Sympathomimetic Toxicity Medication
- Author: Paul Kolecki, MD, FACEP; Chief Editor: Asim Tarabar, MD more...
Medication Summary
Treatment of sympathomimetic toxicity is focused on controlling agitation, managing seizure activity, and treating hypertension unresponsive to sedation. The most accepted pharmacologic option for controlling agitation is the use of benzodiazepines. Butyrophenones lower the seizure threshold, increase the risk of hyperthermia, and may prolong the QT interval (eg, droperidol); the use of butyrophenones is NOT recommended. Sympathomimetic-induced seizures should be treated with benzodiazepines or barbiturates (eg, phenobarbital). Hypertension should be managed with a short-acting, easily titrated agent (eg, nitroprusside) if it is not controlled with benzodiazepine-induced sedation.
Benzodiazepines and other sedatives
Class Summary
Used for controlling sympathomimetic-induced agitation.
Diazepam (Valium)
Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA.
Individualize dosage and increase cautiously to avoid adverse effects. Easily titrated with a long half-life.
Lorazepam (Ativan)
Sedative hypnotic with short onset of effects and relatively long half-life.
By increasing the action of GABA, a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.
Excellent when patient requires sedation for more than 24 h.
Midazolam (Versed)
Used as alternative in termination of refractory status epilepticus. Because water soluble, takes approximately 3 times longer than diazepam to peak EEG effects. Thus, clinician must wait 2-3 min to fully evaluate sedative effects before initiating procedure or repeating dose. Has twice the affinity for benzodiazepine receptors than diazepam. May be administered IM if unable to obtain vascular access.
Phenobarbital (Barbita, Luminal)
Interferes with transmission of impulses from thalamus to cortex of brain. Used for sympathomimetic-induced seizure unresponsive to diazepam.
Cardiovascular agents
Class Summary
Control sympathomimetic-induced hypertension.
Nitroprusside (Nitropress)
Rapidly acting, easily titrated antihypertensive. Produces vasodilation and increases inotropic activity of the heart. At higher dosages, may exacerbate myocardial ischemia by increasing heart rate.
Nitroglycerin IV (Deponit, Nitrostat)
Causes relaxation of vascular smooth muscle by stimulating intracellular cyclic guanosine monophosphate production, resulting in a decrease in blood pressure.
May administer bolus of 12.5-25 mcg before continuous infusion.
Initial infusion rate of 10-20 mcg/min may be increased 5-10 mcg/min q5-10min until desired clinical or hemodynamic response is achieved.
Infusion rates of 500 mcg/min have occasionally been required.
Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline].
Swanson SM, Sise CB, Sise MJ, Sack DI, Holbrook TL, Paci GM. The scourge of methamphetamine: impact on a level I trauma center. J Trauma. Sep 2007;63(3):531-7. [Medline].
Wood DM, Davies S, Greene SL, Button J, Holt DW, Ramsey J, et al. Case series of individuals with analytically confirmed acute mephedrone toxicity. Clin Toxicol (Phila). Nov 2010;48(9):924-7. [Medline].
Centers for Disease Control and Prevention. Emergency department visits after use of a drug sold as "bath salts" --- michigan, november 13, 2010--march 31, 2011. MMWR Morb Mortal Wkly Rep. May 20 2011;60(19):624-7. [Medline].
Schwartz BG, Rezkalla S, Kloner RA. Cardiovascular effects of cocaine. Circulation. Dec 14 2010;122(24):2558-69. [Medline].
Bronstein AC, Spyker DA, Cantilena LR Jr, Green J, Rumack BH, Heard SE. 2006 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clin Toxicol (Phila). Dec 2007;45(8):815-917. [Medline].
Budisavljevic MN, Stewart L, Sahn SA. Hyponatremia associated with 3,4-methylenedioxymethylamphetamine ("Ecstasy") abuse. Am J Med Sci. Aug 2003;326(2):89-93. [Medline].
Chiang WK. Amphetamines. In: Goldfrank LR, ed. Goldfrank's Toxicologic Emergencies. 2002. 7th ed. New York: McGraw-Hill; 2002:1020-1033.
Curry SC, Mills KC, Graeme KA. Neurotransmitters. In: Goldfrank LR, ed. Goldfrank's Toxicologic Emergencies. 7th ed. New York, NY: McGraw-Hill; 2002:133-165.
Duffy MR, Ferguson C. Role of dantrolene in treatment of heat stroke associated with Ecstasy ingestion. Br J Anaesth. Jan 2007;98(1):148-9. [Medline].
Hollander JE, Henry TD. Evaluation and management of the patient who has cocaine-associated chest pain. Cardiol Clin. Feb 2006;24(1):103-14. [Medline].
Hollander JE, Hoffman RS. Cocaine. In: Goldfrank LR, ed. Goldfrank's Toxicologic Emergencies. 7th ed. New York, NY: McGraw-Hill; 2002:1004-1019.
Kolecki P. Inadvertent methamphetamine poisoning in pediatric patients. Pediatr Emerg Care. Dec 1998;14(6):385-7. [Medline].
Lineberry TW, Bostwick JM. Methamphetamine abuse: a perfect storm of complications. Mayo Clin Proc. Jan 2006;81(1):77-84. [Medline].
Paredes VL, Rea TD, Eisenberg MS. Out-of-hospital care of critical drug overdoses involving cardiac arrest. Acad Emerg Med. Jan 2004;11(1):71-4. [Medline].
Sue YM, Lee YL, Huang JJ. Acute hyponatremia, seizure, and rhabdomyolysis after ecstasy use. J Toxicol Clin Toxicol. 2002;40(7):931-2. [Medline].
Print
