CURRENT Essentials of Critical Care.pdf

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Chapter 16 Toxicology 231■■■Digitalis ToxicityEssentials of Diagnosis• Most asymptomatic but may have anorexia, nausea, vomiting,visual changes (amblyopia, photophobia, scotomata, yellow halos),abdominal pain, headache, hallucinations, drowsiness• Cardiac dysrhythmias of virtually any type can occur, includingbradycardia, AV dissociation, supraventricular tachycardia, ventriculartachyarrhythmias• Toxicity can occur from acute, chronic, or acute plus chronicuse; potential for toxicity increased by age, coexisting conditions,hypokalemia, hypomagnesemia, hypercalcemia, hypoxia,other cardiac medications• High potassium and digoxin levels seen in acute, but not necessarilywith chronic toxicityDifferential Diagnosis• Ingestion of cardiac glycoside-containing plants, including foxglove,oleander, lily of the valley, dogbane, red squill• Calcium channel blocker, beta-adrenergic blockers• Tricyclic antidepressant overdoseTreatment• Discontinue digitalis• Emesis or gastric lavage if recent ingestion; multidose activatedcharcoal may be beneficial even if substantial time elapsed fromingestion due to enterohepatic recirculation• Monitor cardiac rhythm• Check electrolytes, digitalis level; replace potassium and magnesiumif low• Purified digoxin-specific antibodies (Fab) indicated for ventriculararrhythmias, bradyarrhythmias, severe hyperkalemia withpotassium level 5.0 mEq/L, or digoxin level exceeding 10–15ng/mL• If digoxin-specific Fab not available in face of ventricular arrhythmia,phenytoin and lidocaine are drugs of choice■ PearlHyperkalemia from digitalis toxicity should not be treated with intravenouscalcium chloride, as this may exacerbate intracellular hypercalcemiaand cause intractable ventricular tachyarrhythmias.ReferenceEichhorn EJ, Gheorghiade M: Digoxin. Prog Cardiovasc Dis 2002;44:251.[PMID: 12007081]
232 Current Essentials of Critical Care■■■Iron OverdoseEssentials of Diagnosis• GI symptoms 2 hours; abdominal pain, vomiting, diarrhea, hematemesis,hematochezia; few symptoms seen 6–24 hourspostingestion• Shock, coma, coagulopathy, acidosis, multisystem organ failuremay occur after 6–72 hours; most deaths occur during this phase• Hepatic necrosis occurs within 48 hours of ingestion with orwithout shock; second most common cause of death• Late complications: bowel obstruction at 2–4 weeks• Iron overdose during pregnancy associated with spontaneousabortion, preterm delivery, maternal death• Serum iron level drawn 4–6 hours postingestion 500 g/dLsignificant; prognosis worsens with level 1000 g/dL; levelsdrawn 6 hours postingestion not useful• Iron tablets seen on abdominal radiographs verify ingestionDifferential Diagnosis• Other causes of acute abdominal pain or GI bleedingTreatment• Gastric lavage with large-bore tube followed by whole-bowelirrigation, particularly if tablets seen on abdominal radiograph• Chelation therapy for severe abdominal symptoms, altered mentalstatus, evidence of systemic hypoperfusion, or serum ironlevel 500 g/dL• Chelation with intravenous deferoxamine, usually 15 mg/kg/h;stop when symptoms resolved, serum iron level 150 g/dL,metabolic acidosis gone, urine color returns to normal• Deferoxamine should only be given after intravascular volumedeficits corrected to avoid acute renal failure; IV deferoxamineadministration 24–48 hours may precipitate acute respiratorydistress syndrome• Evaluation for liver transplantation if acute hepatic necrosis■ PearlIf GI symptoms do not occur within 6 hours of ingestion, iron ingestionwas likely nontoxic unless the patient ingested enteric-coated iron.ReferenceTran T et al: Intentional iron overdose in pregnancy—management and outcome.J Emerg Med 2000;18:225. [PMID: 10699527]
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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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