CURRENT Essentials of Critical Care.pdf

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Chapter 16 Toxicology 243■■■Tricyclic Antidepressant (TCA) OverdoseEssentials of Diagnosis• Constellation of findings reflecting direct CNS, anticholinergic,alpha-adrenergic blockade, direct cardiac effects• Mental status varies widely from alert to comatose• Anticholinergic: tachycardia, mydriasis, dry skin, urinary retention,ileus, fever, altered mental status, seizures• Cardiovascular: tachycardia, dysrhythmias, atrioventricularblock• Hypotension due to decreased cardiac contractility and alphaadrenergicblockade• ECG valuable for evaluating suspected TCA overdose; commonfindings include tachycardia, PR and QT prolongation, nonspecificST changes• QRS duration 100 ms suggests serious overdose with potentialfor significant arrhythmias or seizures; abnormal superior,rightward axis of terminal 40 ms of QRS (wide S in I, aVF andV 6 , with prominent R in aVR) strongly suggests TCA overdoseand can help discriminate TCA overdose from other drug overdosesDifferential Diagnosis• Phenothiazines, anticholinergic, theophylline, beta-blocker, calciumblocker, lidocaine overdose• CNS infection • Sepsis• Hypoglycemia • Head traumaTreatment• Cardiac monitor, urinary catheter, IV access• Gastric lavage if ingestion within 2 hours, followed by activatedcharcoal• Alkalinization of blood reverses most adverse effects, includinghypotension, cardiac arrhythmias, conduction abnormalities• Benzodiazepine for agitation or seizures; lidocaine for cardiacarrhythmias unresponsive to bicarbonate■ PearlBecause hypotension is facilitated by alpha-adrenergic blockade,phenylephrine (a pure alpha-adrenergic agonist) is more effective thandopamine for refractory hypotension.ReferenceKerr GW et al: Tricyclic antidepressant overdose: a review. Emerg Med J2001;18:236. [PMID: 11435353]
244 Current Essentials of Critical Care■■■Warfarin PoisoningEssentials of Diagnosis• Bleeding from single or multiple sites, with bruising, epistaxis,gingival bleeding, hematuria, hematochezia, hematemesis, menorrhagia• Prolonged PT, normal or prolonged PTT, normal thrombin time,normal fibrinogen level• Can occur either by ingestion of warfarin (drug) or ingestion ofrodenticides containing similar agents (most rodenticides containsmall amounts of anticoagulant and rarely associated withsignificant toxicity)• Allopurinol, cephalosporin, cimetidine, tricyclic antidepressant,erythromycin, NSAIDs, ethanol increase anticoagulant actionsof warfarin and contribute to toxicityDifferential Diagnosis• Other causes of coagulopathy, including liver disease, vitaminK deficiency, disseminated intravascular coagulation, sepsis-relatedcoagulopathyTreatment• Gastric decontamination within 1 hour of ingestion• For life-threatening bleeding, immediate reversal with freshfrozen plasma, IV vitamin K• For non-life-threatening bleeding, oral or IV vitamin K in patientsnot requiring long-term anticoagulation• For non-life threatening bleeding in patients requiring subsequentlong-term anticoagulation, partial correction with freshfrozen plasma• For prolonged PT without bleeding, observation alone usuallysufficient■ PearlWarfarin can be associated with several skin abnormalities includingurticaria, purple toe syndrome, and skin necrosis.ReferenceAnsell J, et al: Managing oral anticoagulant therapy. Chest 2001;119(1Suppl):22S. [PMID: 11157641]
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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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