CURRENT Essentials of Critical Care.pdf

240 Current Essentials of Critical Care■■■Sedative-Hypnotic OverdoseEssentials of Diagnosis• Altered sensorium, confusion, dysarthria, ataxia, lethargy, stupor;initial symptoms similar to alcohol intoxication• With severe overdose, coma, respiratory and cardiovascular collapse• Horizontal and vertical nystagmus, depressed deep tendon reflexes,slow shallow respiratory efforts, pulmonary edema• All sedative-hypnotics similar except for duration of action,potential for prolonged effects, especially non-barbiturate/non-benzodiazepines, such as chloral hydrate, ethchlorvynol,glutethimide, meprobamate, methaqualone, methyprylonDifferential Diagnosis• Uremia• Hepatic encephalopathy• Hypoglycemia, hypothyroidism• Stroke, seizure, CNS infectionTreatment• Always have concern about co-ingestions• Intubation for airway protection if cough and gag reflexes aredepressed; fluid volume resuscitation for hypotension; vasopressorsoccasionally required for refractory hypotension• Gastric lavage if ingestion within previous 45 minutes; multidoseactivated charcoal decreases absorption and enhances eliminationin life-threatening phenobarbital overdose• Mannitol-induced diuresis and alkalinization aid in excretion oflong-acting barbiturates, but not other agents■ PearlBromide intoxication can cause abnormalities in anion gap determinationbecause the autoanalyzer cannot distinguish between bromideand chloride. Therefore, patients with altered mental status, highserum chloride, and narrow anion gap should have a bromide levelmeasured.ReferenceMokhlesi B et al: Adult toxicology in critical care: Part II: specific poisonings.Chest 2003;123:897. [PMID: 12628894]