Clinical Pathway: Management Of The Life-Threatening Overdose Intravenous access Oxygen Pulse oximetry n-invasive blood pressure monitoring Accu-Check ECG monitoring and ECG Chest x-ray Respiratory depression? Hypoxia? Assist respirations Intubate as needed (Class I) Unknown overdose or narcotic overdose? Isolated benzodiazepine overdose (not in a chronic user)? Naloxone 2 mg IV or SC (up to 10 mg if no response if suspicion of opioid OD) 0.1 mg aliquots in suspected chronic abusers Start drip as needed Flumazenil 0.2 mg over 30 seconds, then 0.3 mg q 30 seconds up to a total dose of 3 mg (Class III) Acute coronary syndrome associated with cocaine? Nitrates Benzodiazepines Aspirin Phentolamine (especially if persistent hypertension) Cardiology consult if evidence of MI Wide complex tachycardia with pulse? Sodium bicarbonate 1-2 meq/kg titrate to QRS narrowing or ph of 7.5-7.55 If suspected cocaine, may give lidocaine 1.5 mg/kg followed by 1-4 mg/min drip Avoid procainamide Go to top of next page Emergency Medicine Practice 14 August 2001
Clinical Pathway: Management Of The Life-Threatening Overdose (continued) Hypotension? Status seizures? Coma or profoundly depressed mental status? Fluids for hypotension If resistant shock, then epinephrine or norepinephrine drip titrate to response Suspected tricyclic OD: sodium bicarbonate to achieve ph 7.5-7.55 Persistent hypotension: Invasive monitoring when feasible Consider IABP (Class II-III) Glucose for hypoglycemia (Class I) Lorazepam 0.1 mg/kg IV Phenobarbital 20-30 mg/kg IV Pyridoxine for suspected isoniazid overdose Benzodiazepine drip Ensure patent airway Glucose for hypoglycemia (Class I) Narcan if not yet given Toxicology screen if unknown overdose CT scan if profound unexplained coma or focal neurologic signs Suspected or potential calcium-channel blocker or ß-blocker OD: IV glucagon 2-10 mg IV followed by drip if positive response Suspected calciumchannel blocker OD: calcium chloride 1-3 g IV slow IV push Go to Clinical Pathway: Basic Toxicologic Interventions August 2001 15 Emergency Medicine Practice
Clinical Pathway: Basic Toxicologic Interventions Determine the need for lavage or charcoal: Serious overdose presenting to ED within one hour? Potentially serious overdose presenting to ED after one hour? Determine whether toxin is adsorbed to charcoal Routine administration in nontoxic ingestions is not indicated Determine the need for whole bowel irrigation: Large ingestions of iron, heavy metals, lithium, and other drugs poorly adsorbed by activated charcoal Drug packets (body packers) Gastric lavage if life-threatening overdose within one hour of ED arrival (carries risk of aspiration, esophageal perforation) (Class indeterminate) Activated charcoal 1 g/kg or 10:1 ratio of charcoal to toxin Multiple-dose charcoal: Antimalarials (quinine), Aminophylline (theophylline), Barbiturates (phenobarbital), Beta-blockers (Nadolol) (Class II-III) Polyethylene glycol (1-2 L/h in adults, 25 cc/kg in children) orally or by NG tube (Class III) Continue irrigation until the rectal effluent is clear (Class III) Suicide attempt? Determine suicide risk Restrain as needed APAP level (Class III) ECG? X-rays?, if:, if: Cardiotoxin ingestion (known or potential) especially cyclic antidepressants, digitalis, ß-blockers, calciumchannel antagonists, antiarrhythmics, arsenic, cyanide, thioridazine, cocaine, quinine, and carbon monoxide Chest pain or shortness of breath Abnormal heart rate or hypotension Any unstable patient Chest x-ray Dyspnea, tachypnea, coma, or obtundation Cyanosis Symptomatic patients who ingest: Meprobamate, methadone; Opioids; Phenobarbital, phenothiaxines; and Salicylates (MOPS) KUB (especially if suspected metals or drug packets) Chloral hydrate and cocaine packets; Opiate packets; Iron and other heavy metals such as lead, arsenic, and mercury; Neuroleptics; and Sustained-release or enteric-coated preparations (COINS) Go to top of next page Emergency Medicine Practice 16 August 2001
Clinical Pathway: Basic Toxicologic Interventions (continued) Labs? Abnormal vital signs Altered mental status Symptomatic patient and unknown toxin Ingestion of substance that can produce metabolic acidosis Possible or known ingestion of toxic alcohol Cyanosis or respiratory distress Suspected rhabdomyolysis Female of childbearing age Accu-Check Electrolytes (calculate anion gap) Serum osmolality (calculate osmolar gap) ABG CPK Pregnancy test Toxicology screen?, if: Qualitative screen Coma with unknown overdose Quantitative screen (known or suspected overdose with APAP, ASA, lithium, theophylline, toxic alcohols, lead, iron, carbon monoxide, methemoglobin-producing toxins, anticonvulsants, or digoxin) Need for antidote? See Table 13 Dialysis?, if: Go to Clinical Pathway: Disposition Of The Toxicology Patient Symptomatic patient with ingestion of: Isopropanol Salicylates Theophylline (caffeine) Uremia Methanol Barbiturates, beta-blockers (water-soluble, such as atenolol) Lithium Ethylene glycol August 2001 17 Emergency Medicine Practice
Clinical Pathway: Disposition Of The Toxicology Patient Unstable vital signs? Potentially lethal overdose? Cardiotoxic overdose? ICU admission Moderately symptomatic patient with low potential for fatal outcome? Hospital admission Overdose with delayed or sustained-release properties (calciumchannel antagonists, theophylline, lithium, methadone, Lomotil, MAOIs, and oral hypoglycemics)? Prolonged observation or admission (12-24 hours in the asymptomatic patient) (Class III) Mildly symptomatic patient, lowlethality ingestion? Asymptomatic patient, unknown ingestion? Suicidal patient? ED observation for 4-6 hours (Class II-III) Psychiatric consult on inpatient or outpatient basis depending upon suicidal risk and home situation Reliable patient and non-toxic overdose? Short or no observation and discharge home (return for worsening) Emergency Medicine Practice 18 August 2001