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CRITICAL CARE OF OVERDOSE

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CRITICAL CARE OF OVERDOSE

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    1. CRITICAL CARE OF OVERDOSE/DRUG TOXICITY METHAMPHETAMINES JOHN P. CONNOLLY. M.D., FACP, FCCP DIRECTOR ICU LODI MEMORIAL HOSPITAL ASSOCIATE CLINICAL PROFESSOR UC DAVIS

    7. INITIAL EVALUATION VITALS SIGNS/ MENTAL STATUS/ PUPILS THIAMINE 100/ DEXTOSE 25 NARCAN ACLS

    8. OVERDOSE MANAGEMENT SUPPORTIVE CARE DECONTAMINATION/ CHARCOAL ANTIDOTES ENHANCED ELIMINATION POISON CONTROL: 1-800-222-1222

    9. SPECIFIC MEASURES BICARB ATROPINE BENZODIAZEPINES a and ß BLOCKADE

    10. ICU CARE PACO2 > 45 INTUBAITON SEIZURES UNRESPONSIVENESS NONSINUS RHYTHM AV BLOCK SYSTOLIC BP < 80 QRS > 0.12 sec BRETT, AIM 1987

    11. TOXIDROMES CHOLINERGIC (SLUDGE) ANTICHOLINERGIC SYMPATHOMIMETIC NARCOTIC SEDATIVE HYPNOTIC ZIMMERMAN 2003/2008

    12. CHOLINERGIC SALIVATION LACRIMATION URINATION DEFECATION GI UPSET EMESIS SALIVATION/BRONCHORRHEA BRADYCARDIA FASICULATIONS CONFUSION MIOSIS

    13. ANTICHOLINERGIC DRY SKIN HYPERTHERMIA MYDRIASIS TACHYCARDIA DELIRIUM THIRST URINARY RETENTION

    14. SYMPATHOMIMETIC HYPERTENSION TACHYCARDIA CNS EXCITATION/SEIZURES MYDRIASIS DIAPHORESIS

    15. SEDATIVE/HYPNOTIC DECREASED LOC RESPIRATORY DEPRESSION HYPOTENSION DECREASED REFLEXES

    16. NARCOTIC MIOSIS RESPIRATORY DEPRESSION DECREASED LOC HYPOTENSION HYPOREFLEXIA

    17. SPECIFIC DRUGS ACETAMINOPHEN BENZODIAZEPINES ANTIDEPRESSANTS ANTIHYPERTENSIVES OPIOIDS METHAMPHETAMINES

    18. ACETAMINOPHEN PRESENT IN OVER 600 PREPARATIONS HIGHEST # OF DEATHS 1/3 OF OVERDOSES UNINTENTIONAL N-ACETLYCYSTEINE REPLETES GLUTATHIONE RUMACK MATTHEW NOMOGRAM NAC IV: 20 HOUR REGIMEN PO: 72 HOUR REGIMEN/NAUSEA

    20. BENZODIAZEPINES DECREASED LOC LESS RESPIRATORY/CARDIOVASCULAR DEPRESSION SECOND LEADING CAUSE OF MEDICATION RELATED DEATH FLUMAZENIL /ANTAGONIST REVERSES SEDATION QUESTION RESPIRATORY DEPRESSION RESEDATION 1-2 HOURS SEIZURE RISK WITH TCAS

    21. ANTIDEPRESSANTS CYCLIC ANTIDEPRESSANTS NOW LESS COMMON BLOOD ALKALINIZATION WITH QRS >120 MSEC HYPERTONIC SALINE SSRIs TOXICITY AT > 75 TIMES DAILY DOSE SEROTONIN SYNDROME MENTAL STATUS CHANGE HYPERTHERMIA ARRYTHMIAS/DIAPHORESIS NEUROMUSCULAR ABNORMALITY ? CYPROHEPTADINE

    22. CYCLIC ANTIDEPRESSANTS ANTICHOLINERGIC EFFECTS CARDIOVASCULAR EFFECTS QRS > 160 MSEC/VENTRICULAR ARRHYTHMIAS SEIZURES QRS > 100 MSECS SUPPORTIVE MEASURES ACUTE ALKALINIZATION OBSERVATION 48-72 HOURS CARDIAC TOXICITY MOST LETHAL USUALLY IN FIRST 24 HOURS

    23. OPIOIDS GENERALIZED DEPRESSION OF CNS LETHARGY LEADING TO RESPIRATORY ARREST COMA RESPIRATORY FAILURE DUE TO: ALVEOLAR HYPOVENTILATION ASPIRATION PNEUMONIA NONCARDIOGENIC PULMONARY EDEMA

    24. OPIOIDS (cont’d) HYPOTENSION ILEUS RHABDOMYOLYSIS HYPOTHERMIA SEIZURES MAJORITY OF DEATHS DUE TO HEROIN SEVEN TIMES MORE TOXIC THAN MORPHINE NARCAN

    25. ANTIHYPERTENSIVES CALCIUM CHANNEL BLOCKERS HYPOTENSION DUE TO VASODILATION AMLODIPINE/NIFEDIPINE DECREASE BP DILTIAZEM/VERAPAMIL DECREASE HR NAUSEA/VOMITING LETHARGY/ CONFUSION/COMA SUPPORTIVE CARE/FLUIDS IV CALCIUM GLUCAGON INSULIN/GLUCOSE

    26. ANTIHYPERTENSIVES ß BLOCKER HYPOTENSION/BRADYCARDIA AV BLOCK/CHF/PULMONARY EDEMA BRONCHOSPASM/HYPOGLYCEMIA HYPERKALEMIA/LETHARGY COMA/SEIZURES SUPPORTIVE CARE FLUIDS/PRESSORS GLUCAGON/PHENOL TOXICITY

    28. METHAMPHETAMINES SYMPATHOMIMETIC TOXIDROME HALLUCINATIONS AND ACUTE PSYCHOSIS ACUTE CONSEQUENCES MYOCARDIAL ISCHEMIA AND ARRHYTHMIAS SEIZURES INTRACRANIAL HEMORRHAGE/STROKE RHABDOMYOLYSIS/RENAL FAILURE NECROTIZING VASCULITIS LONG TERM USE- DILATED CARDIOMYOPATHY

    29. MDMA 3-4-MethyleneDioxyMethAmphetamine ECSTASY, “E”, XTC INCREASE SEROTONIN RELEASE INHIBIT SEROTONIN UPTAKE BRUXISM/JAW CLENCHING CLUES HYPONATREMIA/LIVER INJURY REPORTED

    37. `Mayo Clinic Proceedings January 2006 vol. 81 no. 1 77-84`Mayo Clinic Proceedings January 2006 vol. 81 no. 1 77-84

    38. METH HISTORY FIRST SYNTHESIZED IN JAPAN 1893?/1919? 1930S INHALERS FOR RHINITIS AND ASTHMA MILITARY USE IN WORLD WAR II AND AFTER INCREASED WAKEFULNESS AND ATTENTION

    39. ACUTE TOXICITY SYMPATHETIC OVERDRIVE CARDIOVASCULAR COLLAPSE RHABDOMYOLYSIS VENTRICULAR TACHYARRHYTHMIAS ASSOCIATED INJURIES HALLUCINATIONS GI ULCERATION ISCHEMIC COLITIS ACUTE NONCARDIOGENIC PULMONARY EDEMA

    40. METH STORM CHEAPER THAN COCAINE, RECIPES ONLINE TWEAKING AND CRASHING METHAMPHETAMINE BURNS PHOSPHINE GAS LINEBERRY, MAYO, 2006

    41. PATHOPHYSIOLOGY CNS STIMULATION/EUPHORIA, SELF ESTEEM, ALERTNESS, AGRESSION, LIBIDO PRESYNAPTIC REUPTAKE OF CATECHOLAMINES BLOCKED BLOCKING PRESYNAPTIC VESICULAR STORAGE OF CATCHOLAMINES DECREASED CYTOPLASMIC DESTRUCTION BY MAO CONTRIBUTIONS FROM DOPAMINE AND SEROTONIN EFFECTS ALSO

    42. PATHOPHYSIOLOGY (CONT’D) T1/2 = 10 – 30 HOURS (10 TIMES COCAINE) GREATER CNS EFFECTS THAN D-AMPHETAMINE MAJORITY IS METABOLIZED TO AMPHETAMINE FURTHER CNS STIMULATION PEAK PLASMA LEVELS 30 MINS AFTER IV OR IM 2-3 HOURS AFTER PO HEPATIC CONJUGATION/URINE EXCRETION OF METABOLITES

    44. METHAMPHETAMINE BURNS HIGHER MORTALITY THAN OTHER BURNS MORE INVASIVE CARDIAC MONITORING MORE PRESSOR SUPPORT MORE PROCEDURES MORE AGGRESSIVE FLUID RESUSCITATION

    45. PHOSPHINE GAS BYPRODUCT OF METH COOKING INHIBITS CYTOCHROME C OXIDASE INCREASE OXYGEN FREE RADICALS OCULAR/RESPIRATORY IRRITATION DYSPNEA/HEADACHE/FATIGUE/ STOMACH PAIN RESPIRATORY HEMODYNAMIC FAILURE

    48. CHRONIC TOXICITY ATHEROSCLEROSIS AND CHRONIC HYPERTENSION MI, CARDIOMYOPATHY SOFT TISSUE INFECTION/ENDOCARDITIS PERIODONTAL DISEASE PERSONALITY DISORDERS HIGH RISK SEXUAL ACTIVITY PULMONARY HYPERTENSION PULMONARY ARTERY MUSCULAR HYPERTROPHY FOREIGN BODY GRANULOMAS RENAL NECROTIZING ANGIITIS

    50. CARDIAC TOXICITY CHEST PAIN/ PALPITATIONS/ DYSPNEA ACUTE THROMBUS FORMATION CAUSING MI MASSIVE OVERDOSES LEADING TO HYPOTENSION, BRADYCARDIA, METABOLIC ACIDOSIS ACUTE/CHRONIC CARDIOMYOPATHY DIRECT AMPHETAMINE CARDIAC MUSCLE TOXICITY ARTERIAL ANEURYSMS/SACCULATIONS ACUTE AORTIC DISSECTIONS

    51. CNS TOXICITY UNCONSCIOUSNESS DUE TO OTHER DRUGS SUCH AS OPIOIDS, METH INDUCED SEIZURES AGITATION, ANXIETY, HALLUCINATIONS, DELIRIUM, PSYCHOSIS, SEIZURES CNS VASCULITIS REPORTED

    52. TREATMENT SUPPORTIVE CARE GASTRIC LAVAGE RARELY HELPFUL IV HYDRATION AIRWAY CONTROL/OXYGENATION/MONITORING TERMINATION OF SEIZURES/ARRTHYMIAS CORRECTION OF HYPOXEMIA, HYPOTENSION, HYPERTHERMIA, ELECTROLYTE ABNORMALITIES ANTIPSYCHOTIC DRUGS/HALDOL BENZODIAZEPINES

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