Carbamazepine Toxicity in Emergency Medicine Treatment & Management

  • Author: Nidhi Kapoor, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Nov 19, 2010
 

Prehospital Care

Prehospital care may include the following:

  • Intravenous heplock, cardiac monitor
  • Intravenous fluids, if the patient is hypotensive
  • Activated charcoal, if the patient has intact mental status and is able to protect airway
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Emergency Department Care

For carbamazepine toxicity, the following ED care may be indicated:

  • Place the patient on a monitor.
  • Administer intravenous fluids as needed for hypotension.
  • Administer intravenous diazepam (5-10 mg, repeat q10-15min prn) or other suitable benzodiazepine to control seizures.
  • Gastric lavage may be helpful if performed within 1 hour of ingestion.
  • Protect the patient’s airway by placing the patient in left lateral decubitus position or by intubating.
  • Induction of emesis is not recommended because of the risk of CNS depression and seizures.
  • Administer activated charcoal if the patient is able to protect his or her airway.
  • Multiple doses of activated charcoal (1 g/kg) can be administered every 2-4 hours to enhance total body clearance and elimination in the patient with significant toxicity.
  • A saline cathartic or sorbitol may be given with the first dose of charcoal, although evidence for their effectiveness is lacking. Do not repeat activated charcoal administration if an ileus is present.
  • Perform whole-bowel irrigation (WBI) after ingestion of extended-release drug formulation:
    • Adults and adolescents: 1.5-2 L/h (20-30 mL/min) of PEG-ELS
    • Small children: 0.5 L/h (25 mL/kg/h)
  • Administer sodium bicarbonate when QRS is wider than 100 msec due to carbamazepine toxicity (sodium channel blockade).
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Consultations

  • Consult a medical toxicologist or a certified poison control center.
  • Nephrology consultation is indicated if considering charcoal hemoperfusion. ·
    • The clinician should be aware of marginal clinical effect of extracorporal carbamazepine removal.
    • Charcoal hemoperfusion is not more effective than MDAC.
    • High-efficiency hemodialysis and venovenous hemodialysis may have a similar effect as charcoal hemoperfusion.
    • Peritoneal dialysis is not useful for carbamazepine removal.
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Contributor Information and Disclosures
Author

Nidhi Kapoor, MD  Clinical Assistant Professor, Department of Emergency Medicine, The Warren Alpert Medical School of Brown University

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  Professor and Chair, 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.

Specialty Editor Board

David C Lee, MD  Research Director, Department of Emergency Medicine, Associate 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.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH  Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, 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.

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, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

References

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