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). |
General |
May be abused by nasal, oral, or IV route |
Rapid onset of symptoms with long (~24 hours) duration of action |
Clinical features |
History may be difficult to obtain |
Severe agitation can occur |
Sympathomimetic toxidrome frequently present: - CNS stimulation (agitation, delirium, or acute psychosis)
- Tachycardia
- Hypertension
- Dilated pupils (mydriasis)
- Diaphoresis
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Hyperthermia (variable; may be severe) |
Laboratory analysis |
Routine testing in poisoned patients - Fingerstick glucose
- ECG to assess for conduction system impairment
- Acetaminophen and salicylate levels
- Pregnancy test in female patients of childbearing age
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Basic electrolytes, BUN, creatinine - Metabolic acidosis, acute renal failure, and hyperkalemia may be seen in severe toxicity
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Creatinine phosphokinase, serum lactate, aminotransferases, coagulation studies |
Treatment |
Agitation (control with aggressive sedation) - Benzodiazepines are first-line therapy; may need large doses
- For severe agitation:
- Lorazepam, 4 mg IV, may repeat every 8 to 10 minutes, titrate to sedation
- Diazepam, 5 to 10 mg IV, may repeat every 8 to 10 minutes, titrate to sedation
- If lacking IV access, midazolam 5 to 10 mg IM, may repeat every 10 minutes, tit rate to sedation
- Consider other agents (refer to UpToDate text) in cases of benzodiazepine failure
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Paralysis and tracheal intubation may be necessary; succinylcholine should not be used for rapid sequence intubation |
Critical hypertension - Benzodiazepines are first-line therapy (refer to dosing above)
- Nitroprusside: start at 0.25 to 0.5 mcg/kg per minute, titrate to effect
- Phentolamine: 1 to 2.5 mg IV for initial dose, titrate to effect, may repeat every 5 to 15 minutes with doses up to maximum 15 mg per dose
- Avoid pure beta blockers; we suggest avoiding combined alpha- and beta-blocking medications in acute poisoning
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Hyperthermia - Sedation with benzodiazepines (refer to dosing above); do not give antipyretics
- Evaporative cooling measures
- Cooling blankets
- Neuromuscular paralysis in severe cases
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