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Pediatric Sedation and Analgesia

Key Concepts Patients of all ages experience pain, including infants, neonates, and premature babies. Oligoanalgesia, the inadequate treatment of pain, has many short-term and long-term consequences: worse patient outcomes, increase in patient’s pain threshold, and development of chronic pain. Pain management may include a combination of techniques: analgesics, topical anesthetics, local anesthetic injections, oral sucrose in infants, and nonpharmacologic interventions. Nonpharmacologic interventions to decrease pain or…

Pediatric Airway Management

Key Concepts Pediatric advanced airway management is a relatively rare skill to perform in most emergency departments (EDs), and skill maintenance is difficult based solely on clinical practice. There are several anatomic differences that impact pediatric airway management, and these occur mostly in the very young child (<2 years of age). Infants have a large occiput and a high, anterior airway, which impacts positioning during intubation.…

Care of the Pediatric Patient

Key Concepts Patterns of illness and injury vary by age, and a number of anatomic and physiologic characteristics affect the presentation and management of pediatric emergencies. A basic understanding of normal development will aid the emergency clinician in assessment of the pediatric patient. The pediatric assessment triangle (PAT) can be used as a tool for rapid evaluation of the patient’s overall status. Tachypnea in children should…

Sedative-Hypnotics

Acknowledgments We would like to acknowledge the valuable contributions of the previous edition authors Drs. Andrea Carlson and Leon Gussow. Key Concepts Supportive care, with a focus on respiratory depression, is the foundation of management of all sedative-hypnotic ingestions. Benzodiazepines are commonly used medications both medically and recreationally. Coingestions with other sedative-hypnotic agents can potentiate their neurologic and respiratory effects. Barbiturate medications are less commonly prescribed,…

Plants, Herbal Medications, and Mushrooms

Key Concepts Most botanical exposures result in minimal toxicity and management is largely supportive. Most serious toxicities result from exposure to plants with anticholinergic, antimitotic, cardiovascular or convulsive properties. Most cases of mushroom ingestion in which gastrointestinal (GI) symptoms begin within the first 2 h will prove to involve a non–life-threatening substance. Delayed GI symptoms with an onset of more than 6–8 h after exposure suggest…

Pesticides

Key Concepts Organophosphates cause symptoms by accumulation of acetylcholine. Treat cholinergic symptoms with atropine. Reverse the inhibition of acetylcholinesterase with oximes. Aging, which results in prolonged toxicity, occurs with organophosphate poisoning, but not with carbamates. Chlorinated hydrocarbons can present with seizures and cardiac toxicity. Substituted phenols are found in weight loss products and exert their toxicity by uncoupling oxidative phosphorylation. These products can cause cardiac, liver,…

Opioids

Key Concepts The opioid toxidrome includes three prominent findings—central nervous system depression, miosis, and, most importantly, respiratory depression—but presentations may be variable. A negative urine screen is often unreliable, and absence of detection should not deter a diagnosis of opioid intoxication when clinical findings support it. Airway protection, oxygenation, ventilation, and early administration of the reversal agent naloxone are the cornerstones for management of patients with…

Antipsychotics

Key Concepts Antipsychotics are commonly categorized into typical, or first-generation antipsychotics (FGAs) with primary antagonism to dopamine receptors, and atypical, or second-generation antipsychotics (SGAs) which include serotonin receptors as a target. Aripiprazole is an example of a third type of antipsychotic that acts as a partial agonist at dopamine sites. Extrapyramidal symptoms are common side effects of antipsychotics. First line treatment is benztropine or diphenhydramine. Lorazepam…

Lithium

Key Concepts The clinical pattern of acute and chronic lithium toxicity is different. Gastrointestinal symptoms occur early, and neurologic toxicity manifests late in acute toxicity. Neurologic findings (e.g., tremors, altered mental status and seizures) often are presenting signs of chronic lithium toxicity, whereas gastrointestinal symptoms often are absent. Neither activated charcoal nor whole bowel irrigation (WBI) is indicated in the routine management of acute or chronic…

Inhaled Toxins

Key Concepts An asphyxiant is any gas that displaces sufficient oxygen from the breathable air. Treatment consists of removal from exposure, supplemental oxygen, and supportive care. Highly water-soluble gases produce rapid irritation and predominantly upper respiratory tract effects, such as airway irritation. Poorly water-soluble gases, like phosgene, often produce delayed lower respiratory tract findings, such as bronchospasm or acute respiratory distress syndrome (ARDS). Carbon monoxide (CO)…

Hydrocarbons

Key Concepts Aspiration is the major toxic risk of hydrocarbon poisoning. Hydrocarbons may cause systemic toxicity, burns, cardiac dysrhythmias, altered mentation, and seizures depending upon the specific agent, dose, and duration of exposure. Gastrointestinal decontamination is potentially harmful in cases of hydrocarbon ingestion and is contraindicated. Hydrocarbon inhalant abuse can cause central nervous system (CNS) and cardiotoxic effects. In most cases of hydrocarbon ingestion or inhalation,…

Iron and Heavy Metals

Key Concepts Asymptomatic patients seeking emergency department (ED) care for an abnormal metal test need follow-up evaluation arranged with a medical toxicologist. Metal testing in the ED should be ordered in consultation with a medical toxicologist or regional poison center. Acute ingestion of the salts of most metals causes rapid severe gastrointestinal pain and emesis. Abnormal neurologic signs in a patient with any metal exposure warrants…

THC and Hallucinogens

Key Concepts Hallucinogens include many types of drugs and chemicals with different associated effects, including action at serotonin receptors, dopamine receptors, and glutamate N -methyl- d -aspartate receptors. Diagnosis and management are based primarily on the history and physical examination, with hallmarks of therapy including supportive care, a calm quiet environment, and sedation with benzodiazepines such as diazepam or lorazepam. Severely agitated patients may benefit from…

Cocaine and Other Sympathomimetics

Key Concepts Excessive use of stimulants can lead to sympathomimetic toxicity , manifesting as tachycardia, hypertension, mydriasis, diaphoresis, hyperthermia, hyperreflexia, and agitation. If untreated, sympathomimetic toxicity can lead to seizures, coma, and death. Administration of benzodiazepines is the key therapeutic intervention for sympathomimetic toxicity. Ketamine, olanzapine, and butyrophenones are alternative adjuncts if the cause of severe agitation is not clearly sympathomimetic toxicity. Worsening hyperthermia portends imminent…

Caustics

Key Concepts Health care workers caring for patients with caustic exposures should adhere to universal precautions to prevent additional exposure. All symptomatic patients should undergo endoscopy and be should be observed for at least 24 hours. Asymptomatic patients can undergo endoscopy in the emergency department or be discharged with close follow-up monitoring. Gastric emptying or GI decontamination is not indicated for the majority of caustic ingestions.…

Cardiovascular Drugs

Cardioactive Steroids (Digoxin) Key Concepts Digoxin toxicity is often occult and should be considered in any patient who is on digoxin and presents with gastrointestinal or visual disturbance and a new dysrhythmia, conduction disturbance or hemodynamic instability, particularly in the setting of ingestion of a natural weight-loss supplement. Digitalis Fab is the specific antidote for digoxin toxicity and is dosed based on chronicity of poisoning; most…

Antidepressants

Key Concepts Although rarely used for depression, MAOIs are used in the treatment of Parkinson disease. Because serious symptoms can occur after a lengthy latent period, patients with reported MAOI overdose should be admitted for 24 hours, regardless of symptoms. Toxicity is characterized by tachycardia, hypertension, and CNS changes, and later cardiovascular collapse. The primary manifestations of TCA toxicity are seizures, tachycardia, hypotension, and intraventricular conduction…

Anticholinergics

Key Concepts Anticholinergic (antimuscarinic) intoxication is common and can occur as a result of ingestion of a variety of plants and drugs, both prescription and over-the-counter. Most patients with antimuscarinic toxicity do well with supportive care and observation. Antimuscarinic syndrome varies in clinical presentation with either peripheral or central manifestations predominating. Central antimuscarinic delirium is most effectively treated with physostigmine. Contraindications to physostigmine administration include narrow…

Aspirin and Nonsteroidal Agents

Key Concepts In the overdose setting, salicylates are profoundly toxic and can be fatal. Salicylate overdose requires vigilant assessment and treatment. The other nonsteroidal antiinflammatory drugs (NSAIDs) generally have self-limited toxicity and respond to supportive measures. There is no specific antidote for any of these drugs. Salicylism should be considered in the differential diagnosis of altered mental status, particularly in the elderly. Acidemia signifies loss of…

Acetaminophen

Key Concepts Acetaminophen concentration should be measured in patients with intentional oral overdoses. Acetaminophen poisoning is relatively silent clinically until serious hepatotoxicity ensues. Repeated supratherapeutic dosing of acetaminophen can lead to life-threatening toxicity. Use the acetaminophen concentration on the nomogram at 4 hours or later post-ingestion to determine whether N -acetylcysteine (NAC) therapy is indicated for acute ingestions. IV NAC is preferable to PO NAC. When…