There is no role for Gastric lavage
Activated charcoal 1gm/kg x1 if <1 hour and patient awake and cooperative without signs of toxicity
Indications:
QRS >100ms, terminal RAD >120 deg, Brugada pattern, ventricular dysrhythmias
Initial Dosing:
Give 1-2 mEq/kg as rapid IVP; may repeat as necessary (stop if pH > 7.50-7.55)
May give as 3 ampules of 8.4% NaHCO3 (150 mEq) or 7.5% NaHCO3 (134 mEq)
Infusion Dosing
Mix 125-150 mEq of NaHCO3 in 1L of D5W; infuse at 250 mL/hr
Treatment Goal:
QRS <100ms
pH 7.50-7.55
May continue for 12-24hrs due to the drugs redistribution from tissue
Treatment Monitoring
Monitor for volume overload, hypocalcemia, hypokalemia, hypernatremia, metabolic alkalosis
Aggressively replace serum electrolytes
QRS >100ms, terminal RAD >120 deg, Brugada pattern, ventricular dysrhythmias
Give 1-2 mEq/kg as rapid IVP; may repeat as necessary (stop if pH > 7.50-7.55)
May give as 3 ampules of 8.4% NaHCO3 (150 mEq) or 7.5% NaHCO3 (134 mEq)
Mix 125-150 mEq of NaHCO3 in 1L of D5W; infuse at 250 mL/hr
QRS <100ms
pH 7.50-7.55
May continue for 12-24hrs due to the drugs redistribution from tissue
Monitor for volume overload, hypocalcemia, hypokalemia, hypernatremia, metabolic alkalosis
Aggressively replace serum electrolytes
Consider in patients unable to tolerate NaHCO3 (renal failure, pulm/cerebral edema)
Hyperventilate to pH of 7.50 - 7.55 (same as bicarb administration)
At 1.5 mg/kg, consider lidocaine for ventricular dysrhythmias if NaHCO3 alone is ineffective
Competitively inhibits sodium channel blockade effects of TCAs
Consider for ventricular dysrhythmias resistant to NaHCO3 and lidocaine
Appropriate in patients with persistent unstable tachydysrhythmias
NEVER use physostigmine in TCA overdose as the combination leads to lethal bradyarrhythmias
Due to dose dependent AV blockade by physostigmine
TCA toxicity and physostigmine interact synergistically to cause AV conduction delays
Due to dose dependent AV blockade by physostigmine
TCA toxicity and physostigmine interact synergistically to cause AV conduction delays
Benzodiazepines are 1st line
Barbituates or propofol are 2nd line
Phenytoin ineffective as no seizure focus in brain
After repeat fluid boluses and with sodium load from NaHCO3 norepinepherine should be the first line vasopressor
ECMO is a successful adjunct for refractory hypotension after maximal therapy has failed
May also consider 200 ml of hypertonic 3% saline for refractory hypotension and ventricular dysrhythmias despite maximal alkalinization (pH > 7.55)
Not useful for enhancing elimination due to the large volume of distribution and high lipid solubility
1.5 mL/kg bolus over 2-3 minutes if life-threatening toxicity refractory to bicarbonate administration
May be repeated once in 5 minutes if no improvement, followed by an infusion of 0.25 ml/kg/min for 15-30 minutes
Tricyclic antidepressant toxicity
Medications[1]
Antipsychotic toxicity
Atropine
Clonidine toxicity
Lomotil toxicity
Benzodiazepine toxicity
Antihistamines