ACETAMINOPHEN TOXICITY, SALICYLATES, NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
BASICS
Common drugs: Tylenol
Acetaminophen poisoning has become the most common cause of acute liver failure in the United States
Pediatric toxicity >250 mg/kg/24 hours
Adult toxicity >12 g ingestion
SIGNS AND SYMPTOMS
Nausea, vomiting within 2 hours, elevated liver enzymes, rise in prothrombin time/international normalized ratio
DIAGNOSTICS
Serum level
If 4-hour Tylenol level >140 mg per dL then treat
TREATMENT
N-acetylcysteine (NAC)
• Works by restoring hepatic glutathione stores
• Best if started within the first 8 hours
BASICS
Common drugs
• Aspirin
SIGNS AND SYMPTOMS
Respiratory alkalosis, tinnitus, anion gap metabolic acidosis
DIAGNOSTICS
Serum level
TREATMENT
Bicarb
Dialysis
Nonsteroidal Anti-Inflammatory Drugs
BASICS
Common drugs
• Ibuprofen, piroxicam
SIGNS AND SYMPTOMS
Most common: gastrointestinal upset
Less common: drowsiness, lethargy, ataxia, nystagmus, tinnitus
Rare and only with massive amounts: seizure, coma, renal failure
DIAGNOSTICS
Based on detailed history
No specific levels available
TREATMENT
Antacids for mild gastrointestinal upset
Treats seizures, coma, hypotension if they occur
No antidote
BASICS
Common drugs
• Antihistamines, tricyclic antidepressant, atropine, Donnatal, Lomotil, oxybutynin, scopolamine, jimson weed
SIGNS AND SYMPTOMS
Dry as a bone, mad as a hatter, blind as a bat, hot as a hare
DIAGNOSIS
Clinical exam findings
Physostigmine trial
TREATMENT
Physostigmine
See substance abuse and overdose in Chapter 12: Psychobehavioral Disorders—3%
BASICS
Common drugs
• Oxycodone, morphine, heroin
SIGNS AND SYMPTOMS
Central nervous system and respiratory depression, miosis
DIAGNOSTICS
Serum level
TREATMENT/ANTIDOTE
Narcan
BASICS
Common drugs
• Cocaine, ritalin, speed
SIGNS AND SYMPTOMS
Agitation, dilated pupils, diaphoresis, irritability, decreased appetite, cardiac arrhythmia
DIAGNOSTICS
History
Toxicology screen
TREATMENT
Supportive
If chest pain, give benzodiazepines
Avoid β-blockers in cocaine and chest pain
BASICS
Common drugs
• Found in household paints
SIGNS AND SYMPTOMS
Abdominal pain, microcytic anemia with basophilic stippling, ataxia, purple lines on gums
DIAGNOSTICS
Serum level
TREATMENT
Ca EDTA
BASICS
Common drugs
• Thimerosal
• Thiazide
SIGNS AND SYMPTOMS
Insomnia, delirium, pulmonary edema
DIAGNOSTICS
Blood level
TREATMENT
Bicarb
Dialysis
BASICS
Common drugs
• Insecticides
• Herbicides for flowers and plants
• Nerve gases
SIGNS AND SYMPTOMS
Impaired memory, disorientation, confusion, headache, nausea, weakness, appetite loss
DIAGNOSTICS
Serum test
TREATMENT
Anticholinergic drugs
TRICYCLICS, MAOI, ANTIPSYCHOTICS, LITHIUM, BENZODIAZEPINES
BASICS
Common drugs
• Amitriptyline, doxepin, nortriptyline
SIGNS AND SYMPTOMS
Anticholinergic symptoms, QRS >100 ms, torsades des pointes
DIAGNOSTICS
Blood level
TREATMENT
Bicarb drip
BASICS
Common drugs
• Isocarboxazid, phenelzine, selegiline
SIGNS AND SYMPTOMS
• Hypertension, delirium, hyperthermia, dysrhythmia, seizures
DIAGNOSTICS
• Clinical exam findings
TREATMENT
Supportive
Treat hypertension with α-blockers or combined α- and β-blockers
BASICS
Common drugs
• Chlorpromazine, haloperidol, droperidol, olanzapine, promethazine, quetiapine, risperidone
SIGNS AND SYMPTOMS
Mild: sedation, small pupils, orthostatic hypotension
Severe: coma, seizures, respiratory arrest
DIAGNOSTICS
History of ingestion combined with physical exam findings and prolonged QT on EKG
TREATMENT
Supportive
QT prolongation may respond to Mg
BASICS
Common drugs
• Lithium
SIGNS AND SYMPTOMS
Lethargy, muscle weakness, slurred speech, ataxia, tremor
DIAGNOSTICS
Serum level
TREATMENT
Supportive
Dialysis for severe cases
BASICS
Common drugs
• Alprazolam, clonazepam, diazepam, lorazepam, midazolam
SIGNS AND SYMPTOMS
Rapid onset of weakness, ataxia, drowsiness, respiratory arrest
DIAGNOSTICS
Serum levels
TREATMENT
Flumazenil
