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SYMPTOMATIC CHEMICAL INGESTION

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) This management is intended for use in the absence of a specific treatment protocol for a product or chemical. It should be used when general guidelines may be needed for patient care. It may also be helpful when an experimental agent has been ingested and there are no toxicity data available.

Specific Substances

    A) GENERAL TERMS
    1) ORAL CHEMICAL EXPOSURE
    2) CHEMICAL INGESTION
    3) ORAL CHEMICAL INGESTION
    4) INGESTION EXPOSURE

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) GENERAL INFORMATION: This monograph is used for chemicals about which there is very little or no information regarding human exposure effects.
    B) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Many chemicals can cause irritant effects including oral mucosal irritation, nausea, vomiting, diarrhea, skin and eye irritation, coughing or bronchospasm.
    2) SEVERE TOXICITY: Some chemicals can cause severe caustic effects or burns; manifestations include persistent vomiting, stridor, drooling, pain with or inability to swallow, and abdominal pain. Upper airway edema, stridor and severe bronchospasm can also develop. Eye or skin exposure can cause severe irritation and burns. Some chemicals can cause narcosis ranging from somnolence to coma. Other chemicals can disrupt metabolic processes inducing hypoglycemia, uncoupling oxidative phosphorylation, inducing metabolic acidosis, causing methemoglobinemia, causing electrolyte abnormalities, etc.

Laboratory Monitoring

    A) Monitor vital signs and mental status.
    B) 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 compound.
    1) Monitor serum electrolytes to evaluate for metabolic acidosis if there is any possibility of deliberate, large or mixed ingestion or uncertain history, or if the patient has significant symptoms.
    2) Monitoring of renal function, hepatic enzymes, arterial blood gases, pulse oximetry, and chest radiographs should be performed if clinically indicated.
    3) Institute continuous cardiac monitoring and obtain an ECG after significant exposure.
    4) Pregnancy testing should be considered in women of childbearing potential.
    5) Obtain serum acetaminophen and salicylate concentrations after deliberate ingestions.
    6) Test the pH of the product to assess for its ability to cause caustic injury.
    C) Obtain a chest radiograph in patients with persistent cough, wheezing or respiratory distress.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) SUPPORT
    1) This management is intended for use in the absence of a specific treatment protocol for a product or chemical when general management guidelines may be needed for patient care. It may also be helpful when an experimental agent has been ingested and no toxicity data are available. Most patients will do well with supportive care. Monitor vital signs and mental status. Treat hypotension with intravenous fluids; add vasopressors if hypotension persists. Arrange for early (ideally within 12 hours) endoscopy for patients with concern for caustic GI injury. Treat bronchospasm with inhaled beta agonists and corticosteroids. Endotracheal intubation and mechanical ventilation may be needed in patients with significant CNS depression or respiratory distress.
    B) HISTORY
    1) Up to 50% of all initial histories are incorrect; history should be obtained from several individuals, if possible. Important information to be obtained from products includes the type of packaging, the amount in the package, and the amount remaining after ingestion. Contact the product manufacturer or your local poison center to obtain more specific information about the chemical in question.
    C) EXAMINATION
    1) Perform serial examinations to determine whether the patient is improving or deteriorating.
    D) DECONTAMINATION
    1) PREHOSPITAL: Prehospital GI decontamination is not recommended as the potential for seizures, coma, aspiration and caustic effects is not known for these chemicals. Remove contaminated clothing; wash exposed skin and irrigate exposed eyes.
    2) HOSPITAL: GI decontamination is not recommended as the potential for seizures, coma, aspiration and caustic effects is not known for these chemicals. Remove contaminated clothing; wash exposed skin and irrigate exposed eyes.
    E) ACTIVATED CHARCOAL
    1) Activated charcoal can be considered after a recent, substantial ingestion but should be avoided if the chemical involved may be caustic or a hydrocarbon. Activated charcoal is contraindicated if the chemical ingested is an acid or alkali, because of the potential for injury of the gastrointestinal mucosa if vomiting occurs and the subsequent obscuring of endoscopy findings. It is relatively contraindicated if the chemical ingested is a hydrocarbon, because of the potential for aspiration pneumonitis if vomiting occurs.
    F) HYPOTENSION
    1) Administer intravenous fluids; add vasopressors if hypotension persists.
    G) VENTRICULAR DYSRHYTHMIAS
    1) Institute continuous cardiac monitoring and obtain serial ECGs. Monitor for and correct hypoxia and electrolyte abnormalities. Treat per ACLS guidelines.
    H) SEIZURES
    1) Treat with benzodiazepines; add propofol or barbiturates if seizures persist.
    I) COMA
    1) Aggressively treat and evaluate coma regardless of suspected cause. Intubate and ventilate as needed. Comatose patients should receive oxygen, naloxone, thiamine (adults), and either D50 or rapid determination of blood glucose. Check core temperature to evaluate for hypo- or hyperthermia. Consider evaluation for CNS lesion or infection with CT scan and lumbar puncture.
    J) PITFALLS
    1) Very little is known about the risks of human exposure to the chemicals coded to this document. Every effort should be made to obtain information from the manufacturer (your local poison center can often assist with this). If possible, test the pH of the chemical to evaluate for the potential of caustic injury.
    K) PATIENT DISPOSITION
    1) HOME CRITERIA: Patients who are asymptomatic or have minimal irritant symptoms after inadvertent lick or taste ingestions can be observed at home.
    2) OBSERVATION CRITERIA: Symptomatic patients, those with deliberate ingestions or more than taste exposures should be referred to a healthcare facility for 6 to 8 hours of observation.
    3) ADMISSION CRITERIA: Patients with persistent symptoms or laboratory abnormalities should be admitted.
    4) CONSULT CRITERIA: Consult a medical toxicologist or poison center for any patient with symptoms or a large exposure. Contact the product manufacturer for more information about the specific chemical in question. Consult a gastroenterologist for early endoscopy in patients with symptoms suggesting caustic injury (pain with or difficulty swallowing, drooling, stridor, persistent vomiting).
    0.4.3) INHALATION EXPOSURE
    A) Refer to "SYMPTOMATIC CHEMICAL INHALATION" management for further information.
    0.4.4) EYE EXPOSURE
    A) Refer to "SYMPTOMATIC CHEMICAL DERMAL EXPOSURE" management for further information.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) Refer to "SYMPTOMATIC CHEMICAL DERMAL EXPOSURE" management for further information.

Range Of Toxicity

    A) TOXICITY: In many cases, the amount of toxin ingested will be unknown, and for substances coded to this management, the toxic dose of the agent itself is unknown. Monitor the patient carefully for clinical evidence of toxicity. In these cases, the amount ingested has less relevance than the patient's clinical condition.

Clinical Effects

Summary Of Exposure

    A) GENERAL INFORMATION: This monograph is used for chemicals about which there is very little or no information regarding human exposure effects.
    B) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Many chemicals can cause irritant effects including oral mucosal irritation, nausea, vomiting, diarrhea, skin and eye irritation, coughing or bronchospasm.
    2) SEVERE TOXICITY: Some chemicals can cause severe caustic effects or burns; manifestations include persistent vomiting, stridor, drooling, pain with or inability to swallow, and abdominal pain. Upper airway edema, stridor and severe bronchospasm can also develop. Eye or skin exposure can cause severe irritation and burns. Some chemicals can cause narcosis ranging from somnolence to coma. Other chemicals can disrupt metabolic processes inducing hypoglycemia, uncoupling oxidative phosphorylation, inducing metabolic acidosis, causing methemoglobinemia, causing electrolyte abnormalities, etc.

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor vital signs and mental status.
    B) 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 compound.
    1) Monitor serum electrolytes to evaluate for metabolic acidosis if there is any possibility of deliberate, large or mixed ingestion or uncertain history, or if the patient has significant symptoms.
    2) Monitoring of renal function, hepatic enzymes, arterial blood gases, pulse oximetry, and chest radiographs should be performed if clinically indicated.
    3) Institute continuous cardiac monitoring and obtain an ECG after significant exposure.
    4) Pregnancy testing should be considered in women of childbearing potential.
    5) Obtain serum acetaminophen and salicylate concentrations after deliberate ingestions.
    6) Test the pH of the product to assess for its ability to cause caustic injury.
    C) Obtain a chest radiograph in patients with persistent cough, wheezing or respiratory distress.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Discuss sample containers and amounts of blood with the analyst, but in general, 10 mL of heparinized blood will suffice.
    2) Appropriate laboratory evaluation is determined in part by the clinical condition of the patient. Initial history is often inaccurate, and many deliberate ingestions in adults and adolescents involve more than one substance.
    a) Serum electrolytes to evaluate for metabolic acidosis should be obtained if there is any possibility of large, deliberate or mixed ingestion or uncertain history (Chabali, 1997).
    b) Tests of hepatic and renal function should be performed if clinically indicated.
    c) Pregnancy testing should be considered in women of childbearing potential, as pregnancy may precipitate suicidal gestures and chemical ingestion may complicate the pregnancy.
    B) ACID/BASE
    1) Arterial blood gases and pulse oximetry should be determined if clinically indicated.
    4.1.3) URINE
    A) URINARY LEVELS
    1) 50 to 100 mL of urine should be collected and sent to the laboratory. Hourly or timed urine specimens may be useful in certain ingestions such as heavy metals - discuss with laboratory. Specific levels, half-lives, etc, are found in specific managements.
    4.1.4) OTHER
    A) OTHER
    1) ECG
    a) A 12-lead ECG should be performed to evaluate for dysrhythmia, tachycardia, or interval prolongation.

Radiographic Studies

    A) CHEST RADIOGRAPH
    1) If respiratory tract irritation is present, monitor chest x-ray.

Methods

    A) MULTIPLE ANALYTICAL METHODS
    1) Toxicology screens should be performed as indicated by history and clinical signs and symptoms. 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). Blood, urine, and gastric contents are potential analytical samples and should be saved. Consult the clinical toxicology laboratory early so that the correct specimens are obtained for the suspected poison.
    2) A study was conducted to compare the use of immunoassay screening and gas chromatography/mass spectroscopy (GC/MS) analysis in the detection of drugs and chemicals in pediatric patients. Of the 139 urine samples tested, 17.3% (n=24) and 88.5% (n=123) were positive for a drug of abuse following analysis by immunoassay and GC/MS, respectively. GC/MS detected 64 different pharmaceuticals. The authors concluded that GC/MS offers the clinician a more comprehensive view into the exposure of the pediatric patient following an unknown chemical ingestion (Kyle et al, 2003).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) Patients with persistent symptoms or laboratory abnormalities should be admitted.
    6.3.1.2) HOME CRITERIA/ORAL
    A) Patients who are asymptomatic or have minimal irritant symptoms after inadvertent lick or taste ingestions can be observed at home.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a medical toxicologist or poison center for any patient with symptoms or a large exposure. Contact the product manufacturer for more information about the specific chemical in question. Consult a gastroenterologist for early endoscopy in patients with symptoms suggesting caustic injury (pain with or difficulty swallowing, drooling, stridor, persistent vomiting).
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Symptomatic patients, those with deliberate ingestions or more than taste exposures should be referred to a healthcare facility for 6 to 8 hours of observation.

Monitoring

    A) Monitor vital signs and mental status.
    B) 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 compound.
    1) Monitor serum electrolytes to evaluate for metabolic acidosis if there is any possibility of deliberate, large or mixed ingestion or uncertain history, or if the patient has significant symptoms.
    2) Monitoring of renal function, hepatic enzymes, arterial blood gases, pulse oximetry, and chest radiographs should be performed if clinically indicated.
    3) Institute continuous cardiac monitoring and obtain an ECG after significant exposure.
    4) Pregnancy testing should be considered in women of childbearing potential.
    5) Obtain serum acetaminophen and salicylate concentrations after deliberate ingestions.
    6) Test the pH of the product to assess for its ability to cause caustic injury.
    C) Obtain a chest radiograph in patients with persistent cough, wheezing or respiratory distress.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) Prehospital GI decontamination is not recommended as the potential for seizures, coma, aspiration and caustic effects is not known for these chemicals.
    B) Remove contaminated clothing; wash exposed skin and irrigate exposed eyes.
    6.5.2) PREVENTION OF ABSORPTION
    A) SUMMARY: GI decontamination is not recommended as the potential for seizures, coma, aspiration and caustic effects is not known for these chemicals. Activated charcoal can be considered after a recent, substantial ingestion but should be avoided if the chemical involved may be caustic or a hydrocarbon. Activated charcoal is contraindicated if the chemical ingested is an acid or alkali, because of the potential for injury of the gastrointestinal mucosa if vomiting occurs and the subsequent obscuring of endoscopy findings. It is relatively contraindicated if the chemical ingested is a hydrocarbon, because of the potential for aspiration pneumonitis if vomiting occurs.
    B) ACTIVATED CHARCOAL
    1) Very few drugs or chemicals 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) 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 a coingestant.
    3) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    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).
    6.5.3) TREATMENT
    A) SUPPORT
    1) This management is intended for use in the absence of a specific treatment protocol for a product or chemical when general management guidelines may be needed for patient care. It may also be helpful when an experimental agent has been ingested and no toxicity data are available. Most patients will do well with supportive care. Monitor vital signs and mental status. Treat hypotension with intravenous fluids; add vasopressors if hypotension persists. Arrange for early (ideally within 12 hours) endoscopy for patients with concern for caustic GI injury. Treat bronchospasm with inhaled beta agonists and corticosteroids. Endotracheal intubation and mechanical ventilation may be needed in patients with significant CNS depression or respiratory distress.
    B) COMA
    1) Aggressively treat and evaluate coma regardless of suspected cause. Intubate and ventilate as needed. Comatose patients should receive oxygen, naloxone, thiamine (adults), and either D50 or rapid determination of blood glucose. Check core temperature to evaluate for hypo- or hyperthermia. Consider evaluation for CNS lesion or infection with CT scan and lumbar puncture.
    C) MONITORING OF PATIENT
    1) Monitor vital signs and mental status.
    2) Monitor serum electrolytes to evaluate for metabolic acidosis if there is any possibility of deliberate, large or mixed ingestion or uncertain history, or if the patient has significant symptoms.
    3) Monitoring of renal function, hepatic enzymes, arterial blood gases, pulse oximetry, and chest radiographs should be performed if clinically indicated.
    4) Institute continuous cardiac monitoring and obtain an ECG after significant exposure.
    5) Pregnancy testing should be considered in women of childbearing potential.
    6) Obtain serum acetaminophen and salicylate concentrations after deliberate ingestions.
    7) Test the pH of the product to assess for its ability to cause caustic injury.
    8) Obtain a chest radiograph in patients with persistent cough, wheezing or respiratory distress.
    D) HYPOTENSIVE EPISODE
    1) SUMMARY
    a) Infuse 10 to 20 milliliters/kilogram of isotonic fluid and keep the patient supine. If hypotension persists, administer dopamine or norepinephrine. Consider central venous pressure monitoring to guide further fluid therapy.
    2) DOPAMINE
    a) DOSE: Begin at 5 micrograms per kilogram per minute progressing in 5 micrograms per kilogram per minute increments as needed (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). If hypotension persists, dopamine may need to be discontinued and a more potent vasoconstrictor (eg, norepinephrine) should be considered (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
    b) CAUTION: If ventricular dysrhythmias occur, decrease rate of administration (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). Extravasation may cause local tissue necrosis, administration through a central venous catheter is preferred (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
    3) NOREPINEPHRINE
    a) PREPARATION: 4 milligrams (1 amp) added to 1000 milliliters of diluent provides a concentration of 4 micrograms/milliliter of norepinephrine base. Norepinephrine bitartrate should be mixed in dextrose solutions (dextrose 5% in water, dextrose 5% in saline) since dextrose-containing solutions protect against excessive oxidation and subsequent potency loss. Administration in saline alone is not recommended (Prod Info norepinephrine bitartrate injection, 2005).
    b) DOSE
    1) ADULT: Dose range: 0.1 to 0.5 microgram/kilogram/minute (eg, 70 kg adult 7 to 35 mcg/min); titrate to maintain adequate blood pressure (Peberdy et al, 2010).
    2) CHILD: Dose range: 0.1 to 2 micrograms/kilogram/minute; titrate to maintain adequate blood pressure (Kleinman et al, 2010).
    3) CAUTION: Extravasation may cause local tissue ischemia, administration by central venous catheter is advised (Peberdy et al, 2010).
    E) CONDUCTION DISORDER OF THE HEART
    1) VENTRICULAR DYSRHYTHMIAS SUMMARY
    a) Obtain an ECG, institute continuous cardiac monitoring and administer oxygen. Evaluate for hypoxia, acidosis, and electrolyte disorders (particularly hypokalemia, hypocalcemia, and hypomagnesemia). Lidocaine and amiodarone are generally first line agents for stable monomorphic ventricular tachycardia, particularly in patients with underlying impaired cardiac function. Amiodarone should be used with caution if a substance that prolongs the QT interval and/or causes torsades de pointes is involved in the overdose. Unstable rhythms require immediate cardioversion.
    2) LIDOCAINE/INDICATIONS
    a) Ventricular tachycardia or ventricular fibrillation (Prod Info Lidocaine HCl intravenous injection solution, 2006; Neumar et al, 2010; Vanden Hoek et al, 2010).
    3) LIDOCAINE/DOSE
    a) ADULT: 1 to 1.5 milligrams/kilogram via intravenous push. For refractory VT/VF an additional bolus of 0.5 to 0.75 milligram/kilogram can be given at 5 to 10 minute intervals to a maximum dose of 3 milligrams/kilogram (Neumar et al, 2010). Only bolus therapy is recommended during cardiac arrest.
    1) Once circulation has been restored begin a maintenance infusion of 1 to 4 milligrams per minute. If dysrhythmias recur during infusion repeat 0.5 milligram/kilogram bolus and increase the infusion rate incrementally (maximal infusion rate is 4 milligrams/minute) (Neumar et al, 2010).
    b) CHILD: 1 milligram/kilogram initial bolus IV/IO; followed by a continuous infusion of 20 to 50 micrograms/kilogram/minute (de Caen et al, 2015).
    4) LIDOCAINE/MAJOR ADVERSE REACTIONS
    a) Paresthesias; muscle twitching; confusion; slurred speech; seizures; respiratory depression or arrest; bradycardia; coma. May cause significant AV block or worsen pre-existing block. Prophylactic pacemaker may be required in the face of bifascicular, second degree, or third degree heart block (Prod Info Lidocaine HCl intravenous injection solution, 2006; Neumar et al, 2010).
    5) LIDOCAINE/MONITORING PARAMETERS
    a) Monitor ECG continuously; plasma concentrations as indicated (Prod Info Lidocaine HCl intravenous injection solution, 2006).
    6) PROCAINAMIDE/INDICATIONS
    a) An alternative drug in the treatment of PVCs or recurrent ventricular tachycardia when lidocaine is contraindicated or not effective. It should be avoided when the ingestion involves agents with quinidine-like effects (e.g. tricyclic antidepressants, phenothiazines, chloroquine, antidysrhythmics) and when the ECG reveals QRS widening or QT prolongation suspected to be secondary to overdose(Neumar et al, 2010; Vanden Hoek,TL,et al).
    7) PROCAINAMIDE/ADULT LOADING DOSE
    a) 20 to 50 milligrams/minute IV until dysrhythmia is suppressed or toxicity develops from procainamide (hypotension develops or the QRS is widened by 50%), or a total dose of 17 milligrams/kilogram is given (1.2 grams for a 70 kilogram person) (Neumar et al, 2010).
    b) ALTERNATIVE DOSING: 100 mg every 5 minutes until dysrhythmia is controlled, or toxicity develops from procainamide (hypotension develops or the QRS is widened by 50%) or 17 mg/kg have been given (Neumar et al, 2010).
    c) MAXIMUM DOSE: 17 milligrams/kilogram (Neumar et al, 2010).
    8) PROCAINAMIDE/CONTROLLED INFUSION
    a) In conscious patients, procainamide should be administered as a controlled infusion (20 milligrams/minute) because of the risk of QT prolongation and its hypotensive effects (Link et al, 2015)
    9) PROCAINAMIDE/ADULT MAINTENANCE DOSE
    a) 1 to 4 milligrams/minute via an intravenous infusion (Neumar et al, 2010).
    10) PROCAINAMIDE/PEDIATRIC LOADING DOSE
    a) 15 milligrams/kilogram IV/Intraosseously over 30 to 60 minutes; discontinue if hypotension develops or the QRS widens by 50% (Kleinman et al, 2010).
    11) PROCAINAMIDE/PEDIATRIC MAINTENANCE DOSE
    a) Initiate at 20 mcg/kg/minute and increase in 10 mcg/kg/minute increments every 15 to 30 minutes until desired effect is achieved; up to 80 mcg/kg/minute (Bouhouch et al, 2008; Ratnasamy et al, 2008; Mandapati et al, 2000; Luedtke et al, 1997; Walsh et al, 1997).
    12) PROCAINAMIDE/PEDIATRIC MAXIMUM DOSE
    a) 2 grams/day (Bouhouch et al, 2008; Ratnasamy et al, 2008; Mandapati et al, 2000; Luedtke et al, 1997; Walsh et al, 1997).
    13) MONITORING PARAMETERS
    a) ECG, blood pressure, and blood concentrations (Prod Info procainamide HCl IV, IM injection solution, 2011). Procainamide can produce hypotension and QT prolongation (Link et al, 2015).
    14) AVOID
    a) Avoid in patients with QT prolongation and CHF (Neumar et al, 2010).
    F) SEIZURE
    1) SUMMARY
    a) Attempt initial control with a benzodiazepine (eg, diazepam, lorazepam). If seizures persist or recur, administer phenobarbital or propofol.
    b) Monitor for respiratory depression, hypotension, and dysrhythmias. Endotracheal intubation should be performed in patients with persistent seizures.
    c) Evaluate for hypoxia, electrolyte disturbances, and hypoglycemia (or, if immediate bedside glucose testing is not available, treat with intravenous dextrose).
    2) DIAZEPAM
    a) ADULT DOSE: Initially 5 to 10 mg IV, OR 0.15 mg/kg IV up to 10 mg per dose up to a rate of 5 mg/minute; may be repeated every 5 to 20 minutes as needed (Brophy et al, 2012; Prod Info diazepam IM, IV injection, 2008; Manno, 2003).
    b) PEDIATRIC DOSE: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed (Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008).
    c) Monitor for hypotension, respiratory depression, and the need for endotracheal intubation. Consider a second agent if seizures persist or recur after repeated doses of diazepam .
    3) NO INTRAVENOUS ACCESS
    a) DIAZEPAM may be given rectally or intramuscularly (Manno, 2003). RECTAL DOSE: CHILD: Greater than 12 years: 0.2 mg/kg; 6 to 11 years: 0.3 mg/kg; 2 to 5 years: 0.5 mg/kg (Brophy et al, 2012).
    b) MIDAZOLAM has been used intramuscularly and intranasally, particularly in children when intravenous access has not been established. ADULT DOSE: 0.2 mg/kg IM, up to a maximum dose of 10 mg (Brophy et al, 2012). PEDIATRIC DOSE: INTRAMUSCULAR: 0.2 mg/kg IM, up to a maximum dose of 7 mg (Chamberlain et al, 1997) OR 10 mg IM (weight greater than 40 kg); 5 mg IM (weight 13 to 40 kg); INTRANASAL: 0.2 to 0.5 mg/kg up to a maximum of 10 mg/dose (Loddenkemper & Goodkin, 2011; Brophy et al, 2012). BUCCAL midazolam, 10 mg, has been used in adolescents and older children (5-years-old or more) to control seizures when intravenous access was not established (Scott et al, 1999).
    4) LORAZEPAM
    a) MAXIMUM RATE: The rate of intravenous administration of lorazepam should not exceed 2 mg/min (Brophy et al, 2012; Prod Info lorazepam IM, IV injection, 2008).
    b) ADULT DOSE: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist (Manno, 2003; Brophy et al, 2012).
    c) PEDIATRIC DOSE: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue (Brophy et al, 2012; Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008; Sreenath et al, 2009; Chin et al, 2008).
    5) PHENOBARBITAL
    a) ADULT LOADING DOSE: 20 mg/kg IV at an infusion rate of 50 to 100 mg/minute IV. An additional 5 to 10 mg/kg dose may be given 10 minutes after loading infusion if seizures persist or recur (Brophy et al, 2012).
    b) Patients receiving high doses will require endotracheal intubation and may require vasopressor support (Brophy et al, 2012).
    c) PEDIATRIC LOADING DOSE: 20 mg/kg may be given as single or divided application (2 mg/kg/minute in children weighing less than 40 kg up to 100 mg/min in children weighing greater than 40 kg). A plasma concentration of about 20 mg/L will be achieved by this dose (Loddenkemper & Goodkin, 2011).
    d) REPEAT PEDIATRIC DOSE: Repeat doses of 5 to 20 mg/kg may be given every 15 to 20 minutes if seizures persist, with cardiorespiratory monitoring (Loddenkemper & Goodkin, 2011).
    e) MONITOR: For hypotension, respiratory depression, and the need for endotracheal intubation (Loddenkemper & Goodkin, 2011; Manno, 2003).
    f) SERUM CONCENTRATION MONITORING: Monitor serum concentrations over the next 12 to 24 hours. Therapeutic serum concentrations of phenobarbital range from 10 to 40 mcg/mL, although the optimal plasma concentration for some individuals may vary outside this range (Hvidberg & Dam, 1976; Choonara & Rane, 1990; AMA Department of Drugs, 1992).
    6) OTHER AGENTS
    a) If seizures persist after phenobarbital, propofol or pentobarbital infusion, or neuromuscular paralysis with general anesthesia (isoflurane) and continuous EEG monitoring should be considered (Manno, 2003). Other anticonvulsants can be considered (eg, valproate sodium, levetiracetam, lacosamide, topiramate) if seizures persist or recur; however, there is very little data regarding their use in toxin induced seizures, controlled trials are not available to define the optimal dosage ranges for these agents in status epilepticus (Brophy et al, 2012):
    1) VALPROATE SODIUM: ADULT DOSE: An initial dose of 20 to 40 mg/kg IV, at a rate of 3 to 6 mg/kg/minute; may give an additional dose of 20 mg/kg 10 minutes after loading infusion. PEDIATRIC DOSE: 1.5 to 3 mg/kg/minute (Brophy et al, 2012).
    2) LEVETIRACETAM: ADULT DOSE: 1000 to 3000 mg IV, at a rate of 2 to 5 mg/kg/min IV. PEDIATRIC DOSE: 20 to 60 mg/kg IV (Brophy et al, 2012; Loddenkemper & Goodkin, 2011).
    3) LACOSAMIDE: ADULT DOSE: 200 to 400 mg IV; 200 mg IV over 15 minutes (Brophy et al, 2012). PEDIATRIC DOSE: In one study, median starting doses of 1.3 mg/kg/day and maintenance doses of 4.7 mg/kg/day were used in children 8 years and older (Loddenkemper & Goodkin, 2011).
    4) TOPIRAMATE: ADULT DOSE: 200 to 400 mg nasogastric/orally OR 300 to 1600 mg/day orally divided in 2 to 4 times daily (Brophy et al, 2012).

Enhanced Elimination

    A) SUMMARY
    1) In general hemodialysis is only useful for toxins with low protein binding, low volume of distribution (1 L/kg or less) and small to moderate molecular weight. Hemoperfusion is useful for toxins with small volumes of distribution, that are adsorbed to activated charcoal and have low endogenous clearance. It can remove toxins of larger molecular weight and those that are protein bound (Pond, 1991). Hemodialysis can be considered for correction of severe acid base or electrolyte abnormalities and to support patients who develop renal failure. Hemodialysis or hemoperfusion can be considered for patients with severe toxicity not responding to supportive care from chemicals that meet the aforementioned kinetic parameters. All of these techniques have inherent risks and should not be utilized unless specifically indicated.

Range Of Toxicity

Summary

    A) TOXICITY: In many cases, the amount of toxin ingested will be unknown, and for substances coded to this management, the toxic dose of the agent itself is unknown. Monitor the patient carefully for clinical evidence of toxicity. In these cases, the amount ingested has less relevance than the patient's clinical condition.

References

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