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TOXICOLOGY 289 TABLE 10-2: Diagnosis: Acetaminophen Overdose (Continued) Reaction Treatment for adult Treatment for pediatric Wheezing or hypotension D/C NAC give supportive care D/C NAC give supportive care Diphenhydramine, 50 mg IVDiphenhydramine, 1 mg/kg up to 50 mg Consider decreasing infusion rate Consider decreasing infusion rate Consider ranitidine, 50 mg IVConsider ranitidine IV, 1 mg/kg up to 50 mg Consider epinephrine (1:1,000), 0. 3-0. 5 m L SQConsider epinephrine (1:1,000), 0. 1 mg/kg Consider fluids Consider fluids Restart NAC IV at slower rate in 1 hr if symptoms resolve or change to oral Restart NAC IV at slower rate in 1 hr if symptoms resolve or change to oral Source: From Bailey B, Mc Guigan MA. Management of anaphylactoid reaction to IV N-acetylcysteine. Ann Emerg Med 1998;31:710-715, with permission. (continued)

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290 TOXICOLOGY FIGURE 10-1: Relationship between Acetaminophen Overdose and Liver Toxicity. Probable hepatic toxicity Possible hepatic toxicity Hepatic toxicity unlikely 25%500 200 150 100 50 10 5 1 48 1 2 16 20 24Acetaminophen ( µg/ml plasma)

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TOXICOLOGY 291 TABLE 10-2: Diagnosis: Acetaminophen Overdose (Continued) Signs and Symptoms: Acetaminophen Overdose (Toxic Dose: 7. 5 g or >140 mg/kg) Stage I (first 24 hrs) Stage II (24-72 hrs) N/V ↑ LFT may be seen Diaphoresis Nephrotoxicity and pancreatitis may occur Pallor RUQ pain and tenderness Lethargy/malaise ↑ PT/INR, PTT, total bilirubin May be asymptomatic Oliguria, acute renal failure LFT may be normal ↑ Amylase and lipase Stage III (72-96 hrs) Stage IV (4 days to 2 weeks) ↑ LFT (LFT peaks during this period)Recovery slower in this phase Jaundice Labs may not normalize for several weeks Confusion (secondary to hepatic encephalopathy) ↑ LFT ↑ Ammonia Jaundice ↑ PT/INR, PTT, total bilirubin Confusion (secondary to hepatic encephalopathy) Hypoglycemia ↑ Ammonia Lactic acidosis ↑ PT/INR, PTT, total bilirubin Acute renal failure (secondary to acute tubular necrosis) Hypoglycemia Lactic acidosis Acute renal failure (secondary to acute tubular necrosis) Note: Alcoholics, malnourished individuals, and patients on anticonvulsives are more prone to liver injury at low doses

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292 TOXICOLOGY TABLE 10-3: Diagnosis: ETOH Withdrawal Disposition Unit/monitor bed Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet NPO Fluid Fluid diuresis is essential (100-150 m L/hr) Note: Give thiamine before giving any glucose-containing solution O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium, LFT, PT/PTT/INR, Mg, PO 4 , calcium, amylase, lipase, UA Radiology and cardiac studies CXR (PA and lateral), CT of head (if intracranial bleeding suspected from fall), ECG Special tests Serum/urine toxicology screen, ETOH level, vitamin B 12 and folate levels Consults Social services, ETOH rehabilitation, ?psychiatry Nursing Seizure precaution, aspiration precaution, soft restraint PRN Avoid Carbamazepine, haloperidol (Haldol) (decreases seizure threshold) Management 1. Thiamine: 100 mg IV/IM, then 100 mg PO daily2. Folate: 1 mg PO daily3. Multivitamin: 1 amp IV, then 1 tablet daily (continued)

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TOXICOLOGY 293 4. Tylenol: 650 mg PO q4-6h PRN for headache (caution in liver toxicity) 5. Withdrawal syndromes: lorazepam (Ativan), 1 mg PO/IV tid-qid; chlordiazepoxide, 50-100 mg PO/IV q6h 6. Delirium tremens: diazepam, 2-5 mg slow IV/IM q5min until patient calm, or diazepam, 5-20 mg IV q5-10min, then lorazepam, 2 mg PO q4h, or diazepam, 5-10 mg PO tid, or chlordiazepoxide, 50-100 mg PO/IV q4-6h 7. Seizure: thiamine, 100 mg IV plus D 50W 50 m L IV, then lorazepam, 1-2 mg IV q5-10min × 2, diazepam, 5-20 mg IV q5-10min Note If refractory to high-dose benzodiazepines continue benzodiazepines and add phenobarbital, 130-260 IV q15-20min (get ready for intubation), or propofol, 1 mg/kg IV, induction agent for intubation Carbamazepine should be avoided in any withdrawal symptoms Lorazepam is minimally metabolized in liver (useful in patient with advanced cirrhosis) Phenothiazines, butyrophenones, and Haldol should be avoided because they ↓ seizure threshold Symptoms: ETOH Withdrawal Time elapsed after last drink Clinical finding correlating with time elapsed after last drink 6-36 hrs Anxiety GI upset Anorexia Headache Diaphoresis Tremulousness 6-48 hrs Generalized tonic-clonic seizure Status epilepticus (continued)TABLE 10-3: Diagnosis: ETOH Withdrawal (Continued)

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294 TOXICOLOGY TABLE 10-3: Diagnosis: ETOH Withdrawal (Continued) 12-48 hrs Hallucinations—visual (occasionally auditory or tactile) 48-96 hrs Agitation Fever Delirium HTN Diaphoresis Tachycardia ETOH level (mg/d L) >100 = intoxication >200 = lethargic >300 = coma Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised Score N/V Headache Paroxysmal sweats 0 No N/V Not present No sweat noted 1 Very mild Barely perceptible 2 Mild 3 Moderate 4 Intermittent nausea with dry heaves Moderately severe Beads of sweat noted on forehead 5 Severe 6 Very severe 7 Constant N/V and dry heaves Extremely severe Drenching sweats Score Anxiety Agitation Tremor 0 No anxiety No agitation No tremor 1 More than normal activity Tremor can be felt at fingertip (continued)

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TOXICOLOGY 295 TABLE 10-3: Diagnosis: ETOH Withdrawal (Continued) Score Anxiety Agitation Tremor 234 Moderately anxious Moderate fidgety and restless Moderate when hands are extended 567 Acute panic state/delirium Severely agitated Severe when hands are extended Score Auditory disturbance Visual disturbance Tactile disturbance 0 Not present Not present Not present 1 Very mild harshness Very mild photosensitivity Very mild paresthesia 2 Mild harshness Moderate photosensitivity Mild paresthesia 3 Moderate harshness Moderately severe photosensitivity Moderate paresthesia 4 Moderately severe hallucination Moderately severe hallucination Moderately severe paresthesia 5 Severe hallucination Severe hallucination Severe hallucination 6 Extremely severe hallucination Extremely severe hallucination Extremely severe hallucination 7 Continuous hallucination Continuous hallucination Continuous hallucination (continued)

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296 TOXICOLOGY TABLE 10-3: Diagnosis: ETOH Withdrawal (Continued) Score Orientation and clouding of sensorium 0 Oriented and can do serial additions 1 Cannot do serial additions 2 Disoriented to date by ≤2 days 3 Disoriented to date by >2 days 4 Disoriented to place and/or person Source: Reprinted from Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). Br J Addict 1989;84:1353, with permission. ICU Admission Criteria Age >40 Cardiac disease (CHF, arrhythmia, angina, recent MI) Hemodynamic instability Acid-base disturbance Electrolyte disturbance Respiratory insufficiency Infection (severe) GI condition (pancreatitis, bleed, peritonitis, hepatic insufficiency) Persistent temperature of >39°C (103°F) Rhabdomyolysis Renal insufficiency High dose of sedation requirement

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TOXICOLOGY 297 TABLE 10-4: Diagnosis: Anticoagulant Overdose Disposition Medical floor Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet PRN Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest Dx studies Labs CBC, PT/PTT/INR Radiology and cardiac studies CXR (PA and lateral), ?CT of head to r/o intracranial bleeding Special tests ?Fibrin split product, fibrinogen, ?serum/ urine toxicology screen Prophylaxis ? Consults Poison control, ?toxicology Nursing Stool guaiac Avoid ASA, warfarin, heparin Management INR above therapeutic and <5 but no significant bleeding hold warfarin ≥5 and <9 and no significant bleeding hold warfarin ≥5 and <9 and high risk of bleeding give vitamin K, ≤5 mg PO If rapid reversal needed 2-4 mg PO and 1-2 mg after 24 hrs >9 and no significant bleeding hold warfarin and give vitamin K, 5-10 mg PO (continued)

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298 TOXICOLOGY Severe bleeding with any INR hold warfarin and give vitamin K, 10 mg IV, slow infusion; supplement with FFP or prothrombin complex concentrate or recombinant factor VIIa depending on urgency; vitamin K, 10 mg IV slow infusion can be repeated q12h PRN Life-threatening bleeding with any INR hold warfarin and give prothrombin complex concentrate plus vitamin K, 10 mg IV slow. Recombinant factor VIIa can be considered as alternative to prothrombin complex concentrate. Source: From Ansell J, Hirsh J, Poller L, et al. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:204S-233S, with permission. TABLE 10-4: Diagnosis: Anticoagulant Overdose (Continued)

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TOXICOLOGY 299 TABLE 10-5: Diagnosis: ASA (Salicylate) Overdose Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet NPO Fluid MIVF ( Note: Be cautious in cerebral and pulmonary edema) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs Serial salicylate level q2h, BMP, calcium, LFT, Mg, PO4, CBC, PT/PTT/INR ABG, anion gap, lactic acid, ketones, DIC panel, UA Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Serum/urine toxicology screen, serum acetaminophen Prophylaxis ? Consults Poison control, nephrology, psychiatry, ?toxicology Nursing I/O, seizure precaution, aspiration precaution, suicide observation Avoid ? Management See Management: ASA (Salicylate) Overdose (continued)

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300 TOXICOLOGY TABLE 10-5: Diagnosis: ASA (Salicylate) Overdose (Continued) Signs and Symptoms: ASA (Salicylate) Overdose Hyperventilation Respiratory arrest N/V Dehydration Pancreatitis GI perforation Altered mental status Tachypnea Agitation Noncardiogenic pulmonary edema Tinnitus Hypotension Deafness Hyperthermia Seizure Cerebral edema Disseminated intravascular coagulation Bleeding Initially respiratory alkalosis, then high anion gap metabolic acidosis Management: ASA (Salicylate) Overdose Less than 50 mg/d L (asymptomatic) 51-110 mg/d L (mild to moderate toxicity)110-120 mg/d L (severe toxicity) Activated charcoal (1 g/kg; max: up to 50 g PO) in water or sorbitol via NG tube Alkalinize urine with Na HCO 3 1. Give bolus of Na HCO3, 2-3 m Eq/kg IV push (adult dosage) 2. Then give maintenance of 132 m Eq Na HCO3 in 1 L D5W at 250 m L/hr (adult dose) 3. For pediatric patient use 100 m Eq Na HCO3 in 1 L D5W at 1. 5-2. 0 times maintenance Note: Do not use acetazolamide to alkalinize the urine (continued)

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TOXICOLOGY 301 TABLE 10-5: Diagnosis: ASA (Salicylate) Overdose (Continued) Consider hemodialysis in following conditions: 1. Profoundly altered mental status2. Pulmonary or cerebral edema3. Renal failure4. Salicylate level >100 mg/d L (7. 2 mmol/L)5. Seizure6. Severe acidosis7. Fluid overload that prevents the administration of Na HCO 3 8. Clinical deterioration despite aggressive and appropriate supportive care

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302 TOXICOLOGY TABLE 10-6: Diagnosis: Benzodiazepine Overdose Disposition Unit Monitor Vitals: BP Cardiac monitoring Electrolyte monitoring (blood glucose)Respiration monitoring Neuromonitoring Diet NPO Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs BMP, calcium, Mg, PO4, LFT Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Serum/urine toxicology screen, serum acetaminophen and ASA, ETOH level Prophylaxis ? Consults Poison control, ?psychiatry, ?toxicology Nursing Seizure precaution, aspiration precaution, suicide observation, oral airway at bedside Avoid Note: Avoid flumazenil in chronic benzodiazepine users and in mixed overdose. If used in these cases, flumazenil can precipitate seizure. Management Supportive care (respiratory support) (continued)

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TOXICOLOGY 303 May use activated charcoal in early presentation (50 g in water or sorbitol via NG tube) Flumazenil: 0. 2 mg IV over 30 secs 30 secs later 0. 3 mg IV over 30 secs 30 secs later 0. 5 mg (max: 5 mg); use with caution in chronic benzodiazepine users Signs and Symptoms: Benzodiazepine Poisoning Blurred vision Irritability Confusion Lethargy leading to coma Dizziness Poor muscle tone Hallucinations Respiratory depression Hypothermia Slurred speech Psychomotor agitation, combative Delirium Autonomic instability Seizure Elevated BP Tachycardia TABLE 10-6: Diagnosis: Benzodiazepine Overdose (Continued)

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304 TOXICOLOGY TABLE 10-7: Diagnosis: Carbon Monoxide Poisoning Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet NPO Fluid Heplock (flush every shift) O 2 100% O2 via high-flow face mask Activity Bedrest Dx studies Labs CBC, ABG, BMP, calcium, Mg, PO4, LFT, troponin q8h × 8, CPK-MB q6h × 3, UA Radiology and cardiac studies CXR (PA and lateral), ECG, head CT Special tests Carboxyhemoglobin level (arterial or venous sample is acceptable) Serum/urine toxicology screen, serum acetaminophen and ASA, lactic acid, ?ETOH level Prophylaxis ? Consults Poison control, ?psychiatry, ?toxicology, social services Nursing Seizure precaution, aspiration precaution, suicide observation Avoid ? Management See Management: Carbon Monoxide Poisoning (continued)

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TOXICOLOGY 305 TABLE 10-7: Diagnosis: Carbon Monoxide Poisoning (Continued) Signs and Symptoms: Carbon Monoxide Poisoning Nausea Vomiting Headache Lethargy leading to coma Malaise Seizure Management: Carbon Monoxide Poisoning Give 100% oxygen via high-flow face mask Continue 100% oxygen until carboxyhemoglobin level is <5-10% Consider hyperbaric oxygen if unconscious, cardiac dysfunction, acidosis, neurologic focus, or pregnancy

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306 TOXICOLOGY TABLE 10-8: Diagnosis: Cocaine Abuse Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet NPO Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, Mg, PO4, calcium, ABG (for withdrawal, decreased respiratory drive) Troponin q8h × 3, CPK-MB q6h × 4, LFT, UA and urine R&M Radiology and cardiac studies CXR (PA and lateral), ECG, CT of head if seizure occurs Special tests Serum/urine toxicology screen, ?HIV Prophylaxis ? Consults ?Psychiatry, social services, ?toxicology Nursing Seizure precaution, aspiration precaution Avoid Avoid nonselective β-blocker, succinylcholine Management Hyperthermia: cooling with ice water baths, mist and fans, and ice packs until a core temperature of 101-102°F is reached within 30-45 mins (avoid phenothiazines) Seizure control: benzodiazepines Sedation: benzodiazepines (continued)

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TOXICOLOGY 307 Chest pain/MI: benzodiazepines, ASA and nitrates ± calcium channel blockers and α-blockers (phentolamine) HTN: nitroprusside, nitroglycerin, phentolamine, or hydralazine (use with pregnancy) May use selective β-blocker (esmolol) but avoid nonselective due to its unopposed α activity Pneumothorax, hemothorax, and pneumomediastinum may be managed with tube thoracostomy, needle aspiration, or expectant management Tachyarrhythmias: calcium channel blocker and lidocaine (avoid nonselective β-blocker) Rhabdomyolysis: fluids and urine alkalization (mannitol and furosemide to have urine output of 3 m L/kg/hr) Signs and Symptoms: Cocaine Overdose HTN CNS bleed Tachycardia MI, stroke Bowel infarction Rhabdomyolysis Hyperpyrexia Seizures Arrhythmia (ventricular tachycardia, ventricular fibrillation) Diaphoresis Euphoria Obstetric complication (continued)TABLE 10-8: Diagnosis: Cocaine Abuse (Continued)

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308 TOXICOLOGY TABLE 10-8: Diagnosis: Cocaine Abuse (Continued) Signs and Symptoms: Cocaine Withdrawal Dysphoria Increased appetite Hypersomnia, vivid dreams Lack of energy (fatigue) Intense craving for the drug Dysphoric mood

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TOXICOLOGY 309 TABLE 10-9: Diagnosis: Digoxin Toxicity Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring, mainly K + Diet NPO Fluid Heplock (flush every shift) O2 PRN Activity Bedrest Dx studies Labs Digoxin level, BMP, calcium, Mg, PO4 Radiology and cardiac studies CXR (PA and lateral), ECG Special tests ?Serum/urine toxicology screen, ?serum acetaminophen and ASA Prophylaxis ? Consults Poison control, cardiology, ?psychiatry, ?toxicology, ?social services Nursing Seizure precaution, aspiration precaution Avoid Calcium and potassium-containing products Management See Management: Digoxin Overdose Signs and Symptoms: Digoxin Overdose Arrhythmia Abdominal pain Blurred vision Confusion/delirium Color perception disturbance Headache (continued)

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310 TOXICOLOGY TABLE 10-9: Diagnosis: Digoxin Toxicity (Continued) ↑ K+ N/V Management: Digoxin Overdose Perform GI decontamination if patient presents within 8 hrs of ingestion If serum K+ >5. 5 m Eq/L see Table 6-4 (avoid calcium) Digibind [digoxin-specific Fab antibody fragments (DSAF)] indications: Ventricular arrhythmias Bradyarrhythmias unresponsive to atropine or pacemaker Ingestion of >10 mg of digoxin in adults or ≥4 mg in children Plasma digoxin concentration above 10 ng/m L (13 nmol/L) Serum K+ >5. 5 m Eq/L in addition to life-threatening arrhythmia Administration of DSAF 1. The IV dose is given over 15-30 mins but can be given bolus in cardiac arrest 2. Dosing depends on steady-state serum digitalis concentration (SDC) or if total amount ingested is known 3. If total amount ingested is known, then follow A. Total body load (TBL) = dose ingested (mg) for digitoxin (which has 100% bioavailability) B. TBL = dose ingested (mg) × 0. 8 for digoxin (which has 80% bioavailability) C. Number of vials = TBL/0. 6 4. If steady-state SDC is not known A. Give 10 vials; repeat with another 10 vials if indicated B. Chronic toxicity: give 6 vials to an adult; one vial to a child (continued)

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TOXICOLOGY 311 TABLE 10-9: Diagnosis: Digoxin Toxicity (Continued) 5. If the steady-state SDC is known A. TBL = [SDC (mg) × 5. 6 × weight (kg)]/1,000 B. TBL = [SDC (mg) × 0. 56 × weight (kg)]/1,000 (Digitoxin has a much smaller volume of distribution: approximately 0. 56 L/kg) C. Calculation of the equimolar dose of DSAF Molecular weight of DSAF: 50,000; molecular weight of digitoxin: 781 I. Dose of DSAF (mg) = TBL × (50,000/781) = TBL × 64 II. 1 vial of DSAF contains 40 mg, which neutralizes approximately 0. 6 mg of digoxin (0. 6 × 64 = 40). Thus, number of vials = TBL/0. 6If we substitute this in equations A and B, where 0. 6 divides roughly easily into the volumes of distribution for digoxin and digitoxin (5. 6 and 0. 56, respectively): D. Number of vials for digoxin = [SDC × weight (kg)]/100 E. Number of vials for digitoxin = [SDC × weight (kg)]/1,000 Hemodialysis or hemoperfusion can help control hyperkalemia or volume overload Source: From Antman EM, Wenger TL, Butler VP, et al. Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments. Final report of a multicenter study. Circulation 1990;81:1744, with permission.

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312 TOXICOLOGY TABLE 10-10: Diagnosis: Ethylene Glycol Overdose Disposition Monitor bed/unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet NPO Fluid Fluid diuresis essential O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs UA, check urine for crystals, BMP, Mg, PO4, calcium, serum osmolality Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Serum/urine toxicology screen, serum acetaminophen and ASA, ETOH level Prophylaxis ? Consults Poison control, nephrology, ?psychiatry, ?toxicology, social services Nursing I/O, seizure precaution, aspiration precaution, suicide observation Avoid ? Management See Management: Ethylene Glycol Overdose Signs and Symptoms: Ethylene Glycol Overdose Lethargy leading to coma Tachypnea Flank pain Renal failure (acute tubular necrosis) (continued)

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TOXICOLOGY 313 TABLE 10-10: Diagnosis: Ethylene Glycol Overdose (Continued) Pulmonary edema Calcium oxalate crystals in urine Management: Ethylene Glycol Overdose Supportive care Calculate osmolal gap Forced diuresis with IVF and mannitol: bolus: 0. 5-1 g/kg, then 0. 25-0. 5 g/kg q4-6h; usual adult dose: 20-200 g/24 hrs Fomepizole (Antizol): loading dose of 15 mg/kg IV, then 10 mg/kg IV q12h for 4 doses, then 15 mg/kg IV q12h thereafter until ethylene glycol level is <20 mg/d L and patient is asymptomatic with normal p H Ethanol: initial dose: 600 mg/kg IV (equivalent to 7. 6 m L/kg using a 10% solution), then Nondrinker: 66 mg/kg/hr (equivalent to 0. 83 m L/kg/hr using a 10% solution) Chronic drinker: 154 mg/kg/hr (equivalent to 1. 96 m L/kg/hr using a 10% solution) Dialysis if Severe acidosis ( Note: Continue ethanol during dialysis) Renal failure Ethylene glycol level of ≤50 mg/d L Folic acid: 50-70 mg IV q4h × day 1 Thiamine: 100 mg IM q6h Pyridoxine: 50 mg IM q6h Charcoal is not effective

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314 TOXICOLOGY TABLE 10-11: Diagnosis: Iron Overdose Disposition Medical floor Monitor Vitals Cardiac monitoring Neuromonitoring Diet NPO Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, LFT, PT/ INR/PTT, serum iron, TIBC, % saturation, TSH Type and cross PRBC Radiology and cardiac studies KUB (to determine tablets in intestine), ECG Special tests ?Serum/urine toxicology screen, ?serum acetaminophen and ASA Prophylaxis ? Consults Poison control, ?psychiatry, ?toxicology, ?social services Nursing I/O (maintain urine output >2 m L/kg/hr), seizure precaution, aspiration precaution Avoid ? Management Whole-bowel irrigation is treatment of choice (continued)

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TOXICOLOGY 315 If presentation ≤30 mins induce emesis (charcoal is not effective) 6 mos-1 yr: Ipecac syrup, 5-10 m L PO followed by 10-20 m L/kg of water 1 yr-12 yrs: Ipecac syrup, 15 m L PO followed by 10-20 m L/kg of water ≥12 yrs: Ipecac syrup, 30 m L PO followed by 240 m L of water Can repeat dose one time if vomiting does not occur within 30 mins If ≤20 mg/kg or unknown amount is ingested consider gastric lavage Left side down with head slightly lower than body Place large-bore orogastric tube and check position by injecting air and auscultating Perform gastric lavage with NS 15 m L/kg boluses until clear (max: 400 m L) If symptomatic or serum iron 350 mcg/d L Deferoxamine: 15 mg/kg/hr continuous infusion until serum level returns to normal range If severely symptomatic or serum iron 1,000 mcg/d L Exchange transfusion If hypotensive place patient in Trendelenburg position and start IVF (10-20 m L/kg)TABLE 10-11: Diagnosis: Iron Overdose (Continued)

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316 TOXICOLOGY TABLE 10-12: Diagnosis: Lead Overdose Disposition Medical floor Monitor Vitals Cardiac monitoring Diet Regular Fluid Heplock (flush every shift) O2 PRN Activity Up ad lib Dx studies Labs CBC, BMP, calcium, LFT, Mg, blood lead level, serum iron level Radiology and cardiac studies CXR (PA and lateral), ECG, ?x-ray fluorescence Special tests ?Serum/urine toxicology screen, ?serum acetaminophen and ASA ?Free erythrocyte protoporphyrin, peripheral smear, ?NCV Prophylaxis ? Consults Poison control, ?toxicology, social services Nursing I/O, pulse oximeter, seizure precaution, aspiration precaution Avoid ? Management If blood level >70 mcg/d L and/or lead encephalopathy (treat for 5 days) Edetate calcium disodium 50 mg/kg/24 hr continuous infusion: 1. 0-1. 5 g/m 2 or 250 mg/m2/dose IM q4h Dimercaprol (BAL): 4 mg/kg/dose IM q4h (continued)

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TOXICOLOGY 317 Symptomatic without encephalopathy (treat for 3-5 days) Edetate calcium disodium continuous infusion: 1 g/m2 for 8-24 hrs or 167 mg/m2/dose IM q4h BAL: 4 mg/kg/dose IM × 1 dose, then 3 mg/kg/dose IM q4h Asymptomatic with blood level of 45-69 mcg/d LEdetate calcium disodium 25 mg/kg/24 hr: continuous infusion for 8-24 hrs or IV q12h or Succimer (Chemet): 10 mg/kg/dose PO q8h × 5 days followed by 10 mg/kg/dose PO q12h × 14 hrs TABLE 10-12: Diagnosis: Lead Overdose (Continued)

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318 TOXICOLOGY TABLE 10-13: Diagnosis: Methanol Overdose Disposition ?Monitor/?unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet NPO Fluid Fluid diuresis is essential (100-200 m L/hr) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs UA, check urine for crystals, BMP, calcium, Mg, PO4, LFT, CBC, serum osmolality Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Serum/urine toxicology screen, serum acetaminophen and ASA, ETOH level Prophylaxis ? Consults Poison control, nephrology, ?psychiatry, ?toxicology, ?social services Nursing I/O, seizure precaution, aspiration precaution, suicide observation, ?social services Avoid ? Management See Management: Methanol Overdose Signs and Symptoms: Methanol Intoxication Lethargy leading to coma Blindness CNS bleeding Pancreatitis (continued)

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TOXICOLOGY 319 TABLE 10-13: Diagnosis: Methanol Overdose (Continued) Management: Methanol Overdose Supportive care Forced diuresis with IVF and mannitol: bolus: 0. 5-1. 0 g/kg, then 0. 25-0. 5 g/kg q4-6h; usual adult dose: 20-200 g/24 hrs Antizol: loading dose of 15 mg/kg IV, then 10 mg/kg IV q12h for 4 doses, then 15 mg/kg IV q12h thereafter until ethylene glycol level is <20 mg/d L and patient is asymptomatic with normal p H Ethanol: initial dose: 600 mg/kg IV (equivalent to 7. 6 m L/kg using a 10% solution), then Nondrinker: 66 mg/kg/hr (equivalent to 0. 83 m L/kg/hr using a 10% solution) Chronic drinker: 154 mg/kg/hr (equivalent to 1. 96 m L/kg/hr using a 10% solution) Sodium bicarbonate Dialysis if Severe acidosis ( Note: Continue ethanol during dialysis) Renal failure Ethylene glycol level of ≤50 mg/d L Folic acid: 50-70 mg IV q4h day 1 Thiamine: 100 mg IM q6h Pyridoxine: 50 mg IM q6h Charcoal is not effective

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320 TOXICOLOGY TABLE 10-14: Diagnosis: Opioid Intoxication (Heroin, Morphine, Meperidine, Fentanyl) Disposition Unit Monitor Vitals Electrolyte monitoring Neuromonitoring Diet NPO Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC; keep O2 saturation >92% (monitor for respiratory depression) Activity Bedrest Dx studies Labs BMP, calcium, Mg, PO4, LFT, CBC, ABG Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Serum/urine toxicology screen, ?HIV Prophylaxis ? Consults Poison control, ?psychiatry, ?toxicology, social services Nursing Seizure precaution, aspiration precaution Avoid ? Management See Management: Opioid Intoxication (Heroin, Morphine, Meperidine, Fentanyl) Signs and Symptoms: Opioid Intoxication (Heroin, Morphine, Meperidine, Fentanyl) Abnormal mental status Miosis (pupillary constriction) Pulmonary edema Anaphylaxis (continued)

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TOXICOLOGY 321 TABLE 10-14: Diagnosis: Opioid Intoxication (Heroin, Morphine, Meperidine, Fentanyl) (Continued) Coma Hypotension and bradycardia Respiratory depression Acute respiratory acidosis Aspiration pneumonitis Management: Opioid Intoxication (Heroin, Morphine, Meperidine, Fentanyl) Naloxone (Narcan): 0. 4-0. 8 mg IV (preferred), IM, intratracheal, SQ q2-3min as needed; may need to repeat doses q20min Note If no response observed after 3 doses question the diagnosis Use 0. 1-to 0. 2-mg increments in patients who are opioid-dependent and in postoperative patients to avoid large cardiovascular changes Duration of action of naloxone is 1-2 hrs Nalmefene: single SQ or IM dose of 1 mg may be effective in 5-15 mins (longer half-life than naloxone) IV: Green-labeled product (1,000 mcg/m L): initially, 0. 5 mg/70 kg; may repeat with 1 mg/70 kg in 2-5 mins If opioid dependency suspected administer a challenge dose of 0. 1 mg/70 kg For postoperative opioid depression: blue-labeled product (100 mcg/m L): initial dose for non-opioid-dependent patient: 0. 25 mcg/kg followed by 0. 25 mcg/kg incremental doses at 2-to 5-min intervals

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322 TOXICOLOGY TABLE 10-15: Diagnosis: Opioid Withdrawal (Heroin, Morphine, Meperidine, Fentanyl) Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet NPO Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs BMP, calcium, Mg, PO4, LFT, CBC Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Serum/urine toxicology screen, ?HIV Prophylaxis ? Consults ?Poison control, ?psychiatry Nursing Seizure precaution, aspiration precaution, ?toxicology, social services Avoid Pentazocine, nalbuphine, butorphanol Management See Management: Opioid Withdrawal (Heroin, Morphine, Meperidine, Fentanyl) Signs and Symptoms: Opioid Withdrawal (Heroin, Morphine, Meperidine, Fentanyl) Mydriasis (pupillary dilatation) Piloerection Yawning Sneezing (continued)

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TOXICOLOGY 323 TABLE 10-15: Diagnosis: Opioid Withdrawal (Heroin, Morphine, Meperidine, Fentanyl) (Continued) Lacrimation, rhinorrhea Anorexia N/V and diarrhea Anxiety Management: Opioid Withdrawal (Heroin, Morphine, Meperidine, Fentanyl) Methadone: See table below to calculate dosing; avoid in severe liver disease Buprenorphine: 0. 1-0. 4 mg IM; slow IV q6h Clonidine: 1. 2 mg/day in divided doses Methadone Dosing Signs and symptoms0 Hrs 6 Hrs 12 Hrs 18 Hrs 24 Hrs Mydriasis Rhinorrhea Lacrimation Goose flesh N/VDiarrhea Yawning Cramps Restlessness Voiced complaints Abnormal vital signs0 points if no symptoms present; 1 point if the symptom is present; and 2 points if the symptom is severe. Give methadone, 1 mg, for each point.

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324 TOXICOLOGY TABLE 10-16: Diagnosis: Organophosphate Intoxication Disposition ?Monitor/?unit Monitor Vitals, oxygen saturation Cardiac monitoring Neuromonitoring (CNS depression) Diet NPO Fluid Heplock (flush every shift) O 2 100% O2 (be ready for intubation in acute intoxication) Activity Bedrest Dx studies Labs BMP, calcium, Mg, PO4, LFT, CBC RBC acetylcholinesterase (to confirm the diagnosis) Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Serum/urine toxicology screen, serum acetaminophen and ASA Prophylaxis ? Consults Poison control, ?pulmonary, ?psychiatry, ?toxicology, social services Nursing Foley catheter, seizure precaution, aspiration precaution, suicide observation Avoid ? Management See Management: Organophosphate Intoxication Signs and Symptoms: Organophosphate Intoxication First 24 hrs CNS depression Hypersecretion (continued)

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TOXICOLOGY 325 TABLE 10-16: Diagnosis: Organophosphate Intoxication (Continued) Cramps Lacrimation Weakness Salivation Muscle fasciculation Sweating Diarrhea Miosis Abdominal cramps Urinary incontinence First 24-96 hrs Respiratory and proximal muscle weakness Management: Organophosphate Intoxication Decontaminate GI tract and skin Airway management is essential Atropine: 2-5 mg IV q15min until bronchial secretions and wheezing stop (may require >1 g) Pralidoxime (2-PAM): 1-2 g IV over 30 mins or continuous infusion at 8 mg/kg/hr Diazepam: 0. 1-0. 2 mg/kg IV; repeat if seizurelike activity

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326 TOXICOLOGY TABLE 10-17: Diagnosis: Theophylline Overdose Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring: neuro check q1-4h Diet NPO Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, LFT, PT/ INR/PTT, theophylline level q6-8h, UA Radiology and cardiac studies CXR (PA and lateral), ECG Special tests ?Serum/urine toxicology screen, ?serum acetaminophen and ASA Prophylaxis ? Consults Poison control, ?psychiatry, ?toxicology Nursing I/O, seizure precaution, aspiration precaution Avoid ? Management See Management: Theophylline Toxicity Signs and Symptoms: Theophylline Toxicity Seizure Hyperthermia Rhabdomyolysis Tachyarrhythmia Respiratory alkalosis (continued)

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TOXICOLOGY 327 TABLE 10-17: Diagnosis: Theophylline Overdose (Continued) Hypokalemia Hypomagnesemia Hyperglycemia Hypophosphatemia Hypercalcemia Management: Theophylline Toxicity Activated charcoal: 1 g/kg/dose (max: 50 g) PO/NG; give first dose with sorbitol; repeat one-half of initial dose q2-4h if indicated If >20 mg/kg ingested or symptomatic consider gastric lavage Left side down with head slightly lower than body Place large-bore orogastric tube and check position by injecting air and auscultating Perform gastric lavage with NS, 15 m L/kg boluses, until clear (max: 400 m L) If serum level >60 mcg/m L or sign of neurotoxicity, seizure, coma, or life-threatening toxicity Consider hemoperfusion If seizure Ativan, 1-2 mg/min IV

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328 TOXICOLOGY TABLE 10-18: Diagnosis: TCA Overdose Disposition Unit Monitor Vitals Cardiac monitoring Neuromonitoring: neuro check q2-4h Diet NPO Fluid Diuresis is essential O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs ABG, BMP, calcium, Mg, UA, CBC Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Serum/urine toxicology screen, serum TCA level, acetaminophen and ASA Prophylaxis ? Consults Poison control, cardiology, neurology, psychiatry, ?toxicology Nursing Seizure precaution, aspiration precaution, suicide observation, pulse oximeter Avoid ? Management Lavage Activated charcoal: 1 g/kg/dose (max: 50 g) PO/NG; give first dose with sorbitol; repeat one-half of initial dose q4h if indicated (continue until level drops to therapeutic range) Magnesium citrate: 300 m L via NG tube × 1 dose (continued)

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TOXICOLOGY 329 Monitor acid-base: keep p H at 7. 5-7. 55 Na HCO3 50-100 m Eq (1-2 amp) IV over 5-10 mins, then 100-150 m L/hr (2 amp in 1 L D5W) If hypotension IVF and pressors If seizure benzodiazepines If conduction block consider pacer If ventricular tachycardia or premature ventricular contractions consider lidocaine or magnesium Indication for Na HCO3 Hypotension Arrhythmia Hemodynamic stable patient with QRS >100 msecs Seizures Signs and Symptoms: TCA Overdose Coma Respiratory depression Seizure Hypotension Arrhythmia Cardiac conduction defect ECG changes Sinus tachycardia, ventricular tachycardia, premature ventricular contractions Prolonged QT, which can lead to torsades de pointes QRS >100 msecs ↑ PR interval TABLE 10-18: Diagnosis: TCA Overdose (Continued)

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330 TOXICOLOGY TABLE 10-19: Toxins and Antidotes Toxin Antidotes Acetaminophen NACETOH Naloxone Anticholinergic Physostigmineβ-Blocker Glucagon Benzodiazepines Flumazenil Calcium channel blocker Calcium Carbon monoxide 100% oxygen, hyperbaric oxygen Copper, arsenic, gold Penicillamine Cyanide Sodium nitrate Sodium thiosulfate Digitalis Digoxin FABEthylene glycol Ethanol Heparin Protamine sulfate Iron Deferoxamine Isoniazid Pyridoxine Methanol Ethanol Methemoglobin Methylene blue Narcotics Naloxone/naltrexone Nitrates Methylene blue Organophosphate Atropine, pralidoxime Phenothiazines Benadryl Warfarin Vitamin K

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331 11 Symptoms OUTLINE Abdominal Pain (See Table 3-9) ETOH Withdrawal (See Table 10-3) 11-1. Altered Mental Status 33211-2. Anaphylaxis Reaction 33711-3. Chest Pain 339 Diarrhea (See Table 3-10)GI Bleed (See Table 3-11)Hemoptysis (See Table 8-6) 11-4. SOB 34211-5. Syncope 345

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332 SYMPTOMS TABLE 11-1: Diagnosis: Altered Mental Status Disposition ?Unit Monitor Vitals Neuromonitoring (if focal finding)Cardiac monitoring Electrolyte monitoring Diet ?Regular/?NPO Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity Quiet room, daily orientation, fall precaution Dx studies Labs CBC with differential, BMP, calcium, Mg, PO 4 , vitamin B 12 , folate, thiamine, LFT, TSH VDRL test/rapid plasma reagin, UA, troponin, ?ETOH level Radiology and cardiac studies CXR (PA and lateral), CT of head with and without contrast, abdominal flat-plate ECG, ?MRI Special tests ?EEG, ammonia, ?ABG, ?serum/urine toxicology screen, ?UA C&S, blood C&S, ?LP ?PTH, ?niacin Prophylaxis DVT Consults ?Neurology Nursing Check mental status every day Avoid ? Management See Management: Altered Mental Status (continued)

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SYMPTOMS 333 TABLE 11-1: Diagnosis: Altered Mental Status (Continued) Altered Mental Status History Baseline mental status History of stroke or seizure Risk factors of delirium History of cardiac, renal, hepatic disease History of psychiatric disorder History of stroke Poor nutrition Dehydration Multiple medication (polypharmacy)ETOH dependence Sedative dependence Sleep disturbance Recent surgery Review medications Physical examination (perform complete physical examination) Monitor BP, pulse, respiratory rate, temperature O 2 saturation Observe general appearance Look for signs of local and systemic infection Mini-Mental State Examination Look for signs of meningitis Detailed neurologic examination Look for signs of liver disease (continued)

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334 SYMPTOMS TABLE 11-1: Diagnosis: Altered Mental Status (Continued) Etiologies: Altered Mental Status Metabolic conditions Drugs Hepatic encephalopathy Drug withdrawal: ETOH, benzodiazepines, barbiturates Hypoglycemia/ hyperglycemia Amphetamines/cocaine Hypoxia/hypercarbia Antihistamines: diphenhydramine (Benadryl)/hydroxyzine (Atarax)Uremia Electrolyte disturbance Narcotics: propoxyphene and acetaminophen (Darvocet)/propoxyphene (Darvon)/meperidine (Demerol)Hyponatremia Hypercalcemia/ hypocalcemia Benzodiazepines: diazepam (Valium)/chlordiazepoxide (Librium)/flurazepam (Dalmane)Hypermagnesemia/ hypomagnesemia Acidosis Steroids Endocrinopathies Anticholinergic drugs Thyroid/parathyroid/ pituitary Antiparkinsonian drugs TCA/phenothiazine/lithium Vitamin deficiencies Anticonvulsants: phenytoin/ phenobarbital/valproic acid Vitamin B 12 /folate/thiamine Toxins: carbon monoxide/ lead/mercury/manganese Antimicrobials Third-and fourth-generation cephalosporins Porphyria Infectious Acyclovir, amphotericin B, quinines, isoniazid Meningitis Encephalitis Rifampin Abscess Cardiovascular drugs Neurosyphilis β -Blocker/digoxin/clonidine (continued)

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SYMPTOMS 335 Infectious Drugs Systemic infection Antineoplastic drugs Bacteremia/sepsis Immunosuppressive agents Neurologic Miscellaneous Stroke/TIA CHF and other cardiovascular causes Seizure Perioperative Head trauma Anesthesia/drug Hypertensive encephalopathy Anemia Embolism Malignancy Hypotension Migraine Fluid shift/electrolyte disturbance Vasculitis Dehydration Limbic encephalitis Sleep deprivation Depression Management: Altered Mental Status Perform Mini-Mental State Examination Sitter Geri Chair Low bed Control noise stimulation Sleep management Reorientation Treatment Thiamine: 100 mg IV or PO (continued) TABLE 11-1: Diagnosis: Altered Mental Status (Continued)

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336 SYMPTOMS TABLE 11-1: Diagnosis: Altered Mental Status (Continued) Use following modalities for safety and controlling agitation: Restraint (Posey vest, four-point restraint only in severe cases) Haloperidol (Haldol): 0. 5-2 mg IV or 2-5 mg IM or 0. 5-2 mg PO q30min (see max dose) Lorazepam (Ativan): 0. 5-2 mg IV q6h 0. 5-2 mg sublingual q30min (see max dose) Risperidone (Risperdal): 0. 5-1 mg PO bid Olanzapine: 2. 5-5 mg (Caution: may cause hyperglycemia and hypertriglyceridemia)

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SYMPTOMS 337 TABLE 11-2: Diagnosis: Anaphylaxis Reaction Disposition ?Unit/?monitor bed Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet Regular Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity Bedrest Dx studies Labs CBC with differential Radiology and cardiac studies CXR (PA and lateral) Special tests ?Mast cell tryptase (within 6 hrs of episode) Intradermal testing and skin testing as an outpatient Prophylaxis ? Consults Allergy immunology Nursing Remove all old clothing Avoid ? Management Acute allergic reaction Medications Dose (adult) Dose (pediatric) Benadryl 25-50 mg PO/IM/IV 1-2 mg/kg PO Loratadine (Claritin) 10 mg PO 5 mg POCetirizine (Zyrtec) 5-10 mg PO 2. 5-5. 0 mg POPrednisone 40-60 mg PO 1-2 mg/kg PO (continued)

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338 SYMPTOMS Mild to moderate anaphylaxis Medications Dose (adult) Dose (pediatric) Epinephrine 1/1,000 (1 mg/1 m L)Epi Pen: 0. 3 mg IM Epi Pen Jr. : 0. 15 mg IM Benadryl 25-50 mg PO, IM, IV1-2 mg/kg PO, IM, IV Ranitidine (Zantac) 50 mg IV 1. 0-1. 5 mg IVCimetidine (Tagamet)300 mg IV 5 mg/kg IV Prednisone 40-60 mg PO 1-2 mg/kg PO Methylprednisolone 125 mg IV/IM 1-2 mg/kg IV/IM Severe anaphylaxis (treat as above plus add the following) Epinephrine 1/10,000 (1 mg/10 m L)0. 005 mg/kg; give over 5 min (0. 05 m L/kg IV in 10 m L NS)0. 01 mg/kg; give over 5 min (0. 1 m L/kg IV in 10 m L NS) 1/100,000 (1 mg/100 m L)0. 75-1. 5 mg/kg IV give slowly (1 m L/min) Source: From Gavalas M, Sadana A, Metcalf S. Guidelines for the management of anaphylaxis in the emergency department. J Accid Emerg Med 1998;15:96-98, with permission. TABLE 11-2: Diagnosis: Anaphylaxis Reaction (Continued)

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SYMPTOMS 339 TABLE 11-3: Diagnosis: Chest Pain Disposition Monitor bed Monitor Vitals Cardiac monitoring Diet NPO except medication Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity Strict bedrest with bedside commode Dx studies Labs Troponin q8h, CPK-MB q8h, BMP, calcium, Mg, LFT, CBC, PT/PTT Radiology and cardiac studies ECG, CXR (PA and lateral), ?ABG, ?CT of abdomen PE is suspected: spiral CT or V/Q scan, ?venous Doppler of lower extremities Aortic dissection suspected: CT of abdomen and chest, cardiac echocardiogram [TTE/TEE (preferred)] Special tests ?Myoglobin q6h, lipid panel, TSH level, ?BNP, ?serum/urine toxicology screen Exercise stress test (see Chapter 1, Table 1-1), homocysteine level in young patient D -dimer if low risk for PE Prophylaxis ? Consults ?Cardiology, ?pulmonary Nursing Call physician if patient reports chest pain, stool guaiac (continued)

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340 SYMPTOMS Avoid Nitroglycerin in patient using sildenafil (Viagra), ASA and ACE inhibitors in pregnancy, caffeine-containing products; if renal insufficiency or pregnancy, avoid spiral CT Management Treat underlying cause; see below Assess patient: site/description/intensity (1-10)/radiation/ associated symptoms (N/V) Quick medical history (recent surgery, cardiac risks*) Assess for life-threatening conditions: MI/PE/aortic dissection/ tension pneumothorax/tachyarrhythmia Other conditions: GERD/esophageal spasm/herpes zoster/ costochondritis/anxiety If MI suspected transfer patient to unit 12-lead ECG (compare with previous ECG)0. 4-mg sublingual nitroglycerin × 3 q5min (check BP before giving nitroglycerin); if chest pain continues and severe pain consider morphine, 2-4 mg IV ( Note: Hold nitroglycerin if systolic BP <90 or pulse <50) ASA: 325 mg crushed Troponin × 3 (first now and q8h), CPK-MB q8h × 24h If pain not relieved by nitroglycerin or morphine consider Maalox, 30 m L, or GI cocktail If documented MI see MI protocol in Chapter 1 If GERD suspected consider Maalox, 30 m L, or Pepto-Bismol, 30 m L If PE suspected venous Doppler of lower extremity/?spiral CT/ ?V/Q scan/ABG (continued)TABLE 11-3: Diagnosis: Chest Pain (Continued)

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SYMPTOMS 341 If pneumothorax suspected get CXR (PA and lateral) Suspect aortic dissection: if back pain and ↑ BP get abdominal CT *Cardiac risks: positive FHx, age, gender, DM, HTN, obesity, dyslipidemia, smoker. TABLE 11-3: Diagnosis: Chest Pain (Continued)

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342 SYMPTOMS TABLE 11-4: Diagnosis: SOB Disposition Monitor bed/?unit Monitor Vitals, continuous O2 saturation monitoring Cardiac monitoring Electrolyte monitoring Diet PRN Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC with differential, CMP, ABG, troponin q8h × 3, CPK-MB q6h × 4, ?B-type natriuretic peptide Radiology and cardiac studies CXR (PA and lateral), ECG, ?spiral CT Special tests ?Myoglobin stat and then q6h, ?serum/ urine toxicology screen, ?blood C&S, ?urine C&S ?Carboxyhemoglobin, ?cardiac echo, ?PFT, ?methemoglobin Prophylaxis ? Consults ?Cardiology, ?pulmonary Nursing Stool guaiac Avoid ? Management Treat underlying cause1 L of NC can ↑ O 2 saturation by 3%, room air has 21% O2 Assess for associated symptoms (think of the following: MI, PE, pneumothorax) (continued)

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SYMPTOMS 343 Medical history [e. g., COPD; do not give high-flow O2 (<2-5 L O2)] Suspicion of possible CHF give furosemide (Lasix), 40-60 mg IV (can be repeated) Suspicion of COPD low-flow O2 (max: 6 L O2) methylprednisolone (Solu-Medrol), 80-120 mg IV q6-8h Wheezing/rhonchi breathing treatment [ipratropium and albuterol (Duo Neb)/albuterol] Suspect PE if recent history of surgery, oral contraceptive use, hypercoagulable state, immobilized Give 2 L O2 4 L 6 L and check O2 saturation If patient doesn't respond to 6 L of O2 call respiratory Give 40% Venti-Mask check ABG in 30 mins 100% Nonrebreather mask check ABG in 30 mins BIPAP settings: ventilation/oxygenation (14/6) check ABG in 30 mins Do not leave patient with COPD on high-concentration O2 for a long time; it can cause respiratory depression Consider intubation Note: See Guide Tables for ventilator setting Sometimes albuterol breathing treatment can cause tachyarrhythmia treat with levalbuterol (Xopenex), 0. 6-1. 25 mg q6-8h Oxygenation Modalities and Fi O2 Relationship NCO2 Fi O2 Modality Fi O2 1 L/min 25% Venturi mask (Venti-Mask) 50% 2 L/min 29% Simple O2 mask 60% 3 L/min 33% Partial rebreathing mask 75%4 L/min 37% Nonrebreathing mask 90%5 L/min 41% (continued)TABLE 11-4: Diagnosis: SOB (Continued)

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344 SYMPTOMS TABLE 11-4: Diagnosis: SOB (Continued) Pa O2 and saturation relationship Pa O2 30 60 75 Saturation 60% 90% 95% Note Venti-Mask is useful in patients who are CO2 retainers; it provides precise administration of O2 Fi O2 >60% for more than 3 days can lead to acute tracheobronchitis and diffuse alveolar damage Oxygenation over 4 L use humidifier NC can support only 6 L of O2 Oxygenation over 6 L use high-flow NC

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SYMPTOMS 345 TABLE 11-5: Diagnosis: Syncope Disposition Monitor bed Monitor Vitals Cardiac monitoring Neuromonitoring Diet Regular Fluid IVF (if orthostatic or dehydration) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC with differential, BMP, calcium, Mg, LFT, TSH, troponin level, UA Radiology and cardiac studies CXR (PA and lateral), CT/MRI of head, ?V/Q scan (PE), EEG, ECG, Holter, echocardiogram, carotid Doppler Special tests Check orthostatic BP, head-up tilt, ?urine C&S ?Serum/urine toxicology screen, ?ABG, ?lipid profile, CPK level (rhabdomyolysis) Prophylaxis ? Consults Cardiology, neurology Nursing Orthostatic BP, stool guaiac, TED stocking Avoid Antihypertensive medications, SSRI Management BP and pulse (orthostasis) (orthostasis: ↑ in pulse of >10 bpm or ↓ 20 mm Hg systolic BP or ↓ 10 mm Hg diastolic BP when patient changes from recumbent to an erect position (usually occurs when 15-20% of fluid has been lost) (continued)

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346 SYMPTOMS Treat underlying cause If vasovagal high-salt diet (salt tablets, sports drinks) and volume repletion with NS If orthostatic hypotension consider fludrocortisone or midodrine If ↑ heart rate search for etiology Etiologies: Syncope (Loss of Consciousness for Brief Period) Neurally mediated Orthostatic Vasovagal Drug-induced (see list below)Carotid sinus syndrome Autonomic nervous system failure: diabetes mellitus, ETOH, amyloid, parkinsonism Situational (cough/ postmicturition) Cardiopulmonary conditions Cardiac arrhythmia MI Sick sinus Aortic dissection AV block Pericardial tamponade/disease SVT/VT PE WPW syndrome/torsades de pointes Aortic stenosis Neurologic Hypertrophic obstructive cardiomyopathy TIA Pulmonary HTN Seizure Medication-induced Migraine Diuretics/vasodilators Psychogenic QT-elongating drugs Anxiety Quinidine, procainamide, disopyramide Hyperventilation (continued)TABLE 11-5: Diagnosis: Syncope (Continued)

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SYMPTOMS 347 TABLE 11-5: Diagnosis: Syncope (Continued) Sotalol, ibutilide, dofetilide, amiodarone Other Phenothiazines Metabolic (glucose)Amitriptyline, imipramine, ziprasidone (Geodon)Anemia (bleed) Erythromycin, pentamidine, fluconazole ETOH use Astemizole Cataplexy Droperidol Acute hypoxemia

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349 12 Symptom Management OUTLINE 12-1. Agitation/Anxiety (Behavioral Management) 351 Confusion (See Table 12-6) 12-2. Chest Congestion 35212-3. Cough/Throat Irritation 35312-4. Constipation Management 35412-5. Death (Pronouncing Death) 35712-6. Delirium 35912-7. Diarrhea 36112-8. Dizziness 36212-9. Dry Nose 363 12-10. Dyspepsia/Heartburn 36412-11. End of Life (Management of Patient with Dyspnea) 36512-12. Epistaxis 36612-13. Fall 36712-14. Fever (Temperature >100. 4°F) 36812-15. Glucose (High) 36912-16. Glucose (Low) 37012-17. Headache 371 Heart Rate (>100) (See Table 12-24)Heart Rate (<60) (See Table 1-8)Heartburn (See Table 12-10)

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350 SYMPTOM MANAGEMENT 12-18. Hiccups 372 Insomnia (See Table 12-23) 12-19. Laceration 37312-20. N/V 374 Nosebleed (See Table 12-12) 12-21. Pain Management 37512-22. Sinus Pause 37912-23. Sleep Disturbance/Insomnia 38012-24. Tachycardia (>100) 38112-25. Unresponsive Patient 382 OUTLINE

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SYMPTOM MANAGEMENT 351 TABLE 12-1: Agitation/Anxiety (Behavioral Management) Assess patient and check vitals Check medication list and electrolytes R/o delirium (see Table 12-6) Haloperidol (Haldol)*: 0. 5-2. 0 mg IV q30min or 2-5 mg IM or 0. 5-2. 0 mg PO q4-6h PRN (use with caution in elderly) or Lorazepam (Ativan): 0. 5-2. 0 mg IV/IM/PO q6-8h PRN (antidote: flumazenil, 0. 2 mg IV/30 secs) or Hydroxyzine (Vistaril, Atarax): 50-100 mg IM/PO q6-24h PRN (avoid in elderly) or Droperidol: 0. 625-2. 5 mg IV or 2. 5-10. 0 mg IM (may cause QT prolongation) or Risperidone: 0. 5-2. 0 mg PO and IM (prolong sedation) or Temazepam (Restoril): 7. 5-30. 0 mg PO qhs PRN, long half-life (antidote: flumazenil, 0. 2 mg IV over 30 secs) or Olanzapine (Zyprexa): 2. 5-10. 0 mg PO (prolong sedation; caution in patient with DM due to risk of hyperglycemia) or Ziprasidone (Geodon): 10-20 mg IM (as effective as Haldol; prolong sedation) or Quetiapine (Seroquel): 25-100 mg PO (may cause hypotension, prolong sedation) Consider Posey vest and/or four-point restraints to prevent injury to self and others *Haldol: Start lowest dose in elderly and have naloxone (Narcan), 0. 4-2. 0 mg q2-3min at bedside due to respiratory depression.

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352 SYMPTOM MANAGEMENT TABLE 12-2: Chest Congestion Guaifenesin/potassium guaiacolsulfonate (Humibid LA): 1-2 tablets q12h, 600-1,200 mg q12h or Guaifenesin: 100-400 mg PO q4h or 600-1,200 mg PO q12h or Pseudoephedrine: 60 mg PO q4h Chest PT (flutter)

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SYMPTOM MANAGEMENT 353 TABLE 12-3: Cough/Throat Irritation Guaifenesin (Robitussin)/brompheniramine and pseudoephedrine (Dimetapp), 10 m L q4h PRN; if congestion Robitussin DM, 10 m L q4h PRN or Benzonatate (Tessalon perles): 100-200 mg PO tid or Menthol (Cepacol Lozenges/Spray) PRN (also comes in sugar-free; good for diabetics) or Menthol/benzocaine (Chloraseptic Lozenges) PRN Note: Avoid Robitussin/Dimetapp in patients with HTN

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354 SYMPTOM MANAGEMENT TABLE 12-4: Constipation Management Note: Maintenance management may require more than one class of drugs Bulk laxative Psyllium (Metamucil, Perdiem, Fiberall) Methylcellulose (Citrucel) Polycarbophil (Fiber Con, Equalactin, Konsyl Fiber) Examples Bran powder: 1-4 tablespoon bid; onset >24 hrs Psyllium: 1 tsp daily-bid; onset >24 hrs Methylcellulose: 1 tsp daily-bid; onset >24 hrs Osmotic laxative Magnesium hydroxide (Milk of Magnesia) Magnesium citrate (Evac-Q-Mag) Sodium phosphate (Fleet enema, Fleet Phospho-Soda, Visicol) Examples Mg hydroxide/Mg sulfate: 20-30 m L daily-bid; onset 3-12 hrs Sodium phosphate: 45 m L in 12 ounces of water; may repeat in 10 hrs, before colonoscopy; onset 1-6 hrs Poorly absorbed sugar Lactulose (Cephulac, Chronulac, Duphalac) Sorbitol (Cytosol) Mannitol Polyethylene glycol and electrolytes (Colyte, Go LYTELY, Nu LYTELY) Polyethylene glycol (Mira Lax) Examples Sorbitol 70%: 30-60 m L daily-tid; onset 24-48 hrs Lactulose: 30-60 m L daily-tid; onset 24-48 hrs (continued)

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SYMPTOM MANAGEMENT 355 Polyethylene glycol: 4 L PO; administer over 2-4 hrs; useful before colonoscopy; onset <4 hrs Stimulant laxative Cascara sagrada (Colamin, Sagrada Lax) Castor oil (Purge, Neoloid, Emulsoil) Bisacodyl (Dulcolax, Correctol) Sodium picosulfate (Lubrilax, Sur-lax) Docusate sodium (Colace, Regulax SS, Surfax) Mineral oil (Fleet mineral oil) Examples Bisacodyl: 5-15 mg PO; onset 6-8 hrs Bisacodyl: 10 mg PR; onset 1 hr Cascara: 4-8 m L/2 tablets; onset 8-12 hrs Senna: 5-15 mg (max: 3 × daily) (useful in constipation due to narcotic use; onset 8-12 hrs) Rectal enema/suppository Phosphate enema (Fleet enema) Mineral oil retention enema (Fleet mineral oil enema) Tap water enema Soapsuds enema Glycerin bisacodyl suppository Examples Tap water enema: 500 m L PR until clear; onset 5-15 mins Phosphate enema: 120 m L PR; onset 5-15 mins (useful for acute constipation) Soapsuds enema: up to 1,500 m L PR; onset 5-15 mins (can cause mucosal damage) (continued) TABLE 12-4: Constipation Management (Continued)

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356 SYMPTOM MANAGEMENT Cholinergic agent Bethanechol (Urecholine) Colchicine (Colsalide) Misoprostol (Cytotec) Prokinetic agent Cisapride (Propulsid)* Tegaserod (Zelnorm) *This drug is available only through a limited-access program (by Janssen Pharmaceuticals and the U. S. Food and Drug Administration). TABLE 12-4: Constipation Management (Continued)

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SYMPTOM MANAGEMENT 357 TABLE 12-5: Death (Pronouncing Death) When called to pronounce death, check the following: 1. Respiration (should be absent)2. Pulse (should be absent)3. Pupillary reaction (should be fixed and dilated) 4. Reaction to pain stimuli sternal rub (should be absent) Document above being absent/present as well as date and time of examination Inform family member and primary care physician about the death Notify family member and ask family about having an autopsy performed Document probable cause of death Inform coroner if necessary Sign a death certificate Death Note: Time and Date Patient name and medical record number Admission date Today's date Time you were notified by a nurse. Time the patient was seen by you. Document the following being absent on examination: 1. Respiration (should be absent)2. Pulse (should be absent)3. Pupillary reaction (should be fixed and dilated)4. Reaction to pain stimuli: test with sternal rub or pressing on nail bed with metal (should be absent) Time the patient was pronounced dead, also document the date Document probable cause of death. (continued)

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358 SYMPTOM MANAGEMENT Document whether the patient's family was notified about having an autopsy performed. Document that next of kin was notified. Inform coroner (if required) Document that the family member and primary care physician were notified Your name and pager number TABLE 12-5: Death (Pronouncing Death) (Continued)

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SYMPTOM MANAGEMENT 359 TABLE 12-6: Delirium Assess patient Check vitals (BP, pulse, respiration, temperature), O 2 saturation, and I/O Check medications (examples of medications that can cause delirium) Atarax Propoxyphene and acetaminophen (Darvocet)Chlordiazepoxide (Librium) Diphenhydramine (Benadryl)Propoxyphene (Darvon)Diazepam (Valium) Flurazepam (Dalmane)Meperidine (Demerol)Vistaril Check labs CBC Troponin I ECG CMP UA ?CXR BGM Toxicology screen ?Urine C&S Management 1. Sitter 2. Geri Chair3. Low bed4. Environmental changes Keep windows open at day time for sunlight exposure Keep a clock and a calendar in the room for orientation Make sure patient wears glasses and hearing aids while awake 5. Make sure patient is well hydrated (be cautious in heart failure patients) 6. Restraint (Posey vest, four-point in extreme cases)7. May consider sedation at evening to prevent “sundowning” (continued)

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360 SYMPTOM MANAGEMENT 8. Haldol: 0. 5-2. 0 mg IV q30min or 2-5 mg IM or 0. 5-2. 0 mg PO or 9. Ativan: 0. 5-2. 0 mg PO sublingual q30min or 10. Olanzapine: 2. 5-5. 0 (max: 15 mg/day) PO daily or 11. Risperidone: 0. 5 mg PO bid (max: 6 mg/day in elderly); may cause hypotension or 12. Quetiapine: 25 mg PO bid (max: 800 mg/day) or 13. Clozapine: 12. 5 mg PO bid (max: 450 mg/day); may cause agranulocytosis or 14. Ziprasidone: 20 mg PO bid (max: 80 mg/day) or 10-20 mg IM bid (max: 40 mg/day) TABLE 12-6: Delirium (Continued)

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SYMPTOM MANAGEMENT 361 TABLE 12-7: Diarrhea If etiology infectious check stool leukocytes, ova, parasite, and culture, CBC with differential, Hep A, Ig M, and Ig G If etiology antibiotic-induced check stool for Clostridium difficile toxin A and B Fluid replacement Search etiology of diarrhea before starting antidiarrheal agents Bismuth subsalicylate (Kaopectate): 1,200-1,500 mg PO after loose bowel movement or Loperamide (Imodium): 2 capsules PO initially or Diphenoxylate and atropine (Lomotil): 2 tablets or 10 m L PO qid or Metamucil: 1-2 tablets with juice or Sucralfate (Carafate): 1 g PO 1 hr before meal and qhs Note: If C. difficile suspected start patient on treatment before receiving toxin results and place patient under isolation precautions

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362 SYMPTOM MANAGEMENT TABLE 12-8: Dizziness Assess patient and check vitals BGM low (50-60) give orange juice if <50 1 amp of glucose D 50 W (1 amp of D 50 W can ↑ glucose by 100) Check medications BP and pulse (check orthostasis) [Orthostasis: ↑ in pulse of >10 bpm or ↓ 20 mm Hg SBP or ↓ 10 mm Hg diastolic BP when patient changes from recumbent to an erect position (usually occurs when 15-20% of fluid has been lost)] Perform fecal occult blood test to r/o GI bleed Check 12-lead ECG to r/o arrhythmia Check electrolytes Studies to consider: echocardiogram, Holter monitor, tilt table, CT/MRI, carotid Doppler tilt table

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SYMPTOM MANAGEMENT 363 TABLE 12-9: Dry Nose OCEAN nasal spray or Saline nasal spray

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364 SYMPTOM MANAGEMENT TABLE 12-10: Dyspepsia/Heartburn Aluminum hydroxide, magnesium hydroxide, and simethicone (Maalox), 30 m L PO, or bismuth subsalicylate (Pepto-Bismol), 30 m L, or aluminum hydroxide, magnesium hydroxide, and simethicone (Mylanta), 30 m L PO, or aluminum hydroxide (Amphojel), 30 m L PO Omeprazole (Prilosec), 20 mg PO daily (PPI), or pantoprazole (Protonix), 40 mg PO daily (PPI), or H2 blocker or Metoclopramide (Reglan), 10 mg 30 mins before meal or GI cocktail: Maalox or Mylanta, 30 m L; plus viscous lidocaine (2%), 10 m L; plus atropine, hyoscyamine, phenobarbital, and scopolamine (Donnatal), 10 m L Consider GI evaluation

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SYMPTOM MANAGEMENT 365 TABLE 12-11: End of Life (Management of Patient with Dyspnea) Mild Severe Critically Ill Hydrocodone: 5 mg q4h or Morphine: 5-15 mg q4h or Morphine or fentanyl infusion Codeine: 30 mg q4h; can be given q2h for breakthrough doses Oxycodone and ASA (Percodan): 5-10 mg q4h Source: From J Am Coll Surg 2002;V194:381, Mosenthal AC, © American College of Surgeons, with permission.

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366 SYMPTOM MANAGEMENT TABLE 12-12: Epistaxis Assess patient and check vitals Have patient lean forward to avoid swallowing blood Apply pressure to distal part of nose Evaluate for anterior versus posterior Posterior bleed may require ear, nose, and throat (ENT) evaluation/consult Next step chemical cautery: silver nitrate, trichloroacetic acid Next step nasal packing Next step Epistat catheter Next step Epistat II catheter Next step Merocel nasal tampon Check CBC with differential and PT/PTT

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SYMPTOM MANAGEMENT 367 TABLE 12-13: Fall Assess patient and check vitals Stabilize patient (ABCs) and assess patient for injury Check medication list (also check list of medications that cause delirium) Ask current symptoms (dizziness, lightheadedness, headache, weakness) Search for etiology and treat appropriately Consider restraint chemical or physical restraint (Haldol, Posey vest) Note: Also see Agitation, Table 12-1, and Delirium, Table 12-6

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368 SYMPTOM MANAGEMENT TABLE 12-14: Fever (Temperature >100. 4°F) If first episode investigate etiology Consider acetaminophen (Tylenol): one 650 mg tablet PO immediately Consider cooling blanket; discontinue when temperature ≤102. 5°F Assess for phlebitis in patients with Foley, IV and arterial lines, decubitus ulcer, skin breakdown, rash Check previous CBC, CXR, cultures If suspicion of sepsis Order CBC with differential, UA, urine R&M, urine C&S Stool C&S, blood C&S × 2 15 mins apart from two different sites, stool C. difficile toxin A and B Also consider CXR (AP and lateral), sputum C&S, and acid-fast stain

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SYMPTOM MANAGEMENT 369 TABLE 12-15: Glucose (High) Assess patient and check vitals Check medication list Give insulin according to sliding scale Note: Insulin sliding scale may vary from institution to institution Check patient's last insulin/antihyperglycemic medication/other medications Check for patient's diet status Search for etiology: medications (e. g., steroids) Blood sugar SQ regular insulin to be given (units) 150-200 2201-250 4251-300 6301-350 8351-400 10401-450 12 Above insulin sliding scale varies from institution to institution If >400 check urine ketones, serum ketone, and BMP (serum ketone measures only acetoacetate) Check for serum β-hydroxybutyrate Recheck blood sugar in 45 mins to 1 hr after giving insulin Note: See Chapter 2 for types of insulin regimens

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370 SYMPTOM MANAGEMENT TABLE 12-16: Glucose (Low) Assess patient and check vitals Check for symptoms (sweating, tachycardia, dizziness, weakness) If between 50-60 give orange juice with crackers If symptomatic or <50 1 amp of glucose D50W (1 amp can ↑ glucose by 100) If no IV access glucagon 1 mg IM (side effects: N/V) Check blood sugar q30min to every hr until stable

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SYMPTOM MANAGEMENT 371 TABLE 12-17: Headache Assess patient and check vitals Check medications (nitroglycerin) Recent procedure (spinal tap, epidural) Check for focal neurologic deficits Consider CT or MRI of head if intracerebral pathology suspected Treatment: low-flow O2 1. Tylenol: 650 mg PO (check LFT; if high, consider alternative) or 2. NSAIDs: ibuprofen, 600 mg PO (check LFT; if high, consider alternative) 3. Antiemetics4. Narcotics (if no response to above modalities)5. Triptans or ergots for migraine headache (be cautious in setting of HTN)

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372 SYMPTOM MANAGEMENT TABLE 12-18: Hiccups Assess patient and check vitals Baclofen: 10-20 mg IV q8h first line Chlorpromazine (Thorazine): 25-50 mg PO/IM q6h second line Metoclopramide: 5-10 mg q6-8h second line Promethazine (Phenergan): 10 mg PO q6h second line Nifedipine: 10-20 mg daily-tid second line Amitriptyline: 10 mg PO tid second line Haloperidol: 2-10 mg IM second line

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373TABLE 12-19: Laceration Assess patient and check vitals Immunization Status Clean, Minor Wound All Other Wounds Tetanus-Diphtheria Toxoid (Td)Tetanus Immuno-globulin (TIG) Td TIG ≥3 doses received in immunization series Give only if last booster >10 yrs No If last booster >5 yrs No* <3 doses received or uncertain of immunization Yes No Yes Yes Td dosage: 0. 5 mg IM × 1 dose Td and TIG should be given on two separate sites *TIG is not given unless patient has humoral immune deficiency (e. g., HIV, agammaglobulinemia). Source: From MMWR Morb Mortal Wkly Rep 1991;40(RR-10):1.

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374 SYMPTOM MANAGEMENT TABLE 12-20: N/V Phenergan: 12. 5-25 mg IV/PO/IM/PR q4-6h or Prochlorperazine (Compazine): 5-10 mg IV over 2 mins, 5-10 mg PO/IM tid-qid, 25-mg suppository PR bid or Ondansetron (Zofran): 8 mg PO bid (if >12 yrs), 4 mg PO tid (if <12 yrs) or Trimethobenzamide (Tigan): 250 mg PO q6-8h, 200 mg IM/PR q6-8h or Reglan: 10 mg IV/IM q2-3h, 10-15 mg PO qid 30 mins before meal (recommended for patient with GI dysmotility)

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SYMPTOM MANAGEMENT 375 TABLE 12-21: Pain Management Note: Patient with DNR status be liberal with pain medication when managing pain Do not give Demerol with monoamine oxidase inhibitor (MAOI)— it can kill a patient Assess pain and document (location, intensity, quality, severity) Consider increasing pain medication dose if the patient is already on pain medication Search for etiology of pain consider treating the cause of pain Be cautious of using opiates in patient with hypotension Mild to moderate pain Tylenol: 325-650 mg PO/PR q4-6h (max: 4 g/24 hrs) or Codeine plus acetaminophen (30/300) (Tylenol #3): 1-2 tablets PO q4-6h or Tylenol with codeine elixir: 15 m L q4-6h or Salicylate ASA: 325-650 mg PO/PR q4-6h or Salsalate: 500-750 mg PO q8-12h or Propionic acids Ibuprofen: 200-600 mg PO q4-6h or Naproxen: 250-500 mg PO bid or Acetic acids Sulindac: 150-200 mg PO bid or Diclofenac: 50 mg PO bid-tid, 75 mg PO bid Moderate pain Acetic acids: ketorolac (Toradol), 10 mg PO q4-6h, 15-30 mg IM/IV q6h (max: 5 days) or Opioid agonist: Codeine: 0. 5-1. 0 mg/kg (15-60 mg PO/IM/IV/SQ q4-6h PRN, oral solution, 15 mg/5 m L) or (continued)

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376 SYMPTOM MANAGEMENT Propoxyphene: 65-100 mg PO q4h PRN or Opioid combination Darvocet: 2 tablets PO q4h PRN or Hydrocodone and acetaminophen (2. 5/500) (Lortab): 1-2 tab PO q4-6h PRN or Oxycodone and acetaminophen (2. 5/325) (Percocet): 1-2 tab PO q6h PRN or Oxycodone and ASA (5/325) (Percodan): 1 tab PO q6h PRN or Hydrocodone and acetaminophen (5/500) (Vicodin): 1-2 tab PO q4-6h PRN Opioid agonist-antagonist Pentazocine (Talwin): 30 mg IV/IM q3-4h PRN or Pentazocine plus naloxone (50/0. 5) (Talwin NX): 1 tablet PO q3-4h PRN or Butorphanol (Stadol): 0. 5-2. 0 mg IV or 1-4 mg IM q3-4h PRN or Stadol: 1 spray (1 mg) in 1 nostril q3-4h PRN Other Tramadol (Ultram): 50-100 mg PO q4-6h PRN (seizure can occur with concurrent use of antidepressants and patient with history of seizure disorder) Moderate to severe pain Morphine: 1-2 mg (max: 15 mg) IM/SQ or slow IV q4h PRN or Morphine CR (MS Contin): 30 mg PO q8-12h or Hydromorphone (Dilaudid): 2-4 mg PO q4-6h PRN or 0. 5-2. 0 mg IM/SQ or slow IV q4-6h PRN (continued)TABLE 12-21: Pain Management (Continued)

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SYMPTOM MANAGEMENT 377 Fentanyl [transdermal patch (Duragesic, Actiq)]: 25-100 mcg/hr (see Fentanyl Patch Dosing) Note 1 mg Dilaudid = 7 mg morphine; 1 mg morphine = 7 mg Demerol If allergy to codeine give Darvocet Darvocet is known to cause delirium in elderly Pain Medications, Onset of Action, and Dosing Equivalents between PO and IV Medication Onset (mins)Dosing (hrs) Equivalents Oral (mg)IV (mg) Codeine 10-30 4 200 120Dilaudid 15-30 4 7. 5 1. 5Levorphanol (Levo-Dromoran)30-90 4 4 2 Demerol 10-45 4 300 75 Methadone 15-60 4 30 10Morphine (Roxanol)15-60 4 30 10 MS Contin 15-60 12 90 — Oxycodone CR (Oxy Contin)15-30 12 30 — Propoxyphene 30-60 4 200 — (continued)TABLE 12-21: Pain Management (Continued)

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378 TABLE 12-21: Pain Management (Continued) Fentanyl Patch Dosing Compared to Other Narcotics, 1 mg = 1,000 mcg (Patch Takes 16 hrs to Take Effect) Fentanyl 25 mcg/hr 50 mcg/hr 75 mcg/hr PO/day IM/day PO/day IM/day PO/day IV/day Codeine (Tylenol plus codeine) 150-447 104-286 448-747 287-481 748-1,047 482-676 Oxycodone (Percocet) 22. 5-67. 0 12-33 67. 5-112. 0 33. 1-56. 0 112. 5-157. 0 56. 1-78. 0 Morphine 45-134 8-22 135-224 23-37 225-314 38-52Dilaudid 5. 6-17. 0 1. 2-3. 4 17. 1-28. 0 3. 5-5. 6 28. 1-39. 0 5. 7-7. 9 Fentanyl 100 mcg/hr 125 mcg/hr 150 mcg/hr PO/day IV/day PO/day IV/day PO/day IM/day Codeine (Tylenol plus codeine)1,048-1,347 677-871 1,348-1,647 872-1,066 1,648-1,947 1,067-1,261 Oxycodone (Percocet) 157-202 78. 1-101. 0 202. 5-247. 0 101. 1-123. 0 247. 5-292. 0 123. 1-147. 0 Morphine 315-404 53-67 405-494 68-82 495-548 83-97Dilaudid 39. 1-51. 0 8-10 51. 1-62. 0 10. 1-12. 0 62. 1-73. 0 12. 1-15. 0

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SYMPTOM MANAGEMENT 379 TABLE 12-22: Sinus Pause Assess patient and check vitals If <2. 5 secs and asymptomatic no treatment needed If 2. 5-3. 0 secs and asymptomatic atropine then epinephrine/ dopamine External pacer at bedside If >3 secs and asymptomatic pacer placement required If symptomatic pacer placement required Atropine: 0. 5-1. 0 mg IV q3-5min (max: 0. 04 mg/kg) Epinephrine: 2-10 mcg/min Dopamine: 5-20 mcg/kg/min

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380 SYMPTOM MANAGEMENT TABLE 12-23: Sleep Disturbance/Insomnia Restoril: 7. 5 mg PO qhs or Zolpidem (Ambien): 5 mg PO qhs (good for patient requiring less sedation) or Trazodone (Desyrel): 50-100 mg PO qhs (use 25 mg in elderly) or Sonata: 10-20 mg PO qhs (half the dose in elderly and patient with liver disease) or Alprazolam (Xanax): 0. 25 mg PO qhs (avoid in elderly or patient with delirium) or Benadryl: 25-50 mg PO qhs (avoid in elderly or patient with delirium)

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SYMPTOM MANAGEMENT 381 TABLE 12-24: Tachycardia (>100) Assess patient and check vitals Check temperature (a high temperature can cause tachycardia) Ask for any symptoms: lightheadedness/dizziness/syncope/ palpitation/shortness of breath/chest pain Check ECG: check for arrhythmia; see Chapter 1 for management Review medications Manage appropriately Note: Also see Table 1-9

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382 SYMPTOM MANAGEMENT TABLE 12-25: Unresponsive Patient Check code status ABCs Assess patient, check vitals, and O2 saturation If BGM low (<55) thiamine, 10 mg IV plus 1 amp of glucose D50W (1 amp can ↑ glucose by 100) Cardiac rhythm (12-lead ECG): look for arrhythmia, blocks, and MI CMP (chem 12) plus Mg ?Serum/urine toxicology If morphine-/other narcotic-induced give Narcan, 0. 2-2. 0 mg IV/IM/SQ q5min If benzodiazepine-induced give flumazenil, 0. 2 mg IV over 30 secs follow by 0. 3 mg IV at 1 min 0. 5 mg IV at 2 mins Note Flumazenil can cause seizure in patient who is on benzodiazepines chronically Flumazenil is contraindicated in hepatic encephalopathy Flumazenil may not be effective in chronic benzodiazepine users Note: Also see Table 11-1 and Table 12-6

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383 Index Page numbers followed by f indicate figures. A Abbreviations, 2-7 Abciximab, in ACS, 29Abdominal pain acute, symptoms of, 111-115. See also Acute abdomi-nal pain causes of, 115diarrhea with or without, 116-117 Abscess(es), tuboovarian, 160-161Abuse cocaine, 306-308. See also Cocaine abuse drug, cellulitis associated with, 132 ACE inhibitors. See Angiotensin-converting enzyme (ACE) inhibitors Acetaminophen in acute pancreatitis, 106antidote to, 330in fever, 368hydrocodone and in nephrolithiasis, 221in pain, 376 overdose of. See Acetamino-phen overdose oxycodone and in nephrolithiasis, 221in pain, 376 in pain, 375in pneumonia, 163in sickle cell crisis, 127in stroke, 244Acetaminophen overdose, 286-291, 290f diagnosis of, 286-287liver toxicity, 290fmanagement of, 287-289signs and symptoms of, 291 Acetazolamide, in hyperphospha-temia, 211 Acetic acid, in pain, 375Acetohydroxamic acid, in neph-rolithiasis, 221 Acetylcholine receptor antibodies, in myasthenic crisis, 234 N -Acetylcysteine (NAC), in aceta-minophen overdose, 287 adverse reaction to, 288-289dosing for, 287-288indications for, 287 Acetylsalicylic acid (aspirin) in ACS, 28in chest pain, 340in CHF, 37in cocaine abuse, 307in dyspnea, 365in giant cell arteritis, 277in MI, 32overdose of, 299-301. See also Acetylsalicylic acid (aspirin) overdose oxycodone and, in pain, 376in pain, 375in stroke, 243in TIA, 251

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384 INDEX Acetylsalicylic acid (aspirin) over-dose, 299-301 diagnosis of, 299management of, 300-301signs and symptoms of, 300 Acid(s) acetic, in pain, 375acetohydroxamic, in nephrolith-iasis, 221 acetylsalicylic. See Acetylsali-cylic acid (aspirin) folic. See Folic acid propionic, in pain, 375trichloroacetic, in epistaxis, 366zoledronic in hypercalcemia, 87, 207in hyperparathyroidism, 87 Acidosis, metabolic, 212-214. See also Metabolic acidosis ACS. See Acute coronary syndrome Activated charcoal in acetaminophen overdose, 287in acetylsalicylic acid (aspirin) overdose, 300 in benzodiazepine overdose, 303in ethylene glycol overdose, 313in methanol overdose, 319in poisoning, 284-285in TCA overdose, 328in theophylline overdose, 327 Acute abdominal pain causes of, 115diagnosis of, 111-112symptoms of, 111-115 epigastric, 114generalized, 114-115in left lower quadrant, 113-114 in left upper quadrant, 112-113 periumbilical, 114-115in right lower quadrant, 113-114 in right upper quadrant, 112-113 Acute coronary syndrome (ACS) diagnosis of, 27-29management of, 28-29ruling out, chest pain and, 22-26. See also Chest pain Acute idiopathic demyelinating polyneuropathy, 231-233. See also Guillain-Barré syn-drome Acyclovir for HSV in HIV infection, 147for HZV in HIV infection, 148 Adrenal crisis, 70-72 diagnosis of, 70DKA, 73-76lab evaluation in, 71-72management of, 71signs and symptoms of, 71vital signs in, 71-72 Aggrastat, in ACS, 29Aggrenox, in TIA, 251Agitation/anxiety, 351 β 2 -Agonist(s) in asthma, 256-257in COPD, 261 Airway management, organophos-phate intoxication and, 325 Albendazole, for Encephalitozoon intestinalis in HIV infection, 148 Albuterol in asthma, 256, 257in COPD, 261, 262in hyperkalemia, 198ipratropium and, in asthma, 257

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INDEX 385 Alcohol, antidote to, 330 Alcohol withdrawal, 292-296 Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, 294-296 diagnosis of, 292ICU admissions criteria for, 296management of, 292-293symptoms of, 293-294 Alcohol withdrawal syndrome, 293 Alendronate, in hyperparathyroid-ism and severe hyper-calcemia, 87 Alkalization, urine, in cocaine abuse, 307 Allergy(ies), penicillin, cellulitis associated with, 132 Allopurinol in gout, 275in nephrolithiasis, 221in pseudogout, 275 Alprazolam, in sleep disturbance/ insomnia, 380 Altered mental status, 332-336 causes of, 334-335diagnosis of, 332-333management of, 335-336patient history of, 333-334physical examination in, 333-334 Aluminum carbonate, in hyper-phosphatemia, 211 Aluminum hydroxide in dyspepsia/heartburn, 364in hyperphosphatemia, 211 Am Bisome, for Histoplasma cap-sulatum in HIV infec-tion, 148 Amikacin for Mycobacterium chelonae in HIV infection, 149for Mycobacterium fortuitum in HIV infection, 149 Aminoglycoside(s), 17 antipseudomonal β -lactam and, for Pseudomonas aeru-ginosa in HIV infection, 150 for Pseudomonas aeruginosa in HIV infection, 151 in pneumonia, 174in septic arthritis, 174 Aminophylline in asthma, 257in COPD, 261 Amitriptyline, in hiccups, 372Amlodipine, in aortic dissection, 68 Amoxicillin in COPD, for acute exacerba-tion, 262 in pneumonia, 167for Streptococcus pneumoniae in HIV infection, 151 Amoxicillin/clavulanate in diverticulitis, 134 Amphotericin B for aspergillosis in HIV infec-tion, 144 for Coccidioides immitis in HIV infection, 145 for Cryptococcus neoformans in HIV infection, 145-146 for Histoplasma capsulatum in HIV infection, 148 for Penicillium marneffei in HIV infection, 150 for thrush in HIV infection, 145 Ampicillin in acute complicated pyelone-phritis, 171 in bacterial meningitis, 155, 156in diverticulitis, 135

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386 INDEX Ampicillin ( Cont. ) gentamicin and in cholangitis, 93, 94in cholecystitis, 91 in prostatitis, 168in UTI, 181 Ampicillin/sulbactam in acute pancreatitis, 106in cholangitis, 93in cholecystitis, 91in diverticulitis, 135 in osteomyelitis, 158 in peritonitis, 108in PID, 160 Anaerobe(s), suspicion of, celluli-tis associated with, 132 Anaphylaxis reaction, 337-338 diagnosis of, 337management of, 337-338 Angiotensin-converting enzyme (ACE) inhibitors in CHF, 36, 38in MI, 32pancreatitis associated with, 104in stroke, 244 Animal bites, cellulitis associated with, 132 Anion gap, urine, in acute renal failure, 219 Antibiotic(s) in asthma, 258classifications of, 15-18in COPD, 262 for acute exacerbation, 262 in nephrolithiasis, 221in septic shock/sepsis, 176for suspicion of meningitis, 155 Antibiotic spectrum, 13-18 aminoglycosides, 17antibiotic classifications, 15-18carbapenems, 17-18cephalosporins, 16glycopeptide, 18 ketolide, 18macrolides, 17medication peak and trough levels, 18 PCNs, 15-16quinolones, 17tetracyclines, 17-18 Antibody(ies), acetylcholine receptor, 234 Anticholinergic agents, antidote to, 330 Anticoagulant overdose, 297-298 diagnosis of, 297management of, 297-298 Antiemetic(s), in headache, 371Anti-inflammatory drugs, nonster-oidal (NSAIDs) in headache, 371in pneumonia, 163 Antipseudomonal β -lactam, ami-noglycoside and, for Pseudomonas aerugin-osa in HIV infection, 150 Antizol, in methanol overdose, 319 Anxiety, 351Aortic dissection, 65-68, 66f classifications of, 66, 66fdescribed, 65, 66fmanagement of, 67-68 Aortic distention, 67-68Apnea test, in coma/brain death, 229-230 Arsenic, antidote to, 330Arteritis, giant cell. See Giant cell arteritis Arthritis septic, 172-174. See also Septic arthritis SLE and, 281

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INDEX 387 Arthroscopy, in septic arthritis, 173 ASA. See Acetylsalicylic acid (aspirin) Asacol, in ulcerative colitis, 110 Ascaris spp., pancreatitis associ-ated with, 105 5-ASES, pancreatitis associated with, 104 Aspergillosis, HIV infection and, 144 Aspiration, in septic arthritis, 174 Aspirin. See Acetylsalicylic acid (aspirin) Aspirin overdose. See Acetylsali-cylic acid (aspirin) over-dose Asthma, 256-258 diagnosis of, 256management of, 256-258 Asystole, 46-47, 46f diagnosis of, 46, 46fmanagement of, 47 Atenolol, in MI, 32Ativan in delirium, 359in theophylline overdose, 327 Atorvastatin, in MI, 32Atovaquone for Cryptosporidium parvum in HIV infection, 146 for Pneumocystis carinii in HIV infection, 150 Atrial fibrillation, 50-53, 51f, 53f Atrial flutter, 50-53, 51f, 53f Atropine in asystole, 47in bradycardia, 49in diarrhea, 361in dyspepsia/heartburn, 364in organophosphate intoxica-tion, 325 in sinus pause, 379Augmentin in COPD, for acute exacerba-tion, 262 in UTI, 180 Azathioprine, in SLE, 281Azithromycin for Bartonella spp. in HIV infection, 144 for Mycobacterium avium com-plex in HIV infection, 149 Aztreonam in acute pyelonephritis in preg-nancy, 171 metronidazole and in cholangitis, 94in cholecystitis, 91 in peritonitis, 108in pneumonia, 166in prostatitis, 169 B Bacitracin, in Clostridium difficile , 133 Baclofen, in hiccups, 372 Bartonella spp., HIV infection and, 144 Bath(s), sitz, in prostatitis, 168Benadryl in anaphylaxis reaction, 337, 338in sleep disturbance/insomnia, 380 Benzathine, for Treponema palli-dum in HIV infection, 152 Benzodiazepine(s) in alcohol withdrawal, 293antidote to, 330in cocaine abuse, 306-307in TCA overdose, 329 Benzodiazepine overdose, 302-303 diagnosis of, 302

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388 INDEX Benzodiazepine overdose ( Cont. ) management of, 302-303signs and symptoms of, 303 Benzonatate, in cough/throat irrita-tion, 353 Bethanechol, in constipation, 356 Bicarbonate, in hyperkalemia, 198 Bilevel positive airway pressure settings, 10 Bisacodyl, in constipation, 355 Bismuth subsalicylate in diarrhea, 361in dyspepsia/heartburn, 364 Bisoprolol, in CHF, 37, 38Bite(s) animal, cellulitis, 132human, cellulitis, 132 Bite block, in seizure, 237Blanket(s), cooling, in fever, 368Bleeding, GI, 118-119. See also Gastrointestinal (GI) bleeding β -Blocker(s) antidote to, 330in CHF, 37, 38in cocaine abuse, 307 Blood pressure (BP) classification of, 40-41control of, in SAH, 249high, 39-43. See also Hyperten-sive emergency management of, 41-43signs and symptoms of, 40 management of in stroke, 244in TIA, 251 BP. See Blood pressure Bradycardia, 48-49, 49f diagnosis of, 48, 49fmanagement of, 49Brain attack, 239-247. See also Stroke Brain dead, criteria for, 229Brain death, 227-230. See also Coma/brain death Brainstem reflexes, in coma/brain death, 229 Bran powder, in constipation, 354Breath, shortness of, 342-344. See also Shortness of breath Bulk laxatives, in constipation, 354 Bumetanide, in CHF, 37 Buprenorphine, in opioid with-drawal, 323 Burn injuries, cellulitis, 132Butoconazole, for vaginitis in HIV infection, 145 Butorphanol, in pain, 376Butyrophenone(s), in alcohol with-drawal, 293 C Calcitonin in hypercalcemia, 87, 207in hyperparathyroidism, 87 Calcium, in giant cell arteritis, 278Calcium acetate, in hyperphos-phatemia, 211 Calcium carbonate in hyperphosphatemia, 211in hypocalcemia, 205 Calcium channel blockers antidote to, 330in cocaine abuse, 307 Calcium chloride in hypermagnesemia, 202in hypocalcemia, 204 Calcium gluconate in hyperkalemia, 197in hypocalcemia, 205 Candida spp., HIV infection and, 144-145

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