Sickle Cell Information Center Guidelines

Edited by James Eckman, M.D. and Allan Platt, PA-C

Drug overdoses occur in patients with sickle cell syndromes through accidental ingestions, inadvertent intake of excessive medication to control pain, and suicide attempts. Management of drug overdose requires identification of the drugs ingested through history, physical, and analysis of blood, urine and gastric contents; specific intervention based on knowledge of the drug’s pharmacology; and intensive medical support. This monograph is meant to provide some general principles of management of a few common medicinal overdoses, however, a Poison Control Center (A list of regional centers is provided in the front of the Physician’s Desk Reference, PDR) or specific literature should be consulted to obtain specific details of management. General supportive measures should be started based on history and physical findings while laboratory results are pending. All patients with a sickle syndrome and significant overdose should be admitted after initial evaluation and treatment.

Present Illness. History is obtained from multiple sources including the patient, relatives, pharmacist, and others. Determine what was taken, how much, and when. Get all of the pill bottles if possible. Determine how much was prescribed and taken. Ask the level of consciousness when found and whether vomiting occurred. Was the patient drinking? Did seizures, hypotension, or aspiration occur?

Past Medical History. Outline other significant medical problems, known chronic medications, or drug allergies. Has the patient received chronic, daily methadone or other narcotics?

General. Immediately determine the adequacy of the airway, breathing, and oxygenation. Assure the presence of a good gag reflex. Blood pressure and pulse are mandatory to detect shock. Level of consciousness is assessed on a five level coma scale:

0 Sleepy but awakable and able to answer appropriately.

Coma present and:

1 Reflexes present, withdraws from painful stimulation.

2 Reflexes present, does not withdraw from painful stimulation, no cardiorespiratory depression.

3 Reflexes absent, no cardiorespiratory depression.

4 Cardiorespiratory depression present with shock or cyanosis from respiratory depression.

AVPU system is a rapid means of documenting the level of consciousness (A = alert; V = response to verbal stimuli; P = response to painful stimuli; U = unresponsive).

Vital Signs. Temperature, blood pressure, pulse and respiratory rate. Repeat all except temperature q 15 minutes initially.

HEENT. Alcohol on breath, head trauma, Battle’s sign, blood behind tympanic membrane or in ear. Gaze paralysis, EOMs, Dolls Eyes, PERRLA, papilledema. quality of gag reflex, airway obstruction.

Chest. Depth of breathing, rate, and rhythm. Rales or rhonchi.

Heart. Rhythm, murmurs, S3.

Abdomen. Bowel sounds. Organomegaly, or masses.

Extremities. Dependent edema.

Neurologic. CNs II-XII. Activity and symmetry of DTRs, clonus. Presence of hyperactivity or seizure activity. Response to deep pain.

Minimum Lab. CBC and Chem profile including electrolytes, BUN, Creat, AST, bilirubin, alk ptase, ECG, Drug screen on blood, urine, and gastric analysis as appropriate, chest x-ray, and blood gasses.

Additional Lab. Monitor parameters frequently based on type of ingestion, initial lab findings, and clinical response.

The differential diagnosis is extensive when a patient presents with an altered level of consciousness. The diagnosis is based on the findings in the history, physical, and laboratory. Drug overdose is established by history and laboratory findings.

- Overdose. Medicinal, poison, carbon monoxide, alcohol excess/withdrawal, cocaine or other street drugs.

- CNS events. Strokes are common in children, subarachnoid hemorrhage in adults.

- Epilepsy. Seizures are common from CNS disease, medications like meperidine, or street drugs like cocaine and amphetamines. Altered mental status is seen in postictal state or status seizures.

- Trauma. Concussion, contusion, and subdural or epidural hematoma cause altered mental status with or without focal findings.

- Infection. Meningitis, encephalitis, sepsis, and other infections can cause altered mental status.

- Metabolic Causes. These include hypothyroid, electrolytes, hepatic encephalopathy, hypoxia, uremia, and hypoglycemia or hyperosmolar coma.

- Temperature Problem.2 Hyperthermia or hypothermia-

- Nutritional Deficiency. Seen with thiamine (Wernicke’s encephalopathy) and niacin.

Management includes initial supportive care which is independent of the cause of the altered mental status followed by specific measures which are determined by the specific overdose.

- Ventilation. Patients who are not intubated should have oral airway at the bedside and be placed on the left side with the head slightly down. Indications for intubation are respiratory failure, grade 2 coma, or poor gag reflex. Consult respiratory therapy or anesthesiology so they are aware of the case.

- Circulation. All patients need a good IV and consider central line with hypotension. With hypotension give normal saline, colloid, or blood. Administer oxygen and bicarbonate as indicated by blood gases. If hypotension is unresponsive to volume, give dopamine 5-25 ug/kg/min. Monitor ECG because dysrhythmias may occur and are managed bases on the rhythm. Hypertension or acute pulmonary edema may occur with some drugs.

- CNS Depression. Record level of coma. 0) awake or drowsy, 1) asleep arousable, 2) responds to pain, 3) unresponsive to pain, reflexes present, 4) reflexes depressed with respiratory failure, 5) reflexes absent with respiratory and circulatory failure. AVPU system is a rapid means of documenting the level of consciousness (A = alert; V = response to verbal stimuli; P = response to painful stimuli; U = unresponsive). Always measure glucose with a Dextrostick or give 50 cc of 50% dextrose solution. Give naloxone for narcotic overdose if patient not on chronic therapy. Diazepam IV is the drug of choice for seizures., administer thiamine (100 mg IV push) for possible Wernicke-Korsakoff syndrome, and give oxygen for possible carbon monoxide intoxication. Give flumazenil for known or suspected benzodiazepine overdose. However, do not give it for unknown overdoses, as this agent may precipitate seizures in cyclic antidepressant overdose. Also, avoid flumazenil administration in patients who have ingested drugs known to cause seizures (cocaine, lithium, theophylline, isoniazid, cyclosporine) or who are known to have a pre-existing seizure disorder (Clin Ther 14:292, 1992).

- Purging. Gastric emptying by emesis or lavage is indicated except with hydrocarbons and corrosives.

- If patient is fully awake, give syrup of ipecac 30 cc PO followed by 500 cc of H2O in the adult and 15 cc followed by 300 cc of what ever the child will drink in children to induce vomiting. Repeat in 20 minutes if unsuccessful. Keep the patient ambulating and stimulate the patient’s gag if no results in 15 minutes. Perform lavage if no results within 20 minutes after second try.

- If the patient has a depressed level of consciousness, perform gastric lavage AFTER INTUBATION! Use a large bore tube (28-36 F Ewald tube) and lavage until clear with 300 cc passes of normal saline. Do not use more in each pass to prevent gastric emptying.

- Other Measures. See specific antidotes under specific drugs. Administration of charcoal, cathartics, forced diuresis, and dialysis should be based on consultation with current literature or a poison center.

- Psychiatric support. Psychiatric evaluation is essential in all patients who deliberately take an overdose.

Management of Specific Drugs

Many intentional and some accidental ingestions result for a combination of potentially toxic substances. Alcohol is frequently one of the multiple drugs. It is very important to screen for all potential toxins that are readily available in the clinical laboratory in any overdose.

- Salicylates. Rule out salicylate involvement in all overdoses. Perform gastric emptying and purge. Charcoal is administered. Induce alkaline diuresis with IV sodium bicarbonate in D5W with KCl to clear the drug and to treatment metabolic acidosis even if respiratory alkalosis is present initially. In severe intoxications, large amounts of volume and potassium are required. Give sodium bicarbonate 1 - 2 amps with potassium 20 - 40 mEq/kg/hour for the first 6 to 8 hours. Urine flow should be maintained at 2 - 3 ml/kg/hour. Vitamin K is usually indicated.

Observe for complications of hyperpyrexia, hypotension, hypoglycemia, hypokalemia, hypoprothrombinemia, GI bleeding, and renal failure.

Levels of 30 mg/dl are toxic and >100 mg/dl reflect severe intoxication. Levels must be estimated at time of ingestion using present levels and nomograms available in standard monographs. Dialysis or hemoperfusion are indicated with severe intoxications, pulmonary edema, or with renal failure.

- Acetaminophen. Acetaminophen toxicity can cause delayed , life threatening hepatic necrosis and liver failure. Therapy should always be based on the determination of plasma levels. Toxicity usually occurs after acute ingestion of more than 140 mg/kg. Levels >40 micrograms within 12 hours of ingestion are potentially toxic (See tables in standard monograms). Gastric lavage WITHOUT charcoal or cathartics is indicated. Administer Acetylcysteine (Mucomyst) 140 mg/kg PO initially followed by 70 mg/kg PO q 4 hours for a total of 17 doses. Intravenous preparations and assistance is available through the Rocky Mountain Poison Control Center, 1-800-525-6115.

- Narcotics. Narcotics cause mental depression, miosis, respiratory depression, hypotension, bradycardia, and acute pulmonary edema. Naloxone HCl is the antidote of choice. Give 0.4 - 0.8 mg IV followed by 2 mg IV if no response in 5 minutes. Repeat dosages as required and observe carefully for 24 hours especially if long acting drugs are involved. Naloxone should be diluted 1:10 and used with caution in patients on narcotics chronically. Treat pulmonary edema with respiratory support, consider intubation with PEEP, and use naloxone as above.

- Tricyclic Antidepressants. Toxic effects include anticolinergic effects, sympathomemeticeffects, and direct myocardial effects. Patients present with CNS stimulation, mydriasis, dry mucosa, ileus, urinary retention, and hyperpyrexia. With serious ingestions, prolonged QT interval is common with numerous other arrhythmias and heart block are seen. Respiratory depression and hypotension may occur. Treatment includes general support, purging, cardiac monitoring and the aggressive administration of sodium bicarbonate to increase the pH >7.5. Forced diuresis is contraindicated. For other specific measures call regional poison control center and see cited literature.

- Barbiturates. Severe CNS depression, hypotension respiratory depression, hypothermia, rhabdomyolysis, and skin lesions may occur. Treatment consists of purging, charcoal administration, general support and alkaline diuresis for the longer acting agents. Very high levels or pulmonary edema are often treated with dialysis or hemoperfusion.

- Diazepines. High therapeutic index but depressed mental status and respirations or hypotension may occur with massive doses. Treatment with purging and observation is indicated.

- Ethanol. Frequently is taken with other medications. Levels or findings of unexplained osmols are helpful. Treatment by purging is indicated. Support includes observation for hypoglycemia or acidosis and general supportive measures.

- Cocaine. Toxicities include hypertension, seizures, arrhythmias, myocardial infarction, subarachnoid hemorrhage, and myocardial infarction from coronary artery spasm. Treatment consists of general support, including maintenance of airway, respiratory and cardiac support. Seizures and general stimulation respond to benzadiazapines, ventricular and supraventricular arrhythmias to propranolol, esmolol, and hypertension to nitroprusside.

- Other Drugs. Consult the cited references, Clinical Pharmacology by Goodman and Gilman, and contact a regional Poison Control Center.

Shannon M, Graef JW. Poisoning. In Manual of Pediatric Therapeutics, 4th ed. Graef, JW ed. Little, Brown and Company. Boston. 1988. pp. 93-114.

Goodenberger D. Medical Emergencies. In Manual of Medical Therapeutics, Carey CF,. Lee HH, Woeltje KF. eds. Lippincott-Raven Publishers. Boston. 1998.

Spoerke DG, Rumack BH. Poisoning In Current Pediatric Diagnosis and Treatment, 10th ed. Hathaway WE, Groothuis JR, Hay WW, Pailley Jw eds. Appleton & Lange. Norwalk Conn. 1991. pp. 928-957.

Viccellio P, Handbook of Medical Toxicology Lippincott Williams and Wilkins 1993.

Nobota, M. C., et al. Acetaminophen accumulation in pediatric patients after repeated therapeutic doses. Eur. J. Clin. Pharmacol. 1984;27:57.

Send mail to aplatt@emory.edu with questions or comments about this web site.
Copyright © 1997 Sickle Cell Information Center
Last modified: October 08, 2000