| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links). |
| Clinical features |
| Neurologic |
| Sedation, coma, seizures |
| Cardiac |
| Tachycardia, hypotension, conduction abnormalities |
| Anticholinergic |
| Dilated pupils, dry mouth, absent bowel sounds, urinary retention |
| Diagnostic evaluation |
| Electrocardiographic changes in severe poisoning: |
| QRS duration >100 msec |
| Rightward deflection of the terminal 40 msec of the QRS complex |
| Deep S wave in leads I, AVL; tall R wave in lead AVR |
| R wave in AVR >3 mm; R/S ratio in AVR >0.7 |
| Serum TCA concentrations do not help to guide therapy |
| Treatment |
| Airway |
| Manage as indicated; many patients require tracheal intubation |
| Breathing |
| Administer supplemental oxygen |
| Circulation |
| Hypotension: Treat with intravenous boluses of isotonic crystalloid. If patient remains hypotensive despite aggressive volume resuscitation, can treat with a vasopressor. Alpha-adrenergic agonists (eg, neosynephrine, norepinephrine) are preferred. |
| Conduction disturbances: If QRS >100 msec, challenge with intravenous sodium bicarbonate (2 to 3 mEq/kg up to 150 mEq IV push) and assess for QRS narrowing. If QRS narrows, begin continuous infusion (150 mEq of sodium bicarbonate in 1 liter of D5W to run at 250 mL/hour in adults or twice the maintenance fluid rate in children). |
| Gastrointestinal decontamination |
| Administer activated charcoal if patient presents within 2 hours of ingestion, unless gastrointestinal complication (ileus, obstruction) suspected. Dose is 1 g/kg (maximum dose 50 g). |
| Seizures |
| Treat with benzodiazepines (eg, diazepam 5 mg IV or lorazepam 2 mg IV) |
| Do NOT treat with phenytoin |
