44796 about the book… Read the reviews about the previous edition “This is a wonderful book! Clinical laboratorians will find it a valuable tool for the laboratory reference book shelf.” — Thomas P. Moyer, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA “…a good reference for the clinician, medical student, and general toxicologist. The wealth of information is, for example, ideal for preparing for an examination on the clinical aspects of toxicology.” — Matthew D. Reed, PhD, DABT A unique reference containing detailed reviews of more than 900 drugs and poisons, the Poisoning and Toxicology Handbook, Fourth Edition provides the latest information on medicinal, biological, herbal, and non-medicinal agents, and antidotes. Increasing its depth and scope with analyses of newer drugs, chemicals, and environmental toxins, including drugs that have been recently approved by the FDA, this book is a compendium of useful resources. The present volume provides locations and phone numbers of poison control centers throughout the country, organizations offering information on toxicology, and teratology information services. It presents diagnostic testing and analytical procedures, evaluates the effectiveness of antidotes, and features an extensive symptoms listing. The section on special topics provides detailed treatment protocols, hospital preparedness guidelines, position statements, and practice guidelines focused on the treatment of toxicities. This fourth edition keeps you up to date in one of the most exciting and expanding fields in medical science. Printed in the United States of America Pharmacology and Toxicology Poisoning and Toxicology handbook FOURTH EDITION Leikin • Paloucek Jerrold B. Leikin Frank P. Paloucek Poisoning and Toxicology handbook FOURTH EDITION Poisoning and Toxicology handbook FOURTH EDITION Poisoning and Toxicology handbook FOURTH EDITION Jerrold B. Leikin, MD Frank P. Paloucek, PharmD Informa Healthcare USA, Inc. 52 Vanderbilt Avenue New York, NY 10017 © 2008 by Lexi-Comp, Inc. All Rights Reserved I nforma Healthcare is an Informa business N o claim to original U.S. Government works P rinted in the United States of America on acid‑free paper 1 0 9 8 7 6 5 4 3 2 I nternational Standard Book Number‑10: 1-4200-4479-6 (Hardcover) I nternational Standard Book Number‑13: 978‑ 1-4200-4479-9 (Hardcover) T his book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are i ndicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the p ublisher cannot assume responsibility for the validity of all materials or for the consequences of their use. 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Library of Congress Cataloging‑in‑Publication Data Poisoning and toxicology handbook / editor (s) Jerrold B. Leikin and Frank P. Paloucek. 4th ed. p. ; cm. Includes bibliographical references and index. ISBN‑13: 978‑1-4200-4479-9 (alk. paper) ISBN‑10: 1-4200-4479-6 (alk. paper) 1. Toxicology Handbooks, manuals, etc. I. Leikin, Jerrold B. II. Paloucek, Frank P. III. Title RA1215.P65 2007 615.9 dc22 2006100358 V isit the Informa Web site at w ww.informa.com a nd the Informa Healthcare Web site at w ww.informahealthcare.com TABLE OF CONTENTS Preface xxix Acknowledgments . . . xxxi Editors xxxiii Contributors . . . . xxxv Editorial Advisory Panel . . xxxix Introduction . . . . . 1 Description of Sections and Fields Used in This Handbook . . . . . 1 FDA Pregnancy Categories . . . . . 2 FDA Name Differentiation Project: The Use of Tall-Man Letters. 3 Safe Writing . . . . 5 General References 6 Poison Information Centers . . . . . 9 General Poison Information Sources . . . . 20 Teratology Information Services . 28 Section I Medicinal Agents Approach to Toxicology . . 35 Stabilization of the Patient . . . . 36 History and Physical Examination 37 Drugs/Toxins Causing Increased Anion Gap (!12 mEq/L) . . . . 39 Drugs/Toxins Causing Decreased Anion Gap (B6 mEq/L) 40 Toxins Causing Osmolar Gap (By Freezing-Point Depression, Gap is !10 mOsm from Baseline Value) . . . . . . . . . . . . . . . . . . . . . 41 Toxins Associated with Oxygen Saturation Gap (!5% Difference Between Measured and Calculated Value) . . . . . . . . . . . . . . . . 41 Prevention of Absorption . . . . . . . . 42 Antidotes . . . . . . . 44 Enhancement of Elimination. . . . . 44 Toxins with Enhanced Elimination by Multiple Dosing of Activated Charcoal. . . . . . 44 Toxins Eliminated by Saline Diuresis . . . . . . . . 45 Toxins Eliminated by Urine Alkalinization . . . . 45 Drugs and Toxins Removed by Hemodialysis 46 Drugs and Toxins Removed by Hemoperfusion (Charcoal) 48 Toxicants for Which Exchange Transfusions May Be Helpful . . 49 References . . . . . 49 Support and Monitoring for Adverse Effects 50 Criteria for Admission of the Poisoned Patient to ICU. . . . 50 Footnotes. . . . . . . 51 Clinical Toxicokinetics 53 Explanations for Variations Between Predicted and Observed Values . . . . 54 Potential Benefits in the Toxicokinetic Evaluation and/or Management of the Overdose Patient . . . 55 Suggested Reading . 55 Highlights of Recent Reports (2006) on Substance Abuse and Mental Health . . 56 Lipid Emulsion Resuscitation for Local Anesthetic and Toxic Cardiac Arrest 60 Background. . . . . 60 Clinical Features of Local Anesthetic Toxicity 60 Animal Studies. . 60 Mechanisms . . . . 60 Clinical Efficacy . 60 General Applicability of Lipid Rescue Resuscitation. 61 Future Directions: Research and Practice 61 Recommendations . . 61 References . . . . . 61 Position Statement and Practice Guidelines on the Use of Multi-Dose Activated Charcoal in the Treatment of Acute Poisoning . . . . . . 63 Summary Statement 63 Introduction . . . . . . . . . . . . . . . . . . . 63 Rationale . . . . . . . . . . . . . . . . . . . . . 63 Animal Studies. . . . . . . . . . . . . . . . 63 Volunteer Studies . . . . . . . . . . . . . 63 Clinical Studies . . . . . . . . . . . . . . . 64 Indications . . . . . . . . . . . . . . . . . . . . 64 Dosage Regimen . . . . . . . . . . . . . 64 Coadministration of a Cathartic 64 Contraindications . . . . . . . . . . . . . 65 Absolute . . . . . . . 65 Relative . . . . . . . 65 Complications of Use . . . . . . . . . 65 Supporting Documentation . . . . . . 65 Introduction . . . . . . . . . . . . . . . . . . . 65 Methodology . . . . . . . . . . . . . . . . . . 65 Rationale . . . . . . . . . . . . . . . . . . . . . 65 Mechanisms of Action . . . . . . . . 66 Animal Studies. . . . . . . . . . . . . . . . 66 Volunteer Studies . . . . . . . . . . . . . 67 Clinical Studies . . . . . . . . . . . . . . . 71 Dosage Regimen . . . . . . . . . . . . . 76 Coadministration of a Cathartic 77 Complications of Use . . . . . . . . . 77 Gastrointestinal Complications . 77 Respiratory Complications 78 Fluid, Electrolyte, and Acid-Base Abnormalities . . . . . . . . 78 References . . . . . . . . . . . . . . . . . . . 78 Substance-Related Disorders . . . . . . . . 83 General Treatment Recommendations 83 Alcohol . 83 v Intoxication/Overdose (see Ethyl Alcohol) 83 Withdrawal . . . . 83 General Treatment. . 84 Cocaine 84 Intoxication/Overdose (see Cocaine) . . . 84 Withdrawal . . . . 85 General Treatment. . 85 Opioids . 85 Intoxication/Overdose 85 Withdrawal . . . . 85 General Treatment. . 86 Sedative/Hypnotic. . . . . . . . . . . . . 86 Intoxication/Overdose 86 Withdrawal . . . . 86 General Treatment. . 87 Benzodiazepine. . . . . . . . . . . . . . . 87 Intoxication . . . . 87 Withdrawal . . . . 87 Gamma Hydroxybutyrate (GHB)/Gamma Butyrolactone (GBL) . 87 Intoxication . . . . 87 Withdrawal . . . . 87 Stimulants . . . . . . . . . . . . . . . . . . . . 88 Intoxication/Overdose 88 Withdrawal . . . . 88 General Treatment. . 88 Caffeine 88 Intoxication . . . . 88 Withdrawal . . . . 88 Hallucinogens. . . . . . . . . . . . . . . . . 88 Intoxication . . . . 88 Withdrawal . . . . 88 General Treatment. . 88 Baclofen 88 Intoxication . . . . 88 Withdrawal . . . . 88 Inhalants . . . . . . . . . . . . . . . . . . . . . 89 Intoxication . . . . 89 Withdrawal . . . . 89 General Treatment. . 89 Selective Serotonin Reuptake Inhibitors (SSRIs). . 89 Intoxication/Overdose 89 Withdrawal . . . . 89 Synthesized Compounds. . . . . . 89 Intoxication/Overdose 89 Withdrawal . . . . 89 General Treatment. . 89 Marijuana. . . . . . . . . . . . . . . . . . . . . 89 Intoxication . . . . 89 Withdrawal . . . . 90 General Treatment. . 90 Nicotine 90 Intoxication/Overdose 90 Withdrawal . . . . 90 General Treatment. . 91 Psychiatric Emergencies - Violence . . . . . . . . . 91 Neuroleptic Malignant Syndrome . . . . . . . . . . . . 92 Catatonia . . . . . . . . . . . . . . . . . . . . . 92 Acute Extrapyramidal Syndromes (Eps) . . . . . 94 Acute Dystonias . . . . 94 Akathisia . . . . . . 94 Drug-Induced Parkinsonism . . . . 94 References . . . . . 95 Acarbose . . . . 97 Acebutolol . . . 97 Acetaminophen . . 98 AcetaZOLAMIDE 102 AcetoHEXAMIDE 103 Acrivastine and Pseudoephedrine . . . . . . 104 Adalimumab 104 Adenosine . . . 105 Albendazole . 106 Albuterol. . . . . 106 Aldesleukin . . 108 Alendronate. . 109 Alfentanil . . . . 110 Alglucerase . . 111 Allopurinol . . . 112 Alprazolam . . 113 Alteplase . . . . 114 Altretamine . . 116 Aluminum Hydroxide . 116 Amantadine. . 117 Amiloride . . . . 118 Aminophylline 119 Amiodarone. . 120 vi Amisulpride . . 122 Amitriptyline . 122 Amlodipine. . . 125 Amoxapine . . 126 Amoxicillin . . . 127 Amphotericin B . . 128 Ampicillin . . . . 129 Amsacrine . . . 130 Androstenedione. 131 Aprotinin. . . . . 131 Arginine . . . . . 132 Aripiprazole . . 132 Ascorbic Acid 133 Atenolol . . . . . 134 Atomoxetine . 135 Atorvastatin. . 136 Azathioprine 137 Azithromycin. 138 Bacitracin. . . . 140 Baclofen . . . . . 140 Belladonna . . 141 Benazepril . . . 142 Benzalkonium Chloride. . . . . . 143 Benzbromarone. . 143 Benzocaine . . 143 Benzonatate . 144 Benztropine. . 145 Bepridil 145 Betamethasone . . 146 Betaxolol . . . . 147 Bethanechol 148 Biperiden . . . . 148 Bisacodyl . . . . 149 Bismuth Subgallate . . 149 Bisoprolol. . . . 150 Blasticidin S . 150 Bleomycin . . . 151 Botulinum Toxin Type A . . . . 151 Bromazepam 153 Buflomedil . . . 154 Bumetanide. . 154 Bunazosin . . . 155 Bupivacaine 155 Buprenorphine . . . 156 BuPROPion . 157 BusPIRone . . 159 Busulfan . . . . . 160 Butorphanol. . 161 Butriptyline . . 162 Caffeine . . . . . 162 Calcitonin. . . . 163 Calfactant . . . 164 Candesartan . 164 Cantharidin . . 165 Capreomycin 165 Captopril. . . . . 166 Carbamazepine . . 167 Carboplatin . . 169 Carfentanil Citrate . . . 170 Carisoprodol . 170 Carmustine . . 171 Carteolol. . . . . 172 Carvedilol. . . . 173 Castor Oil . . . 174 Ceftriaxone . . 174 Cefuroxime . . 175 Celecoxib. . . . 176 Celiprolol . . . . 177 Cephalexin . . 177 Cephradine . . 178 Cetirizine . . . . 178 Chloral Hydrate . . 179 Chlorambucil. 180 Chloramphenicol . 181 Chlordiazepoxide 182 Chlorhexidine Gluconate . . . . 183 Chlormezanone . . 184 Chloroprocaine . . 184 Chloroquine. . 185 Chlorpheniramine 186 ChlorproMAZINE. 186 ChlorproPAMIDE 188 Chlorprothixene . . 189 Chlorthalidone . . . 189 Chlorzoxazone. . . 190 vii Cholecalciferol . . . 190 Choline Magnesium Trisalicylate . . . . . . . 191 Cidofovir. . . . . 191 Cimetidine . . . 192 Ciprofloxacin. 194 Cisapride . . . . 196 Cisplatin . . . . . 197 Citalopram. . . 198 Cladribine. . . . 200 Clarithromycin . . . 201 Clemastine . . 202 Clenbuterol . . 203 Clobazam . . . 203 Clofibrate . . . . 204 ClomiPHENE 204 ClomiPRAMINE. . 204 Clonazepam . 206 Clonidine . . . . 207 Clorazepate. . 209 Clotrimazole 210 Clozapine. . . . 210 Cocaine . . . . . 212 Codeine . . . . . 215 Colchicine . . . 216 Cortisone . . . . 217 Cromolyn . . . . 218 Cyanocobalamin . 219 Cyclizine. . . . . 219 Cyclobenzaprine . 220 Cyclophosphamide. . . 221 CycloSERINE 222 CycloSPORINE . . 222 Cyproheptadine . . 226 Cytarabine. . . 227 Dalteparin . . . 228 Danaparoid . . 229 Danazol . . . . . 229 Dantrolene. . . 230 Dapsone. . . . . 231 DAUNOrubicin Hydrochloride . . . . . . . . . . 232 Dehydroepiandrosterone . . . . 233 Desipramine . 233 Deslanoside . 235 Dexamethasone . 235 Dexfenfluramine . 237 Dextroamphetamine . 237 Dextromethorphan . . . 238 Diazepam . . . 239 Diazoxide. . . . 241 Dibenzepin . . 242 Dibucaine. . . . 242 Diclofenac . . . 243 Dicumarol . . . 244 Dicyclomine. . 244 Didanosine . . 245 Diethylcarbamazine . . 246 Diethylpropion . . . 247 Diethylstilbestrol . 247 Diethyltoluamide . 248 Diflunisal . . . . 248 Digitoxin . . . . . 249 Digoxin 250 Diltiazem . . . . 252 DimenhyDRINATE . . . 254 Dimethyl Sulfoxide . . . 255 DiphenhydrAMINE . . . 255 Diphenoxylate and Atropine . 257 Dipyridamole. 258 Dirithromycin. 258 Disopyramide 259 Disulfiram. . . . 260 Docetaxel. . . . 260 Docusate . . . . 262 Dofetilide . . . . 262 Donepezil. . . . 263 Dornase Alfa. 264 Doxazosin . . . 264 Doxepin . . . . . 265 DOXOrubicin 266 Doxycycline. . 268 Doxylamine . . 269 Droperidol . . . 270 Duloxetine . . . 271 Edrophonium 273 Eflornithine . . 273 viii Enalapril . . . . . 274 Enfuvirtide . . . 275 Enoxacin . . . . 276 Enoxaparin . . 276 Ephedrine . . . 277 Epoetin Alfa . 278 Eptifibatide . . 280 Ergotamine . . 281 Erythromycin 282 Escitalopram. 284 Esmolol 286 Esomeprazole . . . 286 Estazolam . . . 287 Estrogens, Conjugated. . . . . . 288 Estrogens (Esterified) 290 Ethacrynic Acid . . 291 Ethambutol . . 292 Ethchlorvynol 292 Ethionamide 293 Ethosuximide 293 Ethotoin . . . . . 294 Ethyl Alcohol. 294 Ethyl Chloride 297 Ethyl Loflazepate 297 Etidronate Disodium . 297 Etodolac . . . . . 298 Etoposide. . . . 299 Famciclovir . . 300 Famotidine . . 301 Felodipine . . . 302 Femoxetine . . 302 Fenoldopam 303 Fenoprofen . . 303 Fenproporex . 304 Fentanyl . . . . . 304 Fexofenadine 307 Finasteride . . 307 Flecainide . . . 308 Fleroxacin . . . 309 Floxuridine. . . 309 Fluconazole. . 310 Flunitrazepam . . . 311 Fluoride . . . . . 311 Fluorouracil . . 313 Fluoxetine . . . 314 Fluphenazine 316 Flurazepam. . 318 Flurbiprofen. . 318 Flutamide. . . . 320 Fluvastatin. . . 320 Fluvoxamine . 321 Foscarnet. . . . 323 Fosfomycin . . 324 Fosinopril . . . . 325 Fosphenytoin 326 Furosemide. . 327 Gabapentin . . 329 Gallium Nitrate. . . 329 Gallopamil . . . 330 Galsulfase . . . 330 Gamma Hydroxybutyric Acid 331 Ganciclovir . . 333 Gemfibrozil . . 334 Gentamicin . . 334 Glimepiride . . 336 GlipiZIDE . . . . 337 Glutamine . . . 338 Glutethimide . 338 GlyBURIDE. . 339 Glycerin . . . . . 340 Gold Compounds 340 Granisetron . . 341 Griseofulvin. . 342 Guaifenesin. . 342 Guanabenz . . 343 Guanadrel . . . 343 Guanethidine 344 Guanfacine . . 345 Guanidine . . . 345 Haloperidol . . 345 Heparin 347 Heroin 349 Hexachlorophene 351 Hirudin 352 Histoplasmin . 352 ix [...]... chapter in toxicology Jerrold B Leikin, MD Frank P Paloucek, PharmD xxix ACKNOWLEDGMENTS The Poisoning & Toxicology Handbook exists in its present form as the result of the concerted efforts of the following individuals: Robert D Kerscher, publisher and president of Lexi-Comp Inc; Lynn D Coppinger, managing editor; David C Marcus, director of information systems; Matthew C Kerscher, product manager; and Tracey... Information was derived from Lexi-Comp’s Poisoning and Toxicology database (www.lexi.com) for this book The authors wish to thank their families, friends, and colleagues who supported them in their efforts to complete this book xxxi EDITORS Jerrold Blair Leikin, MD, FACP, FACEP, FACMT, FAACT, FACOEM Dr Leikin is director of medical toxicology at Evanston Northwestern Healthcare-OMEGA, Glenbrook Hospital,... Minnesota Dr Leikin has presented over 100 abstracts at national meetings and has published over 200 articles in peer-reviewed medical journals He is coeditor of the American Medical Association Handbook of First Aid and Emergency Care He has written chapters on the subjects of toxicology, emergency medicine, critical care medicine, internal medicine, and observational medicine in medical textbooks Dr Leikin. .. 1323 xxviii PREFACE The term toxicology can today be defined as the assault, absorption, and adverse effects of foreign substances upon the human body As such, toxicology is truly one of the most exciting and expanding fields in the medical sciences The depth and scope of this discipline are increasing yearly with the discovery and the analysis of newer drugs, chemicals, or environmental... Staphylococcus Food Poisoning Star-of-Bethlehem (Hippobroma longiflora) Star-of-Bethlehem (Ornithogalum pyrenaicum) Star-of-Bethlehem... member of the American Academy of Clinical Toxicology since 1989, and a Diplomate of the American Board of Applied Toxicology since 1991 He has been a director of a postdoctoral clinical toxicology fellowship program since 1991 and is now director of residency programs at the University of Illinois Hospital In addition to numerous scientific posters and clinical toxicology publications, Dr Paloucek is... 740 4-Bromo-2,5-Dimethoxyphenylethylamine 741 4-Methylthioamphetamine 741 4,4?-Methylenebis (2-Chloroaniline) ... Medical College and professor of emergency medicine at Feinberg School of Medicine at Northwestern University in Chicago, Illinois Dr Leikin received his medical doctorate degree from the Chicago Medical School in 1980 and completed a combined residency in internal medicine and emergency medicine at Evanston Hospital and Northwestern Memorial Hospital in 1984 He completed a fellowship in medical toxicology. .. the above specialties Dr Leikin was the associate director of the emergency department from 1988 to 2001 at Rush-Presbyterian-St Luke’s Medical Center in Chicago He was medical director of the Rush Poison Control Center for 11 years and was the medical director of the United States Drug Testing Laboratory for 5 years Dr Leikin is also a consultant with the Illinois Poison Center and Wisconsin Poison Center... 739 3,4-Methylenedioxymethamphetamine 739 3,4-Methylenedioxy-N-Methyl-Butanamine 740 4-Aminopyridine . Leikin Frank P. Paloucek Poisoning and Toxicology handbook FOURTH EDITION Poisoning and Toxicology handbook FOURTH EDITION Poisoning and Toxicology handbook FOURTH EDITION Jerrold B. Leikin, MD Frank. exciting and expanding fields in medical science. Printed in the United States of America Pharmacology and Toxicology Poisoning and Toxicology handbook FOURTH EDITION Leikin • Paloucek Jerrold B. Leikin Frank. Jerrold B. Leikin and Frank P. Paloucek. 4th ed. p. ; cm. Includes bibliographical references and index. ISBN‑13: 978‑ 1-4 20 0-4 47 9-9 (alk. paper) ISBN‑10: 1-4 20 0-4 47 9-6 (alk. paper) 1. Toxicology