Page 1729 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1198 PART 11: Special Problems in Critical Care

of the offending agent, supportive care, and benzodiazepines. Other exposure, the examination may reveal signs of a toxic syndrome (or
therapeutic options such as bromocriptine, amantadine, dantrolene, toxidrome). A toxidrome is a pattern of signs and symptoms that sug-
and electroconvulsive therapy have been used in severe cases. gests a specific class of poisoning—however, coingestions should still be
26
Malignant hyperthermia is an inherited disorder characterized by considered in patients presenting with a classic toxidrome. Common
hyperthermia, rigidity, and metabolic acidosis. It occurs in response to toxidromes are listed in Table 124-7.
inhalational anesthetic agents and succinylcholine, and is treated with
dantrolene.

DIAGNOSIS OF TOXIC INGESTION TABLE 124-7 Common Toxidromes
■ HISTORY AND PHYSICAL EXAMINATION Toxidrome Features Drugs Drug Treatment

Clinical features mandating consideration of drug overdose or poison- Anticholinergic Mydriasis Antihistamines Physostigmine (do not
use in cyclic antidepres-
Atropine
Blurred vision
ing are listed in Table 124-6. Whenever possible, a careful history should sant overdose because of
be elicited from the patient to identify potential drugs or toxins, the “Hot as a hare, Fever Baclofen potential worsening of
timing and amount of drugs taken, and the clinical course. Information dry as a bone, red Dry skin Benztropine conduction disturbances)
should be sought regarding prescription medications, over-the-counter as a beet, blind Flushing Cyclic antidepressants
drugs, herbal medications, dietary supplements, and illicit substances. as a bat, mad as a
Friends, relatives, and other involved health care providers (including hatter” Ileus Phenothiazines Sodium bicarbonate in
paramedics) should be questioned, and medications available to or in Urinary retention Propantheline cyclic antidepressant
the vicinity of the patient should be identified. The pharmacy on the overdose
medication label should be called to determine the status of all pre- Tachycardia Scopolamine
scription medications. Information gathered might prove unreliable Hypertension
or incomplete, particularly in cases of attempted suicide or illicit drug
abuse, but it may also favorably impact care. 27 Psychosis
Physical examination is directed toward evaluation and support of Coma
airway patency, respiration, and circulation (see above), followed by Seizures
rapid assessment of mental status, temperature, pupil size, muscle tone, Myoclonus
reflexes, skin, and peristaltic activity. In cases of a single or dominant
Cholinergic Salivation Carbamate Atropine
SLUDGE Lacrimation Organophosphates Pralidoxime for
organophosphates
TABLE 124-6 Clinical Features Mandating Consideration of Toxic Ingestion
Urination Physostigmine
Past history of drug overdose or substance abuse
Diarrhea Pilocarpine
Suicidal ideation or prior suicide attempt
GI cramps
History of other psychiatric illness
Emesis
Agitation
Wheezing
Stupor or coma
Diaphoresis
Delirium or confusion
Bronchorrhea
Seizures
Bradycardia
Muscle rigidity
Miosis
Dystonia
β-Adrenergic Tachycardia Albuterol β-Blockade (caution in
Cardiopulmonary arrest
asthmatics)
Unexplained cardiac arrhythmia
Hypotension Caffeine
Hyper/hypotension
Tremor Terbutaline
Ventilatory failure
Theophylline
Aspiration
α-Adrenergic Hypertension Phenylephrine Treat hypertension
Bronchospasm with phentolamine or
Bradycardia Phenylpropanolamine
Liver failure Mydriasis nitroprusside; not with
Renal failure β-blockers alone
Both β-and Hypertension Amphetamines Benzodiazepines
Hyper/hypothermia α-adrenergic
Rhabdomyolysis Tachycardia Cocaine
Mydriasis Ephedrine
Elevated osmol gap
Diaphoresis Phencyclidine
Elevated anion gap acidosis
Dry mucous Pseudoephedrine
Elevated oxygen saturation gap membranes
Hyper/hypoglycemia
Sedative-hypnotic Stupor and coma Anticonvulsants Naloxone for opioids
Hyper/hyponatremia
Confusion Antipsychotics Flumazenil for
Hyper/hypokalemia benzodiazepines
Polypharmacy (Continued)

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