Table Of ContentFOURTH
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.
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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
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and the Informa Healthcare Web site at
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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
Description: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
