Dialysis MAY be initiated following exposure to the following agents, if clinical condition deems the procedure necessary (patient deteriorating despite intense supportive care):
5) RARE INDICATIONS: There is NO indication for dialysis, other than as a supportive measure in the presence of renal failure, following exposure to 1) acetaminophen
2) antidepressants
3) antihistamines
4) belladonna compounds
5) benzodiazepines
6) digitalis and related agents
7) glutethimide
8) hallucinogens
9) heroin and other opioids
10) methaqualone
11) phenothiazines
12) synthetic anticholinergics
F) PERITONEAL DIALYSIS/EXCHANGE TRANSFUSION
1) May be more useful in small children than hemodialysis. The main point of these procedures may not be for removal of poison but restoration of fluid or acid-base balance. The infant who has been poisoned and whose serum sodium is rising because of excessive bicarbonate may be helped considerably by an exchange even if little poison is removed.
G) HEMOPERFUSION
1) CHARCOAL HEMOPERFUSION may be more effective than dialysis in removing drugs with larger molecular weights, poor water solubility or significant protein binding. Complications include thrombocytopenia, air embolism, reduced glucose, calcium and urate levels, and hemorrhage secondary to the loss of clotting factor and the need for heparinization. Hemoperfusion may be more difficult to initiate and less effective from a practical standpoint than hemodialysis because it is less frequently performed in most institutions. It may be more effective than hemodialysis in clearing the following drugs: 1) chloramphenicol
2) diphenylhydantoin
3) ethchlorvynol
4) glutethimide
5) phenobarbital
6) pentobarbital
7) theophylline
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