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Most patients respond to empiric treatment with repeated 200 mL intravenous boluses of 09% saline or other isotonic crystalloid up to a total of 1 2 L If fluid therapy is not successful, give dopamine, 5 15 mcg/kg/min by intravenous infusion Consider pulmonary artery catheterization if hypotension persists Hypotension caused by certain toxins may respond to specific treatment For hypotension caused by overdoses of tricyclic antidepressants or related drugs, administer sodium bicarbonate, 50 100 mEq by intravenous bolus injection



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Norepinephrine 4 8 mcg/min by intravenous infusion is more effective than dopamine in some patients with overdoses of tricyclic antidepressants or of drugs with predominantly vasodilating effects For -blocker overdose, glucagon (5 10 mg intravenously) may be of value For calcium channel blocker overdose, administer calcium chloride, 1 2 g intravenously (repeated doses may be necessary; doses of 5 10 g and more have been given in some cases)





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Arrhythmia Sinus bradycardia Common Causes -Blockers, calcium channel blockers, clonidine, digitalis glycosides, organophosphates, opioids, sedative-hypnotics -Blockers, calcium channel blockers, class Ia antiarrhythmics (including quinidine), carbamazepine, clonidine, digitalis glycosides, lithium, tricyclic antidepressants -Agonists (eg, albuterol), amphetamines, anticholinergics, antihistamines, caffeine, cocaine, ephedrine, theophylline, tricyclic and other antidepressants Class Ia and class Ic antiarrhythmics, phenothiazines (eg, thioridazine), potassium (hyperkalemia), tricyclic antidepressants, diphenhydramine (severe overdose) Arsenic, cisapride, class Ia and class III antiarrhythmics, droperidol, lithium, methadone, pentamidine, sotalol, thioridazine, venlafaxine, and many other drugs (see http://wwwtorsadesorg) Amphetamines, cocaine, ephedrine, caffeine, chlorinated or fluorinated hydrocarbons, digoxin, aconite (found in some Chinese herbal preparations), fluoride, theophylline QT prolongation can lead to atypical ventricular tachycardia (torsades de pointes)

Hypertension may be due to poisoning with amphetamines, anticholinergics, cocaine, yohimbine-containing performanceenhancing products, monoamine oxidase (MAO) inhibitors, and other drugs Severe hypertension (eg, diastolic blood pressure > 105 110 mm Hg in a person who does not have chronic hypertension) can result in acute intracranial hemorrhage, myocardial infarction, or aortic dissection Patients often present with headache, chest pain, or encephalopathy

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Treat hypertension if the patient is symptomatic or if the diastolic pressure is greater than 105 110 mm Hg especially if there is no prior history of hypertension Hypertensive patients who are agitated or anxious may benefit from a sedative such as lorazepam, 2 3 mg intravenously For persistent hypertension, administer phentolamine, 2 5 mg intravenously, or nitroprusside sodium, 025 8 mcg/kg/min intravenously If excessive tachycardia is present, add propranolol, 1 5 mg intravenously, or esmolol, 25 100 mcg/kg/min intravenously, or labetalol 02 03 mg/kg intravenously Caution: Do not give -blockers alone, since doing so may paradoxically worsen hypertension as a result of unopposed -adrenergic stimulation

The next line defines the local connection (Any packet for the 1012140) (/24 network ID) (don t use a gateway) (just ARP on the LAN interface to get the MAC address and send it directly to the recipient) (Cost of 1 to use this route)

QT interval prolongation and torsades de pointes Ventricular premature beats and ventricular tachycardia

Arrhythmias may also occur as a result of hypoxia, metabolic acidosis, or electrolyte imbalance (eg, hyperkalemia or hypokalemia, hypocalcemia)

Arrhythmias may occur with a variety of drugs or toxins (Table 38 1) They may also occur as a result of hypoxia, metabolic acidosis, or electrolyte imbalance (eg, hyperkalemia, hypokalemia, or hypocalcemia), or following exposure to chlorinated solvents or chloral hydrate overdose Atypical ventricular tachycardia (torsades de pointes) is often associated with drugs that prolong the QT interval

sodium bicarbonate, 50 100 mEq intravenously by bolus injection (See discussion of tricyclic antidepressant poisoning) Torsades de pointes associated with prolonged QT interval may respond to intravenous magnesium (2 g intravenously over 2 minutes) or overdrive pacing Treat digitalis-induced arrhythmias with digoxin-specific antibodies (see discussion of cardiac glycoside poisoning) For tachyarrhythmias induced by chlorinated solvents, chloral hydrate, Freons, or sympathomimetic agents, use propranolol or esmolol (see doses given above in Hypertension section)

Seizures may be due to poisoning with many poisons and drugs, including amphetamines, antidepressants (especially tricyclic antidepressants and bupropion), antihistamines, antipsychotics, cocaine, isoniazid (INH), and theophylline Seizures may also be caused by hypoxia, hypoglycemia, hypocalcemia, hyponatremia, withdrawal from alcohol or sedative-hypnotics, head trauma, central nervous system infection, or idiopathic epilepsy Prolonged or repeated seizures may lead to hypoxia, metabolic acidosis, hyperthermia, and rhabdomyolysis

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