• Consider complete workup if the above syndrome suspected or in the setting of altered mental status
• Stabilize airway, breathing, and circulation
• Patients may be hyper-alert/agitated or have reduced alertness
• Perform a complete neurologic evaluation
• Consider infection, particularly if fever is present
• Check electrolytes (esp glucose)
• Assess for trauma
• Perform toxicology screen & call local poison control center if + or high suspicion
Decontamination
• Activated charcoal: 1 g/kg PO/NG (max 50–60 g) (see below for sorbitol)
• Contraindicated in ileus/obstruction, hydrocarbons, caustics, lithium, Fe, boric acid, electrolyte solution, obtunded patient
• Substances poorly absorbed by charcoal: Electrolytes, iron, mineral acids/bases, alcohols, cyanide, most solvents, most water-insoluble compounds per recommendation of Poison Control, as standard for administration changes
• Orogastric lavage: Intubate prior to procedure if airway cannot be protected; lavage can be used if ingestion <1 hr PTA
• Contraindicated with caustic or hydrocarbon ingestions, co-ingestion of sharp objects
• Method: Place pt on left w/ head lower than body. Place OG tube (18–20°F in children, 36–40°F in adults). Lavage w/ NS 15 mL/kg/cycle (up to 200 mL) until gastric contents are clear
• Cathartics: May be used in conjunction with 1st dose of activated charcoal
• Sorbitol 2 cc/kg if >2 yr (not for children <2 yr), or Mg citrate 4–8 cc/kg – max 300 cc
• Contraindications: Caustic ingestions, no bowel sounds, recent bowel surgery. Avoid magnesium with poor renal function
• Whole bowel irrigation:
• Polyethylene glycol solution via cont NG infusion may be useful for toxic iron, lithium, or sustained release prep, ingestion of vials or whole packets of illicits or lead chips
• Contraindications: GI bleed or obstruction, ileus, unintubated obtunded/comatose pt
• Children: Polyethylene glycol (e.g., GoLYTELY) @ 500 mL/hr for 4–6 hr or till stools clear. Adults: 1–2 L/hr for4–6 hr
• Urine alkalinization:
• For elimination of weak acids (i.e., salicylates, barbiturates, and MTX)
• Bolus NaHCO3 1–2 mEq/kg, then D5W w/ NaHCO3 132 mEq/L at 1.5–2× maint
• Hemodialysis:
• For low–molecular-weight drugs; aspirin, theophylline, lithium, phenobarb, & alcohols
Acetaminophen Overdose (Pediatrics 2001;108:1020)
• Metabolites are hepatotoxic. Reactive intermediates can cause liver necrosis
• 5–10% of acetaminophen metabolized to NAPQI (toxic), detoxed by glutathione
• Four phases of intoxication
• First: P/w nausea, vomiting, anorexia, malaise, diaphoresis; nonspecific
• Second: Above sx resolve & develop RUQ pain, hepatomegaly & in some oliguria
• Inc LFTs and bilirubin levels, prolonged PT
• Third: 3–5 d into course return of N/V, anorexia w/ evidence of hepatic failure (jaundice, encephalopathy, coagulopathy, hypoglycemia). Can see renal and cardiac failure too
• Fourth: Recovery or death from liver failure
• Risk factors assoc w/ hepatotoxicity; multi-ingestion, <10 yo w/ inapprop dosing, delay initiation NAC, use sustained release form or co-admin w/ OTC drugs w/ acetaminophen
• Rectal admin w/ peak drug levels, which can vary up to 9-fold, often fail to reach therapeutic levels and have longer dosing intervals (q6–8h vs. q4h)
• History: Timing critical. Initial nonspecific symptoms NOT predictive of outcome
• Dose of ingestion: 120–150 mg/kg or >7.5 g is considered toxic
• PE: As above; in the -1st 24 hr nonspecific. Evidence of hepatotoxicity in 24–36 hr
• Labs: Plasma acetaminophen level at 4 hr predictive (use Rumack–Matthew nomogram) (Pediatrics 1975;55:871) or available online at www.utoronto.ca/kids/aceta.htm. Check baseline Chem 7, LFTs, coags
• Serum transaminases peak by 3–4 d after ingestion. Serum and urine toxicology
• Treatment
• Activated charcoal given if <8 hr since ingestion or if co-ingestion suspected
• Mucomyst: N-acetylcysteine: 20% NAC diluted 1:4 in carbonated beverage PO/PNG
• Loading: 140 mg/kg then 70 mg/kg/dose q4h × 17 doses. IV dosing below
Antidotes
