Journal of Pharmacy Practice

Gastrointestinal decontamination plays an important role in the management of poisoned patients. The use of ipecac syrup has declined, and the use of activated charcoal has increased, during the period 1983 to 1991. If an emetic is used, ipecac syrup is the emetic of choice. If gastric emptying is done in an emergency department, gastric lavage is preferred. Recent studies in animals, human volunteers, and poisoned patients suggest that activated charcoal and a cathartic is as effective, or more effective, than ipecac or lavage plus activated charcoal and a cathartic. As such, activated charcoal and a cathartic should be considered the primary decontamination procedures to be used in a hospital.

Toxicokinetics, the application of pharmacokinetic principles in the assessment and management of the poisoned patient, is demonstrated for theophylline poisonings. Theophylline intoxication and its treatment is briefly reviewed and differentiated for acute or chronic etiologies. A toxicokinetic strategy for the simple calculation and evaluation of serum theophylline concentrations following sustained-release products overdosage is presented. A toxicokinetic basis for treatment durations of activated charcoal, hemoperfusion, or hemodialysis is described. Common toxicokinetic factors responsible for presentation with chronic theophylline intoxication are mentioned.

Antidotal therapy is useful for only a meager number of poisonous agents in which reversal of the effects of the toxin, or treatment of the toxin-induced pathophysiologic derangements, is possible. This review of selected antidotes is meant to acquaint the reader with some of the new and/or controversial uses for a few of our older agents, to introduce two new agents recently marketed, and to refresh information on antidotes not often used.

Longitudinal data are necessary to identify changes in drug abuse and resultant toxicity. The development of COC-LOG, a longitudinal database used to assess cocaine-associated emergency department patient visits at Truman Medical Center, the University of Missouri-Kansas City, is described. COC-LOG currently contains 1,054 patient visits. The data demonstrate that cocaine toxicity has remained relatively constant in our emergency department (ED) over the last 4 years. The majority of cocaine use is through smoking crack, and major differences in toxicity are not seen between this route and IV cocaine use. The relatively low prevalence of severe cardiac toxicity and deaths has lead to a series of projects to evaluate cocaine toxicity's clinical course. Electrocardiographic abnormalities are common, but do not frequently indicate severe clinical toxicity. In the first 3 years after ED discharge, deaths in cocaine patients occur almost twice as frequently as in age-, race-, and sex-matched control ED patients. Urine drug testing of pregnant patients suggests that documentation of recent cocaine use by history alone underestimates the prevalence of cocaine use in ED patients approximately four-fold. COC-LOG is a useful method of following cocaine's impact on department patients. Study results can be applied to patient care and the education of ED faculty, residents, students, and personnel.

Toxicology testing is an extremely valuable asset to the pharmacist in the evaluation and management of the poisoned patient. There is extensive use of toxicology screens and expensive and time-consuming quantitative analysis for toxins that could be more appropriately directed by the pharmacist who has an extensive background in toxicokinetics and pharmacology. Application of the results of toxicology testing by the pharmacist can contribute to decisions regarding the patient's therapy and prognosis.

Although newer cyclic antidepressants have been introduced over the past several years, the tricyclic antidepressants (TCAs) continue to be the leading cause of morbidity from drug overdose in the United States. Overdose features depend on the particular cyclic antidepressant ingested and its pharmacological properties, and can include CNS depression, cardiac arrhythmias, hypotension, seizures, and anticholinergic symptomatology. Life-threatening symptomatology almost always begins within 2 hours, and certainly within 6 hours, after arrival to the emergency department. Plasma TCA levels are unreliable predictors of TCA toxicity and are not recommended. An ECG with a prolonged QRS complex more than 100 msec seems to be the best indicator of serious sequelae with TCAs. Management consists of stabilization of vital signs, gastrointestinal decontamination, intravenous sodium bicarbonate, and supportive care. Agents once thought to be useful for the treatment of cardiac dysrhythmias and seizures such as phenytoin and physostigmine should be avoided. The future of TCA antibody fragments in the treatment of TCA overdose seems promising. Newer and, to some degree, safer antidepressants in overdose have recently been introduced, and they include fluoxetine, trazodone, and sertraline. Amoxapine, bupropion, and maprotiline seem to be as toxic as the TCAs. A significant interaction between cyclic antidepressants and monoamine-oxidase inhibitors exists. Management includes supportive care and basic poison management. Prevention of poisoning seems to be the most logical and effective method of maintaining patient safety. TCAs should be avoided in children younger than 6 years old. All adults with suicidal ideations should receive no more than a 1-week supply (about 1 g) of drug. Finally consideration should be given to using one of the newer, safer antidepressants in all patients with suicidal ideations.