eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Carbamazepine: Differential Diagnoses & Workup

Author: Nidhi Kapoor, MD, Emergency Physician, Clinical Assistant Professor Emergency Medicine, Brown Medical School, Department of Emergency Medicine, Brown University School of Medicine
Coauthor(s): Richard J Hamilton, MD, FAAEM, FACMT, Chairman, Department of Emergency Medicine, Drexel University College of Medicine
Contributor Information and Disclosures

Updated: Aug 14, 2008

Differential Diagnoses

Alcohol and Substance Abuse Evaluation
Toxicity, Anticholinergic
Encephalitis
Toxicity, Antidepressant
Headache, Tension
Toxicity, Lithium
Hepatitis
Toxicity, Medication-Induced Dystonic Reactions
Hypothermia
Toxicity, Phenytoin
Neuroleptic Malignant Syndrome
Toxicity, Valproate
Sinus Bradycardia
Stevens-Johnson Syndrome
Syndrome of Inappropriate Antidiuretic Hormone Secretion

Other Problems to Be Considered

Hypersensitivity reactions (eg, dermatitis, eosinophilia, lymphadenopathy, vasculitis, splenomegaly)
Pancytopenia (eg, aplastic anemia, leukopenia)
Drug-drug interactions

Workup

Laboratory Studies

  • Obtain a fingerstick glucose measurement for possible explanation of altered mental status.
  • Measure carbamazepine plasma level to verify that carbamazepine toxicity is present.
  • Perform liver function tests to ascertain if liver damage has occurred.
  • Obtain a complete blood count with differential.
  • Measure electrolyte levels; hyponatremia is not uncommon with chronic dosing but rarely is noted in acute overdose.
  • Perform blood urea nitrogen and creatinine tests to ascertain if renal damage has occurred.
  • Measure arterial blood gas if pulse oximetry reads less than 90-95% or if any respiratory compromise is evident.
  • Obtain a pregnancy test in females of childbearing age.

Imaging Studies

  • Obtain an abdominal radiograph because patients with rising serum levels may have a bezoar of undigested tablets that may be visualized radiographically.
  • Obtain a chest x-ray if crackles or rales are heard on physical examination and pulmonary edema is suspected or to confirm endotracheal (ET) placement if respiratory depression occurs.

Other Tests

  • Obtain a 12-lead electrocardiogram (ECG) to determine any conduction abnormalities or interval prolongations.
    • QRS widening
    • Sinus tachycardia
    • Varying degrees of atrioventricular block
    • QT prolongation

Procedures

  • Repeat doses of activated charcoal and whole bowel irrigation

More on Toxicity, Carbamazepine

Overview: Toxicity, Carbamazepine
Differential Diagnoses & Workup: Toxicity, Carbamazepine
Treatment & Medication: Toxicity, Carbamazepine
Follow-up: Toxicity, Carbamazepine
References
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References

  1. Montgomery VL, Richman BJ, Goldsmith LJ, Rodgers GC Jr. Severity and carbamazepine level at time of initial poison center contact correlate with outcome in carbamazepine poisoning. J Toxicol Clin Toxicol. 1995;33(4):311-23. [Medline].

  2. van Opstal JM, Janknegt R, Cilissen J, et al. Severe overdosage with the antiepileptic drug oxcarbazepine. Br J Clin Pharmacol. Sep 2004;58(3):329-31. [Medline].

  3. Fischer M, Hamm H, Wirbelauer J. [Severe drug-related skin reaction: toxic epidermal necrolysis caused by carbamazepine]. Klin Padiatr. Sep-Oct 2004;216(5):288-93. [Medline].

  4. Allam JP, Paus T, Reichel C, et al. DRESS syndrome associated with carbamazepine and phenytoin. Eur J Dermatol. Sep-Oct 2004;14(5):339-42. [Medline].

  5. Vander T, Odi H, Bluvstein V, Ronen J, Catz A. Carbamazepine toxicity following Oxybutynin and Dantrolene administration: a case report. Spinal Cord. Apr 2005;43(4):252-5. [Medline].

  6. Apfelbaum JD, Caravati EM, Kerns WP, et al. Cardiovascular effects of carbamazepine toxicity. Ann Emerg Med. May 1995;25(5):631-5. [Medline].

  7. Bass J, Miles MV, Tennison MB, et al. Effects of enteral tube feeding on the absorption and pharmacokinetic profile of carbamazepine suspension. Epilepsia. May-Jun 1989;30(3):364-9. [Medline].

  8. Goldfrank L, Flomenbaum NE, Lewin NA. Carbamazepine. In: Goldfrank's Toxicologic Emergencies. Appleton & Lange; 1994:594-5.

  9. Graudins A, Peden G, Dowsett RP. Massive overdose with controlled-release carbamazepine resulting in delayed peak serum concentrations and life-threatening toxicity. Emerg Med (Fremantle). Mar 2002;14(1):89-94. [Medline].

  10. Klimaszyk D, Lukasik-GLebocka M. [Cardiac toxicity of carbamazepine]. Przegl Lek. 2002;59(4-5):384-5. [Medline].

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  14. Litovitz TL, Smilkstein M, Felberg L, et al. 1996 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1997;15(5):447-500. [Medline].

  15. Micromedex. Toxicologic Managements of Carbamazepine. Healthcare Series Micromedex;95.

  16. Miles MV, Lawless ST, Tennison MB, et al. Rapid loading of critically ill patients with carbamazepine suspension. Pediatrics. Aug 1990;86(2):263-6. [Medline].

  17. Riva R, Contin M, Albani F, et al. Free and total plasma concentrations of carbamazepine and carbamazepine-10,11-epoxide in epileptic patients: diurnal fluctuations and relationship with side effects. Ther Drug Monit. 1984;6(4):408-13. [Medline].

  18. Romero Maldonado N, Sendra Tello J, Raboso Garcia-Baquero E, Harto Castano A. Anticonvulsant hypersensitivity syndrome with fatal outcome. Eur J Dermatol. Sep-Oct 2002;12(5):503-5. [Medline].

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  20. Van Der Meyden CH, Kruger AJ, Muller FO, et al. Acute oral loading of carbamazepine-CR and phenytoin in a double-blind randomized study of patients at risk of seizures. Epilepsia. Jan-Feb 1994;35(1):189-94. [Medline].

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Further Reading

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Keywords

toxicity carbamazepine, carbamazepine toxicity, carbamazepine poisoning, 5H-dibenzazepine-5-carboxamide toxicity, antiepileptic drug toxicity, carbamazepine overdose, carbamazepine ingestion, carbamazepine exposure, antiepileptic drugs, AEDs, simple and complex partial seizures treatment, trigeminal neuralgia treatment, bipolar affective disorder treatment, iminostilbene derivative

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Contributor Information and Disclosures

Author

Nidhi Kapoor, MD, Emergency Physician, Clinical Assistant Professor Emergency Medicine, Brown Medical School, Department of Emergency Medicine, Brown University School of Medicine
Nidhi Kapoor, MD is a member of the following medical societies: American College of Emergency Physicians, Rhode Island Medical Society, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Richard J Hamilton, MD, FAAEM, FACMT, Chairman, Department of Emergency Medicine, Drexel University College of Medicine
Richard J Hamilton, MD, FAAEM, FACMT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

David C Lee, MD, Research Director, Department of Emergency Medicine, Assistant Professor, North Shore University Hospital and New York University Medical School
David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, ABAT, Director of Pharmacy, Sacred Heart Hospital
John T VanDeVoort, PharmD, ABAT is a member of the following medical societies: American Academy of Clinical Toxicology and American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

John G Benitez, MD, MPH, FACMT, FACPM, FAAEM, Associate Professor, Departments of Emergency Medicine (Toxicology), Environmental Medicine, Community & Preventive Medicine and Pediatrics, University of Rochester School of Medicine; Director, Finger Lakes Regional Resource Center; Managing and Associate Medical Director, Ruth A Lawrence Poison and Drug Information Center, University of Rochester Medical Center
John G Benitez, MD, MPH, FACMT, FACPM, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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