Ebook The intensive care unit manual (2/E): Part 2
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Ebook The intensive care unit manual (2/E): Part 2
Drug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2on emergency medical system (EMS) and emergency’ department (ED) personnel (1) initiating the critical interventions of airway’ management and cardiovascular stabilization, (2) simultaneously obtaining a thorough history, and (3) targeting specific therapies based on the suspected exposure. Communic Ebook The intensive care unit manual (2/E): Part 2ation between the ED and the intensive care unit (1CU) will be paramount for continuing successful resuscitations in rhe ĨCU.Not all “drug overdoses”Ebook The intensive care unit manual (2/E): Part 2
are intentional. Toxic ingestions may be accidental or result from the ingestion of products stored inappropriately—for example, lye stored in a soda Drug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2 Occasionally, chronic medications precipitate acute toxicity’caused by a drug interaction or a change in drug metabolism. Acute management of poisoned patients will depend on the ingestion; however, disposition of patients following ICƯ care depends on whether or not the overdose was intentional..A Ebook The intensive care unit manual (2/E): Part 2lthough deep sedation and coma in patients admitted to the ICƯ may be attributed to a drug ingestion, patients with unclear histories should undergo eEbook The intensive care unit manual (2/E): Part 2
valuation for other causes of altered mental status. Intracranial pathologic conditions should be excluded by computed tomograpilic (CT) scan of the hDrug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2any suspected poisoning, including those resulting from “new” recreational drugs with serious toxic side effects, such as “bath salts” or synthetic cannabinoids (“K2/Spicc”), and new therapies including use of lipid therapy’ for hemodynamically significant poisonings.Mechanisms of InjuryDIRECT DRUG Ebook The intensive care unit manual (2/E): Part 2EFFECTSNearly all drugs produce harmful effects if taken in excessive amounts. Systemic toxicity is due to selective effects of the toxin or a metabolEbook The intensive care unit manual (2/E): Part 2
ite on specific targets, such as binding to specific receptors (therapeutic drugs), disruption of metabolic pathways (cyanide, salicylates, iron), celDrug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2a’/K’-ATPase by digoxin; anticholinesterase by organophosphates). Some toxins produce effects by several mechanisms, l or example, isoniazid causes both hepatotoxicity’via a cytochrome P-450 pathway’ metabolite and neurotoxicity via the inhibition of pyridoxal 5-phosphate. Pathologic effects may’ al Ebook The intensive care unit manual (2/E): Part 2so occur ar the sire of exposure as a result of cytotoxic chemical reactions (c.g., caustic acid or alkali ingestions) that damage exposed tissue.5575Ebook The intensive care unit manual (2/E): Part 2
585 -FRESENT1NG PROBLEMS FOR INTENSIVE CARE UNIT ADMISSIONCOMPLICATIONSAspiration occurs in poisoned patients as a complication of vomiting, orogastriDrug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2 diminisliing the risk of aspiration. Acute lung injury may complicate recovery following life-threatening ingestions. Hyperthermia may occur for several reasons: increased motor activity that occurs with agitation or seizures, direct drug effects on rhe hypothalamus (sy'mpathomi merles), or aspirat Ebook The intensive care unit manual (2/E): Part 2ion and pneumonia. Rhabdomyolysis (see Chapter 81) can occur in patients after prolonged periods of immobilization because of obtundation, protractedEbook The intensive care unit manual (2/E): Part 2
agitation or seizures, or cocaine or amphetamine use. Under these circumstances, aggressive hydration and maintenance of urine output are important. ADrug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2ple, from drug-induced hypotension. Acute hepatic failure (see Chapter 59) most commonly results from acetaminophen poisoning but may also occur because of the multiorgan effects of diffuse toxins such as mercury or iron.ManagementDIAGNOSTIC APPROACHInitial assessment of the airway, breathing, and c Ebook The intensive care unit manual (2/E): Part 2irculatory status (ABCs) and frequent reassessment are critical to monitoring the dynamic status of ongoing toxicity. Empty pill bottles or discussionEbook The intensive care unit manual (2/E): Part 2
s with family members regarding medicines available in the home are helpful in focusing the diagnostic workup. Physical examination should screen for Drug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2for conduction defects associated with cyclic antidepressants, calcium channel antagonists, beta-blockers, or digoxin. QR and QT prolongation herald impending cardiotoxicity and should be followed serially. Toxicology screening should be performed if the results will be available in a sufficiently s Ebook The intensive care unit manual (2/E): Part 2hort time frame to be clinically relevant. All patients with intentional ingestions should have an acetaminophen level checked to exclude a clinicallyEbook The intensive care unit manual (2/E): Part 2
silent, potentially' overlooked but treatable acetaminophen ingestion.THERAPEUTIC APPROACHAfter initial stabilization of rhe ABCs, certain therapies Drug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2on (50 mL of 50% dextrose). Patients with the triad of signs suggesting opioid toxicity (respiratory' depression, pinpoint pupils, and coma) warrant treatment with the opioid antagonist naloxone. TV fluid therapy is important in many patients with overdoses to compensate for volume losses associated Ebook The intensive care unit manual (2/E): Part 2 with vomiting. Parenteral benzodiazepine sedation is indicated for agitated or uncooperative patients because it may prevent rhabdomyolysis, hypertheEbook The intensive care unit manual (2/E): Part 2
rmia, and injuries to the patient or staff as well as decrease rhe risk of seizures.Gastrointestinal (GĨ) decontamination is no longer routinely' recoDrug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2ge-bore tube (Ewald tube) may be critical in patients ingesting large quantities of drugs not bound by' activated charcoal, such as iron or lithium. Tt can be life saving in serious calcium channel antagonist overdoses by' removing a clinically significant fraction of drug, decreasing toxicity. Orog Ebook The intensive care unit manual (2/E): Part 2astric lavage should only be considered in patients manifesting signs of toxicity following a potentially life-threatening ingestion, and only performEbook The intensive care unit manual (2/E): Part 2
it after the judging the patient’s airway to be protected, often necessitating endotracheal intubation.https://khothuvien.cori!57 -DRUG OVERDOSES ANDDrug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2-acetytcysteineOrally 140 mg/kg X 1; followed by 70 mg/kg every 4 hours X 17 doses IV: 150 rng/kg IV over (X) minutes, followed by an infusion ol 12.5 rng/kg/h over a 4 hour period, and finally an illusion ol 6.25 rng/kg/h ovex a 16 hour periodAnticholinergic agentsPhysostigmine1-2 mg IV over 5 minu Ebook The intensive care unit manual (2/E): Part 2tes: use with caution for severe delirium (may cause seizures, bronchospasm, asystole, cholinergic exists)1 tola adrenergic antagonistsGlucagon2 5 mgEbook The intensive care unit manual (2/E): Part 2
IV; titrate repeal doses; may use infusion of 2 lOmg/hCalcium channel blockersCalcium gluconate Insulin1 g (10 mL of 10% solution) IV over 5 minutes wDrug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2g/h; can bo titrated up to a rale of 1 U/kg/h with a dextrose infusion to maintain euglycomiaCyclic antidepressantsSodium bicarbonate1-2 mEq/kg IV; titrate to arterial pH of 7.5 or electrocardiographic alterations (see text)DigoxinDigoxin antibodies (Diglbind)Vials (number) - (digoxin level [ng/mL] Ebook The intensive care unit manual (2/E): Part 2X weight [kgjyiOOor 10-20 vials for a life-threatening arrhythmiaMethanol Ethylene glycolFomepizoleLoading dose of 15 mg/kg IV over 30 minutes: subseqEbook The intensive care unit manual (2/E): Part 2
uent 4 doses every 12 hours at 10 mg/kg: further dosing per poison centerOpioidsNaloxone0.05-0.4 mg IV. repeat as needed: infusion: two thirds of reveDrug Overdoses andToxic IngestionsPia Chatterjee ■ Jeanmarie PerroneSuccessful management of patients after a life threatening drug overdose depends o Ebook The intensive care unit manual (2/E): Part 2dialysis (the diffusion of high plasma drug levels back into the gut lumen to be bound to activated charcoal and excreted) or interruption of enterohcpatic circulation of active metabolites. Sustained release preparations (e.g., calcium channel blockers) and drugs nor bound to activated charcoal (e. Ebook The intensive care unit manual (2/E): Part 2g., lithium, iron) may be cleared from the gut using whole bowel irrigation. Bowel irrigation is performed with polyethylene glvcol-clectrolyte lavageEbook The intensive care unit manual (2/E): Part 2
solutions (c.g., GoLYTELY, CoLYTE) administered via nasogastric tube at a rate of 1 to 2 L/h in adults.The regional poison control center should be cGọi ngay
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