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PEDIATRIC TOXICOLOGIC ANTIDOTES YOU NEED TO KNOW
Richard M. Cantor, MD FAAP/FACEPProfessor of Emergency Medicine and Pediatrics
Section Chief, Pediatric Emergency MedicineDirector, Pediatric Emergency Medicine Fellowship
Golisano Children’s Hospital, Syracuse, NY
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THIS COULD BE SERIOUS
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HISTORY
A 2 year old female presents to the ED with irritability, for the past 4 hours
Awoke well that morning, ate breakfast, and went out to play with her older siblings in the backyard of her home
She returned to the homeacting strangely
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PHYSICAL EXAMINATION
• Vitals• T 37C• HR 72• RR 24• BP 90/70
• General• Very sleepy toddler, irritable
when stimulated• HEENT
• Pupils anisocoric but reactive • Fundi not seen
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PHYSICAL EXAMINATION
• Neurologic• DTR 3+ on right/ +1 on left• Seems weak on left side• Responds to pain
assymetrically
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PROBLEM LIST
• Altered Level of Consciousness
• Unequal but reactive pupils
• Focal motor deficits
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PROGRESSIVE CAUSES
OF LETHARGY
IN CHILDREN
Mass EffectsEpidural SubduralCerebral Edema
Meningitis
Opioids
Hypoglycemia
MUST BE IDENTIFIEDAND
TREATED EMERGENLY
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PROGRESSIVE CAUSES OF LETHARGY IN CHILDREN
Mass EffectsEpidural SubduralCerebral Edema
Meningitis
Opioids
Hypoglycemia
IMAGING
ANTIBIOTICS
NARCAN
FINGERSTICK
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NON PROGRESSIVE CAUSES OF LETHARGY
IN CHILDREN
• Metabolics
• DKA• Hyponatremia• Hypernatremia
• Encephalitis• Postictal State• Poisoning
DIAGNOSISAND
TREATMENTMAY BE
DELAYED
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PEDIATRIC MNEMONIC FOR LETHARGY
A AlcoholE EpilepsyI InsulinI IntussusceptionO OverdoseU UremiaT TraumaI InfectionsP PsychiatricS Shock
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LAB RESULTS
• CBC, BMP pending
• CT ordered
• Urine tox ordered
• What’s next?
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LAB RESULTS
• CT normal• CBC normal• CSF normal
• BMP• glucose 10!
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FURTHER HISTORY
• Grandma lives in the home
• Some of her “sugar pills” are missing (Glyburide)
• Child received D50 with complete resolution of symptoms• hypoglycemia resolved after
24 hours
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TAKE HOME MESSAGE
• Always obtain a bedside glucose in any ill infant or child
• Any serious illness• Any gastroenteritis (esp.
rotavirus)• Any odd neurological
presentation• Any child with syncope
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RECOMMENDATION
• Revise The ABC’s to ABCD
• Airway• Breathing• Circulation
• Dextrostick
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A GOOD GIRL GONE BAD
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HISTORY
A 10 year old girl arrives with her
parents who claim that ever since she woke up this morning she
has behaved as if she was “possessed!”
She is presently recovering from an
active case of chicken pox
She reports no fever, stiff neck, nausea,
vomiting, or new rash
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PHYSICAL EXAMINATION
HEENTDilated,
reactive pupils TM clear Pharynx dry
General
Combative, cursing adolescent
Vital Signs
T 40C HR 140 RR 20 BP 140/95
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PHYSICAL EXAMINATION
Abdomen
Distended Suprapubicmass
Absent bowel sounds
Chest
PMI normal, no murmur Clear lungs
Neck
Supple
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PHYSICAL EXAMINATION
Skin
Dried Chicken Pox lesions
Neurologic
Non focal agitation Postures when stimulated
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PRIMARY SURVEY
Encephalopathy
CNS issues
Dextrostix 120
ABC’S intact
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INITIAL PROBLEM LIST
Fever
Altered mental status
Mydriasis
Posturing and hyperreflexia
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DIFFERENTIAL DIAGNOSIS
Infectious Encephalopathy
Metabolic Encephalopathy
Toxic Encephalopathy
Acute Organic Psychosis
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INVESTIGATIONS
Normal Labs
CBC, lytes
LFT’s, ammonia
CT/ CSF normal
required large amounts of versed to
sedate
Tox screen negative
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COULD THIS BE THE CLASSIC ANTICHOLINERGIC SYNDROME?
Warm, dry,
flushed skin (red
as a beet)
Dry mouth (dry as a
bone)
Mydriasis(blind as a
bat)Tachy-cardia Ileus
Delirium (mad as a
hatter)
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DRUGS WITH ANTICHOLINERGIC EFFECTS
Antihistamines (almost all)
Antipsychotics
Antispasmodics (Lomotil)
Muscle Relaxants (Flexeril)
Tricyclics
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ANTIHISTAMINE OD
Therapeutic as H1 receptor antagonists
In OD mimic anticholinergicpoisoning
In general, toxicity occurs after ingestion of 3-5X usual daily
dose
Children are more sensitive to the toxic effects of
antihistamines than adults
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A BIT OF HISTORY
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TREATMENT OF ANTICHOLINERGIC SYNDROME
Most cases need only supportive measures
It’s never too late for charcoal or lavage
Physostigmine (Antilirium)• Only indicated in patients with
coma, delirium, unstable vitals
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CASE PROGRESSION
Given IV Physostigmine
mentation returned to normal
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TOXIN IN THIS CASE: TOPICALLY APPLIED BENADRYL
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BAD NIGHT TO BE ON CALL
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HISTORY
A 4 month old infant arrives with a chief complaint of
diarrhea, vomiting, and “looking ill”
Well until 3 days PT ED
visit, his stools are described as frequent(15-20/day),
foul, green, and mostly water-no blood is
noted
The emesis is sporadic, non
bilious
Others in the home have
similar symptoms, but are recovering
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HISTORY
Over the past 12
hours, his activity level
has decreased
and his parents
don’t like his color
Tmax at 38C
No rash or cough is
described
His urine output is
inestimable due to the
profuse diarrhea
Birth and PMH are normal -
immunized
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PHYSICAL EXAMINATION
Vital Signs
T 38CHR 140RR 60
BP 80/46
OSAT 88%
General
Tired, lethargic infant
Chest
PMI normal, no murmur
Clear lungs
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PHYSICAL EXAMINATION
Pulses
Fair
Extremities
Full ROM
Neurologic
Non focal lethargy
Skin
Normal Cap Refill
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DEFINE THE SYMPTOM COMPLEX
Hypoxia
Pale
No murmur
Clear lungs
Diarrhea
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ESTABLISH A FRAMEWORK FOR INVESTIGATION
Sepsis?
Pan cultures and
antibiotics
Compensated shock?
Volume replacement
Cyanotic presentation?
Cardiac studies
Pulmonary workup
Other
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INTERVENTION/RESPONSE
• OSAT 87% in room air
• 87% in 100% O2
• CXR normal
• ABG in 100% O2
• pH 7.33 pCO2 35 pO2 300 (OSAT 88%)
CAN DISSOLVE IT CAN’T CARRY IT
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BLOOD ON THE TRACKS
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WHAT IS METHEMOGLOBINEMIA?
• The conversion (oxidation) of iron in the heme moiety from ferrous to ferric state, rendering it incapable of binding oxygen
• Fe++ Fe+++
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ETIOLOGIES OF METHEMOGLOBINEMIA
Nitrates• Amyl Nitrate• Nitroglycerin• Infectious
DiarrheaBenzocaineLidocaine
Quinone Sulfonamides Napthalene
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TREATMENT
Level >30%: Methylene blue
Intravenous: 1-2 mg/kg over 5
minutesMay repeat dose within one hour
Contraindicatedin G6PD
Deficiency
Mild cases: Remove offending agents + supplemental oxygen
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CASE PROGRESSION
Methemoglobin level = 30
Received methylene blue over 8 hours
Stool grew rotavirus
The mechanism of methemoglobinemia in infants with bacterial overgrowth most probably involves the endogenous production of nitrates in the
gastrointestinal tract by the altered gastrointestinal flora
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STATUS PANICUS
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CASE
EMS call: A 9 year old
Southeast Asian 3 year old in status epilepticus
Prehospitalcare involved
rectal Ativan to no avail
An interpreter is called
The child arrives in
status
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CASE
Vitals• Afebrile• HR 140• RR 40• BP 90/50• OSAT 98%• Chemstrip 120
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CASE
Atraumatic exam
Pupils sluggish
Fundi not seen
Seizing
No obvious anomalies
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INTERVENTIONS
Given multiple doses of
lorazepam (3)
No effect
Given a loading dose of
fosphenytoin
No effect
Given 20 mg/kg
phenobarbital
Stops breathing
Intubated
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CASE PROGRESSION
Normal Labs
CBC
BMP
Calcium
Magnesium
Phosphorus
Normal Studies
CT brain
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CASE PROGRESSION
• Family and Interpreter Information
• An uncle in the house has Tuberculosis and takes medications
• Any thoughts?
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ISONIAZID INDUCED SEIZURES
• It All Starts With GABA (the major neuroinhibitory transmitter)
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PATHOPHARMACOLOGY OF INH SEIZURES
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THE ROLE OF PYRIDOXINE
• Pyridoxine (vitamin B6) is a water-soluble vitamin
• INH produces a syndrome resembling cerebral vitamin B6deficiency, which results in seizures
• It overcomes the inhibition of GABA synthesis by INH overdose
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CLINICAL USE OF PYRIDOXIME
• Dose in grams = the amount of INH ingested
• Unknown quantities of ingested INH warrant initial empiric treatment with a pyridoxine dose of no more than 5 grams (pediatric dose: 70 mg/kg to a maximum of 5 grams)
• Administer at a rate of 1 gram every 2-3 minutes
• Seizures that persist beyond administration of the initial 5-g dose should be treated by administration of an additional 5 grams of pyridoxine
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CASE PROGRESSION
• Given 5 grams of Pyridoxine
• Seizure resolved
• Open bottle of INH found within the home
• Child discharged 2 days later
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A DROP IN THE BUCKET?
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CASE
• A 2 year old is found with an open bottle of Visine Eye Drops
• She is sleepy and barely responsive
• Her skin is cool and clammy
• An ambulance is called………
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CASE PE
• Pertinent Physical Findings
• CNS Depression
• Pinpoint Pupils
• Bradycardia
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VISINE
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IS THIS CLONIDINE?
• Imidazoline compound
• Presynaptic α2-adrenergic agonist
• Decrease sympathetic outflow
• First studied as a nasal decongestant
• Subsequently used as an anti-hypertensive
• Widespread use
• ADHD Indications
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OTHER DRUGS TO CONSIDER
• Intuniv® (Extended Release Guanfacine)
• FDA Indication for ADHD
• Tenex® (Guanfacine)
• Kapvay® (Extended release Clonidine)
• FDA Indication for ADHD
• Zanaflex® (Tizanidine)
• Precedex® (Dexmedetomidine)
• IV administration/inpatient use
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PATHOPHYSIOLOGY
• Stimulation of α-adrenergic receptors in the brain
• Decreases heart rate, vascular tone and blood pressure
• In overdose, peripheral α-adrenergic agonism can occur
• Vasoconstriction and hypertension
• Imidazoline binding sites in the brain
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IN OVERDOSE…
• CNS depression
• Bradycardia
• Hypotension
• Respiratory depression
• Sinus bradycardia
• Pinpoint pupils
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WHEN ACLS MAY NOT BE ENOUGH
• Naloxone
• α2 and µ receptors are coupled to inhibitory G proteins and open K+ channels
• Variable Response
• Higher Doses
• Continuous infusions
• Atropine
• Patient Stimulation
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CASE PROGRESSION
• Child continued to improve after stimulation
• Naloxone 2 mg dose increments up to 10 mg done
• Very little response
• Improved over next 12 hours and discharged the next day
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WHO HAS THE BREATH MINTS?
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HISTORY
• A 3 year old presents with a three day history of fever, progressive sleepiness, and respiratory distress
• Previously healthy, his parents report that he developed a fever (101) at first, for which they gave Tylenol
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HISTORY
• His behavior has become that of a lethargic and irritable child, with what the parents describe as a “funny, fast breathing pattern”
• No rash, URI, nausea, vomiting or diarrhea is described
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PHYSICAL EXAMINATION
• Vital Signs• T 40C, HR 140, RR 70 and deep, BP 140/70
• General
• Sleepy toddler, responding to mother’s voice• HEENT
• Normal pupils, Pharynx dry• Neck
• Supple
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PHYSICAL EXAMINATION
• Chest
• PMI normal, no murmur
• Clear lungs
• Abdomen
• Soft, No mass
• Bowel sounds normal
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PHYSICAL EXAMINATION
• Pulses
• Normal
• Extremities
• Full ROM
• Neurologic
• Non focal lethargy
• Skin
• Medicinal smell
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PRIMARY AND SECONDARY SURVEY
• ABC’S intact
• Chemstrip 100
• Nonfocal lethargy
• Pupils normal
• Supple neck
• Clear chest
• Negative PMH, medications, allergies
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INITIAL PROBLEM LIST
• Fever
• Lethargy
• Hyperpnea
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TOXINS THAT CAUSE HYPERVENTILATION
• P.A.N.T.
• P PCP, Pneumonitis (chemical)
• A ASA (central CNS stimulation)
• N Non cardiogenic pulmonary edema
• T Toxic metabolic acidosis
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INITIAL DIFFERENTIAL
• Sepsis
• Pneumonia
• Meningitis
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INVESTIGATIONS
• CBC/diff normal
• Electrolytes = Anion Gap 30
• CXR normal
• ABG (room air)
• pH 7.50 pCO2 20 pO2 100 BE -15
PRIMARY RESPIRATORY ALKALOSIS PRIMARY METABOLIC ACIDOSIS
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TOXINS THAT CAUSE ANION GAP ACIDOSIS
• M Methanol
• U Uremia
• D DKA
• P Phen (met) formin
• I Iron, INH
• L Lactate
• E Ethanol, Ethylene glycol
• S Salicylates
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LAB RESULTS
• Serum Osmolarity= 280
• Calculated Osmolarity= 288
• Ethanol= 0
• BUN= 8
• Salicylates= 66mg/dL
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SALICYLATES
• Central stimulation of the respiratory center= primaryrespiratory alkalosis and insensible fluid losses
• Uncouples oxidative phosphorylation and interrupts glucose metabolism (primary metabolic acidosis)
• Alter platelet function and bleeding time
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TOXIC DOSE
• Therapeutic dose = 10-15 mg/kg
• Toxic acute dose is > 140 mg/kg
• Severe intoxication seen with 300-500 mg/kg
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CLINICAL MANIFESTATIONS
• Vomiting, hyperpnea, tinnitus, and lethargy
• Severe intoxication
• coma
• seizures
• hypoglycemia
• hyperthermia
• pulmonary edema
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DIAGNOSIS
• History and ASA level
• Anion gap metabolic acidosis
• Initial respiratory alkalosis, dissipates with general clinical deterioration
• Abdominal xrays may demonstrate radiopaque enteric-coated or sustained-release tablets
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SODIUM BICARBONATE
• Increases urine pH, ion trapping ASA
• Initial dose at 1-2 meq/kg
• Drip of 3 amps in 850 cc D5W at 1.5 - 2 times maintenance
• Attempt to keep urine pH over 7.5
• Hemodialysis is also very effective
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DIAGNOSIS
• Oil of Wintergreen Linament
• 30 grams ASA/15cc
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HOW SLOW CAN YOU GO?
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CASE HISTORY
• A 2 year old accidentally gets into Grandpa’s heart medications
• The only open bottle found is Verapamil SR
• The Poison Center is called, and the child is brought in within 45 minutes
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CASE PHYSICAL
Afebrile• HR 60• RR 20
• BP 70/30• OSAT 98%
Somnolent
Good capillary refill
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CALCIUM CHANNEL BLOCKER OVERDOSE
• Pharmacologic effects
• Myocardial depression
• Peripheral vasodilation
• Bradycardia
• Hypotension
• Heart block
• Children may be stable initially, but progress rapidly to full cardiovascular collapse
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THERAPY
• Gastrointestinal decontamination is a critical intervention
• Induced emesis should be avoided because CCB-poisoned patients can rapidly deteriorate and become severely hypotensive
• Establish 2 IV Lines, PICU admission
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DRUG THERAPY
• Atropine
• the drug of choice for patients with symptomatic bradycardia
• clinical experience demonstrates it to be largely ineffective in improving heart rate in severe CCB-poisoned patients
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DRUG THERAPY
• Calcium Chloride
• Appears to be a logical choice
• Tends to improve blood pressure more than it does the heart rate
• Exact mechanism is unclear, boluses of Ca2+ increase the extracellular Ca2+ concentration, increase the intracellular concentration gradient through unaffected calcium channels
• Unfortunately, this effect is often short-lived and more severely poisoned patients may not improve significantly with calcium salt administration
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DRUG THERAPY
• Catecholamines
• next line of therapy
• numerous case reports describe the success or failure of a wide variety of vasopressors, including epinephrine, norepinephrine, dopamine, isoproterenol, dobutamine, and vasopressin
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SO WHAT ELSE CAN WE TRY?
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GLUCAGON
• Endogenous hormone secreted by the pancreatic α cells in response to hypoglycemia and catecholamines
• Has significant inotropic and chronotropic effects
• Glucagon is a therapy of choice for β-adrenergic antagonist and calcium channel blocker poisoning because of its ability to bypass the β-adrenergic receptor and activate adenylate cyclase in the myocardium
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INSULIN AND GLUCOSE (HIE)
• The most promising treatment for patients who are severely poisoned with CCBs may be hyperinsulinemia/euglycemia therapy (HIE)
• High-dose insulin has positive inotropic effects
• Although some indirect evidence suggests that increased Ca2+ entry may be involved, there is growing support for the hypothesis that improved myocardial use of carbohydrates is responsible for clinical improvement
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INSULIN AND GLUCOSE (HIE)
• Dosing
• if the serum glucose is <250 mg/dL an initial bolus of 25-50 g of dextrose (0.5-1 g/kg), should be followed by a dextrose infusion of 0.25-0.5 g/kg/h
• administer an initial insulin bolus of 1 unit/kg bolus, followed by an insulin infusion at a rate of 0.5-1.0 unit/kg/h, which should be increased if there is no hemodynamic response within 60 minutes
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CASE RESOLUTION
• HR soon dropped to 50, BP 60/40
• Given volume and atropine, transient improvement
• Given calcium chloride, transient improvement
• Glucagon administered, good clinical effect for 1 hour
• HIE started in PICU, maintained for 30 hours
• VS stable, discharged in 2 days
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SUMMARY
• Sympathomimetic presentations may be exogenous
• Drug induced encephalopathy may respond to physostigmine
• Hypoxemia resistant to supplemental oxygen in the absence of cardiopulmonary disease may be methemoglobinemia
• Consider pyridoxine in refractory status epilepticus
• Glucagon and HIE are current new therapies for Beta blocker and Calcium Channel Blocker overdoses