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92 Cards in this Set

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Anticonvulsant overview
ABC's due to primary CNS depression
Dextrose, O2, Naloxone, Thiamine
AMI? Also check, Bleed/Inf
Intentional OD? urine drug screen, APAP level, pregnancy, and ethanol
What OD ACs get levels checked?
PHY, CBZ, VPA, PB
PHY normal level?
when do peaks occur?
normal is 10-20 mcg/mL
IR peaks 1.5-3hour
ER peaks within 12h
Peak may be delayed 24-38h in OD...
Get serial levels!
PHY ADME
Formula??? (exam)
90% protein bound, so no dialysis
malnourished increases free levels
correct = measured/[(0.2xalbumin)+0.1]
normal alb level 3.5-5
Formula to correct for impaired renal function of PHY?
What CrCl requires this level?
crrct PHY = measured/[(0.1xalbumin)+0.1]
req'd for <20ml/min
What kinetics is PHY?
MM kinetics so in an OD situation the half-life roughly doubles
PHY with levels of...
>20?
>30?
>40?
>50?
>20 - nystagmus
>30 - ataxia, slurred speech
>40 - mental status changes
>50 - Coma; seizures
ON EXAM...
The only form of PHY that cause Cardiotoxic and how?
IV PHY causes dysrhythmias and hypotension with rapid admin. Due to propylene glycol solvent.
CBZ...
Therapeutic levels
time frames
Properties of note
therapy from 4-12mcg/mL... lower if on other drugs
Peak: suspension 1.5h, IR 6h, ER 12h
delayed in OD setting... bezoar
Anticholinergic.
Does MDAC benefit CBZ or PHY?
MDAC benefits CBZ only!
CBZ levels of...
>12?
>30?
>40?
>12 increased incidence of nystagmus
>30 CNS depression
>40 coma, seizures, cardiotox
tx seizures w/benzo!
other CBZ AE
Chronic?
dystonia use benadryl, Choreoathetosis
Chronic causes hyponatremia due to release of vasopressin
CV effects of CBZ may include
hypo, tachy, conduction abnormal, QT prolonger!! acute or chronic tox
When to admin AC with CBZ
due to anticholinergic effects, consider AC later. maybe up to 4 hours post ingestion?
CBZ hemodialyze? seizures? Dystonias?
no hemodialyze
seizure? use benzo
dystonia? use diphenhydramine
CBZ causes QRS widening. What to admin?
consider NaHCO3
VPA
Therapy level?
% abs?
peaks?
bound?
50-100mcg/mL
100% oral abs
IR 1-4h; ER 4-5h for peak, up to 24h in OD setting
90% protein bound - can dec in OD; consider dialyze
VPA and carnitine?
VPA OD depletes carnitine
results in hyperNH3 and liver tox
decrease carnitine increase NH3
Toxic effects of VPA
initially CNS depression
large dose causes resp. depression
major AE at levels >450mcg/mL
hyperNH3 can be acute or chronic OD
What happens 3-5d after acute OD of VPA?
VPA can cause metabolic acidosis
BMS can occur; leuko/thrombocytopenia
anemia
other VPA AE
liver failure, pancreatitis, renal failure
Most frequent tx of VPA OD?
supportive care ABCs
be prepared to intubate
as with other anticonvulsants consider AC if not aspiration risk
WBI if large ingestion of EC tablets
Which AC consider MDAC?
rarely used
only considered for CBZ and VPA
Only AC drug and OD needing hemodialyze?
VPA because huge OD can dec protein binding
When to consider carnitine supplements?
with VPA OD and hyperammonemia
carnitine will decrease NH3
VPA OD with what 3 indications point to use of carnitine?
hepatox
elevated NH3
serum OD
USE carnitor!
Gabapentin OD
CNS depression, typically benign
Felbamate OD
acute vs. chronic
CNS depression, tachy, N/V
Chronic toxicity: anemia, liver fail
Lamotrigene OD
Seizures, dysrhythmias,
QRS widening? consider NaHCO3 if >100msec
Vigabatrin
delirium and agitation can be treated with a benzo.
Zonisamide
Resp depression, hypotension, brady
tx with fluids and atropine
be prepped to intubate
Topiramate
Metabolic acidosis and seizures
benzos for seizures
prep to intubate
Tiagabine
BP?
HR?
CNS depression, possible seizures
HTN tx with nitroprusside if severe
esmolol if severe tachy
OXC
BP
HR
Electrolyte?
Hypo, brady, hyponatremia
APAP ADME
10-30% protein bound (low)
0.75-1 L/kg
95% is eliminated
normal t1/2 2-3h
What is the toxic metabolite?
NAPQI is produced when metabolized from 2E1! inducible by chronic EtOH
NAPQI is product of all cyps
2E1 is inhibited in presence of acute alcohol
Glutathiones role in acute tox
reacts without an enzyme
removal of highly reactive groups
liver exports it to plasma
20 enzymes are GSH dependent
APAP toxic to...
liver
kidney
other tissues
liver-NAPQI tox is not countered by GSH in liver
Kidney-may result in proximal tubular necrosis!!; renal 2E1,
other tissue tox is related to these 2
Stage 1 APAP OD
asymptomatic, n/v, lethargy, sweating
0-24h
Stage 2 APAP OD
asymptomatic, mild alt inc, upper right quadrant pain
24-48h
Stage 3 APAP OD
72-96hours
huge increases in ALT/AST
hepatic failure, enceph, coma,
brain gets no glucose from liver!
hemorrhage due to no clotting factors
jaundice!
Stage 4 APAP OD (if surived #3)
liver will regenerate over time
near normal labs within 1 week
may last months
Refer to ER for APAP OD if...
adult ingest >10g
Ped ingest >200mg/kg
all attempted suicides
Gastric Decontamination w/APAP OD
AC effectively abs APAP
best when given within 1-2hours
AC also absorbs NAC
DO NOT delay NAC to give AC
Role of lavage or emesis for APAP OD?
Nope
! therapy levels of APAP
>_10mcg/mL is analgesia
4-18mcg/mL is antipyretic
hepatotox >_150mcg/mL
WHEN measured 4 hours after dose
When to use the nomogram?
Rumack-Matthew Nomogram only for single acute dose w/in 4-24hours
above line? toxic dose
ONLY from 4-24 hours!
even useful for ER APAP forms
What is NAC?
effects?
N-actylcysteine
source of cysteine for GSH directly conj. of NAPQI
source of SO4 for conjugation
Anti-inflam rad scavenger
When to give NAC?
Give NAC when above the toxic line of the nomogram.
Best results if started w/in 8h
give regardless
NAC dosing!!!
LD
MD
dilution
LD 140mg/kg
MD 70mg/kg q 4 h for 72 hours!!
NAC should be 5% final solution
dilute w/juice due to rotten egg taste
minimum 3 days at hospital
Shortened NAC?
LD and 5 MD (20 hour course)
only for less severe cases
IV NAC dosing!
LD
MD
LD 150mg/kg in 200ml D5W, given over 1 hour
1st MD 50mg/kg in 500ml D5W over 4 h
2nd MD 100mg/kg 1L of D5W over 16h
Concern w/IV NAC in children?
Severe hyponatremia due to excess free H2O
Caution if child less than 40kg
Labs to check with APAP OD
AST/ALT peak at 3-4days
serum bili
PT time
Scr and BUN
electrolytes
glucose
APAP levels unnecessary after NAC started?
APAP ER OD?
when to give NAC?
if APAP below probable tox line but above 10mcg/mL, then start NAC and get APAP levels at 8 and 12 hours
Extend NAC is APAP is detectable after 72h of dosing
Chronic APAP OD dosing
Use nomogram in chronic doses?
10-15mg/kg/dose NMT 5 dose/day
NAC is indicated if APAP dose exceeds 200mg/kg/day or 10g/24hour
Nomogram is not used for Chronic Doses!!!
NAC tx for chronic APAP OD
look at transaminases to determine extent of liver damage
IV NAC should be continued until AST/ALT <_2x normal
Why monitor Na in Li OD decontamination?
hyponat causes increase reabs of Na and Li in kidney.
Li tox, acute v. chronic
acute - no cutaneous or endo problems; mostly seize or inc QT
Chronic - myocarditis and cutaneous ulcers; hypothyroidism
oral tx of NMS?
5mg tid of bromocriptine, can increase to 20mg qid if needed
what 2 antidespressants are assoc. with seizures?
venlafaxine or bupropion
Consequences of uncoupling w/salicylate poisoning
initial resp alkalosis due to O2 use w/no energy created.
later evolves to profound met. acidosis
will get elevated anion gap
when to refer aspirin OD?
>_150mg/kg/dose or day?
when to use dialysis in aspirin OD?
>_100mg/dL... watch units!!
Why alkalizine urine in ASA OD?
100x more excreted at pH 7 vs. pH 5
goal urine is pH=7.54
may need cont. inf NaHCO3
toxic ingestion of APAP
>10g/day adult or 200mg/kg/day kid
Therapy levels of Dig
tox level?
0.6-2 ng/mL
>6ng/mL lethal for 50%
What to avoid in dig OD?
Do not use Ca2+ or kayexalate
these will create abnormalities later
Ind for digibind (doses of dig)
ingestion of...
>10mg if adult
>4mg if child
exam! formula for digibind admin
(conc@SS + wt in kg)/100
= number of vials to admin
When are fab frags given in infants and children? (dig/wt dose)
>_0.3mg/kg!!
What to do about brady in clonidine OD?
give atropine if HR<60bpm, consider pacing if refractory
Diff b/w BB and CCB OD?
BB - hypogly, bronchospz, CNS effects
CCB - hypergly, pulmonary edema, more cardiac effects
Similarity b/w BB and CCB OD?
both cause hypotension and bradycardia
What special effect does sotalol have?
blockade of K channels
so potential for torsades
tx of CCB and BB OD similarity
give atropine and IV fluids to combat hypotension and brady
also IV Ca2+ is beneficial in both cases
tx specific to BB OD
give glucagon because it bypasses need for cAMP for contraction
IV calcium role in CCB and BB OD
CaCl2 if good access,
otherwise use Cagluconate to reduce irritability
Always give glucagon 1st if in BB OD!
tx specific for CCB OD
give insulin and glucose to...
support metabolic heart demands
increase energy and coronary flow to heart
hyperinsulin euglycemia
0.5 - 1 IU/kg w/25g dextrose
titrate with 0.5-1IU/kg/hour
dilute 1IU with 1 mL NS
monitor glucose q 30min
1st 5 of 10 toxic exposures in children
cosmetics
analgesics
cleaning substance
foreign body
topical prep
2nd 5 of 10 toxic exposures in kids
vitamins
cold/cough
antihistamines
pesticides
plants
drugs specific to tramadol OD
consider naloxone
admin lorazepam for seizures
NS for hypotension
Drugs specific to Li OD
which is more severe acute or chronic?
Chronic OD is more severe.
Normal Li level?
mod symptoms
severe symptoms
normal 0.6-1.2mmol/L
mod: 1.5-2.5 mmol/L
lethal: 3-4mmol/L
What specific drug can be used to manage Li OD causing arrhythmia?
MgSO4 bolus
Jimson Weed OD... what not to use?
avoid phenothiazine and benadryl due to anticholinergic effects!
What's 1 drug of use in jimson weed OD?
MOA: Achinhibitor called physostigmine
TCA OD; QT prolonger when to be worried?
>100msec QT interval causes problems>100 -> 33% seized
>160? 50% had dysrhythmia
Acute OD of TCA: symptoms
hot as a hare
dry as a bone
mad as a hatter
blind as a bat
red as a beet
TCA OD effect on myocardium
TCA block myocardial Na channels (fast) resulting in dec conduction and increased
vasopressors used in...
clonidine OD?
TCA OD?
clonidine use dopamine
TCA use NE