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Sympathomimetic Toxicity Medication

  • Author: Paul Kolecki, MD, FACEP; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Apr 28, 2015
 

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.

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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.

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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.

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Contributor Information and Disclosures
Author

Paul Kolecki, MD, FACEP Associate Professor, Department of Emergency Medicine, Director of Undergraduate Emergency Medicine Student Education, Thomas Jefferson University Hospital, Jefferson Medical College of Thomas Jefferson University; Consultant, Philadelphia Poison Control Center

Paul Kolecki, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Attending Physician in Emergency Medicine, Excela Health System

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.

Additional Contributors

Mark S Slabinski, MD, FACEP, FAAEM Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Ohio State Medical Association

Disclosure: Nothing to disclose.

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