Contentions in the administration of TCA poisonous quality: bicarb and after that what

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Contentions in the administration of TCA lethality: bicarb and afterward what?? Loot Hall MD Case of the week November 28, 2003

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Case of the week TCA case from this week

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ECG

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Treatment Intubation, Gastric Lavage NS 2 L bolus Sodium Bicarbonate 2 amps iv bolus took after by bicarb dribble: rehash boluses bicarb (add up to 6 amps) What if there is no reaction to the above treatment in spite of pH being in target 7.50 – 7.55?

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Objectives Is there any part for Hypertonic Saline or Phenytoin in the administration of TCA overdoses?

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Hypertonic Saline Theory Na+ load to beat Na+ channel bar by the TCA Na+ stack without the unfavorable impacts of alkalosis as observed with sodium bicarbonate Able to give significantly more Na+ than with typical saline Normal Saline: 0.9% NaCl Hypertonic Saline: 7.5% NaCl

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Hypertonic Saline Goldfrank 2003 Theoretical advantage however not satisfactorily studied Ford 2001 Not specified

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Hypertonic Saline Hoegholm. Clinical Toxicology. 1991 Case Report of TCA overdose Hypotensive, wide QRS, intermittent VT and VF Intubated, lavaged Sodium bicarb, lidocaine, dopamine, and hyperventilation (the amount of each???) Sodium chloride 170 mEq given more than 5 min Immediate narrowing of the QRS, expanded BP, no further VT or VF One case report, very little for points of interest, measure of bicarb could have been more essential

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Hypertonic Saline McCabe. Acad Emerg Med. 1994 Swine model of TCA poisonous quality Nortiptyline until SBP half of gauge and QRS > 120 msec Randomized gatherings 10 ml/kg of 7.5% hypertonic saline + 6% dextran 10 ml/kg of 0.9% ordinary saline NO bicarbonate treatment arm

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Hypertonic Saline: McCabe. Acad Emerg Med. 1994

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Hypertonic Saline McKinney. Ann Emerg Med. 2003 Case Report 29 yo female ingested 8 gm of nortryptylline Coma, BP 80/40, QRS 124 msec Intubated, lavaged, hyperventilation, 3L typical saline, dopamine 20 ug/kg/min, norepinephrine 22 ug/min, 4 amps bolus sodium bicarb, pH 7.54 QRS 135 msec Given 200 ml of hypertonic saline (7.5%)

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Hypertonic Saline McKinney. Ann Emerg Med. 2003 BP 0 3 5 10 30 min 78/42 85/50 104/60 112/68 115/68 QRS 136 msec 120msec

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Hypertonic Saline: other case reports Dolara. J Clin Tox No bicarb given before H.S., physostigmine utilized Seitz. Dtsch Med Wochesnschr ?german

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Hypertonic Saline McCabe. Ann Emerg Med 1998 Swine demonstrate (N=24) Nortyptyline until SBP < 50 and QRS > 120 msec Group 1 = D5W 10 ml/kg Group 2 = Hypertonic Saline 7.5% 10 ml/kg Group 3 = Sodium Bicarb 8.4% 3mEq/kg Group 4 = Hyperventilation to target pH 7.5-7.6 and D5W 10 ml/kg Hypertonic saline looked entirely great!! �� 

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Hypertonic Saline: McCabe. Ann Emerg Med 1998

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Hypertonic Saline: Conclusions There is creature proof to bolster the utilization of hypertonic saline after different treatments have been expanded Human confirmation is constrained to case reports Consider Hypertonic Saline for TCA poisonous quality if sodium bicarbonate incapable and pH of 7.50-7.55 has been come to

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Hypertonic Saline: Conclusions Should Hypertonic Saline be utilized rather than sodium bicarbonate? NO Lots of proof for sodium bicarb and very little for hypertonic saline Needs more study

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What about phenytoin?

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Phenytoin Theory: expands AV conduction hence upgrades conveyance of supraventricular driving forces and stifles ventricular rhythms; additionally diminishes reentry BUT isn't phenytoin a Na+ channel blocker - could compound the situation!

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Phenytoin Goldfranks 2003 Not prescribed Ford 2001 Not talked about So what proof is there?

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Phenytoin Callaham. J Pharmacol Exp Ther. 1988 Dog display Control aggregate: amitriptyline mixture Experimental gathering: phenytoin stacking before amitriptyline implantation Results No distinctions in physiologic parameters Ventricular tachycardia significantly expanded in phenytoin assemble

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Phenytoin Kulig. Vet Hum Toxicol 1984 (theoretical) Canine model Amitiptyline until QRS 160 msec Phenytoin pretreatment and save No bicarb, no pressors Phenytoin avoided ventricular arrythmias just when given as pretreatment Details not gave

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Phenytoin Mayron. Ann Emerg Med 1986. Rabbit display Amitripyline Looked at "prophylaxis" and "save" treatment with phenytoin Outcome measure was dosage of amitriptyline important to bring about wide QRS/arrythmia or demise NO BP information Specifics of QRS width not introduced

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Phenytoin Mayron. Ann Emerg Med 1986. Phenytoin had NO impact on the amitriptyline measurements required to bring about "danger" No pretreatment: mean 11.4 mg/kg (2 – 39range) Phenytoin pretx: mean 10.0 mg/kg (2.8-23.3 territory) Phenytoin had NO impact on the amitriptyline dosage required for lethality Phenytoin protect measurement after poisonous quality had an impact in 2/12 (contracted the QRS) and no impact in 10/12 Concluded: no impact with pretreatment or save

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Phenytoin Cantrill. J Emerg Med. 1983 Case Report 33yo female with amitripyline overdose BP 70, QRS 170 msec, out cold Intubated, lavaged, charcoal, bicarb dribble Phenytoin given QRS contracted to 90 msec on an ECG 30 minutes after the fact Concluded: Phenytoin is the medication of decision for TCA harmfulness

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Phenytoin Several other case reports exist in the writing

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Phenytoin Hagerman. Ann Emerg Med. 1981 10 patients with TCA harming 9/10 had wide QRS, 1/10 had ordinary QRS yet wide PR interim Phenytoin measurement was 5 – 7 mg/kg Don't say the utilization of bicarb, hyperventilation, typical or hypertonic saline Note: there is NO control assemble

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Phenytoin Hagerman. Ann Emerg Med. 1981 Pre Treatment Post Treatment Mean QRS 130 +/ - 7 106 +/ - 6 Range QRS 100 – 160 80 – 140 Mean PR 204 +/ - 12 175 +/ - 5 Concluded that phenytoin was helpful

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Phenytoin: Conclusions Animal Data is clashing Human information restricted to case reports and case arrangement No controlled human information exists Bicarbonate is the treatment of decision for QRS conduction irregularities Effect of phenytoin in cases unmanageable to bicarb basically obscure Hypertonic saline appears like a superior decision

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What different alternatives are there? Lidocaine Magnesium Propranolol Topics for one more day …

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Questions? Remarks?

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