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Coma is commonly associated with ingestion of large doses of antihistamines, barbiturates, benzodiazepines and other sedative-hypnotic drugs, -hydroxybutyrate (GHB), ethanol, opioids, antipsychotic drugs, or antidepressants The most common cause of death in comatose patients is respiratory failure, which may occur abruptly Pulmonary aspiration of gastric contents may also occur, especially in victims who are deeply obtunded or convulsing Hypoxia and hypoventilation may cause or aggravate hypotension, arrhythmias, and seizures Thus, protection of the airway and assisted ventilation
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The choice of gut decontamination procedure depends on the toxin and the circumstances (See below for a more detailed discussion of methods)
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Copyright 2008 by The McGraw-Hill Companies, Inc Click here for terms of use
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are the most important treatment measures for any poisoned patient
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effect longer than that of naloxone but still shorter than that of the opioid methadone c Flumazenil Flumazenil, 02 05 mg intravenously, repeated every 30 seconds as needed up to a maximum of 3 mg, may reverse benzodiazepine-induced coma Caution: Flumazenil should not be given if the patient has coingested a tricyclic antidepressant, is a user of high-dose benzodiazepines, or has a seizure disorder because its use in these circumstances may precipitate seizures In most circumstances, use of flumazenil is not advised as the potential risks outweigh its benefits Note: Flumazenil has a short duration of effect (2 3 hours), and resedation requiring additional doses is common
Treatment
A Emergency Management
The initial emergency management of coma can be remembered by the mnemonic ABCD, for Airway, Breathing, Circulation, and Drugs (dextrose, thiamine, and naloxone or flumazenil), respectively 1 Airway Establish a patent airway by positioning, suction, or insertion of an artificial nasal or oropharyngeal airway If the patient is deeply comatose or if there is no gag or cough reflex, perform endotracheal intubation These airway interventions may not be necessary if the patient is intoxicated by an opioid or a benzodiazepine and responds rapidly to intravenous naloxone or flumazenil (see below) 2 Breathing Clinically assess the quality and depth of respiration, and provide assistance if necessary with a bagvalve-mask device or mechanical ventilator Provide supplemental oxygen The arterial blood CO2 tension is useful in determining the adequacy of ventilation The arterial blood PO2 determination may reveal hypoxemia, which may be caused by respiratory arrest, bronchospasm, pulmonary aspiration, or noncardiogenic pulmonary edema Pulse oximetry provides an assessment of oxygenation but is not reliable in patients with methemoglobinemia or carbon monoxide poisoning 3 Circulation Measure the pulse and blood pressure and estimate tissue perfusion (eg, by measurement of urinary output, skin signs, arterial blood pH) Place the patient on continuous electrocardiographic monitoring Insert an intravenous line, and draw blood for complete blood count, glucose, electrolytes, serum creatinine and liver tests, and possible quantitative toxicologic testing 4 Drugs a Dextrose and thiamine Unless promptly treated, severe hypoglycemia can cause irreversible brain damage Therefore, in all comatose or convulsing patients, give 50% dextrose, 50 100 mL by intravenous bolus, unless a rapid bedside blood sugar test is available and rules out hypoglycemia In alcoholic or very malnourished patients who may have marginal thiamine stores, give thiamine, 100 mg intramuscularly or over 2 3 minutes intravenously b Narcotic antagonists Naloxone, 04 2 mg intravenously, may reverse opioid-induced respiratory depression and coma It is often given empirically to any comatose patient with depressed respirations If opioid overdose is strongly suspected, give additional doses of naloxone (up to 5 10 mg may be required to reverse the effects of potent opioids or propoxyphene) Note: Naloxone has a much shorter duration of action (2 3 hours) than most common opioids; repeated doses may be required, and continuous observation for at least 3 4 hours after the last dose is mandatory Nalmefene, a newer opioid antagonist, has a duration of
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