5607fm01.qxd_cs 9/9/03 1:11 PM Page iii fourth edition POISONING & DRUG OVERDOSE by the faculty, staff and associates of the California Poison Control System Edited by Kent R. Olson, MD, FACEP, FACMT, FAACT Clinical Professor of Medicine, Pediatrics, and Pharmacy, University of California, San Francisco; Medical Director, California Poison Control System, San Francisco Division Associate Editors Ilene B. Anderson, PharmD Richard F. Clark, MD, FACEP Associate Clinical Professor of Pharmacy, Professor of of Medicine, University of California, San Francisco; University of California, San Diego; Senior Toxicology Management Specialist, Director, Division of Medical Toxicology California Poison Control System, and Medical Director, San Francisco Division California Poison Control System, San Diego Division Neal L. Benowitz, MD Thomas E. Kearney, PharmD, ABAT Professor of Medicine Professor of Clinical Pharmacy, and Chief, Division of Clinical Pharmacology University of California, San Francisco; and Toxicology, Managing Director, University of California, San Francisco; California Poison Control System, Associate Medical Director, San Francisco Division California Poison Control System, San Francisco Division John D. Osterloh, MD, MS Chief Medical Officer, Division of Laboratory Sciences Paul D. Blanc, MD, MSPH National Center for Environmental Health, Professor of Medicine and Chief, Division of Centers for Disease Control and Prevention, Occupational and Environmental Medicine, Atlanta, Georgia University of California, San Francisco Lange Medical Books/McGraw-Hill Medical Publishing Division New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto 5607fm01.qxd_cs 9/9/03 1:11 PM Page iv Poisoning & Drug Overdose, Fourth Edition Copyright ©2004 by The McGraw-Hill Companies, Inc. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the publisher. Previous editions copyright ©1999, 1994, 1990 by Appleton & Lange 1 2 3 4 5 6 7 8 9 0 DOC/DOC 0 9 8 7 6 5 4 3 ISBN: 0-8385-8172-2 ISSN: 1048-8847 Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. The book was set by Pine Tree Composition, Inc. The editors were Shelley Reinhardt and Barbara Holton. The production supervisor was Phil Galea. The illustration manager was Charissa Baker. The index was prepared by Kathy Pitcoff. RR Donnelly was printer and binder. This book is printed on acid-free paper. 5607fm01.qxd_cs 9/9/03 1:11 PM Page vi Authors Timothy E. Albertson, MD, PhD Professor of Medicine, Pharmacology, Toxicology and Anesthesiology, University of California, Davis School of Medicine; Medical Director, California Poison Control System, Sacramento Division [email protected] Section II: Amphetamines; Barbiturates; Dextromethorphan; Opiates and Opioids Judith A. Alsop, PharmD, DABAT Associate Clinical Professor, School of Pharmacy, University of California, San Francisco; Associate Clinical Professor, School of Medicine, University of California, Davis; Director, California Poison Control System, Sacramento Division [email protected] Section II: Plants; Section III: Metoclopramide; Ondansetron; Potassium Ilene B. Anderson, PharmD Associate Clinical Professor of Pharmacy, University of California, San Francisco; Senior Toxicology Management Specialist, California Poison Control System, San Francisco Division [email protected] Section II: Botulism; Camphor and Other Essential Oils; Ethylene Glycol and Other Glycols; Lomotil and Other Antidiarrheals; Methanol; Warfarin and Related Rodenticides John Balmes, MD Professor, Department of Medicine, University of California, San Francisco; Chief, Division of Occupational and Environmental Medicine, San Francisco General Hospital [email protected] Section II: Asbestos; Formaldehyde; Gases, Irritant; Molds; Phosgene; Sulfur Dioxide Shireen Banerji, PharmD Specialist In Poison Information, Rocky Mountain Poison and Drug Center, Denver, Colorado [email protected] Section II: Angiotensin Blockers & ACE Inhibitors; Vasodilators James David Barry, MD Fellow, Division of Medical Toxicology, and Clinical Instructor of Emergency Medicine, University of California, San Diego Medical Center [email protected] Section II: Phenytoin Neal L. Benowitz, MD Professor of Medicine and Chief, Division of Clinical Pharmacology and Toxicology, University of California, San Francisco; Associate Medical Director, California Poison Control System, San Francisco Division [email protected] Section II: Anesthetics, Local; Antiarrhythmic Drugs; Antidepressants, General (Noncyclic); Antidepressants, Tricyclic; Beta-Adrenergic Blockers; Calcium Antagonists; Cardiac Glycosides; Chloroquine and Other Aminoquinolines; Cocaine; Ergot Derivatives; Lithium; Marijuana; Monoamine Oxidase Inhibitors; Nicotine; Nitrates and Nitrites; Nitroprusside; Pseudoephedrine, Ephedrine and Other Decongestants; Quinidine and Other Type IA Antiarrhythmic Drugs; Quinine; Vacor (PNU); Section III: Dopamine; Epinephrine; Norepinephrine Kathleen Birnbaum, PharmD Toxicology Management Specialist, Department of Clinical Pharmacy, University of California, San Francisco [email protected] Section III: Insulin; Leucovorin Calcium vi 5607fm01.qxd_cs 9/9/03 1:11 PM Page vii AUTHORS vii Paul D. Blanc, MD, MSPH Professor of Medicine, University of California, San Francisco [email protected] Section II: Carbon Disulfide; Cyanide; Isocyanates; Manganese; Metal Fume Fever; Methemoglobinemia; Nitrogen Oxides; Section IV: Evaluation of the Patient with Occupational Chemical Exposure Stephen C. Born, MD, MPH Associate Clinical Professor, Division of Occupational and Environmental Medicine, University of California, San Francisco [email protected] Section II: Dioxins, Ethylene Oxide Alan Buchwald, MD Consultant in Medical Toxicology and Medical Director, Occupational Health Center, Dominican Santa Cruz Hospital, Santa Cruz, California [email protected] Section II: Copper F. Lee Cantrell, PharmD Assistant Clinical Professor of Pharmacy, School of Pharmacy, University of California, San Francisco; Assistant Director, California Poison Control System, San Diego Division [email protected] Section II: Thyroid Hormone; Section III: Cyproheptadine; Folic Acid Terry Carlson, PharmD Toxicology Management Specialist, California Poison Control System, Fresno Division [email protected] Section III: Naloxone and Nalmefene Gregory Cham, MBBS, FRCSEd Toxicology Fellow, California Poison Control System, San Francisco Division [email protected] Section II: Phencyclidine (PCP) and Ketamine Chulathida Chomchai, MD Assistant Professor of Pediatrics, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand [email protected] Section II: Ipecac Syrup Summon Chomchai, MD, MPH Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand [email protected] Section II: Phosphine and Phosphides; Phosphorus Richard F. Clark, MD Professor of Medicine, University of California, San Diego; Director, Division of Medical Toxicology and Medical Director, California Poison Control System, San Diego Division Section II: Hymenoptera; Lionfish and Other Scorpaenidae; Scorpions; Snakebite; Section III: Antivenom, Crotalinae (Rattlesnake); Antivenom, Latrodectus Mactans (Black Widow Spider); Antivenom, Micrurus Fulvius (Coral Snake) and Exotic Antivenoms Delia A. Dempsey, MD, MS Assistant Adjunct Professor of Pediatrics, Medicine, and Clinical Pharmacy; Assistant Medical Director, California Poison Control System, University of California, San Francisco Section I: Special Considerations in Pediatric Patients; Section II: Bromides; Methyl Bromide; Pentachlorophenol and Dinitrophenol Jo Ellen Dyer, PharmD Associate Clincial Professor of Pharmacy, University of California, San Francisco; Senior Toxicology Management Specialist, California Poison Control System, San Francisco Division [email protected] Section I: Special Consideration in the Evaluation of Drug-Facilitated Assault; Section II: Azide, Sodium; Gamma Hydroxybutyrate (GHB) 5607fm01.qxd_cs 9/9/03 1:11 PM Page viii viii POISONING &DRUG OVERDOSE Andrew Erdman, MD Clinical Pharmacology Fellow, University of California, San Francisco [email protected] Section II: Isoniazid (INH) Gary W. Everson, PharmD Toxicology Management Specialist, California Poison Control System, Fresno Division [email protected] Section II: Phenol and Related Compounds; Section III: Mannitol Thomas J. Ferguson, MD, PhD Associate Clinical Professor of Internal Medicine, University of California, Davis; Medical Director, Cowell Student Health Center, University of California, Davis [email protected] Section II: Chromium; Thallium Frederick Fung, MD, MS Clinical Professor of Occupational Medicine, University of California, Irvine; Chief Toxicologist, Sharp Rees-Stealy Medical Group, San Diego, California [email protected] Section II: Carbon Tetrachloride and Chloroform Mark Galbo, MS Specialist, California Poison Control System, San Francisco Division [email protected] Section II: Naphthalene and Paradichlorobenzene; Warfare Agents – Chemical Fabian Garza, PharmD Doctor of Pharamcy, School of Pharmacy, University of California, San Francisco; Toxicology Management Specialist, California Poison Control System, Fresno Division [email protected] Section III: Methylene Blue Richard J. Geller, MD, MPH Assistant Clinical Professor, University of California, San Francisco School of Medicine; Medical Director, California Poison Control System, Fresno Division Section II: Disulfiram; Selenium; Paraquat and Diquat; Section III: Atropine and Glycopyrrolate; Pralidoxime (2-PAM) & Other Oximes Colin S. Goto, MD Attending Toxicologist, California Poison Control System, San Diego Division; Pediatric Emergency Medicine Physician, Children’s Hospital and Health Center; Clinical Assistant Professor of Pediatrics, University of California, San Diego [email protected] Section II: Hydrocarbons Christine A. Haller, MD Assistant Adjunct Professor of Medicine, University of California, San Francisco; Assistant Medical Director, California Poison Control System, San Francisco Division [email protected] Section II: Caffeine; Herbal and Alternative Products; Section III: L-Carnitine; Silibinin Or Milk Thisle (Silybum Marianum) Patricia Hess Hiatt, BS Administrative Operations Manager, California Poison Control System, San Francisco Division [email protected] Section IV: The Toxic Hazards of Industrial and Occupational Chemicals & Table IV-4 Yao-min Hung, MD Attending Physician, Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan [email protected] Section II: Colchicine 5607fm01.qxd_cs 9/9/03 1:11 PM Page ix AUTHORS ix Leslie M. Israel, DO, MPH Assistant Clinical Professor, Department of Medicine, Divison of Occupational and Environmental Medicine, University of California, San Francisco; Medical Director, University of California, San Francisco Employee and Occupational Health Services Section II: Cadmium Thomas E. Kearney, PharmD, DABAT Professor of Clinical Pharmacy, University of California, San Francisco; Managing Director, California Poison Control System, San Francisco Division [email protected] Section II: Carbamazepine; Valproic Acid; Section III: Introduction; Acetylcysteine (N-Acetylcysteine [NAC]); Apomorphine; Benzodiazepines (Diazepam, Lorazepam, and Midazolam); Benztropine; Bicarbonate, Sodium; Botulinum Antitoxin; Bretylium; Bromocriptine; Charcoal, Activated; Cimetidine and Other H Blockers; Dantrolene; 2 Diazoxide; Digoxin-Specific Antibodies; Diphenhydramine; Esmolol; Ethanol; Fomepizole (4-Methylpyrazole, 4-MP); Glucagon; Glucose; Haloperidol and Droperidol; Isoproterenol; Labetalol; Lidocaine; Methocarbamol; Morphine; Neuromuscular Blockers; Nicotinamide (Niacinamide); Nitroprusside; Octreotide; Penicillamine; Pentobarbital; Phenobarbital; Phentolamine; Physostigmine and Neostigmine; Propranolol; Protamine; Pyridoxine (Vitamin B); Thiamine (Vitamin B); Vitamin K (Phytonadione) 6 1 1 Susan Kim, PharmD Associate Professor of Clinical Pharmacy, University of California, San Francisco; Senior Toxicology Management Specialist, California Poison Control System, San Francisco Division [email protected] Section II: Antidiabetic Agents; Antineoplastic Agents; Beta-2-Adrenergic Stimulants; Food Poisoning: Bacterial; Food Poisoning: Fish and Shellfish; Jellyfish and Other Cnidaria; Salicylates; Skeletal Muscle Relaxants; Section III: Thiosulfate, Sodium Michael J. Kosnett, MD, MPH Associate Clinical Professor of Medicine, Department of Clinical Pharmacology and Toxicology, University of Colorado Health Sciences Center, Denver [email protected] Section II Arsenic; Arsine; Lead; Mercury; Section III: BAL (Dimercaprol); EDTA, Calcium (Calcium Disodium EDTA, Calcium Disodium Edetate, Calcium Disodium Versenate); Succimer (DMSA); Unithiol (DMPS) Amy Kunihiro, MD Department of Emergency Medicine, Community Hospital of Los Gatos, Los Gatos, California Section II: Isopropyl Alcohol Grant D. Lackey, PharmD, CSPI, FASCP Toxicology Management Specialist, California Poison Control System, Sacramento Division; Assistant Clinical Professor of Medicine, University of California, Davis, and Assistant Clinical Professor of Medicine, Univeristy of California, San Francisco [email protected] Section II: Antipsychotic Drugs; Arsenic; Section III: Phenytoin and Fosphenytoin Chi-Leung Lai, PharmD Assistant Clinical Professor of Pharmacy, University of California, San Francisco; Assistant Clinical Professor of Medicine, University of California, Davis Medical Center; Toxicology Management Specialist, California Poison Control System, Sacramento Division [email protected] Section II: Boric Acid, Borates, and Boron Rita Lam, PharmD Toxicology Management Specialist, California Poison Control System, San Francisco Division [email protected] Section II: Diuretics 5607fm01.qxd_cs 9/9/03 1:11 PM Page x x POISONING &DRUG OVERDOSE Shelly Lam, PharmD Toxicology Management Specialist, California Poison Control System, San Francisco Division Section II: Chlorinated Hydrocarbon Pesticides John P. Lamb, PharmD Assistant Clinical Professor of Pharmacy, University of California, San Francisco; Associate Clinical Professor of Medicine, University of California, Davis School of Medicine; Toxicology Management Specialist, California Poison Control System, Sacramento Division [email protected] Section II: Pyrethrins and Pyrethroids Darren H. Lew, PharmD Toxicology Management Specialist, California Poison Control System, Fresno Division [email protected] Section II: Chlorinated Hydrocarbon Pesticides Diane Liu, MD, MPH Chief, Occupational Health Clinic, University Health Services, Tang Center, University of California, Berkeley [email protected] Section II: Polychlorinated Biphenyls (PCBS); Trichloroethane, Trichloroethylene and Perchloroethylene Binh T. Ly, MD Associate Fellowship Director, Medical Toxicology; Associate Residency Director, Emergency Medicine; Assistant Clinical Professor of Medicine, University of California, San Diego Section II: Hydrogen Fluoride and Hydrofluoric Acid; Methylene Chloride; Section III: Calcium Richard Lynton, MD Toxicology Fellow, Department of Internal Medicine/Toxicology, University of California, Davis Medical Center Section III: Propofol Beth H. Manning, PharmD Assistant Clinical Professor, School of Pharmacy, University of California, San Francisco; Toxicology Management Specialist, California Poison Control System, San Francisco Division [email protected] Section II: Anticholinergics; Antihistamines Anthony S. Manoguerra, PharmD Professor of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco; Director, California Poison Control System, San Diego Division [email protected] Section II: Iron; Section III: Deferoxamine; Inamrinone (Formerly Amrinone); Ipecac Syrup Kathy Marquardt, PharmD, DABAT Associate Clinical Professor, School of Pharmacy, University of California, San Francisco; Associate Clinical Professor, School of Medicine, University of California, Davis; Senior Toxicology Management Specialist, California Poison Control System, Sacramento Division [email protected] Section II: Mushrooms; Mushrooms, Amatoxin-Type Kathryn H. Meier, PharmD Assistant Clinical Professor, School of Pharmacy, University of California, San Francisco; Toxicology Management Specialist, California Poison Control System, San Francisco Division [email protected] Section II: Dapsone; Fluoride; Magnesium; Section III: Hydroxocobalamin 5607fm01.qxd_cs 9/9/03 1:11 PM Page xi AUTHORS xi Michael A. Miller, MD Program Director, Department of Emergency Medicine, Darnall Army Community Hospital, Ft. Hood, Texas; Medical Toxicology Consultant, Central Texas Poison Center, Temple, Texas [email protected] Section II: Lithium; Organophosphorus and Carbamate Insecticides; Warfare Agents – Chemical; Section III: DTPA; Iodine (Potassium Iodine, KI) Eileen Morentz Poison Information Provider, California Poison Control System, San Francisco Division [email protected] Section II: Nontoxic or Minimally Toxic Household Products Walter H. Mullen, PharmD Assistant Clinical Professor of Pharmacy, University of California, San Francisco; Toxicology Management Specialist, California Poison Control System, San Francisco Division [email protected] Section II: Caustic and Corrosive Agents; Iodine; Section III: Flumazenil; Nitrite, Sodium and Amyl Stephen W. Munday, MD, MPH, MS Medical Toxicologist, Sharp Rees-Stealy Medical Group, San Diego, California [email protected] Section II: Hydrogen Sulfide Steve Offerman, MD Assistant Clinical Professor of Emergency Medicine, University of California, San Diego School of Medicine; Medical Toxicology Fellow, Emergency Department Attending, University of California, San Diego Medical Center [email protected] Section II: Fluoroacetate Kent R. Olson, MD, FACEP, FACMT, FAACT Clinical Professor of Medicine, Pediatrics, and Pharmacy, University of California, San Francisco; Medical Director, California Poison Control System, San Francisco Division [email protected] Section I: Emergency Evaluation and Treatment; Section II: Acetaminophen; Amantadine; Carbon Monoxide; Oxalic Acid; Smoke Inhalation; Theophylline; Vitamins; Section III: Oxygen & Hyperbaric Oxygen; Section IV: Emergency Medical Response to Hazardous Materials Incidents; The Toxic Hazards of Industrial and Occupational Chemicals Michael O’Malley, MD, MPH Associate Clinical Professor, School of Medicine, University of California, Davis [email protected] Section II: Chlorophenoxy Herbicides Manish Patel, MD Medical Toxicologist, Centers for Disease Control and Prevention, Atlanta, Georgia [email protected] Section II: Lysergic Acid Diethylamide (LSD) and Other Hallucinogens Cyrus Rangan, MD, FAAP Assistant Medical Director, California Poison Control System, San Francisco Division; Director, Toxics Epidemiology Program, Los Angeles County Department of Health Services; Attending Staff, Childrens Hospital Los Angeles [email protected] Section II: Clonidine and Related Drugs Pending Freda M. Rowley, PharmD Assistant Clinical Professor of Pharmacy, University of California, San Francisco; Toxicology Management Specialist, California Poison Control System, San Francisco Division [email protected] Section II: Anticonvulsants, Newer 5607fm01.qxd_cs 9/9/03 1:11 PM Page xii xii POISONING &DRUG OVERDOSE Thomas R. Sands, PharmD Assistant Clinical Professor, School of Pharmacy, University of California, San Francisco; Associate Clinical Professor, School of Medicine, University of California, Davis; Toxicology Management Specialist, California Poison Control System, Sacramento Division [email protected] Section II: Bromates; Chlorates Aaron Schneir, MD Assistant Clinical Professor, University of California, San Diego Medical Center, and California Poison Control System, San Diego Division [email protected] Section II: Nitrous Oxide Jay Schrader, CPhT Poison Information Provider, California Poison Control System, San Francisco Division [email protected] Section II: Nontoxic or Minimally Toxic Household Products Kerry Schwarz, PharmD Toxicology Management Specialist, California Poison Control System, Sacramento Division [email protected] Section II: Antiseptics and Disinfectants Dennis Shusterman, MD, MPH Professor of Clinical Medicine, University of California, San Francisco [email protected] Section II: Freons and Halons Karl A. Sporer, MD Associate Clinical Professor, University of California, San Francisco; Attending Physician, San Francisco General Hospital [email protected] Section II: Tetanus Jeffrey R. Suchard, MD, FACEP Assistant Clinical Professor, Director of Medical Toxicology, Department of Emergency Medicine, University of California, Irvine Medical Center, Orange, California [email protected] Section II: Spiders Winnie W. Tai, PharmD Assistant Clinical Professor of Pharmacy, University of California, San Francisco; Toxicology Management Specialist, California Poison Control System, San Francisco Division [email protected] Section II: Metaldehyde; Nonsteroidal Anti-Inflammatory Drugs David A. Tanen, MD Assistant Program Director and Research Director, Emergency Medicine Department, Naval Medical Center, San Diego, California [email protected] Section II: Warfare Agents - Biological John H. Tegzes, VMD Associate Professor, Toxicology, Western University of Health Sciences, Pomona, California [email protected] Section III: Tetanus Toxoid and Immune Globulin 5607fm01.qxd_cs 9/9/03 1:11 PM Page xiii AUTHORS xiii R. Steven Tharratt, MD, MPVM, FACMT Professor of Medicine and Anesthesiology, University of California, Davis; Associate Medical Director, Califoria Poison Control System, Sacramento Division [email protected] Section II: Ammonia; Chlorine; Section IV: Emergency Medical Response to Hazardous Materials Incidents Ben Tsutaoka, PharmD Assistant Clinical Professor, School of Pharmacy, University of California, San Francisco; Toxicology Management Specialist, California Poison Control System, San Francisco Division [email protected] Section II: Benzodiazepines; Sedative-Hypnotic Agents Peter Wald MD, MPH Associate Clinical Professor of Occupational Medicine, University of Southern California; Assistant Clinical Professor of Occupational Medicine, University of California Los Angeles and Irvine; Assistant Vice-President Wellness, USAA, San Antonio, Texas [email protected] Section II: Antimony and Stibine; Benzene Michael J. Walsh, PharmD Assistant Clinical Professor, School of Pharmacy, University of California, San Francisco; Toxicology Management Specialist, California Poison Control System, Sacramento Division [email protected] Section II: Detergents Janet Weiss, MD Director, TheToxDoc, Berkeley, California [email protected] Section II: Ethylene Dibromide; Toluene and Xylene R. David West, PharmD Toxicology Management Specialist, California Poison Control System, Fresno Division [email protected] Section III:Magnesium Saralyn R. Williams, MD Associate Clinical Professor of Medicine, University of California, San Diego; Assistant Medical Director, California Poison Control System, San Diego Division [email protected] Section II: Ethanol; Strychnine Olga F. Woo, PharmD Associate Clinical Professor of Pharmacy, University of California, San Francisco; Clinical Pharmacist/Toxicologist, First DataBank, Inc., The Hearst Corporation, San Bruno, California [email protected] Section II: Antibacterial Agents; Antiviral and Antiretroviral Agents; Barium Evan T. Wythe MD Associate Director, Eden Emergency Medical Group, Inc., Castro Valley, California [email protected] Section II: Radiation (Ionizing)