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HYPOTHERMIA Assessment & Complications
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Hypothermia commonly accompanies coma due to opioids, ethanol, hypoglycemic agents, phenothiazines, barbiturates, benzodiazepines, and other sedative-hypnotics and depressants Hypothermic patients may have a barely perceptible pulse and blood pressure and often appear to be dead Hypothermia may cause or aggravate hypotension, which will not reverse until the temperature is normalized
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Treatment of hypothermia is discussed in 37 Gradual rewarming is preferred unless the patient is in cardiac arrest
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HYPOTENSION Assessment & Complications
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Hypotension may be due to poisoning by many different drugs and poisons, including antihypertensive drugs, blockers, calcium channel blockers, disulfiram (ethanol interaction), iron, trazodone, quetiapine, and other antipsychotic agents and antidepressants Poisons causing hypotension include cyanide, carbon monoxide, hydrogen sulfide, arsenic, and certain mushrooms Hypotension in the poisoned or drug-overdosed patient may be caused by venous or arteriolar vasodilation, hypovolemia, depressed cardiac contractility, or a combination of these effects
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Most patients respond to empiric treatment with repeated 200 mL intravenous boluses of 09% saline or other isotonic crystalloid up to a total of 1 2 L If fluid therapy is not successful, give dopamine, 5 15 mcg/kg/min by intravenous infusion Consider pulmonary artery catheterization if hypotension persists Hypotension caused by certain toxins may respond to specific treatment For hypotension caused by overdoses of tricyclic antidepressants or related drugs, administer sodium bicarbonate, 50 100 mEq by intravenous bolus injection
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Norepinephrine 4 8 mcg/min by intravenous infusion is more effective than dopamine in some patients with overdoses of tricyclic antidepressants or of drugs with predominantly vasodilating effects For -blocker overdose, glucagon (5 10 mg intravenously) may be of value For calcium channel blocker overdose, administer calcium chloride, 1 2 g intravenously (repeated doses may be necessary; doses of 5 10 g and more have been given in some cases)
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Table 38 1 Common toxins or drugs causing arrhythmias1
Arrhythmia Sinus bradycardia Common Causes -Blockers, calcium channel blockers, clonidine, digitalis glycosides, organophosphates, opioids, sedative-hypnotics -Blockers, calcium channel blockers, class Ia antiarrhythmics (including quinidine), carbamazepine, clonidine, digitalis glycosides, lithium, tricyclic antidepressants -Agonists (eg, albuterol), amphetamines, anticholinergics, antihistamines, caffeine, cocaine, ephedrine, theophylline, tricyclic and other antidepressants Class Ia and class Ic antiarrhythmics, phenothiazines (eg, thioridazine), potassium (hyperkalemia), tricyclic antidepressants, diphenhydramine (severe overdose) Arsenic, cisapride, class Ia and class III antiarrhythmics, droperidol, lithium, methadone, pentamidine, sotalol, thioridazine, venlafaxine, and many other drugs (see http://wwwtorsadesorg) Amphetamines, cocaine, ephedrine, caffeine, chlorinated or fluorinated hydrocarbons, digoxin, aconite (found in some Chinese herbal preparations), fluoride, theophylline QT prolongation can lead to atypical ventricular tachycardia (torsades de pointes)
Atrioventricular block
HYPERTENSION Assessment & Complications
Hypertension may be due to poisoning with amphetamines, anticholinergics, cocaine, yohimbine-containing performanceenhancing products, monoamine oxidase (MAO) inhibitors, and other drugs Severe hypertension (eg, diastolic blood pressure > 105 110 mm Hg in a person who does not have chronic hypertension) can result in acute intracranial hemorrhage, myocardial infarction, or aortic dissection Patients often present with headache, chest pain, or encephalopathy
Sinus tachycardia
Wide QRS complex
Treatment
Treat hypertension if the patient is symptomatic or if the diastolic pressure is greater than 105 110 mm Hg especially if there is no prior history of hypertension Hypertensive patients who are agitated or anxious may benefit from a sedative such as lorazepam, 2 3 mg intravenously For persistent hypertension, administer phentolamine, 2 5 mg intravenously, or nitroprusside sodium, 025 8 mcg/kg/min intravenously If excessive tachycardia is present, add propranolol, 1 5 mg intravenously, or esmolol, 25 100 mcg/kg/min intravenously, or labetalol 02 03 mg/kg intravenously Caution: Do not give -blockers alone, since doing so may paradoxically worsen hypertension as a result of unopposed -adrenergic stimulation
QT interval prolongation and torsades de pointes Ventricular premature beats and ventricular tachycardia
Arrhythmias may also occur as a result of hypoxia, metabolic acidosis, or electrolyte imbalance (eg, hyperkalemia or hypokalemia, hypocalcemia)
ARRHYTHMIAS Assessment & Complications
Arrhythmias may occur with a variety of drugs or toxins (Table 38 1) They may also occur as a result of hypoxia, metabolic acidosis, or electrolyte imbalance (eg, hyperkalemia, hypokalemia, or hypocalcemia), or following exposure to chlorinated solvents or chloral hydrate overdose Atypical ventricular tachycardia (torsades de pointes) is often associated with drugs that prolong the QT interval
sodium bicarbonate, 50 100 mEq intravenously by bolus injection (See discussion of tricyclic antidepressant poisoning) Torsades de pointes associated with prolonged QT interval may respond to intravenous magnesium (2 g intravenously over 2 minutes) or overdrive pacing Treat digitalis-induced arrhythmias with digoxin-specific antibodies (see discussion of cardiac glycoside poisoning) For tachyarrhythmias induced by chlorinated solvents, chloral hydrate, Freons, or sympathomimetic agents, use propranolol or esmolol (see doses given above in Hypertension section)
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