G - Give Specific Antidotes and Treatments

Question 1

Describe: Urine Alkalinization Treatment for ASA Overdose (3)

Answer 1

• urine pH > 7.5
• fluid resuscitate first, then 3 amps NaHCO3/L of D5W at 1.5x maintenance
• add 20-40mEq/LKCl if patient is able to urinate

Question 2

Describe: Protocol for Warfarin Overdose (5)

Answer 2

Question 3

Describe tx: Acetaminophen (2)

Answer 3

• Decontaminate (activated charcoal)
• N-acetylcysteine

Question 4

What’s the toxic dose of Acetaminophen?

Answer 4

Toxic dose >200 mg/kg (>7.5 g adult)

Question 5

Is Acetaminophen overdose clinically silent? (1)

Answer 5

Often clinically silent; evidence of liver/renal damage delayed >24 h

Question 6

How to monitor acetaminophen overdose? (8)

Answer 6

• Monitor drug level 4 h post-ingestion
• Liver enzymes
• INR, PTT
• BUN, Cr
• Hypoglycemia
• Metabolic acidosis
• Encephalopathy poor prognosis
• Dialysis may be required to manage in very high overdoses

Question 7

Describe tx: Acute Dystonic Reaction (2)

Answer 7

• Benztropine: 1-2 mg IM/IV then 2 mg PO x 3 d
  
  • Benztropine (Cogentin®) has euphoric effect and the potential for misuse
• OR Diphenhydramine 1-2 mg/kg IV, then 25 mg PO qid x 3d

Question 8

Describe tx: Anticholinergics (2)

Answer 8

• Consider decontamination (activated charcoal)
• Supportive care

Question 9

Describe tx: ASA (2)

Answer 9

• Consider decontamination (activated charcoal)
• Alkalinize urine; want urine pH >7.5

Question 10

Describe monitoring of ASA overdose (3)

Answer 10

• Monitor serum pH and drug levels closely
• Monitor K+ level; may require supplement for urine alkalinization
• Hemodialysis may be needed if intractable metabolic acidosis, very high levels, or end-organ damage (i.e. unable to diurese)

Question 11

Describe tx: Benzodiazepines (3)

Answer 11

• Consider decontamination (activated charcoal)
• Flumazenil
• Supportive care

Question 12

Desribe tx: β-blockers (5)

Answer 12

• Consider decontamination (activated charcoal, consider whole bowel irrigation for extended-release ingestion)
• IV glucagon
• IV calcium chloride
• IV high-dose insulin (with dextrose)
• IV intralipid

Question 13

Describe tx: Calcium Channel Blockers (6)

Answer 13

• Consider decontamination (activated charcoal, consider whole bowel irrigation for extended-release ingestion)
• IV glucagon
• IV calcium chloride
• IV high-dose insulin (with dextrose)
• IV intralipid
• Order ECG, electrolytes (especially Ca2+, Mg2+, Na+, K+)

Question 14

Describe tx: Cocaine (4)

Answer 14

• Decontaminate (activated charcoal) if oral
• Aggressive supportive care
• β-blockers are contraindicated in acute cocaine toxicity
• Intralipid for life-threatening symptoms

Question 15

Describe tx: CO poisoning (3)

Answer 15

• Supportive care
• 100% O2 ; may require hyperbaric O2
• Order ECG, VBG. Consider lactate and troponin depending on specific presentation

Question 16

Describe tx: Cyanide (1)

Answer 16

Hydroxocobalamin

Question 17

Describe tx: Digoxin (6)

Answer 17

• Consider decontamination (activated charcoal)
• Digoxin-specific Ab fragments
• 10-20 vials IV if acute; 3-6 if chronic
• 1 vial (40 mg) neutralizes 0.5 mg of toxin
• Use for life-threatening dysrhythmias unresponsive to conventional therapy, 6 h serum digoxin >12 nmol/L, initial K+ >5 mmol/L, ingestion >10 mg (adult)/>4 mg (child)
• Common dysrhythmias include VFib, VTach, and conduction blocks

Question 18

Describe tx: Ethanol (4)

Answer 18

• Thiamine 100 mg IM/IV
• Manage airway and circulatory support
• Mouthwash = 70% EtOH; perfumes and colognes = 40-60% EtOH
• Order serum EtOH level and glucose level; treat glucose level appropriately

Question 19

Describe tx: Ethylene Glycol/ Methanol (4)

Answer 19

• Fomepizole (4-methylpyrazole) 15 mg/kg IV load over 30 min, then 10 mg/kg q12h OR
• Ethanol (10%) 10 mL/kg over 30 min, then 1.5 mL/h
• CBC, electrolytes, glucose, ethanol level
• Consider hemodialysis

Question 20

Describe tx: Heparin (2)

Answer 20

• Protamine sulfate 25-50 mg IV
• For unfractionated heparin overdose only

Question 21

Describe tx: Insulin IM/SC/ Oral Hypoglycemic (2)

Answer 21

• Glucose IV/PO/NG tube
• Glucagon: 1-2 mg IM (if no access to glucose)

Question 22

__ carries highest risk of hypoglycemia among oral agents

Question 23

Consider ___ for oral hypoglycemics in these cases; consult local Poison Information Centre

Answer 23

Consider octreotide for oral hypoglycemics (50-100 μg SC q6h) in these cases; consult local Poison Information Centre

Question 25

Describe tx: MDMA (4)

Answer 25

• Consider decontamination (activated charcoal)
• Supportive care
• Monitor CK; treat rhabdomyolysis with high flow fluids: aggressive external cooling for hyperthermia
• Review medical history if possible for serotonergic use

Question 26

Describe tx: TCAs (5)

Answer 26

• Consider decontamination (activated charcoal)
• Aggressive supportive care
• Sodium bicarbonate (NaHC03) bolus for wide QRS/seizures
• Also consider cardiac and hypotension support, seizure control
• Intralipid therapy

Question 27

___ antidote contraindicated in combined TCA and benzodiazepine overdose

Answer 27

Flumazenil antidote contraindicated in combined TCA and benzodiazepine overdose