NINTH EDITION Goldfrank's Toxicologic Emergencies

NINTH EDITION Goldfrank's Toxicologic Emergencies Lewis S. Nelson, MD, FAAa, FACEP, FACMT Associate Professor of Emergency Medicine New York Universit...

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NINTH EDITION

Goldfrank's Toxicologic Emergencies Lewis S. Nelson, MD, FAAa, FACEP, FACMT

Robert S. Hoffman, MD, FAACT, FACMT

Associate Professor of Emergency Medicine New York University School of Medicine Attending Physician, Emergency Medicine Bellevue Hospital Center and New York University Eangone Medical Center Director, Fellowship in Medical Toxicology New York City Poison Center and New York University School of Medicine New York, New York

Associate Professor of Emergency Medicine and Medicine (Clinical Pharmacology) New York University School ol Medicine Attending Physician, Emergency Medicine and Internal Medicine Bellevue Hospital Center and New York University Eangone Medical Center Director, New York City Poison Center New York, New York

Neal A. Lewin, MD, FACEP, FACMT, FACP

Lewis R. Goldfrank, MD, FAAEM, FAACT, FACEP, FACMT, FACP

The Stanley and Fiona Druckenmiller Clinical Professor of Emergency Medicine and Medicine (Pharmacology) New York University School of Medicine Director, Didactic Education Emergency Medicine Residency Attending Physician, Emergency Medicine and Internal Medicine Bellevue Hospital Center and New York University Eangone Medical Center Consultant, New York City Poison ("enter New York, New York

Herbert W. Adams Professor and Chair Department of Emergency Medicine New York University School of Medicine Director, Emergency Medicine Bellevue Hospital ("enter and New York University Langone Medical ('enter Medical Director, New York City Poison ("enter New York, New York

Mary Ann Howland, PharmD, DABAT, FAACT

Neal E. Flotnenbaum, MD, FACEP, FACP

Clinical Professor of Pharmacy St. John's University College of Pharmacy Adjunct Professor of Emergency Medicine New York University School of Medicine Bellevue Hospital Center and New York University Eangone Medical Center Senior Consultant in Residence New York City Poison Center New York, New York

Professor ol Clinical Medicine Weill Cornell Medical College of Cornell University Emergency Physician-in-Chief New York-Presbyterian Hospital Weill Cornell Medical Center Consultant, New York City Poison Center New York, New York

Medical N e w York Milan

Chicago

San I-'rancisco

N e w Delhi

San Juan

Lisbon Seoul

London Singapore

Madrid Sydney

Mevico ( iiy Toronto

TABLE OF ANTIDOTES IN DEPTH Readers of previous editions o/Goldfrank's Toxicologic Emergencies are undoubtedly aware that the editors have always felt that an emphasis on general management of poisoning or overdoses eoupled with sound medical management is more important or as important as the selection and use of a specific antidote in the vast majority of cases. Nevertheless, there are some instances where nothing other than the timely use of a specific antidote or therapy will he essential for a patient. For this reason, and also because the use of such strategies may be problematic, controversial, or unfamiliar to the practitioner (as new antidotes continue to emerge), we have included a section (or sections) at the end of each chapter where an in-depth discussion of such antidotes and therapies are relevant. The following Antidotes in Depth are included in this edition.

Activated Charcoal..

Ethanol

108

Mary Ann Howland

Mary Ann Howland

Antivenom (Crotaline)

Flumazenil

i6ii

Fomepizole

1582

Glucagon

1473

1109

Glucarpidase (Carboxypeptidase G2)

Robert S. Hoffman, Lewis S. Nelson, and Mary Ann Howland

Botulinum Antitoxin

Hydroxocobalamin

695

Hyperbaric Oxygen

1381

Insulin-Euglycemia Therapy

1001

intravenous Fat Emulsions

604

7

L-Carnitine

28

Leucovorin (Folinic Acid) and Folic Acid

946

1229

fVtethylene Blue

. . i 708

Marv Ann Howland

JV-Acetylcysteine Mary Ann I lowland and

1779

Joseph (7'. Relln

Edetate Calcium Disodium (CaNa2EDTA)

783

Mary Ann Howland

Mary Aim Howland

DTPA [Pentetic Acid or Pentetate (Zinc or Calcium) Trisodium]

711

Mary Ann Howland

Mary Ann Howland

Dimercaprol (British Anti-Lewisite or BAL)

976

Theodore (.. Kania

Larissa I. Velez and Kathleen A. Delaney

Digoxin-Specific Antibody Fragments

893

William Kerns II

Mary Ann Howland

Dextrose

167

Stephen R. 1'hoin

Kenneth M. Sutin

Deferoxamine

1695

Mary Ann Howland

Mary Ann Howland

Dantrolene Sodium

787

Silas W. Smith

Lewis R. Goldfrank and Howard L. Geyer

Calcium

910

Mary Ann Howland

Mary Ann Howland

Benzodiazepines

1414

Mary Ann Howland

Richard F. Clark

Atropine

1072

Mary Ann Howland

Anthony F. Pizon, Bradley D. Riley, and Anne-Michelle Ruha

Antivenom (Scorpion and Spider).

1419

Octreotide 1290

Miiry Ann I lowland

Mary Ann Howland

Vff

500 IUJ.'VI)

G. Hendriekson

734

I

Table of Antidotes in Depth

Opioid Antagonists

579 759

1775

1467

880

Mary Ann Howland

Prussian Blue

1334

Mary Ann Howland

Syrup of Ipecac

104

Thiamine Hydrochloride

1129

Vitamin K,

876

Mary Ann Howland

845

Mary Ann Howland

Sodium and Amyl Nitrite

1284

Robert S. Hoffman

Robert S. Hoffman

Pyridoxine

Succimer (2,3-Dimercaptosuccinic Acid)

Mary Ann Howland

Mary Ann Howland

Protamine

1692

Mary Ann Howland

Joseph G. Rella

Pralidoxime

Sodium Thiosulfate Mary Ann I lowland

Mary Ann Howland

Potassium Iodide

520

Paul M. Wax

Mary Ann Howland and Lewis S. Nelson

Physostigmine Salicylate

Sodium Bicarbonate

1689

Whole-Bowel Irrigation and Other Intestinal Evacuants Mary Ann Howland

114

TABLE OF CONTENTS Contributors

xv

Preface

xxvii

Acknowledgments

xxviii

1 Historical Principles and Perspectives

PARTB THE FUNDAMENTAL PRINCIPLES OF MEDICAL TOXICOLOGY

155

Biochemical and Molecular Basis

157

1

Paul M. Wax 2 Toxicologic Plagues and Disasters in History

18

Paul M. Wax

1 1 Chemical Principles

157

Stephen ) . I'raub and Lewis S. Nelson

1 2 Biochemical and Metabolic Principles

PART A

Kurt (.'. Kleinsehniidt and Kathleen A. Dchinev

THE GENERAL APPROACH TO MEDICAL TOXICOLOGY 3 Initial Evaluation of the Patient: Vital Signs and Toxic Syndromes

1 3 Neurotransmitters and Neuromodulators

31

4 Principles of Managing the Acutely Poisoned or Overdosed Patient

33

37

Lewis S. Nelson, Neal A. Lewin, Mary Ann Howland, Robert S. Hoffman, Lewis R. Goldfrank, and Neal E. Flomenbaum 5 Diagnostic Imaging

45

David 7'. Schwartz

1 4 Withdrawal Principles

221

Richard J. Hamilton

Pathophysiologic Basis: Organ Systems

228

1 5 Thermoregulatory Principles

228

Susi L'. \'assallo and Kathleen A. Delancv

1 6 Fluid, Electrolyte, and Acid-Base Principles .

6 Laboratory Principles I'etrie M. Rainey

70

1 8 Neurologic Principles Itiintu

104

Mary Ann Howland

Activated Charcoal

265

Kishor Midavdtlc and Mark R. Server

90

llocgbcrg

Syrup of Ipecac

249

Alan N. ('barney and Robert S. Hoffman

1 7 Psychiatric Principles

7 Techniques Used to Prevent Gastrointestinal Absorption

189

Steven C. Curry. Kirk Charles Mills. Anne-Michelle Ruha, and Ayrn D. OX'onuor

Lewis S. Nelson, Neal A. Lewin, Mary Ann Howland, Robert S. Hoffman, Lewis R. Goldfrank, and Meal E. Flomenbaum

Anne- Bolette Glide and l.olle (.'. G.

70

B. Uuo

1 9 Ophthalmic Principles Adhi Sharma

108

Mary Ann Howland

20 Otolaryngologic Principles

292

William K. Chiang

Whole-Bowel Irrigation and Other Intestinal Kvacuants Mary Arm Howland 8 Pharmacokinetic and Toxicokinetic Principles Mary Ann I lowland

11-1

21 Respirator}' Principles , Andrew

119

Stolihtch

,uul Robert S.

303 Hoffman

22 Electrophysiologic and Eleclrocardiographic Principles ( athleen ( Luii v

9 Principles and Techniques Applied to Enhance Elimination

135

Robert \ llessler

David S. Gohljarb

1 0 Use of The Intensive Care Unit Murk A. Kirk

2 3 HemtuK'namic Principles

1 18

24 1 lemalologic Principles M
SniU'lii

40

Contents

2 5 Gastrointestinal Principles

359

Richard G. Church and Kavita M. Babu

2 6 Hepatic Principles

Joshua G. Seiner

367

Intrathecal Administration of Xenobiotics

548

Rama B. Rao

Kathleen A. Delaney

2 7 Renal Principles

3 7 Cokhicine, Podophyllin, and the Vinca Alkaloids. . . 537

381

3 8 Opioids

559

Lewis S. Nelson and Dean Olsen

Donald A. Feinjeld and Nikolas B. Harbord

2 8 Genitourinary Principles Jason Chu

396

2 9 Dermatologic Principles

410

Opioid Antagonists

579

Mary Ann Howland and Lewis S. Nelson

B. Foods, Dietary and Nutritional Xenobiotics

Neal A. Lewin and Lewis S. Nelson

3 9 Dieting Agents and Regimens

586 586

Jeanna M. Marraffa

Special Populations

423

4 0 Iron

596

Jeanmarie Perrone

3 0 Reproductive and Perinatal Principles Jeffrey S. Fine

423

31 Pediatric Principles

447

Jeffrey S. Fine

Deferoxamine Mary Ann Howland 41 Vitamins

604 609

Beth Y. Ginsburg

3 2 Geriatric Principles

461

Judith C. Ahronheim and Mary Ann Howland

4 2 Essential Oils

624

Sarah Eliza Haleomb

3 3 Postmortem Toxicology

471

Rama B. Rao and Mark A. Flomenbaum

4 3 Herbal Preparations Oliver L. Hung

631

4 4 Athletic Performance Enhancers

654

O r g a n Procurement from Poisoned Patients . . . . 479

Rama B. Rao

Susi U. Vassallo

PARTC THE CLINICAL BASIS OF MEDICAL TOXICOLOGY

481

4 5 Food Poisoning Michael G. Tunik

668

4 6 Botulism

682

Howard L. Geyer

Botulinum Antitoxin

695

Lewis R. Goldfrank and Howard L. Geyer

A. Analgesics and Antiinfiammatory Medications 3 4 Acetaminophen

483

C. Pharmaceuticals

698

483

4 7 Anticonvulsants

698

Robert G. Hendriekson

iV-Acetylcysteine

Suzanne Doyon

500

Mary Ann Howland and Robert G. Hendriekson

3 5 Salicylates

508

William J. Holubek

4 8 Antidiabetics and Hypoglycemics

714

George M. Basse

520

Paul M. Wax

3 6 Nonsteroidal Antiinfiammatory Drugs

711

Mary Arm Howland

Neal /:'. Flomeidiaum

Sodium Bicarbonate

L-Carnitine

Dextrose

728

Larissa I. Velez and Kathleen A. Delaney

528

Octreotide Mary Ann Howland

734

Contents

4 9 Thyroid and Antithyroid Medications

738 748 759

763

770

778

783

787

Silas W. Smith Extravasation of Xenobiotics

914

6 3 Antidysrhythmics

925

6 4 Cardioactive Steroids

936

Digoxin-Specific Antibody Fragments

946

Mary Ann Howland

Mary Ann Howland Glucarpidase (Carboxypeptidase G )

6 2 Other Antihypertensives

Jason B. Hack

Richard Y. Wang Leucovorin (Folinic Acid) and Folic Acid

910

Lewis S. Nelson and Neal A. Lewin

Richard Y. Wang 5 3 Antineoplastics: Methotrexate

Glucagon

Francis Jerome DeRoos

Jason Chu 5 2 Antineoplastics Overview

896

Mary Ann Howland

Mary Ann Howland 51 Antimigraine Medications

61 (3-Adrenergic Antagonists Jeffrey R. Brubacher

Anthony J. Tomassoni and Richard S. Weisman

Physostigmine Salicylate

893

William Kerns

Nicole C. Bouchard

5 0 Antihistamines and Decongestants

Insulin-Euglycemia Therapy

793

6 5 Methylxanthines and Selective (3, Adrenergic Agonists

952

Robert J. Hoffman

Richard Y. Wang 5 4 Miscellaneous Antineoplastics

796

Richard Y. Wang 5 5 Pharmaceutical Additives

F. Anesthetics and Related Medications 6 6 Local Anesthetics

803

Sean P. Nordt and Lisa E. Vivero

965 965

David R. Schwartz and Brian Kaufman Intravenous Fat Emulsions

976

Theodore C. Bania

D. Antimicrobials 5 6 Antibacterials, Antifungals, and Antivirals

817 817 834

Pyridoxine

845

989

Kenneth M. Sutin Dantrolene Sodium

Christina H. Hernon and Edward W. Bayer

982

Brian Kaufman and Martin Griff el 6 8 Neuromuscular Blockers

Christine M. Stork

5 7 Antituberculous Medications

6 7 Inhalational Anesthetics

100 I

Kenneth M. Sutin

Mary Ann Howland 5 8 Antimalarials

849

/. Drive Barry

G. Psychotropic Medications 6 9 Antipsychotics

1003 1003

David N. Juurlink

E. Cardiopulmonary Medications 5 9 Anticoagulants

861 861 876

Protamine

880

1027

Alex [•'. Manini

72 Serotonin Reuptake Inhibitors and Atypical Antidepressants

Mary Ann Howland

1016

Howard A. Greller

71 Monoamine Oxidase Inhibitors

Mark Su Vitamin K:

7 0 Lithium

1037

Christine M. Stork

Mary Ann Howland

7 3 Cyclic Antidepressants 6 0 Calcium Channel Blockers Francis Jerome DeRoos

884

Erica I. Liebelt

1049

Contents

74 Sedative-Hypnotics

1060

Mary Ann Howland

David C. Lee and Kathy Lynn Ferguson

Flumazenil

1072

7 5 Amphetamines

8 9 Bismuth

1233

Rama B. Rao

Mary Ann Howland

H. Substances of Abuse

D i m e r c a p r o l (British Anti-Lewisite o r BAL) . . . . 1229

1078 1078

9 0 Cadmium Stephen }. Traub and Robert S. Hoffman

1237

9 1 Chromium

1243

Steven B. Bird

William K. Chiang

7 6 Cocaine

1091

Jane M. Prosser and Robert S. Hoffman

Internal Concealment of Xenobiotics

1103

Jane M. Prosser

Benzodiazepines

1109

Robert S. Hoffman, Lewis S. Nelson, and Mary Ann Howland

7 7 Ethanol

1115

Luke Yip

Thiamine Hydrochloride

1129

Robert S. Hoffman

7 8 Ethanol Withdrawal

1134

Jeffrey A. Gold and Lewis S. Nelson

7 9 Disulfiram and Disulfiram-Like Reactions

1143

Edwin K. Kuffner

8 0 y-Hydroxybutyric Acid Brenna M. Farmer

1151

8 1 Inhalants

1157 1166 1177 1185

9 4 Lead

1266

Fred M. Henretig

Succimer (2,3-Dimercaptosuccinic Acid)

1191

Mary Ann Howland

Edetate Calcium Disodium (CaNa,EDTA) Mary Ann Howland

9 5 Manganese

1294

Sari Soghoian

9 6 Mercury

1299

Young-Jin Sue

9 7 Nickel

1308

9 8 Selenium

1316

9 9 Silver

1321

100 Thallium

1326 and Robert S. Hoffman

Prussian Blue 101 Zinc

1202

J. Household Products 102 Antiseptics, Disinfectants, and Sterilants

87 Antimony

1207 1207

Asim F. farabar

8 8 Arsenic Stephen W. Mundav and Marsha /). Ford

1290

1334 1339

Nima Majlesi

Brenna M. F'armer

I. Metals

1284

Robert S. Hoffman

Ruben E. Olmedo

8 6 Aluminum

1256

Lewis S. Nelson

Maria Mercurio-Zappala

Sari Soghoian

8 5 Phencyclidine and Ketamine

9 3 Copper

Mclisa W. Lai Becker and Michele Burns Ewaid

Michael A. McGuigan

8 4 Nicotine

Gar Ming Chan, MD

Diane P. Calello

Kavita M. Balm

8 3 Cannabinoids

1248

John A. Curtis and David A. Haggerty

Heather Long

8 2 I lallucinogens

9 2 Cobalt

1214

1345 1345

Paul M. Wax

1 0 3 Camphor and Moth Repellents

1358

Edwin K. Kuffner

1 0 4 Caustics Jessica A. Fulton

] 364

conients

1 0 5 Hydrofluoric Acid and Fluorides

1374

L. Natural Toxins and Envenomations

1522

Mark Su

1 1 7 Mushrooms Calcium

1381

1522

Lewis R. Goldfrank

Mary Ann Howland

1 1 8 Plants 1 0 6 Hydrocarbons

1386

1537

Mary Emery Palmer and Joseph M. Bel:

David D. Cummin

1 1 9 Arthropods 1 0 7 Toxic Alcohols

1400

1561

lu-Hci Halm

Sage W. Wiener

Antivenom (Scorpion and Spider) Diethylene Glycol

1411

Riclhird

1582

Prunklin (lark

Joshua G. Schier Fomepizole

1414

1 2 0 Marine Envenomations

1387

P>. Eric Brush

Mary Ann I lowland Ethanol

1419

Mary Ann Howland

121 Snakes and Other Reptiles Briiillcv /). Riley. Anthony P. Pizou, and Anne Michelle Rului Antivenom (Crotaline)

K. Pesticides 1 0 8 Pesticides: An Overview of Rodenticides and a Focus on Principles

1423

1434

1437

1440

Insecticides: Organic Phosphorus Compounds and Curbamates

14 15

114

1 2 4 Simple Asphyxiants and Pulmonary Irritants . . . 1643

1 2 5 Carbon Monoxide

I Ivperbaric ()xygen 1450

Steplieu

lr>38

1473

1 <->7

R. l!n>w

1 2 6 Cyanide and 1 Ivdrogen Sulfide 1467

Mary Ann I lowland Atropine

1625

( 'hristian IOmiis::ewski

Michael Lddleslou and Richard Franklin ('lark Pralidoxime

1 2 3 Nanotoxicology

Lewis S. Nelson and Ohuhipo A. Odujebe

)'iu-cheuug ( ban 113

1615

Silas W. Smith

Michael C. Beuhler 1 1 2 Strychnine

1 2 2 Industrial Poisoning: Information and Control

1615

Peter H. Wald

Fermin Barrueto, Jr. 1 1 1 Phosphorus

Anthony F. Pizon, Bradley /). Riley, and Anne-Michelle Ruha

1. Occupational and Environmental Toxins.

Andrew Dawson 1 1 0 Sodium Monofluoroacetate and Fluoroacetamide

1611

1423

Neal E. Flomenbaum 1 0 9 Barium

1601

lcTS

Christi'pher P. llolstege. Gary /•'. Isom, and Mark A. Kirk

Sodium and Amyl Nitrite

Mary Ann Howland

Mtirv Ann llowliind

Insecticides: Organic Chlorines, Pyrethrins/Pyrethroids, and Insect Repellents. . . 1477

Sodium Thiosulfate

1689

1 f>92

Miirv Ami Ilowuunl

Michael G. Holland 1 ivdroxocobulamin 1 1 5 Herbicides

1491

Darren M. Roberts 1 1 6 Methyl Bromide and Other Fumigants Keiili K. Burkbarl

\/W/T Ami Howland

1 2 7 Methemoglobin Inducers 131b

I (•>*•> 5

Denm, P. Price

1 (^'S

I

Contents

Methylene Blue

1708

Mary Ann Howland

1 2 8 Smoke Inhalation

1711

Nathan Phillip Charlton and Mark A. Kirk

Poison Centers and Epidemiology 1 3 4 Poison Prevention and Education

1782 1782

Lauren Schwartz

N. Disaster Preparedness 1 2 9 Risk Assessment and Risk Communication

1721 1721

Charles A. McKay

1 3 0 Hazmat Incident Response

1735

1 3 6 International Perspectives on Medical Toxicology 1 3 7 Principles of Epidemiology and Research Design

1750

Joseph G. Rella

1811

Louis R. Cantilena

1 3 9 Medication Safety and Adverse Drug Events.. . . 1820 Brenna M. Farmer

1775

1 4 0 Risk Management and Legal Principles

Joseph G. Rella

DTPA [Pentetic Acid or Pentetate (Zinc or Calcium) Trisodium]

138 Adverse Drug Events and Postmarketing Surveillance

1759

Joseph G. Rella

Potassium Iodide

1803

Kevin C. Osterhoudt

Jeffrey R. Suchard

1 3 3 Radiation

1796

Michael Eddleston

Jeffrey R. Suchard

1 3 2 Biological Weapons

1789

Robert S. Hoffman

1727

Bradley J. Kaufman

131 Chemical Weapons

135 Poison Centers and Poison Epidemiology

1831

Barbara M. Kirrane and Dainius A. Drukteinis

1779 Index

1839