CURRENT Essentials of Critical Care.pdf

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Chapter 16 Toxicology 229■■■Calcium Channel Blocker OverdoseEssentials of Diagnosis• Bradycardia, hypotension, heart block, and asystole• Drowsiness, metabolic acidosis, hyperglycemia, seizure, andcoma may also be seenDifferential Diagnosis• Beta-blocker toxicity• Barbiturate overdose• Antiarrhythmic toxicity• Tricyclic antidepressant toxicityTreatment• Supportive care• Gastric lavage for patients within 2–4 hours of ingestion; activatedcharcoal and cathartic agents if acute ingestion• For cardiotoxicity: calcium chloride, 10% 10 mL intravenously,or calcium gluconate, 30 mL intravenously initially, followedby repeated doses if needed• Glucagon, 0.1 mg/kg intravenous bolus followed by 0.1 mg/kg/hdrip, if intravenous calcium ineffective• Atropine and vasopressor agents such as dopamine or dobutaminein patients refractory to treatment■ PearlLarge ingestions of sustained-release preparations may result in formationof stomach concretions. Whole-bowel irrigation has been suggestedfor use in such ingestions.ReferenceProano L et al: Calcium channel blocker overdose. Am J Emerg Med1995;13:444. [PMID: 7605536]
230 Current Essentials of Critical Care■■■CocaineEssentials of Diagnosis• Tachycardia, hypertension, hyperthermia, agitation, and seizures• Cardiac dysrhythmias, including atrial fibrillation or tachycardia,ventricular tachycardia, or asystole• End-organ ischemia can cause stroke, myocardial infarction,bowel ischemia, renal infarction, limb ischemia; severe hypertensioncan lead to intracranial hemorrhage (subarachnoid or intraparenchymal)or aortic dissection• Pneumothorax or pneumomediastinum can be seen when cocainesmoked or snorted• Excess muscle activity can lead to rhabdomyolysis or hyperthermia• Can be used by snorting, smoking, or intravenous injectionDifferential Diagnosis• Sympathomimetic, theophylline, phencyclidine intoxication• Ethanol or benzodiazepine withdrawal• Thyrotoxicosis• CNS infectionTreatment• Supportive care• Active cooling measures for hyperthermia• Benzodiazepines for agitation and seizures• Phenobarbital or phenytoin for seizures refractory to benzodiazepines• Intravenous nitroprusside for severe hypertension• If myocardial ischemia or infarction, usual therapy except avoidbeta blockers because of potential for severe hypertension fromunopposed alpha-adrenergic stimulation; phentolamine may beused for coronary vasospasm• Intravenous fluids and alkalinization of urine for rhabdomyolysis■ PearlLidocaine is often ineffective for cocaine-induced ventricular dysrhythmias;consider cocaine toxicity in a young otherwise healthy patientin an agitated state with ventricular dysrhythmia unresponsiveto lidocaine.ReferenceShanti CM, Lucas CE: Cocaine and the critical care challenge. Crit Care Med2003;31:1851. [PMID: 12794430]
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a LANGE medical bookCURRENTESSENTIA
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ContentsPreface....................
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ContentsvLife-Threatening Hemoptysi
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Antineutrophil cytoplasmic antibodi
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Confusion, 227, 234, 235, 239, 240,
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Endoscopy, 170, 174gastric varices
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Hyperkalemia (continued)in endocrin
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Lidocaine, 8, 130, 230, 231, 243Lig
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Oxygen therapy, 87, 93for hypervole
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Respiratory failure, 56, 83, 86, 10
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Trismus (lockjaw), 156Trousseau sig
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