Table Of Content

FOURTH EDITION Pharmacology and Toxicology Poisoning about the book… T Read the reviews about the previous edition o “This is a wonderful book! Clinical laboratorians will find it a valuable tool for the and laboratory reference book shelf.” x — Thomas P. Moyer, Department of Laboratory Medicine and Pathology, Mayo Clinic, i Rochester, Minnesota, USA cP Toxicology “…a good reference for the clinician, medical student, and general toxicologist. The o wealth of information is, for example, ideal for preparing for an examination on the o clinical aspects of toxicology.” l i — Matthew D. Reed, PhD, DABT s o handbook o g 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 n y medicinal, biological, herbal, and non-medicinal agents, and antidotes. Increasing its depth and i scope with analyses of newer drugs, chemicals, and environmental toxins, including drugs that FOURTH EDITION n h 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 ag the country, organizations offering information on toxicology, and teratology information services. It presents diagnostic testing and analytical procedures, evaluates the effectiveness of n a antidotes, and features an extensive symptoms listing. The section on special topics provides dn 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 bd of the most exciting and expanding fields in medical science. o Printed in the United States of America o k Leikin • Paloucek Jerrold B. Leikin 44796 Frank P. Paloucek Poisoning and Toxicology handbook F O U R T H E D I T I O N Poisoning and Toxicology handbook F O U R T H E D I T I O N 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 Informa Healthcare is an Informa business No claim to original U.S. Government works Printed in the United States of America on acid‑free paper 10 9 8 7 6 5 4 3 2 International Standard Book Number‑10: 1-4200-4479-6 (Hardcover) International Standard Book Number‑13: 978‑1-4200-4479-9 (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the consequences of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, 978‑750‑8400. CCC is a not‑for‑profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation with‑ out intent to infringe. 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 Visit the Informa Web site at www.informa.com and the Informa Healthcare Web site at www.informahealthcare.com TABLE OF CONTENTS Preface...........................................................................................................................xxix Acknowledgments ................................................................................................................xxxi Editors...........................................................................................................................xxxiii Contributors ..................................................................................................................... xxxv EditorialAdvisoryPanel..........................................................................................................xxxix Introduction......................................................................................................................... 1 DescriptionofSectionsandFieldsUsedinThisHandbook...................................................................... 1 FDAPregnancyCategories..................................................................................................... 2 FDANameDifferentiationProject:TheUseofTall-ManLetters.................................................................. 3 SafeWriting.................................................................................................................... 5 GeneralReferences ............................................................................................................ 6 PoisonInformationCenters ..................................................................................................... 9 GeneralPoisonInformationSources........................................................................................... 20 TeratologyInformationServices................................................................................................ 28 SectionIMedicinalAgents ApproachtoToxicology............................................................................................................35 StabilizationofthePatient ..................................................................................................... 36 HistoryandPhysicalExamination.............................................................................................. 37 Drugs/ToxinsCausingIncreasedAnionGap((cid:1)12mEq/L)..................................................................39 Drugs/ToxinsCausingDecreasedAnionGap(B6mEq/L)...................................................................40 ToxinsCausingOsmolarGap(ByFreezing-PointDepression,Gapis (cid:1)10mOsmfromBaselineValue).....................41 ToxinsAssociatedwithOxygenSaturationGap((cid:1)5%DifferenceBetweenMeasuredandCalculatedValue) ................41 PreventionofAbsorption....................................................................................................... 42 Antidotes...................................................................................................................... 44 EnhancementofElimination.................................................................................................... 44 ToxinswithEnhancedEliminationbyMultipleDosingofActivatedCharcoal..................................................44 ToxinsEliminatedbySalineDiuresis........................................................................................45 ToxinsEliminatedbyUrineAlkalinization....................................................................................45 DrugsandToxinsRemovedbyHemodialysis................................................................................46 DrugsandToxinsRemovedbyHemoperfusion(Charcoal)...................................................................48 ToxicantsforWhichExchangeTransfusionsMayBeHelpful ................................................................49 References.................................................................................................................... 49 SupportandMonitoringforAdverseEffects .................................................................................... 50 CriteriaforAdmissionofthePoisonedPatienttoICU........................................................................50 Footnotes...................................................................................................................... 51 ClinicalToxicokinetics..............................................................................................................53 ExplanationsforVariationsBetweenPredictedandObservedValues........................................................... 54 PotentialBenefitsintheToxicokineticEvaluationand/orManagementoftheOverdosePatient.................................. 55 SuggestedReading............................................................................................................ 55 HighlightsofRecentReports(2006)onSubstanceAbuseandMentalHealth.......................................................56 LipidEmulsionResuscitationforLocalAnestheticandToxicCardiacArrest.........................................................60 Background.................................................................................................................... 60 ClinicalFeaturesofLocalAnestheticToxicity................................................................................... 60 AnimalStudies................................................................................................................. 60 Mechanisms................................................................................................................... 60 ClinicalEfficacy................................................................................................................ 60 GeneralApplicabilityofLipidRescueResuscitation............................................................................. 61 FutureDirections:ResearchandPractice ...................................................................................... 61 Recommendations............................................................................................................. 61 References.................................................................................................................... 61 PositionStatementandPracticeGuidelinesontheUseofMulti-DoseActivatedCharcoalintheTreatmentofAcutePoisoning......63 SummaryStatement........................................................................................................... 63 Introduction.................................................................................................................63 Rationale...................................................................................................................63 AnimalStudies..............................................................................................................63 VolunteerStudies...........................................................................................................63 ClinicalStudies.............................................................................................................64 Indications..................................................................................................................64 DosageRegimen...........................................................................................................64 CoadministrationofaCathartic..............................................................................................64 Contraindications ...........................................................................................................65 Absolute................................................................................................................65 Relative ................................................................................................................65 ComplicationsofUse.......................................................................................................65 SupportingDocumentation..................................................................................................... 65 Introduction.................................................................................................................65 Methodology................................................................................................................65 Rationale...................................................................................................................65 MechanismsofAction ......................................................................................................66 AnimalStudies..............................................................................................................66 VolunteerStudies...........................................................................................................67 ClinicalStudies.............................................................................................................71 DosageRegimen...........................................................................................................76 CoadministrationofaCathartic..............................................................................................77 ComplicationsofUse.......................................................................................................77 GastrointestinalComplications ..........................................................................................77 RespiratoryComplications ..............................................................................................78 Fluid,Electrolyte,andAcid-BaseAbnormalities..........................................................................78 References.................................................................................................................78 Substance-RelatedDisorders ......................................................................................................83 GeneralTreatmentRecommendations ......................................................................................... 83 Alcohol.....................................................................................................................83 v Intoxication/Overdose(seeEthylAlcohol) ...............................................................................83 Withdrawal .............................................................................................................83 GeneralTreatment......................................................................................................84 Cocaine ....................................................................................................................84 Intoxication/Overdose(seeCocaine)....................................................................................84 Withdrawal .............................................................................................................85 GeneralTreatment......................................................................................................85 Opioids.....................................................................................................................85 Intoxication/Overdose...................................................................................................85 Withdrawal .............................................................................................................85 GeneralTreatment......................................................................................................86 Sedative/Hypnotic...........................................................................................................86 Intoxication/Overdose...................................................................................................86 Withdrawal .............................................................................................................86 GeneralTreatment......................................................................................................87 Benzodiazepine.............................................................................................................87 Intoxication.............................................................................................................87 Withdrawal .............................................................................................................87 GammaHydroxybutyrate(GHB)/GammaButyrolactone(GBL)...............................................................87 Intoxication.............................................................................................................87 Withdrawal .............................................................................................................87 Stimulants..................................................................................................................88 Intoxication/Overdose...................................................................................................88 Withdrawal .............................................................................................................88 GeneralTreatment......................................................................................................88 Caffeine....................................................................................................................88 Intoxication.............................................................................................................88 Withdrawal .............................................................................................................88 Hallucinogens...............................................................................................................88 Intoxication.............................................................................................................88 Withdrawal .............................................................................................................88 GeneralTreatment......................................................................................................88 Baclofen....................................................................................................................88 Intoxication.............................................................................................................88 Withdrawal .............................................................................................................88 Inhalants ...................................................................................................................89 Intoxication.............................................................................................................89 Withdrawal .............................................................................................................89 GeneralTreatment......................................................................................................89 SelectiveSerotoninReuptakeInhibitors(SSRIs).............................................................................89 Intoxication/Overdose...................................................................................................89 Withdrawal .............................................................................................................89 SynthesizedCompounds....................................................................................................89 Intoxication/Overdose...................................................................................................89 Withdrawal .............................................................................................................89 GeneralTreatment......................................................................................................89 Marijuana...................................................................................................................89 Intoxication.............................................................................................................89 Withdrawal .............................................................................................................90 GeneralTreatment......................................................................................................90 Nicotine ....................................................................................................................90 Intoxication/Overdose...................................................................................................90 Withdrawal .............................................................................................................90 GeneralTreatment......................................................................................................91 PsychiatricEmergencies-Violence.........................................................................................91 NeurolepticMalignantSyndrome............................................................................................92 Catatonia...................................................................................................................92 AcuteExtrapyramidalSyndromes(Eps).....................................................................................94 AcuteDystonias........................................................................................................94 Akathisia ...............................................................................................................94 Drug-InducedParkinsonism.............................................................................................94 References.................................................................................................................... 95 Acarbose..............................................................................................................................97 Acebutolol.............................................................................................................................97 Acetaminophen........................................................................................................................98 AcetaZOLAMIDE .................................................................................................................... 102 AcetoHEXAMIDE.................................................................................................................... 103 AcrivastineandPseudoephedrine.................................................................................................... 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 AluminumHydroxide................................................................................................................. 116 Amantadine.......................................................................................................................... 117 Amiloride............................................................................................................................ 118 Aminophylline........................................................................................................................ 119 Amiodarone.......................................................................................................................... 120 vi Amisulpride.......................................................................................................................... 122 Amitriptyline ......................................................................................................................... 122 Amlodipine........................................................................................................................... 125 Amoxapine .......................................................................................................................... 126 Amoxicillin........................................................................................................................... 127 AmphotericinB...................................................................................................................... 128 Ampicillin............................................................................................................................ 129 Amsacrine........................................................................................................................... 130 Androstenedione..................................................................................................................... 131 Aprotinin............................................................................................................................. 131 Arginine ............................................................................................................................. 132 Aripiprazole.......................................................................................................................... 132 AscorbicAcid........................................................................................................................ 133 Atenolol ............................................................................................................................. 134 Atomoxetine......................................................................................................................... 135 Atorvastatin.......................................................................................................................... 136 Azathioprine......................................................................................................................... 137 Azithromycin......................................................................................................................... 138 Bacitracin............................................................................................................................ 140 Baclofen............................................................................................................................. 140 Belladonna .......................................................................................................................... 141 Benazepril........................................................................................................................... 142 BenzalkoniumChloride............................................................................................................... 143 Benzbromarone...................................................................................................................... 143 Benzocaine.......................................................................................................................... 143 Benzonatate......................................................................................................................... 144 Benztropine.......................................................................................................................... 145 Bepridil.............................................................................................................................. 145 Betamethasone...................................................................................................................... 146 Betaxolol ............................................................................................................................ 147 Bethanechol......................................................................................................................... 148 Biperiden............................................................................................................................ 148 Bisacodyl............................................................................................................................ 149 BismuthSubgallate.................................................................................................................. 149 Bisoprolol............................................................................................................................ 150 BlasticidinS......................................................................................................................... 150 Bleomycin........................................................................................................................... 151 BotulinumToxinTypeA ............................................................................................................. 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 CarfentanilCitrate ................................................................................................................... 170 Carisoprodol......................................................................................................................... 170 Carmustine.......................................................................................................................... 171 Carteolol............................................................................................................................. 172 Carvedilol............................................................................................................................ 173 CastorOil ........................................................................................................................... 174 Ceftriaxone.......................................................................................................................... 174 Cefuroxime.......................................................................................................................... 175 Celecoxib............................................................................................................................ 176 Celiprolol............................................................................................................................ 177 Cephalexin .......................................................................................................................... 177 Cephradine.......................................................................................................................... 178 Cetirizine............................................................................................................................ 178 ChloralHydrate...................................................................................................................... 179 Chlorambucil......................................................................................................................... 180 Chloramphenicol..................................................................................................................... 181 Chlordiazepoxide .................................................................................................................... 182 ChlorhexidineGluconate............................................................................................................. 183 Chlormezanone...................................................................................................................... 184 Chloroprocaine ...................................................................................................................... 184 Chloroquine.......................................................................................................................... 185 Chlorpheniramine.................................................................................................................... 186 ChlorproMAZINE..................................................................................................................... 186 ChlorproPAMIDE .................................................................................................................... 188 Chlorprothixene...................................................................................................................... 189 Chlorthalidone....................................................................................................................... 189 Chlorzoxazone....................................................................................................................... 190 vii Cholecalciferol....................................................................................................................... 190 CholineMagnesiumTrisalicylate..................................................................................................... 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 DAUNOrubicinHydrochloride ........................................................................................................ 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 DimethylSulfoxide................................................................................................................... 255 DiphenhydrAMINE................................................................................................................... 255 DiphenoxylateandAtropine.......................................................................................................... 257 Dipyridamole......................................................................................................................... 258 Dirithromycin......................................................................................................................... 258 Disopyramide........................................................................................................................ 259 Disulfiram............................................................................................................................ 260 Docetaxel............................................................................................................................ 260 Docusate............................................................................................................................ 262 Dofetilide............................................................................................................................ 262 Donepezil............................................................................................................................ 263 DornaseAlfa......................................................................................................................... 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 EpoetinAlfa ......................................................................................................................... 278 Eptifibatide .......................................................................................................................... 280 Ergotamine.......................................................................................................................... 281 Erythromycin ........................................................................................................................ 282 Escitalopram......................................................................................................................... 284 Esmolol.............................................................................................................................. 286 Esomeprazole....................................................................................................................... 286 Estazolam........................................................................................................................... 287 Estrogens,Conjugated............................................................................................................... 288 Estrogens(Esterified)................................................................................................................ 290 EthacrynicAcid...................................................................................................................... 291 Ethambutol.......................................................................................................................... 292 Ethchlorvynol........................................................................................................................ 292 Ethionamide......................................................................................................................... 293 Ethosuximide........................................................................................................................ 293 Ethotoin ............................................................................................................................. 294 EthylAlcohol......................................................................................................................... 294 EthylChloride........................................................................................................................ 297 EthylLoflazepate .................................................................................................................... 297 EtidronateDisodium ................................................................................................................. 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 GalliumNitrate....................................................................................................................... 329 Gallopamil........................................................................................................................... 330 Galsulfase........................................................................................................................... 330 GammaHydroxybutyricAcid......................................................................................................... 331 Ganciclovir .......................................................................................................................... 333 Gemfibrozil.......................................................................................................................... 334 Gentamicin.......................................................................................................................... 334 Glimepiride.......................................................................................................................... 336 GlipiZIDE............................................................................................................................ 337 Glutamine ........................................................................................................................... 338 Glutethimide......................................................................................................................... 338 GlyBURIDE.......................................................................................................................... 339 Glycerin ............................................................................................................................. 340 GoldCompounds.................................................................................................................... 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

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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 dr
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FOURTH EDITION Pharmacology and Toxicology Poisoning about the book… T Read the reviews about the previous edition o “This is a wonderful book! Clinical laboratorians will find it a valuable tool for the and laboratory reference book shelf.” x — Thomas P. Moyer, Department of Laboratory Medicine and Pathology, Mayo Clinic, i Rochester, Minnesota, USA cP Toxicology “…a good reference for the clinician, medical student, and general toxicologist. The o wealth of information is, for example, ideal for preparing for an examination on the o clinical aspects of toxicology.” l i — Matthew D. Reed, PhD, DABT s o handbook o g 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 n y medicinal, biological, herbal, and non-medicinal agents, and antidotes. Increasing its depth and i scope with analyses of newer drugs, chemicals, and environmental toxins, including drugs that FOURTH EDITION n h 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 ag the country, organizations offering information on toxicology, and teratology information services. It presents diagnostic testing and analytical procedures, evaluates the effectiveness of n a antidotes, and features an extensive symptoms listing. The section on special topics provides dn 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 bd of the most exciting and expanding fields in medical science. o Printed in the United States of America o k Leikin • Paloucek Jerrold B. Leikin 44796 Frank P. Paloucek Poisoning and Toxicology handbook F O U R T H E D I T I O N Poisoning and Toxicology handbook F O U R T H E D I T I O N 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 Informa Healthcare is an Informa business No claim to original U.S. Government works Printed in the United States of America on acid‑free paper 10 9 8 7 6 5 4 3 2 International Standard Book Number‑10: 1-4200-4479-6 (Hardcover) International Standard Book Number‑13: 978‑1-4200-4479-9 (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the consequences of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, 978‑750‑8400. CCC is a not‑for‑profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation with‑ out intent to infringe. 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 Visit the Informa Web site at www.informa.com and the Informa Healthcare Web site at www.informahealthcare.com TABLE OF CONTENTS Preface...........................................................................................................................xxix Acknowledgments ................................................................................................................xxxi Editors...........................................................................................................................xxxiii Contributors ..................................................................................................................... xxxv EditorialAdvisoryPanel..........................................................................................................xxxix Introduction......................................................................................................................... 1 DescriptionofSectionsandFieldsUsedinThisHandbook...................................................................... 1 FDAPregnancyCategories..................................................................................................... 2 FDANameDifferentiationProject:TheUseofTall-ManLetters.................................................................. 3 SafeWriting.................................................................................................................... 5 GeneralReferences ............................................................................................................ 6 PoisonInformationCenters ..................................................................................................... 9 GeneralPoisonInformationSources........................................................................................... 20 TeratologyInformationServices................................................................................................ 28 SectionIMedicinalAgents ApproachtoToxicology............................................................................................................35 StabilizationofthePatient ..................................................................................................... 36 HistoryandPhysicalExamination.............................................................................................. 37 Drugs/ToxinsCausingIncreasedAnionGap((cid:1)12mEq/L)..................................................................39 Drugs/ToxinsCausingDecreasedAnionGap(B6mEq/L)...................................................................40 ToxinsCausingOsmolarGap(ByFreezing-PointDepression,Gapis (cid:1)10mOsmfromBaselineValue).....................41 ToxinsAssociatedwithOxygenSaturationGap((cid:1)5%DifferenceBetweenMeasuredandCalculatedValue) ................41 PreventionofAbsorption....................................................................................................... 42 Antidotes...................................................................................................................... 44 EnhancementofElimination.................................................................................................... 44 ToxinswithEnhancedEliminationbyMultipleDosingofActivatedCharcoal..................................................44 ToxinsEliminatedbySalineDiuresis........................................................................................45 ToxinsEliminatedbyUrineAlkalinization....................................................................................45 DrugsandToxinsRemovedbyHemodialysis................................................................................46 DrugsandToxinsRemovedbyHemoperfusion(Charcoal)...................................................................48 ToxicantsforWhichExchangeTransfusionsMayBeHelpful ................................................................49 References.................................................................................................................... 49 SupportandMonitoringforAdverseEffects .................................................................................... 50 CriteriaforAdmissionofthePoisonedPatienttoICU........................................................................50 Footnotes...................................................................................................................... 51 ClinicalToxicokinetics..............................................................................................................53 ExplanationsforVariationsBetweenPredictedandObservedValues........................................................... 54 PotentialBenefitsintheToxicokineticEvaluationand/orManagementoftheOverdosePatient.................................. 55 SuggestedReading............................................................................................................ 55 HighlightsofRecentReports(2006)onSubstanceAbuseandMentalHealth.......................................................56 LipidEmulsionResuscitationforLocalAnestheticandToxicCardiacArrest.........................................................60 Background.................................................................................................................... 60 ClinicalFeaturesofLocalAnestheticToxicity................................................................................... 60 AnimalStudies................................................................................................................. 60 Mechanisms................................................................................................................... 60 ClinicalEfficacy................................................................................................................ 60 GeneralApplicabilityofLipidRescueResuscitation............................................................................. 61 FutureDirections:ResearchandPractice ...................................................................................... 61 Recommendations............................................................................................................. 61 References.................................................................................................................... 61 PositionStatementandPracticeGuidelinesontheUseofMulti-DoseActivatedCharcoalintheTreatmentofAcutePoisoning......63 SummaryStatement........................................................................................................... 63 Introduction.................................................................................................................63 Rationale...................................................................................................................63 AnimalStudies..............................................................................................................63 VolunteerStudies...........................................................................................................63 ClinicalStudies.............................................................................................................64 Indications..................................................................................................................64 DosageRegimen...........................................................................................................64 CoadministrationofaCathartic..............................................................................................64 Contraindications ...........................................................................................................65 Absolute................................................................................................................65 Relative ................................................................................................................65 ComplicationsofUse.......................................................................................................65 SupportingDocumentation..................................................................................................... 65 Introduction.................................................................................................................65 Methodology................................................................................................................65 Rationale...................................................................................................................65 MechanismsofAction ......................................................................................................66 AnimalStudies..............................................................................................................66 VolunteerStudies...........................................................................................................67 ClinicalStudies.............................................................................................................71 DosageRegimen...........................................................................................................76 CoadministrationofaCathartic..............................................................................................77 ComplicationsofUse.......................................................................................................77 GastrointestinalComplications ..........................................................................................77 RespiratoryComplications ..............................................................................................78 Fluid,Electrolyte,andAcid-BaseAbnormalities..........................................................................78 References.................................................................................................................78 Substance-RelatedDisorders ......................................................................................................83 GeneralTreatmentRecommendations ......................................................................................... 83 Alcohol.....................................................................................................................83 v Intoxication/Overdose(seeEthylAlcohol) ...............................................................................83 Withdrawal .............................................................................................................83 GeneralTreatment......................................................................................................84 Cocaine ....................................................................................................................84 Intoxication/Overdose(seeCocaine)....................................................................................84 Withdrawal .............................................................................................................85 GeneralTreatment......................................................................................................85 Opioids.....................................................................................................................85 Intoxication/Overdose...................................................................................................85 Withdrawal .............................................................................................................85 GeneralTreatment......................................................................................................86 Sedative/Hypnotic...........................................................................................................86 Intoxication/Overdose...................................................................................................86 Withdrawal .............................................................................................................86 GeneralTreatment......................................................................................................87 Benzodiazepine.............................................................................................................87 Intoxication.............................................................................................................87 Withdrawal .............................................................................................................87 GammaHydroxybutyrate(GHB)/GammaButyrolactone(GBL)...............................................................87 Intoxication.............................................................................................................87 Withdrawal .............................................................................................................87 Stimulants..................................................................................................................88 Intoxication/Overdose...................................................................................................88 Withdrawal .............................................................................................................88 GeneralTreatment......................................................................................................88 Caffeine....................................................................................................................88 Intoxication.............................................................................................................88 Withdrawal .............................................................................................................88 Hallucinogens...............................................................................................................88 Intoxication.............................................................................................................88 Withdrawal .............................................................................................................88 GeneralTreatment......................................................................................................88 Baclofen....................................................................................................................88 Intoxication.............................................................................................................88 Withdrawal .............................................................................................................88 Inhalants ...................................................................................................................89 Intoxication.............................................................................................................89 Withdrawal .............................................................................................................89 GeneralTreatment......................................................................................................89 SelectiveSerotoninReuptakeInhibitors(SSRIs).............................................................................89 Intoxication/Overdose...................................................................................................89 Withdrawal .............................................................................................................89 SynthesizedCompounds....................................................................................................89 Intoxication/Overdose...................................................................................................89 Withdrawal .............................................................................................................89 GeneralTreatment......................................................................................................89 Marijuana...................................................................................................................89 Intoxication.............................................................................................................89 Withdrawal .............................................................................................................90 GeneralTreatment......................................................................................................90 Nicotine ....................................................................................................................90 Intoxication/Overdose...................................................................................................90 Withdrawal .............................................................................................................90 GeneralTreatment......................................................................................................91 PsychiatricEmergencies-Violence.........................................................................................91 NeurolepticMalignantSyndrome............................................................................................92 Catatonia...................................................................................................................92 AcuteExtrapyramidalSyndromes(Eps).....................................................................................94 AcuteDystonias........................................................................................................94 Akathisia ...............................................................................................................94 Drug-InducedParkinsonism.............................................................................................94 References.................................................................................................................... 95 Acarbose..............................................................................................................................97 Acebutolol.............................................................................................................................97 Acetaminophen........................................................................................................................98 AcetaZOLAMIDE .................................................................................................................... 102 AcetoHEXAMIDE.................................................................................................................... 103 AcrivastineandPseudoephedrine.................................................................................................... 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 AluminumHydroxide................................................................................................................. 116 Amantadine.......................................................................................................................... 117 Amiloride............................................................................................................................ 118 Aminophylline........................................................................................................................ 119 Amiodarone.......................................................................................................................... 120 vi Amisulpride.......................................................................................................................... 122 Amitriptyline ......................................................................................................................... 122 Amlodipine........................................................................................................................... 125 Amoxapine .......................................................................................................................... 126 Amoxicillin........................................................................................................................... 127 AmphotericinB...................................................................................................................... 128 Ampicillin............................................................................................................................ 129 Amsacrine........................................................................................................................... 130 Androstenedione..................................................................................................................... 131 Aprotinin............................................................................................................................. 131 Arginine ............................................................................................................................. 132 Aripiprazole.......................................................................................................................... 132 AscorbicAcid........................................................................................................................ 133 Atenolol ............................................................................................................................. 134 Atomoxetine......................................................................................................................... 135 Atorvastatin.......................................................................................................................... 136 Azathioprine......................................................................................................................... 137 Azithromycin......................................................................................................................... 138 Bacitracin............................................................................................................................ 140 Baclofen............................................................................................................................. 140 Belladonna .......................................................................................................................... 141 Benazepril........................................................................................................................... 142 BenzalkoniumChloride............................................................................................................... 143 Benzbromarone...................................................................................................................... 143 Benzocaine.......................................................................................................................... 143 Benzonatate......................................................................................................................... 144 Benztropine.......................................................................................................................... 145 Bepridil.............................................................................................................................. 145 Betamethasone...................................................................................................................... 146 Betaxolol ............................................................................................................................ 147 Bethanechol......................................................................................................................... 148 Biperiden............................................................................................................................ 148 Bisacodyl............................................................................................................................ 149 BismuthSubgallate.................................................................................................................. 149 Bisoprolol............................................................................................................................ 150 BlasticidinS......................................................................................................................... 150 Bleomycin........................................................................................................................... 151 BotulinumToxinTypeA ............................................................................................................. 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 CarfentanilCitrate ................................................................................................................... 170 Carisoprodol......................................................................................................................... 170 Carmustine.......................................................................................................................... 171 Carteolol............................................................................................................................. 172 Carvedilol............................................................................................................................ 173 CastorOil ........................................................................................................................... 174 Ceftriaxone.......................................................................................................................... 174 Cefuroxime.......................................................................................................................... 175 Celecoxib............................................................................................................................ 176 Celiprolol............................................................................................................................ 177 Cephalexin .......................................................................................................................... 177 Cephradine.......................................................................................................................... 178 Cetirizine............................................................................................................................ 178 ChloralHydrate...................................................................................................................... 179 Chlorambucil......................................................................................................................... 180 Chloramphenicol..................................................................................................................... 181 Chlordiazepoxide .................................................................................................................... 182 ChlorhexidineGluconate............................................................................................................. 183 Chlormezanone...................................................................................................................... 184 Chloroprocaine ...................................................................................................................... 184 Chloroquine.......................................................................................................................... 185 Chlorpheniramine.................................................................................................................... 186 ChlorproMAZINE..................................................................................................................... 186 ChlorproPAMIDE .................................................................................................................... 188 Chlorprothixene...................................................................................................................... 189 Chlorthalidone....................................................................................................................... 189 Chlorzoxazone....................................................................................................................... 190 vii Cholecalciferol....................................................................................................................... 190 CholineMagnesiumTrisalicylate..................................................................................................... 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 DAUNOrubicinHydrochloride ........................................................................................................ 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 DimethylSulfoxide................................................................................................................... 255 DiphenhydrAMINE................................................................................................................... 255 DiphenoxylateandAtropine.......................................................................................................... 257 Dipyridamole......................................................................................................................... 258 Dirithromycin......................................................................................................................... 258 Disopyramide........................................................................................................................ 259 Disulfiram............................................................................................................................ 260 Docetaxel............................................................................................................................ 260 Docusate............................................................................................................................ 262 Dofetilide............................................................................................................................ 262 Donepezil............................................................................................................................ 263 DornaseAlfa......................................................................................................................... 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 EpoetinAlfa ......................................................................................................................... 278 Eptifibatide .......................................................................................................................... 280 Ergotamine.......................................................................................................................... 281 Erythromycin ........................................................................................................................ 282 Escitalopram......................................................................................................................... 284 Esmolol.............................................................................................................................. 286 Esomeprazole....................................................................................................................... 286 Estazolam........................................................................................................................... 287 Estrogens,Conjugated............................................................................................................... 288 Estrogens(Esterified)................................................................................................................ 290 EthacrynicAcid...................................................................................................................... 291 Ethambutol.......................................................................................................................... 292 Ethchlorvynol........................................................................................................................ 292 Ethionamide......................................................................................................................... 293 Ethosuximide........................................................................................................................ 293 Ethotoin ............................................................................................................................. 294 EthylAlcohol......................................................................................................................... 294 EthylChloride........................................................................................................................ 297 EthylLoflazepate .................................................................................................................... 297 EtidronateDisodium ................................................................................................................. 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 GalliumNitrate....................................................................................................................... 329 Gallopamil........................................................................................................................... 330 Galsulfase........................................................................................................................... 330 GammaHydroxybutyricAcid......................................................................................................... 331 Ganciclovir .......................................................................................................................... 333 Gemfibrozil.......................................................................................................................... 334 Gentamicin.......................................................................................................................... 334 Glimepiride.......................................................................................................................... 336 GlipiZIDE............................................................................................................................ 337 Glutamine ........................................................................................................................... 338 Glutethimide......................................................................................................................... 338 GlyBURIDE.......................................................................................................................... 339 Glycerin ............................................................................................................................. 340 GoldCompounds.................................................................................................................... 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

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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 dr
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