วันจันทร์ที่ 2 กันยายน พ.ศ. 2556


Psychiatric medicine

  • Symptoms present within 6 hr: coma, cardiac conduction delays, SVT, hypotension, respiratory depression, seizures; QRS >100 msec, RAD > 120 degrees, Brugada pattern, hypotension, VT
  • Tx: NaHCO3 therapy iv push+drip until improve or serum pH 7.5-7.55; BZD if seizure; NE if hypotension refractory to Tx
  • Serotonin syndrome (confusion, autoniomic, neuromascular (tremor, hyperreflexia), avoid meperidine, tramadol, dextromethorphan
  • Tx: Supprotive Tx, improve within 24 hr, cyproheptadine 4-12 mg po
  • EPS (acute dystonia, parkinsonism, tadive dyskinesia), Neuroleptic malignant syndrome (fever, muscle rigidity, increase CK)
  • Tx: EPS: Benztopine 1-2 mg iv/im, BZD; NMS: Supportive Tx, ETT, non-depolarizing agent, BZD, external cooling
  • N/V, diarrhea, polyuria, tremor, stupor, seizure, hypotension; EKG: QTc > 440, TWI
  • Tx: NSS 2L iv bolus then 200 ml/h, Na polystyrene sulfonate 15 gm PO qid, dialysis if level > 4 (>3.5 if chronic use)
  • Resemble-alcoholic toxicity, respiratory depression, hypotension, hypothermia, > 10 times of normal dose
  • Tx: Supportive Tx
  • Sedation
  • Tx: Flumazenil 0.2 mg iv(limited utility in ED)
NonBZD sedation
  • Sedation
  • Tx: Supportive Tx, iv β-blocker if chloral hydrate indure ventricular arrthymia

Elevated osmolar gap (highly suggestive if > 50) due to calculated serum osmolarity = 2Na + (BUN/2.8) + (glucose/18) + (ethanol/4.6) + (isopropanol/6.0) + (methanol/3.2) + (ethylene glycol/6.2)

  • Depressed mental status, hypoglycemia, horizontal gaze nystagmus, non significant anion gap acidosis
  • Tx: Supportive Tx, thiamine, metadoxine
  • Gastric irritation, potent CNS depression, ketonuria & ketonemia (acetone) without acidosis
  • Tx: Supportive Tx, HD if refractory hypotension or level > 400 mg/dL
  • GI toxicity (gastritis, pancreatitis, transaminitis), mild CNS depression, headache, vertigo, seizure, metabolic acidosis, visual change, photophobia, blurred or "snow field" vision, present > 12 hr after exposure
  • Tx: Fomipizole 15 mg/kg in > 30 min or 10% Ethanol 10 mL/kg (800 mg/kg) then 1.2 mL/kg/h or 40% ethanol 1.5-2.0 mL/kg PO then 0.2-0.5 mL/kg/h If methanol/ethylene glycol > 20 mg/dL or suspected toxicity with ethanol level < 100; folinic/folic acid 1 mg/kg (upto 50) iv for methanol; thiamine 100 mg iv + pyridoxime 50-100 mg iv + MgSO4 2 gm iv for ethylene glycol
Ethylene glycol
  • Gastritis, CNS depression, metabolic acidosis, renal failure (>24 hr), MOF due to calcium oxalate deposit(meningoencephalitis, CHF, ALI, myositis), hypocalcemia, urine monohydrate/dihydrate calcium oxalate crystals
  • Tx: as methanol
Opioid(include dextrometrophan)
  • Opioid intoxication toxidrome, circumstancial evidence (needle mark, tourniquet, drug paraphernalia, bystander); methadone: QTC > 500; propoxyphene (Na channel blockage): wide QRS, prolong QT, AV block, ventricular bigeminy; tramadol induced seizure(>500 mg po)
  • Tx: Naloxone 0.05 (dependent) - 0.4 (naïve) IV(IM/SC/nasal) for CNS depression; 2 mg iv q 3 min for apnea then drip 2/3 wake-up dose/hr; methadone: correct electrolyte; propoxyphene: NaHCO3 iv
Opioid withdrwal
  • Anxiety, yawning, lacrimation, diaphoresis, rhinorrhea, diffuse myalgias; 6-12 hr of last heroin use, 30 hrs of last methadone
  • Tx: Clonidine 5 g/kg PO if BP >90 mmHg, antidiarrhea, antiemetic, hydroxyzine 50-100 mg PO qid x 5d, methadone 20 mg PO or 10 mg IM; buprenorphine 0.3-1.2 mg IV/IM if admission
  • Symphatomimetic toxidrome, rhabdomyolysis (methylphenidate, ephedrine, pseudoephedrine, phenylpropanolamine)
  • Tx: Supportive Tx, BZD, cooling, iv fluid, Tx HT
  • Hallucination, bizarre behavior, symphatomimetic toxidrome (LSD, psilocybe, ecstasy, PCP, cannabis, dextrometrophan, etc.)
  • Tx: Supportive Tx, BZD, haloperidol
  • N/V, tinnitus, hearing loss, sweating, hyperventilation, triple-mixed acid-base (AG acidosis, metabolic alkalosis, respiratory alkalosis); Chronic toxicity: neurologic abnormality (tremor, papilledema, agitation, paranoid, bizarre behavior, memory deficits, confusion, stupor); ferric chloride test (10% FeCl several drops in 1 ml urine turn to purple)
  • Tx: Hydration, urine alkalinization, K replacement, after resuscitation all IV fliud should contain 5% dextrose; keep hyperventilation if on ventilator, early HD if Tx failure, renal insuff, severe symptoms
  • Toxic dose: >10 gms or 200 mg/kg/24hrs, >6 gms or 150 mg/kg/24hrs x 2 days; Rumack-Matthew nomogram, level not available in 8 hr if < 24 hr ingestion, APAP > 10 or AST/ALT increased if > 24 hr ingestion or unknown
  • Tx: Acetylcysteine 150 mg/kg IV load over 60 min then 50 mg/kg IV over 4 h then 100 mg/kg IV over 16 h
  • > 100 mg/kg: abdominal pain, N/V within 4 hr; mefenamic-seizure
  • > 400 mg/kg: coma, apnea, metabolic acidosis, electrolyte imbalance
  • Tx: Supportive Tx
  • N/V, symphatomimetic, adenosine antagonist (arrthymia, seizure); caffeine >100 mg/kg PO(1 cup/kg)
  • Tx: Supportive Tx, ondansetron, ranitidine, BZD, phenobarbital (dilantin=contra), β-blocker (metoprolol); HD if level >90 g/mL (acute), >40 with significant symptoms or comorbidities
  • N/V, mental status change, Bradyarrhythmias/SVT with AV block/Bidirectional VT; ventricular arrthymia (chronic), hyperkalemia (acute)
  • Tx: ECG monitoring; Digoxin Fab Ab if Bradyarrthymia (after atropine, pacemaker) VT(MgSO4 2-4 gm, lidocaine 1 mg/kg, (fos)phenytoin 15 mg/kg, cardioversion 10-25 J (last resort)), hyperkalemia (avoid Ca)
***Digoxin-specific Fab antibody: 5-10 vial iv bolus/drip in 30 min; Number of vial = PO mg x 0.8 x 2 or Level(ng/mL) x BW/100

  • Bradycardia, shock, ventricular arrthymai(sotalol), depressed mental status, bronchospasm, hypoglycemia/euglycemia
  • Tx: Glucagon 3-5 mg (0.05-0.15 mg/kg) IV slow push in 1-2 min จะออกฤทธิ์ใน 1-5 นาีที เห็นผลใน 10-20 นาที +/- IV drip 2-10 mg/h (ขนาดเท่ากับขนาดที่ทำให้ดีขึ้นใน 1 ชั่วโมง); NE, atropine, Insulin/glucose, 10% Ca Gluconate 0.6 ml/kg IV in 5 min ให้ซ้ำถ้า BP ไม่ดีขึ้นใน 10-20 นาที +/- IV drip 0.6-1.5 ml/kg/hr to raise ionized Ca level 2 x normal (ให้ได้จน corrected total Ca ประมาณ 14 mg/dL); NaHCO3 2-3 mEq/kg keep QRS<120 ms; Pacing
***Endpoint tx: EF > 50%, QRS <120 msec, HR >60, SBP > 90 mmHg, UO > 1-2 ml/kg/hr, improved mentation

***Hyperinsulinemia euglycemic tx: RI 1 U/kg iv then 0.5-1 U/kg/hr (RI 500 u in NSS 500 mL) ถ้า DTX < 200 mg/dL ให้ 50% glucose 50 mL (0.5 gm/kg) then 10Dw 100 ml/hr monitor glucose q 10-30 min until euglycemia, then monitor q 1 hr keep DTX 100-200; keep K > 2.5 (>3.5 in CCB toxicity)

  • Dihydropyridine (nifedipine > 50mg): systemic vasodilatation(flushed skin), tachycardia, mild-moderate hypotension; Diltiazem > 420mg/verapamil > 720mg: profound bradycardia, hypotension; Hyperglycemia
  • Tx: 10% Ca Gluconate/CaCl2 10 ml iv repeat upto 3 dose if no response, epinephrine, NE, insulin/glucose, glucagon, IABP, atropine, Intralipid fat emulsion
***Intralipid fat emulsion (IFE): 20% intralipid 100 ml (ในเด็กให้ 1.5 ml/kg) IV in 2-3 min ให้ซ้ำได้ในในขนาด 0.25-0.5 mL/kg/h เป็นเวลา 30-60 นาที ห้ามใช้ในผู้ป่วยที่แพ้ถั่วเหลือง (soybean) หรือไข่ (yolk egg) ภาวะแทรกซ้อนคือ fat emboli syndrome (เพิ่ม pulmonary vascular resistant การแลกเปลี่ยนก๊าสลดลง) ปกติจะไม่เกิดถ้า < 10 mL/kg/h

  • Hypotension; Diuretic: tachycardia, electrolyte abnormality; Symphatolytic: bradycardia; ACI/ARB: angioedema, hyperkalemia; Vasodilator (hydralazine): MI, tachycardia, lupus-like syndrome
  • Tx: IVF, NE, phenylephrine (alpha-blocker, hydralazine toxicity), high dose naloxone 1 mg iv upto total 10 mg (clonidone, ACEI)


  • IV: hypotension, bradycardia (prolong PR, wide QRS, ST/TW change); PO: nystagmus (force lateral gaze), ataxia, dysarthria, N/V, seizure (level > 30 g/mL), coma
  • Tx: Supportive Tx, corrected acidosis, reaccess level in 2-3 d after PO toxicity
  • coma, seizure, respiratory failure, cardiac arrthymia (wide QRS), anticholinergic toxidrome
  • Tx: Supportive Tx, NaHCO3(if wide QRS), HD
  • CNS & respiratory depression, hypotension, hypogly/Ca/Na/PO4, AG acidosis, transaminitis, increase NH3 & lactate, pancreatitis, thrombocytopenia; Level > 150 g/mL
  • Tx: L-carnitine 50mg/kg/d, high dose naloxone, HD
2nd generation anticonvulsant
Drowsiness; Felbamate (crystalluria, hematuria, ARF), Lamotrigine (seizure, wide QRS, QT prolong, pancreatitis), Tiagabine (seizure, myoclonus, muscle rigidity), Topiramate (seizure, non AG acidosis, renal stone)

Iron (ionic)
  • > 20 mg element iron/kg PO(FeSO4 20 tab), level > 500 g/mL, vin rose urine; 5 stage: (0-6h)GI irritation(vomit) -> (6-24h)latent -> (<24h)shock, lactic acidosis, coagulopathy, MOF -> (>2d)hepatic failure -> (4-6wk)gastric outlet obstruction
  • Tx: Deferoxamine 1000 mg IV/IM start 5 upto 15 mg/kg/h total 6 gm/24hr (360mg/d) if systemic symptoms, acidosis, level > 500; antiemetic, vitamin K, FFP
  • Aspirate pneumonitis, CNS depression, chronic numbness, GI irritation; Haloginate, aromatic: catecholamine sensitization induce ventricular arrthymia, renal toxic, transaminitis; RTA: toulene; Hydrocarbon-induced hemolysis: gasoline, kerosene, tetrachloroethylene, naphthalene, inhalation of mineral spirits; Benzene: AA, AML, MM; Delayed carboxyhemoglobinemia: methylene chloride exposure
  • Tx: Supportive Tx, no steroid, Arrthymia: avoid catecholamine/procainamide/amiodarone, Tx with propanolol, esmolol, lidocaine
    • Aliphatic HC(oil product): poorly absorbed
    • Aromatic HC(benzene, toluene, xylene)
    • Haloginate HC(CCl4, chloroform, Methylene chloride, Trichloroethylene, Trichloroethane, Tetrachloroethylene)
  • Local inflammation, perforation, lactic acidosis, AG/non AG acidosis
  • Tx: Endoscopy < 12 hr if intentional or unintentional with S&S of injury (burning, drooling, vomiting, food refusal)

  • Symphatomimetic (early), Cholinergic toxidrome (SLUDGE BAM), muscle fasciculation + miosis, QTc prolong; intermediate syndrome (proximal m. weakness) 1-4 days; delay neuropathy 1-3 wks; cognitive dysfn(chronic)
  • Tx: Atropine 2 mg iv double dose q 15 min until resolve from 3B (average 24 mg) + 2PAM 1-2 gm+NSS iv 5-10 min then 500 mg/hr
  • Cholinergic toxidrome
  • Tx: Atropine iv, single agent carbaryl poisoning ห้ามให้ 2PAM
Organochlorine (DDT, lindane)
  • Neurologic hyperexcitability, fever, seizure; Hydrocarbon poisoning (slovent): catecholamine sensitization
  • Tx: Supportive Tx, avoid catecholamine, BZD, cooling
  • Pyrithrine: Allergic hypersensitivity reactions (dermatitis, asthma, AR, pneumonitis, anaphylaxis); Pyrithroid: hyperexcitability, etc (nonspecific)
  • Tx: Supportive Tx
  • Restless, seizure, hypotension, bradycardia (heavy exposure)
  • Tx: Supportive Tx

(Paraquat or non-paraquat: glyphosate, chlorphenoxy-ยาฆ่าหญ้าตราม้าแดง, aniline dye)

Paraquat (Bipyridyl)
  • 4 signs (blue dye, oral burn, urine test positive (if neg in 24 hr-r/o), ARF); ไต(ARF) -> ตับ(hepatocellular necrosis 2-5d) -> ปอด(lung fibrosis > 5d)
  • Tx: PIP with low FiO2; AC/fuller’s earth/bentonite q 4 hr; Charcoal hemoperfusion as soon as possible; Dexa 30mg/d + cyclophosphamide + vit C,vit E
  • Corrisive burn from surfactant polyoxyethyleneamine
  • Tx: Supportive Tx, AC
  • Mimic organophosphate, hyperthermia, muscle fasciculation
  • Tx: Supportive Tx, urine alkalinization, HD
Aniline dye
  • Urea-substituted herbicides; methemoglobinuria
  • Tx: Methylene blue

Rodenticide(anticoagulant or non-anticoagulant (etc.))

  • >5 mg/d >5d; INR x 2 normal range then serial q 4 hr
  • Tx: Vitamin K1 1-5 mg(child), 20 mg/d bid-qid
Superwarfarin(-one, -coum)
  • INR 24-48 hr post ingestion
  • Tx: Vitamin K1 PO titrate to MT normal INR or iv < 1mg/min, FFP, Fc VII
  • Conscious seizure
  • Tx: Quiet environment, BZD, NM blockage
Zine phosphide
  • fishy breath, black vomitus, GI irritation, myocardial toxicity, shock, noncardiogenic pulmonary edema
  • Tx: Intragastric alkalinization with NaHCO3, dilution with water or milk, Tx hypocalcemia

  • Antidepressant, antihistamine, antipakinson, antipsychotic, antispasmodic, mydriatic, muscle relaxant, atropine, amanita; be careful & Tx Na channel blockage
  • Tx: Supportive Tx, adequate sedation (BZD), physostigmine 0.5-2 mg iv in 5 min + EKG monitoring (response in 15-20 min) if severe agitation not response to BZD

  • Acute: encephalopathy, seizure, coma, colicky abdominal pain, hemolysis, constitutional symptoms; Chronic: metallic taste, bluish gray gingival lead line; basophilic stripping, radiographic lead line at knee metaphysic & radioopaque in bowel, level > 10 g/mL
  • Tx: Dimercarprol(BAL), edetate calcium disodium (CaNa2EDTA), succimer (DMSA), consult toxicologist before Tx
  • Acute: N/V, cholera like diarrhea, metallic taste, torsades de pointes, MOF, urine arsenic > 0.1 mg/d; chronic: DM, HT, PAD, neuropathy, delirium, QT prolong, hyperpigmentation, keratoses, bowen disease
  • Tx: Dimercarprol (BAL), succimer (DMSA)
  • Element mercury: acute lung injury, poor GI absorbtion; Inorganic mercury: corrosive gastroenteritis, tremor, neurasthenia (fatigue, depression), erethism (easy blushing, extreme shyness), acrodynia (edema/erythema of the palms, soles, face)
  • Tx: Dimercarprol (BAL), succimer (DMSA)
  • Pulmonary irritation; NO2: triphasic illness (dyspnea, flulike symptoms -> transient improvement -> worsening dyspnea 24-72 hr after exposure)
  • Tx: Supportive Tx
  • Headache, vomiting, confusion, high O2 saturation; elevate COHb (VBG with co-oxymetry), lactate, AG acidosis, CPK, troponin
  • Tx: High concentration O2; HBO if neurological symptoms, syncope, MI, COHb > 25% or >15% in pregnancy
Cyanide; acetonoitrile
  • Profond hypoxemia symptoms, almond ador, cherry-red skin, unexplain lactic acidosis (>10), decrease arterial-mixed venous oxygen difference
  • Tx: 100% O2, IVF, vasopressor, NaHCO3; Amyl nitrite inhale over 30s (if no iv), 3% Na nitrite 10ml iv > 5min (300 mg)(avoid if severe hypotension + unclear dx), 25% Na thiosulfate 50mL (12.5 gm) + repeat; Hydroxocobalamin 5 mg iv > 30 min
  • Pulmonary irritation, cyanide symptoms, rotten egg odor
  • Tx: 100% O2, nitrite component tx
  • Antimalaria, dapsone+cimetidine, local anesthetic, nitrite, nitrate: less symptomatic cyanosis, gray discoloration of skin, hypoxemia symptom, lactic acidosis, chocolate color blood, O2 sat 80-85%, false elevate PaO2, co-oxymetry
  • Tx: O2, IVF, 1%methylene blue 0.1ml/kg iv > 15 min, PRC or exchange transfusion if unstable
  • More cyanosis, milder symptoms, dark greenish-black color blood, false low O2 saturation
  • Tx: Supportive Tx, PRC or exchange transfusion if unstable

1 ความคิดเห็น:

  1. Paracetamol overdose: new accelerated regimen
    NAC 100 mg/kg + NSS 1000 mL drip in > 2 hr then
    NAC 200 mg/kg + NSS 1000 mL drip in > 10 hr
    + ondansetron IV ก่อนให้ NAC