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Appendix: Sympathomimetic Pressors

Jeffrey Brent

Contents Dopamine Dopamine ...... 3009 Action and Structure ...... 3009 Action and Structure Dosage and Administration ...... 3010 Precautions and Contraindications ...... 3010 Dopamine (Fig. 1) exerts its action predominantly Epinephrine ...... 3011 through the following three mechanisms: Action and Structure ...... 3011 Dosage and Administration ...... 3011 Precautions and Contraindications ...... 3012 1. agonism: Dopamine is an agonist for the dopamine receptor. Dopamine ...... 3013 administration causes dopamine1 (D1) Action and Structure ...... 3013 – Dosage and Administration ...... 3013 receptor mediated vasodilation. Precautions and Contraindications ...... 3013 2. β1-receptor agonism: At doses higher than Phenylephrine ...... 3014 those required for D1 receptor agonism (see Action ...... 3014 subsequently), dopamine may cause stimula- Dosage and Administration ...... 3014 tion of β1-receptors. Precautions and Contraindications ...... 3015 3. Generation of norepinephrine: As shown in Fig. 2, dopamine is a precursor in the biosyn- thetic pathway of epinephrine and norepineph- rine. Approximately 75% of an administered dose of dopamine is inactivated by either monoamine oxidase (MAO) or catechol O-methyl transferase (COMT), and only about 25% is stoichiometrically converted to norepinephrine. Because of this, norepinephrine-mediated α-receptor agonism is seen only when high doses (see subse- quently) of dopamine are administered.

Based on animal data, it seems that dopamine J. Brent does not cross the placenta, and it does not cross Department of Medicine, Division of Clinical – Pharmacology and , University of Colorado, the blood brain barrier except in preterm infants. School of Medicine, Aurora, CO, USA Its volume of distribution has been reported to

# Springer International Publishing AG 2017 3009 J. Brent et al. (eds.), Critical Care Toxicology, DOI 10.1007/978-3-319-17900-1 3010 J. Brent

Fig. 1 Chemical structures of dopamine, norepinephrine, epinephrine, and phenylephrine. Where indicated, the (R)-isomer, which possesses the most adrenergic activity, is shown

range from 1.81 to 2.45 L/kg, and dopamine’s 2. Intermediate dose: At doses ranging from 3 to primary metabolite by MAO and COMT is homo- 10 μg/kg/min, predominantly β1-receptor vanillic acid. Its half-life is approximately 2 min effects are seen. There is still an increase in in adults, although it can be significantly longer in D1-mediated blood flow in the above- small children. Plasma dopamine concentrations described vascular territories and in the are normally less than 100 pg/mL. β1-receptor effects on the heart, resulting in an increase in heart rate, cardiac contractility, cardiac index, and conduction. At these doses, Dosage and Administration there may be modest increases in blood pres- sure but generally few effects on systemic vas- Dopamine should be administered intravenously. cular resistance (SVR), although small Solutions may be prepared by mixing decreases in SVR, may be seen. 200–800 mg of dopamine in 250–1000 mL of 3. High dose: At doses greater than 10 μg/kg/min, any standard intravenous solution. the α-adrenergic effects from norepinephrine Because of the various mechanisms by which synthesis tend to predominate and may over- dopamine acts, its effects depend on the dose whelm the D1 receptor–mediated vasodilation administered. There are several possible ranges of the above-described vascular beds. Doses of doses, as follows: greater than 50 μg/kg/min predictably cause severe vasoconstriction and generally should 1. Low dose: Doses ranging from 1 to 3 μg/kg/ not be used. min act primarily to dilate renal, intracerebral, mesenteric, and coronary vascular beds

through activation of the D1 receptor. At these Precautions and Contraindications doses, there tends to be little observed effect on most monitored hemodynamic parameters, Because MAO is a major enzyme in the catabo- although in some cases the vasodilation of lism of dopamine, patients taking an inhibitor of these beds may cause a decrease in mean and this enzyme (see ▶ Chap. 50, “Monoamine Oxi- diastolic blood pressure. dase Inhibitors”) are expected to have a Appendix: Sympathomimetic Pressors 3011

Epinephrine

Action and Structure

Epinephrine (see Fig. 1), a term applicable only to the L-isomer of 1-(3,4-dihydroxy phenyl)-2- methylamino , exerts its action predomi- nantly through the following two mechanisms:

1. β-Receptor agonism: Epinephrine is an agonist at β-receptors causing an increase in cardiac index, contractility, conduction, and heart rate. At low doses (see subsequently), the vasodilating effects of β-receptor agonism pre- dominate, resulting in a decrease in SVR and widening of the pulse pressure. Epinephrine is not an ideal first-line vasopressor except in cases of anaphylactic shock. 2. α-Receptor agonism: At higher doses (see subsequently), epinephrine has significant α-receptor agonism resulting in an increase in SVR and mean arterial blood pressure. These effects may result in a reflex decrease in heart rate.

Plasma epinephrine concentrations normally are 15–55 pg/mL. It is metabolized by MAO and COMT (Fig. 3). Its half-life is 2–3 min.

Dosage and Administration

Epinephrine is compatible with most standard intravenous fluid solutions. Autooxidation may Fig. 2 Biosynthesis of catecholamines occur in bicarbonate-containing solutions, how- ever. It is generally constituted as a 1:1000 (1 mg/mL) or 1:10,000 (100 μg/mL) solution; 10 mL of 1:100,000 is equivalent to 1 mg. When substantially exaggerated effect. It is generally given as a constant infusion, typically 1–2mgis recommended that doses of dopamine approxi- diluted into 250 mL (i.e., 4–8 μg/mL) of 5% mating one tenth of standard doses be adminis- dextrose in water or normal saline. tered in patients taking these agents. If these doses Epinephrine is best administered intrave- are ineffective, the dose can be titrated to the nously. If access is not immediately available, desired clinical effect. Because many dopamine other routes are possible. It can be given subcuta- preparations contain sodium metabisulfite, neously, typically as a 1:1000 solution, but the patients with sulfite allergies may develop allergic effects are delayed and variable, particularly reactions to dopamine administration. because of the local vasoconstriction it causes. 3012 J. Brent

Fig. 3 Metabolism of norepinephrine and epinephrine by glycol, DHMA 3,4-dihydroxymandelic acid, MHPG monoamine oxidase (MAO) and catechol O-methyl- 3-methoxy-4-hydroxyphenylethylene glycol, VMA transferase (COMT). DHPGAL 3,4-dihydroxyphenyl- 3-methoxy-4-hydroxymandelic acid, MHPGAL 3-methoxy- glycolaldehyde, DHPEG 3,4-dihydro-xyphenyl 4-hydroxyphenylglycol aldehyde

Epinephrine also can be administered via an endo- α-adrenergic effects become evident and eventu- tracheal tube in an emergent situation, whereby its ally predominate. The exact doses at which these pharmacologic effect is approximately half of that effects occur in the individual patient are variable which would be achieved by intravenous and should be determined based on the assess- administration. ment of the clinical response. In almost all circumstances in a critically ill patient, epinephrine should be infused intrave- nously, typically at doses ranging from 1 to Precautions and Contraindications 10 μg/min (0.02–0.2 μg/kg/min) and subse- quently titrated to the desired effect. At the lower Patients on β- therapy may end of this dose spectrum, β-adrenergic effects have an exaggerated hypertensive effect after the predominate. As the dose is increased, administration of epinephrine due to unopposed Appendix: Sympathomimetic Pressors 3013

α-receptor agonism. In patients taking these Norepinephrine generally is used primarily for agents, epinephrine should be used at the lowest its α-receptor–mediated vasoconstrictive proper- possible doses, which can be titrated as necessary. ties. As described earlier, it is preferable to epi- This effect potentially is seen even with patients nephrine in this regard despite norepinephrine’s using β-receptor antagonist eye drops. Because lower potency at the α-receptor because of epi- patients taking tricyclic antidepressants or nephrine’s vasodilating effect secondary to its venlafaxine have reduced reuptake of sympatho- agonist properties at the β2-receptor. The net result mimetic amines, their response to epinephrine of the administration of norepinephrine is an may be exaggerated. Here too doses should start increase in SVR and mean arterial blood pressure. low and be titrated gradually to the desired clinical Norepinephrine is metabolized by COMT and effect. MAO. The product of COMT metabolism is Because of a possible “catecholamine-sensitiz- normetanephrine, which is inactive. MAO action ing” effect of halogenated hydrocarbons on the forms norepinephrine aldehyde, which is subse- heart, epinephrine and other β-receptor agonists quently methylated by COMT to the inactive should be used cautiously in patients poisoned by vanillylmandelic acid. these agents. If it is necessary to use sympathomi- Norepinephrine generally is supplied as the metics such as epinephrine in these patients, ther- bitartrate (Levophed); 2 mg of the bitartrate is apy should be initiated at the lowest possible dose equivalent to 1 mg of norepinephrine base. and titrated as necessary. When specifying doses, it is important to be For patients with circulatory shock, the unambiguous about the bitartrate versus the

β2-adrenergically mediated decrease in SVR of base. It is preferable to express dosage in terms epinephrine may be detrimental. Agents with of norepinephrine base, and that convention is predominantly α-adrenergic activity and few followed here.

β2Àadrenergic effects, such as norepinephrine or phenylephrine, are preferable. Dosage and Administration

Norepinephrine It is best to dilute norepinephrine bitartrate in dextrose-containing solutions because the latter Action and Structure inhibits its oxidation. It is generally prepared by adding 1 ampule (4 mg of norepinephrine base) Norepinephrine (levarterenol) (see Fig. 1), a term to 250–1000 mL. Infusions should start at applicable only to the L-isomer of 1-(3,4 0.5–1 μg/min and should be titrated to the desired dihydroxy phenyl)-2-amino ethanol, exerts its clinical effect. Pediatric infusion should begin at action predominantly through the following two 0.05–0.1 μg/kg/mL (or approximately 2 μg/m2). mechanisms: Because of the powerful vasoconstricting effect of norepinephrine, it should not be given subcutane- 1. α-Receptor agonism: Norepinephrine is a ously or intramuscularly, and precautions should direct-acting agonist at α-receptors and is be taken to prevent extravasation by its adminis- predominantly used for this effect. Although tration into large peripheral or central veins. it is a less potent α-receptor agonist than

epinephrine, the lack of β2-agonism makes norepinephrine a preferable α-adrenergic vaso- Precautions and Contraindications constrictor (see later). 2. β1-Receptor agonism: Norepinephrine is a As described earlier, it is important to avoid

direct-acting agonist at the β1-receptor. Its ago- extravasation of norepinephrine. In the event of nistic properties at this receptor are roughly an extravasation, the local vasoconstriction equal in potency to that of epinephrine. should be treated by α-receptor blockade, which 3014 J. Brent

0

−20

Threshold −40

−60

Membrane potential (mV) − 80 100 msec

Fig. 4 Transmembrane potentials of pacemaker cells of an (From Smith CM, Reynard AM [eds]: mammalian heart illustrating slowing of the rate of dia- Textbook of pharmacology. Philadelphia, WB Saunders, stolic depolarization produced by vagus nerve stimulation 1995, with permission) (darker curve). Threshold is the potential for generation of can be accomplished by the administration of norepinephrine. The latter activity is probably phentolamine. A typical dose is 5–10 mg of phen- not responsible for its pressor effects, although it tolamine diluted in 10–15 mL of normal saline can have some significance for potential drug administered through a fine needle; this should be interactions, which are explained subsequently infiltrated diffusely in the area of extravasation. (Fig. 4). Patients taking guanethidine may have When administered as a vasopressor, phenyl- an exaggerated hypertensive effect from norepi- ephrine can be given intravenously, subcutane- nephrine or other direct-acting α-adrenergic ously, or intramuscularly. The intravenous route agonists because guanethidine decreases the is always preferred and except in extraordinary uptake of these agents and may induce receptor circumstances should be used exclusively when supersensitivity. Patients taking amine seeking a vasopressor effect. Phenylephrine’s uptake–inhibiting antidepressants, such as tricy- duration of action after intravenous use is approx- clic antidepressants, also can be expected to have imately 15 min, in contrast to hours after subcu- an exaggerated effect of direct-acting sympatho- taneous or intramuscular injection. The long mimetic amines such as norepinephrine second- duration of action for these routes is probably ary to decreased uptake. Patients taking any of the the result of the delayed release from these aforementioned agents should be treated with sites because of phenylephrine’s α-adrenergic minimal doses of norepinephrine initially, which vasoconstricting properties. can be titrated to the desired clinical effect. Approximately 16% of an intravenous dose is excreted unchanged. It is not appreciably protein bound. Its volume of distribution is reported to be Phenylephrine 4.9 L/kg. Peak serum concentrations are generally in the vicinity of 200 ng/mL. Action

Phenylephrine (Neo-Synephrine) (see Fig. 1)is Dosage and Administration primarily a direct-acting α1-adrenergic agonist and is devoid of activity at β-adrenergic receptors. Phenylephrine infusions generally are administered It also seems to have a component of indirect at a rate of 40–360 μg/min, although it is unusual action causing the release of dopamine and to require dose rates greater than 180 μg/min. Appendix: Sympathomimetic Pressors 3015

The usual pediatric dose is 0.1–0.5 μg/kg/min. If Precautions and Contraindications needed, an initial bolus of 200–500 μg(5–20 μg/kg) can be given before the infusion. An enhanced pressor effect may be expected in If it is necessary to use the subcutaneous or patients taking guanethidine because of guanethi- intramuscular route, the usual adult dose is dine’s inhibition of phenylephrine uptake from the 2–10 mg repeated every 10–15 min. The pediatric neuromuscular junction or possibly by adrenergic dose is typically 0.05–1 mg/10 kg or 0.1 mg/kg receptor hypersensitivity. Patients taking MAO (3 mg/m2) as a single dose. Because of the long inhibitors may be anticipated to have an exagger- duration of action of phenylephrine given by these ated response to phenylephrine secondary to its routes, it should be administered only every 1–2h. indirect effects. In patients taking these agents, it Phenylephrine solutions for infusion generally is best to start with the lowest possible dose and are prepared by mixing 10 mg with 500 mL of any titrate the dose as clinically indicated. Patients tak- standard intravenous solution. For a more concen- ing tricyclic antidepressants also may have an trated solution, 20 mg/500 mL may be used. exaggerated response to phenylephrine, and they When mixed with , the solution may too should be treated with the lowest possible doses form precipitates. followed by a titration to clinical effect. Grading System for Levels of Evidence Supporting Recommendations in Critical Care Toxicology, 2nd Edition

I. Evidence obtained from at least one properly results in uncontrolled experiments (such as randomized controlled trial. the results of the introduction of II-1. Evidence obtained from well-designed con- treatment in the 1940s) could also be trolled trials without randomization. regarded as this type of evidence. II-2. Evidence obtained from well-designed III. Opinions of respected authorities, based cohort or case-control analytic studies, pref- on clinical experience, descriptive studies erably from more than one center or research and case reports, or reports of expert group. committees. II-3. Evidence obtained from multiple time series with or without the intervention. Dramatic

# Springer International Publishing AG 2017 3017 J. Brent et al. (eds.), Critical Care Toxicology, DOI 10.1007/978-3-319-17900-1 Index

A Action potential, 824–829 Abciximab, 1352 Activated charcoal (AC), 165, 166, 885, 893, 896, 1061, Abnormal glucose metabolism, 256–257 1067, 2138 Abortifacients, 168–171 multiple-dose, 1305 , 2215, 2217, 2218, 2220 single-dose ,1302 Abrus precatorius, 2164, 2171, 2215 uses, 1274, 1281 Acarbose, 1369, 1374 Acute interstitial nephritis (AIN), 413, 414, 419, 1227 Acetaminophen, 171–172, 386, 388, 390, 401, 402, (AKI), 401, 559, 685, 1746, 1754, 2879, 2885 2534, 2536, 2539, 2630–2632 acute single oral , 1156–1157 Acute failure (ALF), 386, 388, 390, 392, 394, 399, clinical pharmacology, 1147–1148 401, 403, 1226 clinical presentation and life-threatening Acute liver injury (ALI), 1160 complication, 1147–1148 Acute lung injury (ALI), 367 differential diagnosis, 1155–1156 Acute radiation injuries ICU admission, indications for, 1157 causes, 605 ICU discharge, criteria for, 1163 delayed effects, 614 intravenous acetaminophen overdose, 1157 internal contamination, 614 laboratory evaluation, 1153–1155 management of, 613–614 liver transplantation and fulminant hepatic failure personal protection principles, 608 management, 1160–1161 radiation units, 607–608 medical management, 1161–1163 Acute radiation syndrome, 607, 609, 611 multiple ingestions and therapeutic error, 1157 Acute renal failure, 241 NAC, 1157–1160 Acute respiratory distress syndrome, (ARDS), 81, 88, 90, overdoses, 11 223, 225, 360, 1991 pathophysiology, 1149–1150 causes, 238 pharmacokinetics of, 1148 clinical definition(s), 365–367 special populations, 1163 mortality, 367, 368 Acetohexamide, 1367 pathophysiology, 364–365 Acetone, 1761, 1765 treatment, 368 (ACh), 427, 441, 1831, 1834, 1845, Acute - withdrawal, 947 2725–2726, 2943, 2944 Acute toxic inhalation Acetylcholinesterase (AChE), 440, 1830, 1832, 1837, classification, 1976 1840, 1844, 2656, 2916, 2921 long term effects, 1990 Acetyl salicylic acid, 1222 Acute tubular (ATN), 411, 413, 417, 419 Achee, 2165 Adders Acidosis, 327–328, 331, 335, 347, 349 night, 2323 Aconitine, 831, 2164, 2169, 2190, 2191, 2194, 2195, puff, 2323 2197, 2198 Addiction, 597 Aconitum, 2189, 2191, 2194 Adenosine, 454–455, 885, 887, 895, 1199 Acrochordidae, 2406 receptors, 887 Acrodynia, 1709, 1711 Admission criteria, 877 Acrylonitrile, 1801–1802, 1805 Adolapin, 2629

# Springer International Publishing AG 2017 3019 J. Brent et al. (eds.), Critical Care Toxicology, DOI 10.1007/978-3-319-17900-1 3020 Index

Adrenal insufficiency, 253 Alpha-amanitin, 2140 Adrenergic receptors, 483–484, 487, 496, 498, 554–555, Alpha particles, 606, 608, 609, 615 852–854 Alpha-2 receptor agonists, 131 β-Adrenergic receptor, 88, 552, 854, 856, 857 Alteplase, 1343, 1344 Adult botulism, 2613–2614 Altered drug metabolism, 258–259 Adverse drug reactions, (ADRs), 572, 575, 578, 586 Altered mental status, 2180 allergic/hypersensitivity, 695–698 Aluminum, 2771 cardiovascular, 699–705 Aluminium phosphide (AlP), 1888, 1890, 1897 dermatologic, 698–699 history, 1876 gastrointestinal, 711–714 phosphide treatment, 1880–1882 hematologic, 706–707 phosphide diagnosis, 1879–1880 neurologic, 716–722 physical properties, 1876 pulmonary, 707–711 toxicokinetics, 1876–1877 renal, 714–716 , 2130 Adverse drug-related events (ADEs), 194, 196, 198 A. bisporigera, 2130 Aflatoxin, 389 A. muscaria,2114 African honeybees, 2627 A. pantherina, 527, 2115 African snakes A. phalloides, 389, 2129, 2136, 2138 diagnosis of envenoming, 2331–2333 A. smithiana, 521, 2107 hemorrhagic syndrome, 2326–2327 (see ) inflammatory syndrome, 2330 A. verna, 2130, 2144 necrosis, 2331 A. virosa, 2130, 2131 neurological syndrome, 2330 α-Amanitin, 393, 402 treatment of envenoming, 2333–2336 , 1107–1109 composition, 2326–2327 Amatoxins, 393, 2106, 2110, 2130 venomous, 2322–2326 chemistry, 2131 Africanized bees, 2627, 2629, 2631 clinical presentation, poisoning, 2132–2134 Afterdepolarizations (ADs), 478, 479, 482, 483, diagnosis, poisoning, 2134–2136 493, 501 hepatoxicity, 2132 Agitation, 530–531 toxicokinetics, 2131 abnormal routine laboratory test, 531 treatment, poisoning, 2136–2143 Agkistrodon, 2286 Amazonian parasitic catfish, 2061–2062 A. piscivorus, 2503, 2518 American Association of Control Centers, 1288 Aglycone, 2190 Americium (Am), 2937, 2938 Air purifying respirator, 608 Aminocaproic acid, 1344 Albiglutide, 1369 Aminohexadienoic acid, 2107 Albumin dialysis, 273 Aminoimidazole carboxyamide ribonucleotide , 249 transformylase (AICRT), 1181 abuse, 2993 Aminolevulinic acid, 1819 withdrawal, 259–260, 595–596 Aminophylline, 884, 896, 1203, 1983, 1992, 2674 (ADH), 1748, 1761, 1770, Aminopterin, 1172 1771, 1777 4-Aminopyridine (4-AP), 307 gastric levels, 2796 Amiodarone, 490, 492, 823, 835 inhibition of, 2798 Amitriptyline, 521, 975, 980 inhibitor, 2795 Amlodipine, 794, 801 , 596 Ammonia, water-soluble gas, 1984 Alcoholic , 250, 260 , 12, 549, 551, 554, 556, 559, 562 , 257–258 Amputation, 2533 (ALD), 249, 251, 253, 257, 260 Amylin analogs, 1370, 1374 Aldehyde dehydrogenase, 1781, 2797 Amyl nitrite, 1940, 2737, 2739, 2741, 2779, 2889 Aldicarb, 1844 absorption, 2890 Aldrich-Mees lines, 1648 adminstration, 2893 Alexander Litvinenko, 608, 615 properties, 2890 ALF. See Acute (ALF) Analatro®, 2600 Alkalemia, 2968, 2970, 2975, 2976 Analgesic nephropathy, 415 Alkalinization, 980, 985, 987 Analgosedation, 132 Allotropic forms, 1721 Anaphylactic reactions, 2396 Alogliptin, 1370 Anaphylactic shock, 2498 Alopecia, 1736 Anaphylactoid reaction, 695, 2498 Index 3021

Anaphylaxis, 573–575, 579, 581, 584, 1221, 2498, 2628, levetiracetam, 1071–1073 2630, 2633 , 1073–1077 Anavip, 2843 Anticonvulsant hypersensitivity syndrome, 1048, 1058 Androctonus, 2241–2242 Antidepressants, 9, 10, 12, 1012, 1014, 1015. Anesthesia-induced myodystrophy, 621 See also Angel’s trumpet, 521, 2164, 2177 toxicity, 2971 Angioedema, 696–698 Antidiabetic agents, 1364 Aniline dyes, 650 clinical presentation, 1375–1378 Anion gap (AG), 331, 1229, 1258–1259, 1747 diagnostic consideration, 1378–1379 analytic limitations and errors, 331–332 treatment for poisoning, 1379–1382 hyperphosphatemia, 334 uses, 1364 lactate in, 333 Anti-digoxin Fab fragments, 808, 813–816 potassium, in, 333–334 administration, 2720–2722 serum albumin, 332–333 adverse effects, 2719–2720 water excess/deficit, 333 contraindications, 2719 Anorexigens, 1414, 1425 elderly patients, 2718 Anthrax, 2648–2649 history, 2715–2716 Antibiotic prophylaxis, 371 neonatal and pediatric patients, 2718 Antibiotics, 194, 198, 199, 202, 252, 253, 255, pharmacodynamics, 2717 256, 259 pharmacokinetics, 2717–2718 effects, 875, 877, 979, 981 precautions, 2719 Anticholinergic-induced , 2949–2950 pregnant and breast-feeding patients, 2718 Anticholinergic , 2176 properties, 2716 , 2176 renal insufficiency patients, 2719 biochemistry and clinical pharmacology, 2178–2179 Antidiuretic hormone, 994 clinical diagnosis of poisoning, 2180–2181 , 3, 4, 6, 11, 19, 20, 69, 166 clinical presentation and complications, 2179–2180 and specific treatments, 1866 species, 2177 Antidysrhythmic agents, 829, 2973, 2974 differential diagnoses, 2181 Antidysrhythmics, 828, 830, 836 Duboisia species, 2177 Antiepileptic drug, 1086, 1087 , 2178 , 2845, 2846, 2850 Mandragora species, 2178 Antihistamines, 519, 821, 822, 2972. pathophysiology of toxic effects, 2178–2179 See also treatment, 2181–2183 biochemistry and clinical pharmacology, 870 Anticholinergic syndrome, 441, 519, 529, 531–534, 1137, clinical presentation and life-threatening effects, 1138. See also Antimuscarinic toxidrome 874–876 adverse drug reactions, 526 diagnosis, 876 cardiovascular effects, 528 special populations, 877–878 clinical presentation, 526 toxic effects, pathophysiology, of, 870–874 differential diagnosis, 530–531 treatment of, 876–877 exposure routes, 526 Antimony, 1620 toxic causes, 527 biochemistry and clinical pharmacology, 1620–1622 toxicologic analyses, 531 clinical presentation and life-threatening Anticholinergic toxicity, 544, 2947–2948 complications, 1622–1625 asthma, 2949 diagnosis, 1625 , 2948–2951 pathophysiology, 1622 US hospitalizations and physostigmine, 2944 stibine (see Stibine) Anticholinergic toxidrome, 519, 524, 525. treatment, 1626–1627 See also Anticholinergic syndromes Antimuscarinic, 977, 979 Anticholinesterases, 2943, 2946, 2949 clinical manifestation, 979 Anticoagulants, 194, 200, 2413 effects, 982 biochemistry, 1889 symptoms, 982 clinical presentation, 1896 Antimuscarinic toxidrome, 34–36 diagnosis, 1898–1899 Antipsychotic agents pathophysiology, 1892–1893 blood dyscrasias, 923 treatment, 1900–1901 cardiovascular toxicity, 921–922 Anticonvulsants classification, 908–910 gabapentin, 1066–1068 clinical pharmacology, 910–915 lamotrigine, 1068–1071 diagnosis, 924–925 3022 Index

Antipsychotic agents (cont.) chronic intoxication, 1640 drug interactions, 917–919 chronic treatment, 1659 extrapyramidal syndromes, 923–924 concentration, 1654 hepatotoxicity, 922–923 containing herbicide, 1653 overdose, 919–921 human toxicity causes, 1640 pharmacokinetics, 917 impurities, 1643 seizures, 922 infants organs, 1661 special population, 928–929 inorganic, 1657 therapeutic and toxic effects, 915–917 inorganic poisoning diagnosis, 1648–1652 treatment, 925–928 metabolism compounds, 1640 Antitoxin, 2611, 2615, 2617, 2618, 2620–2622 neuropathy, 1657 Antitubulin agents, 1392. See also Vinca alkaloids; organoarsenicals, 1642 Colchicine pentoxide, 1640 Antivenin, 2845, 2849 poisoned patient, 1658 , 2262–2264, 2274, 2286, 2309–2313, poisoning, 1646–1647 2334–2336, 2377, 2389, 2447, 2450, prolongation of, 1655–1659 2496–2499, 2560–2561, 2589, 2843, systemic absorption, 1655 2850–2851 treatment, 1655 administration of, 2391 trioxide, 1640, 1657, 1659, 1661 contraindication, 2391 Arsine, 650, 1627, 1628, 1640, 1643, 1644, 1654–1655, criteria for, 2393–2394 1659–1660 dose of, 2392 Arterial blood gases (ABGs), 38 economic constraints in, 2354 Arylcyclohexamines, 1440. See also ; follow up, 2392–2393 ; indications, 2484–2485 Ascites, 254, 1175 intravenous infusion, 2391 management, 254 intravenous “push” injection, 2391 Ascorbic acid, 653, 654 local envenoming, 2390–2391 Aseptic meningitis, 1223 pediatric patients, 2485–2486 Asian coral snakes, 2344, 2368, 2371, 2380 pregnant patients, 2485–2486 administration of antivenom, 2391 provision, 2485 antivenom reactions, 2395 reactions, 2395 biochemical abnormalities, 2385 selection, storage and shelf life of, 2391 bitten part, treatment of, 2396–2397 systemic envenoming, 2390 blood film, 2385 therapy, 2534, 2538, 2539, 2541–2544, 2599–2602 Colubridae, 2377–2378 treatment of, 2396, 2487 compartmental syndrome, 2397 Anxiolytic/sedative-hypnotic (ASH), 936 contraindications to antivenom, 2391 , 938–940 differential diagnosis, 2385–2386 Aortic dissection, 1532, 1533, 1539 dose of antivenom, 2392 , 2629 Elapidae, 2368–2377 Apiaceae, 2205, 2227 elderly patients, 2398 Apis, 2627 emergency and intensive care, 2386–2388 Apixaban, 1326, 1328, 1331, 1335, 1337 first aid treatment, 2379–2381 Apoptosis, 2689–2690 follow up, 2392–2393 Arachidonic acid, 1220, 1221 haemoglobin concentration/haematocrit, 2385 Araneomorphae, 2552, 2555 history and examination in hospital, 2382–2383 ARDS. See also Acute respiratory distress syndrome , 2389–2390 (ARDS) intravenous infusion, 2391 antibiotic prophylaxis in toxic, 371 intravenous push injection, 2391 Argatroban, 1350 kinematics of, 2345 , 130, 910, 912, 913, 915, 918, 919, 929 laboratory studies, 2384–2385 Arrhythmias, 890, 894–895, 1272, 1276, 1282 local and systemic examination, 2383 Arrhythmogenesis, 477, 480–484 local envenoming, 2390–2391 Arsenic, 1620, 1625, 1627, 2933, 3006 pediatric patients, 2397–2398 acute arsenic intoxication, 1644–1646 plasma/serum, 2385 acute ingestion, 1643–1644 platelet count, 2385 admission, 1656 pregnant patients, 2398 blood levels, 1650 regional distribution and pathophysiology, 2345–2348 Index 3023

rehabilitation, 2397 GABAB receptors binding, 1120–1121 selection, storage and shelf life of, 2391 ICU conditions, 1125, 1126 systemic envenoming, 2390 imaging, 1124 urine examination, 2385 laboratory studies, 1124 Viperidae, 2349–2368 long-term use, side effects, 1123 white blood cell count, 2385 nonantidotal treatment, 1125 Asian spitting cobras, 2374–2375 pharmacokinetics, 1120 Asian vipers, 2345, 2347, 2353, 2388 pregnant women, 1127 Asphyxiants, 1980 treatment, 1124–1126 Aspiration pneumonitis, 2180 withdrawal, 2747 Aspirin (acetylsalicylic acid), 1254–1258 clinical conditions, 1123–1124 Asthma, 1225, 2949 common errors, 1126 Atelectrauma, 368 hyperthermia, 1121, 1123 ATP7A, 2931 ICU conditions, 1125, 1126 ATP7B, 2931 neurologic treatment, 1125 ATP-binding-cassette (ABC) transporters, 1180 syndrome, children, 1126 Atractaspididae, 2280 Bagging, 1954 Atrax, 2552 BAL. See British antilewisite (BAL) bite effects, 2570 Banana , 2552, 2559, 2561 taxonony and distribution, 2566 (s), 430, 465, 467, 557, 564 venom, 2567 barbiturate withdrawal syndrome, 961 Atrioventricular block, 793, 799 biochemical and pharmacokinetic properties, 956–957 Atropa belladonna, 2164, 2170, 2176, 2725 clinical presentation and life-threatening , 521, 527, 1833, 1834, 1839, 1846, 2114, 2117, complications, 957–959 2164, 2166, 2170, 2179, 2479, 2663, diagnosis, 959 2667–2671, 2673, 2675, 2676, 2725, 2916, elderly patients, 962 2919, 2922 pathophysiology of, 957 adminstration, 2729–2730 pediatric patients, 961–962 children, 2675 pregnant and breastfeeding patients, 962 contradindications, adverse effects and precautions, receptor, 593 2727–2728 treatment, 959–961 high dose, 525 veterinary medicine professionals, 962–963 pharmacodynamics, 2725–2726 Barium pharmacokinetics, 2727–2728 biochemistry, 1889 treatment, 2728 clinical presentation, 1896 Atypical antipsychotic , 132 diagnosis, 1899 Aum Shinrikyo, 2616 pathophysiology, 1893 Autumn crocus, 1387, 2164, 2171 treatment, 1901 brew, 1597 Bark (Centruroides sculpturatus), 2269 Azospermia, 1205 biochemistry, 2271 clinical presentation, 2272–2273 diagnosis, 2273 B envenomation, grading system, 2273 BabyBIG, 2620, 2621 mortality, 2270–2271 Baclofen (β-(4-chlorophenyl)-γ-aminobutyric acid) pathophysiology, 2271–2272 acute presentation, 1122 size and habitat, 2270 administration routes, 1122 toxicokinetic study, 2271 antidotal treatment, 1126 Barotrauma, 368 brain death, 1123 Basophilic stippling, 1649, 1652 chemical structure, 1120 , 1417, 1418, 1487, 1489, 1509, 1511, 1512 children, 1126 Bazett’s QTc, 513, 514 clinical manifestations, 1123 method, 513 common errors, poisoning, 1126 Becquerel (Bq), 605, 615 chronic intoxation, 1123 Bee venom, 2628–2630, 2633, 2634 diagnosis, 1124 Belladonna alkaloids, 519, 525, 527 elderly patients, 1127 Benlate. See Benomyl electroencephalography, 1124 Benomyl, 1812 GABA agonist, 1119 Benzocaine, 644, 648, 650 3024 Index

Benzodiazepine(s), 9, 10, 33, 34, 120, 125, 126, 129, 132, , 2609, 2611–2613, 2615–2617, 2619 439, 442, 462, 465, 466, 545, 546, 557, 560, Botulism, 2609–2622 564, 599–600, 717, 719–720, 936, 1070, 1075, Box jellyfish, 2046, 2048, 2051, 2052 1294, 1613, 2156, 2181, 2811, 2814, 2815. Bradycardia, 486–487, 493, 495, 496, 498, 502 See also Bradydysrhythmias, 211, 776, 778–780 biochemistry and clinical pharmacology of, 936–938 Bradykinin, 696, 704 clinical presentation and life-threatening Brain death, 969, 1123–1124. See also Brain scintigraphy; complications, 938–940 Cerebral four-vessel angiography; management, 946 Electroencephalogram (EEG); Evoked pathophysiology of toxic effects, 938 potentials; Positron emission tomography; pediatric patients, 948 Transcranial doppler elderly patients, 948 acetaminophen overdose, 281 pregnant and breast-feeding patients, 948 diagnosis, 283–286 receptor, 439, 462, 2812 electrophsiyologic study, 285 Benzoylecgonine, 1527, 1531 mechanism, 281–282 , 2136, 2139 poisoning, 282 Beriberi, 2994 multimodality pattern, 284 Beta particle, 606, 608, 609, 615 Brain scintigraphy, 282–283 Beta-, 2368 Breast feeding patients, 783 Beta receptor antagonists, 773 Brevenal, 2039 beta receptor(s), 773–775 Brevetoxins, 2039 beta receptor blockade, 775–776 British antilewisite (BAL), 1653, 1658, 1661, 1688, 2791, classification methods, 772 2793. See also Dimercaprol clinical presentation, 776–777 ‘Broken neck’ sign, 2372 diagnosis, 778 , 1888 pharmacokinetics, 772 biochemistry, 1890 toxicity, 771 clinical presentation, 1896 treatment, 778–783 diagnosis, 1899 Bicarbonate, 2968 pathophysiology, 1893 Bidirectional ventricular tachycardia, 488, 494 treatment, 1901 Biguanides, 1368–1369, 1372 Bromfenac, 1222, 1226 Bilevel positive airway pressure (BiPAP), 218 , 1112, 1114 Biologic agents, 2641 Bromophos, 1831 Biological Warfare Convention, 2640 , 870, 873, 876 Biotrauma, 368 Bronchiolitis Bipolar disorders, 992, 1000 obliterans, 2695 Bipyridyl herbicides, 1855 obliterans producing agents, 1988 Birch reduction, 1421 Bronchospasm, 698 Birth defects, 1086 Brown snakes, 2285, 2296, 2298. See also Loxosceles Bismuth subsalicylate, 1252 Brugada syndrome, 824, 829, 2974–2975 Bite cells, 646 , 2164, 2170 Bivalirudin, 1351 Buddhist’s rosary, 2215 Black locust tree, 2215 Bufenolides, 2166 Black , 1722 Bufotenine, 1587, 1588, 1590, 1591, 1596 Black snake, 2407 Bufo toad, 808 Bleach. See Hypochlorite Bulbar symptoms, 2650 Bleeding risk, 251, 252 β-, 2368, 2369 Blindness, 1273, 1278, 1280, 1281 Bungarus, 2285, 2456, 2470. See also Kraits Blind snakes, 2406 Bupivacaine, 829, 2859, 2861, 2862 Blister agent, 2692 Buprenorphine, 1242, 1246, 2909 β-blockers, 194, 200 Bupropion, 84, 90, 2971 Blowfish, 2086 cardiovascular support Blue-ringed octopus, 2064, 2065, 2087 cardiovascular instability, 971–972 Blue thistle, 2165, 2172 conduction abormalities, 971 Boas, 2281 clinical significance of, 967 Boidae, 2406 decontamination, 971 Boomslangs, 2283, 2298, 2459 diagnosis, 970 Borderline personality disorder (BPD), 120, 132, 143, 144 effects on neuronal tissue, 966 Bothrops, 2456, 2531–2536 erythrohydrobupropion, 967 Index 3025

hydrochloride and metabolites, 966 Calcium edetate hydroxybupropion, 967 adminstration, 2735 overdose adverse effects, 2735 brain death, 969 chemical properties, 2734 cardiovascular toxicity, 969 contraindication and precaution, 2734–2735 death, 969 history, 2733 neurologic toxicity, 968–969 pharmacodynamics, 2734 pharmacokinetic properties of, 966–967 pharmacokinetics, 2734 phenylethylamine, 966 Calcium EDTA, 1684, 1688, 1689, 1691, 1692, recreational abuse of, 969–970 1695, 1696 seizures, 971 , 797 supportive care, 970 Calcium oxalate, 1747, 1748 therapeutic doses, 967 Calcium phosphide, 1876 threohydrobupropion, 967 Calomel, 1706 Bush vipers, 2288, 2323 Canagliflozin, 1370, 1375 1,4-Butanediol (1,4-BD), 1555, 1556, 1560, 1581 receptor agonists, 1613 Bute, 1229 biochemistry and clinical pharmacology, 1610 Buthidae, 2241–2244 clinical presentation and complications, 1611 Buthus occtitanus, 2243, 2256, 2263 diagnosis of cannabinoid intoxication, Butyrophenones, 129, 130, 442 1612–1613 Butyrylcholinesterase (BChE), 2657 pathophysiology of toxic effecs, 1611 in young children, 1613 treatment for cannabinoid toxicity, 1613 C Cannabinoid(s) Cacodylic acid, 1642 description, 1609 Cadmium, 232, 238, 241 plant-derived, 1609 acute intoxication, 1670 receptors, 1610 biochemistry and kinetics, 1669–1670 synthetic, 1611 chronic exposure, 1670 , 1609, 1610 diagnosis, 1671–1672 Caranguejeiras, 2553 treatment, 1672–1673 insecticides, 2670–2671 , 550, 884, 885, 887, 898 biochemistry and clinical pharmacology, Calabar beans, 2943 1843–1844 Calcium, 796, 2025–2027 clinical presentation and life-threatening Calcium arsenate, 1640 complications, 1844–1845 Calcium channel antagonists, 88, 788 diagnosis, 1845 arterial vasculature, 793 pathophysiology of toxic effects, 1844 cardiac conduction deficits, 794 treatment, 1845–1847 cardiac dysrhythmias, 794 , 240 diagnosis, 794 (CBZ) , 794 absorption of, 1055 mitochondrial calcium intake, 793 adverse effects, 1060 myocardium and cardiac pacemaker cells, 791 American Association of Poison Control noncardiogenic pulmonary edema, 794 Centre, 1054 pancreatic insulin, 793 cardiovascular effects, 1057 pediatric population, 801 effects, 1057 pharmacokinetics, 789–790 extracorporeal, 1059 treatment, 795–801 massive ingestion, 1056 vasodilating and negative chronotropic effects, 788 medical conditions, 1054 Calcium channel(s), 476, 481–482, 491, 496–497 metabolism, 1055 antagonists (see Calcium channel antagonists) plasma concentration, 1054 calcium channel blockers, 194, 197, 200, 487, preparation of, 1059 496–497 serum, 1056 L-type, 789, 791 toxicity clinical effects, 1058 slow, 788 Carbaryl, 1845, 1847 voltage-gated, 790 Carbon disulfide, 239, 242, 244, 1802 Calcium chloride, 797 Carbon monoxide (CO), 12, 104, 175–177, 227, 239, 244, Calcium disodium ethylenediaminetetraacetic acid 1974, 1981, 1989, 1995, 1996 (EDTA), 2733, 2734 biochemistry, 1912–1915 3026 Index

Carbon monoxide (CO) (cont.) flumazenil effects, 1139 clinical effects, 1917–1918 pharmacokinetics and metabolism, 1134 clinical importance, 1911 side effects, 1138 diagnostic tools, 1918 toxic effects pathophysiology, 1137 pathophysiology, 1915–1917 prevention and treatment, 1140 poisoning in children, 1922 Carnitine therapy, 1087, 1090 poisoning in pregnant patients, 1921–1922 Carukia barnesi, 2046, 2048, 2050 treatment for CO poisoning, 1918–1921 Cascabella thevetia, 2164, 2166 Carbon tetrachloride, 240, 241, 392 CAs. See Cyclic antidepressants (CAs) Carboxyhemoglobin, 1912, 1920, 1989, 1996 Castor bean, 2164, 2171, 2213–2215 Cardenolides, 2191, 2193 Catechol O-methyltransferase (COMT), 551, 555, 852, Cardiac arrest 853, 855, 856 clinical assessment, 102–103 Catecholamines, 300, 311, 551, 559, 563, 852, 853, 855, hemodynamic management, 104–106 857, 860 hypothermia, 109–111 Catechol-O-methyltransferase inhibitors, 1114–1115 neuroprognostication, 111–112 Catfish, 2060 poison-based interventions, 106–109 Amazonian parasitic catfish, 2061–2062 ventilator management, 104 clinical presentation and life-threatening Cardiac arrhythmias, 486–495 complications, 2060 Cardiac conduction defects, 777, 780 diagnosis, 2060–2061 Cardiac dysrhythmias, 53–54 pathophysiology, 2060 Cardiac effects treatment, 2061 potassium efflux blockade, 873 Catha edulis, 1414, 1486 blockade, 873 , 1414, 1417. See also ; Cardiac glycosides, 482, 501, 807, 809, 813, 814, Methylenedioxypyrovalerone 2165–2166, 2188–2193, 2196, 2198, 2715, description, 1486 2717, 2720 groups of, 1496 Cardiac output, 104, 106 in neonatal and paediatric populations, 1516 Cardiac physiology, 475–477 structure, 1486 Cardiac sodium channel, 2973, 2974 Caustics Cardioactive steroids, 2192 clinical signs and symptoms, 2008 Cardiogenic pulmonary edema, 299 definition, 2005 Cardiogenic shock, 297, 298, 704, 796, 799 epidemiology, 2006 Cardiopulmonary bypass (CPB) , 82, 83, 108 pathophysiology, 2006–2008 Cardiopulmonary failure, 83, 88, 93, 94 predictors of injury, 2008–2009 Cardiopulmonary resuscitation, 82, 83, 88 treatment, 2009–2015 , 528, 1275–1276, 1282 CBZ. See Carbamazepine (CBZ) chloroquine, 2972 Celecoxib, 1222, 1223, 1226, 1230 , 2972 Cellosolves, 1756–1757 diphenhydramine, 2972 Cellular asphyxiants, 1963, 1967 lamotrigine-induced, 2972 Central core disease, 625 sodium bicarbonate treatment, 2969, 2971 Central (CNS), 425, 436, 440, 443 sodium channel, 2972 Centrally acting muscle relaxants, 1134 Vaughan Williams class agents, 2973–2974 clinical presentation, 1137–1138 Cardiovascular , 209–211, 969 extracorporeal removal techniques, 1139 β-adrenergic receptor blockers, 496 ICU admission indication, 1139 amphetamines and cocaine, 498–499 ICU discharge criteria, 1140 , 499 pharmacokinetics, 1134–1135 antihistamines, 500 Centruroides, 2243 antipsychotic drugs, 502 C. exilicauda, 2269 (see also Centruroides exilicauda caffeine and , 500–501 (Scorpion) Immune F(ab’)2 antivenom, 2274 calcium channel blockers, 496–497 C. sculpturatus, 2269, 2847 (see also Bark scorpion cardiac glycoside, 501 (Centruroides sculpturatus)) tricyclic antidepressants, 498, 500 Cerebral edema, 386, 395–398, 1086, 1088, 1091 type I antiarrhythmic, 501–502 Cerebral four-vessel angiography, 282 , 1134, 1135 Cerebral vasculitis, 1531 centrally acting agent, 1134 Cerebrospinal fluid (CSF) concentration, 1175 clinical presentation, centrally acting muscle Cerebrovascular accidents, 1222–1223 relaxants, 1137–1138 Cesium, 608, 2958 Index 3027

Chan su, 2166 Chlorzoxazone, 1134, 1135 Chaparral, 392 flumazenil effects, 1139 Chelating agents, 1688, 1693, 1696 toxic effects pathophysiology, 1137 Chelation, 1653, 1654, 1657–1659, 1661, 1684, pharmacokinetics and metabolism, 1134 1688–1696 Cholestasis, 391 antidotal treatment, 1713–1716 , 1834 extracorporeal removal techniques, 1713 Cholinergic neurotoxic poisoning, 2112–2114 urinary mercury concentration, 1712 Cholinergic poisoning, 2729 Chemical agents, 2641 Cholinergic receptors, 484, 2943, 2945 Chemical, biologic, radiologic or nuclear (CBRN) weapon Cholinergic toxidrome, 36 description, 2640 Cholinesterase, 1527, 1541 intensive care planning for CBRN events, 2642 Cholinesterases, 2945 low-frequency/high-consequence event, 2640 Choral hydrate, 941 military use versus civilian use, 2641 Chronic encephalopathy, 1184 misconceptions, 2640 , 2206, 2225, 2226, 2228 terrorist use, 2641 C. virosa, 2165, 2168 Chemical structure, 871 , 2165, 2168 Chemical warfare agent (CWA), 2656, 2676 description, 2228 Chemical Weapon Convention, 2685 LD50 values, 2229 Chemical weapons, 2727 and , 2228 Chemoprophylaxis, 2648 toxicity, 2230 Chemoreceptor trigger zone, 890, 896 Ciguatera, 2093 Chemotherapeutic agents, 194 biochemistry and clinical pharmacology, 2034 Child-Turcotte-Pugh, 250, 261 clinical presentation, 2035–2037 Chironex fleckeri, 2046–2049, 2051 diagnosis, 2037, 2038 , 592, 942, 948, 949 history, 2033–2034 treatment, 946 special population, 2039–2040 Chlorates, 645, 650, 652 toxix effects, 2035 Chlordecone, 242 treatment, 2038–2039 Chlorine, 229, 231, 1982 moderate chemical reactivity, 1981 clinical effects, 2035 upper and lower airway injury, 1985 nature of, 2038 Chlorine dioxide, 1803 production, 2033 Chlorine gas inhalation, sodium bicarbonate treatment, properties, 2034 2978–2979 sodium channel activators, 2035 Chlorophenoxy herbicide(s), 2978 Cimetidine, 870, 875, 876, 878 biochemistry, 1789 Circulatory assist devices, 220 chemical structures, 1790 Cirrhosis, 249, 258, 261 clinical presentation and life-threatening Citalopram, 1030, 1032 complications, 1791–1792 Clichy Criteria, 2141, 2142 description, 1789 Clinical pharmacists, 744 diagnosis, 1793 , 2113, 2122 pathophysiology of toxic effects, 1790–1791 Clomipramine, 521 poisoning, 1789 Clonidine, 484, 2910, 2911 toxicokinetics, 1790 adult intoxication, 764 treatment, 1793–1794 adverse effects of, 760 Chlorophyllum molybdites, 2121–2122 animal studies of, 763 Chloropicrin, 1800 antihypertensive effect of, 752, 757 Chloroquine, 84, 90, 835, 2972 chemical structures of, 755 chemistry and pharmacology, 1272 high concentration of, 755 clinical presentation and life-threatening hypotensive effect of, 757 complications, 1273–1274 mechanism of action, 752 diagnosis, 1274 metabolism of, 759 special populations, 1277 monotherapy, 764 toxic effects, pathophysiology of, 1272 peripheral sympathomimetic effects of, 757 treatment, 1274–1277 side effect profiles, 752 Chlorpheniramine, 870, 873 transdermal dosing of, 755 , 520, 916, 919, 921, 922, 924 use of, 755 Chlorpropamide, 1366 xylazine, 751 3028 Index

Clonus, 541, 542, 544, 545 pharmacology, 2066–2067 Clopidogrel, 1352 treatment, 2067–2068 , 2609–2610, 2611, 2614, 2617 Congenital methemoglobinemia, 650, 653 C. botulinum, 2609, 2614, 2616, 2650 Coniine, 2165, 2168, 2206–2207, 2209 Clove oil, 2172, 2173 diagnosis, 2209 , 520 physiologic effects, 2207–2208 Cnidarian, 2046, 2047, 2049, 2052 Conium, 2205 Coagulation abnormalities, correction of, 251 C. maculata, 2231 Coagulopathy, 395, 398, 400, 401, 1161, 1315, 2140, C. maculatum, 2165, 2168, 2205–2207, 2227, 2233 2351–2353, 2358, 2362, 2378, 2384, 2470, ,2111 2473, 2478 Contact dermatitis, 1630 consumptive, 2470, 2476 Continuous positive airway pressure (CPAP), 218 evidence, 2484 Continuous renal replacement therapy (CRRT), 272, 420 venom-induced, 2486 Convallamarin, 808 Cobalt-EDTA, 1940, 2779 Convallaria majalis, 2164, 2188. See also Lily of the valley Cobinamide, 1941, 1968 Convallarin, 808 Cobras, 2282, 2285, 2291, 2296, 2313, 2324–2325, 2344, Convallatoxin, 808, 2164 2368, 2370, 2371, 2373–2375, 2406, 2433, Convection, 269 2454, 2493. See also Mambas; Coral snakes; Co-oximeters, 650, 651, 655, 656 Sea snakes Copper compounds, 3006 Cocaethylene, 1528 clinical presentation, 1823 Cocaine, 4, 177–178, 498–499, 549, 556, 559, 562, 564, diagnosis, 1823 684, 1525, 2972, 2975 ICU conditions, 1823–1824 chemistry, 1526–1527 ingestion, 1822 clinical presentation, 1529–1536 pathophysiology, 1823 diagnosis, 1536–1540 pharmacokinetics, 1823 pathophysiology, 1527–1529 treatment, 1823 treatment, 1540–1544 Copperheads, 2313, 2504 withdrawal, 597 envenomation, 2519 Colchicine, 84, 90, 1387, 2164, 2171 Copper overload, 2929, 2933 acute ingestion, 1391 Copper sulfate, 647, 1822 diagnosis, 1392 Copper transporters, 2931 elderly patients, 1393 , 2119, 2120 mechanisms of action, 1390 Coprinus atramentarius, 2118, 2119 oral, 1388 Coral snakes, 2313, 2454, 2493 pharmacokinetics, 1388–1389 bites pregnancy, 1394 in children, 2499 structure, 1388 clinical presentation, 2495–2496 toxicity stages, 1391 diagnosis, 2496 uses, 1388 patients with late presentation, 2499 Colchicum autumnale, 1387, 2164, 2171 in pregnancy, 2499 Cold allodynia, 2036 treatment, 2496–2499 Colony-stimulating factors, 613, 614 venom biochemistry and pathophysiology, Colubridae, 2280, 2282, 2298, 2320, 2325, 2346, 2494–2495 2377–2378, 2406, 2408, 2422, 2423, 2425, eastern, 2493 2433, 2454 Texas, 2493 Colubrids, 2406, 2456, 2482 Corkwood, 2177 Coma, 425, 427, 430, 437–438, 443, 1762, 1764, Corporal techniques, 267 1766, 1792 Corrosive, 2005, 2006, 2015 atropine high dose, 525 Corticosteroids, 229, 231, 234, 238, 2013, 2589, 2698 “Coma cocktail”, 436 , 2108 Comfrey, 2165, 2172 CO. See Carbon monoxide (CO) Common oleander, 2164 Cottonmouth, 2289, 2300, 2504. See also Water moccasin Compartment(al) syndrome, 2397, 2487, 2533, 2537, 2544 COX-1, 1220, 1223 Computerized prescriber order entry (CPOE), 743 COX-2, 1220, 1223 COMT. See Catechol O-methyltransferase (COMT) C peptide, 1364, 1366, 1379 Cone snails, 2066 Crack, 1525, 1526, 1530, 1533 clinical presentation and life-threatening dancing, 1531 complications, 2067 lung, 1534 Index 3029

Cranial nerves, 2495 Cyclobenzaprine, 1134, 1135, 1138 Crank bugs, 1425 clinical presentation, centrally acting muscle relaxants, Creatine phosphokinase, 859 1137–1138 Creatinine phosphokinase (CPK), 544 pharmacokinetics and metabolism, 1134 Criteria/indication for ICU toxic effects pathophysiology, 1137 admission, 1274, 1281 Cyclodienes, 242 discharge, 1277, 1283 Cyclooxygenase, 696, 715, 1220 Cross-tolerance, 592, 599 Cyclopeptides, 2134–2136 Crotalidae, 2346 , 393 polyvalent immune Fab, 2843 Cyclophosphamide, 84, 90 Crotalinae, 2284, 2345, 2503, 2516, 2518, 2843, 2850, 2852 , 545, 870, 873 Crotalinae envenomation, 2514, 2516, 2517 adminstration, 2752 cardiovascular effects, 2508 adverse effects, 2749–2751 compartment syndrome, 2511, 2516–2517 contraindications, 2749 copper head, 2509, 2522 in pediatrics, 2752 digit dermotomy, 2517 pharmacodynamics, 2748–2749 hematologic effects, 2508 pharmacokinetics, 2749 local tissue effects, 2507–2508 physicochemical properties, 2747 neurotoxic effects, 2508 in pregnancy, 2753 treatment, 2516 treatment, 2751–2752 venom, 2505, 2508, 2516 , 2165 Crotalinae species, 2504, 2507 Cytochrome C oxidase, 2891 Crotalus, 2503, 2537–2539 Cytochrome oxidase (cytochrome-C), 1877 C. adamanteus, 2506 Cytochrome-b5 reductase, 2870, 2875 C. agkistrodon, 2847 C. spp., 2512 C. scutulatus, 2507 D Cryoprecipitate, 1343 Dabigatran, 1326, 1328, 1331, 1333, 1335, 2848 medically significant hazard features, 2476 Dantrolene, 632, 637, 2599 replacement therapy indications, 2486–2487 adminstration, 2765–2766 Cryptic shock, 297 contraindications, 2762 Crystalluria-induced AKI, 415, 418 indications, 2764–2765 CSF drainage, 1201 in neonatal and geriatric populations, 2761 Curium (Cm), 2937, 2938 pharmacodynamics, 2758–2759 Cutaneous , 2582, 2588, 2589 pharmacokinetics, 2758–2759 Cutaneous-hemolytic loxoscelism, 2583, 2584, 2589, 2591 precautions, 2762–2764 Cyanide, 177, 227, 242, 843–847, 1945, 2164, 2166, 2167, pregnant and breast-feeding population, 2762 2645, 3002, 3003 properties, 2758 against, 4-DMAP , 2788 Dapagliflozin, 1370 animal poisioning studies, 2781–2782 Dapsone, 650, 652, 1302, 2578, 2589, 2870 antidote kit, 2779–2780, 2889, 2890 clinical pharmacology, 1303 adminstration, 2740 clinical presentation, 1303–1304 adverse effects, 2741 diagnosis, 1304 , 2784 in G6PD deficient pateints, 1306 pharmacodynamics, 2738 pathophysiology, 1303 4-DMAP blood level test, 2787 in pregnant pateints, 1306 4-DMAP usage precautions, 2786 treatment, 1304–1305 poisoning, 2890, 2892, 2893 , 531, 2164, 2170, 2177. poisioning, contraindication, 2784 See also Jimson weed salts, 1930–1933, 1935, 1941 DDT, 242 Cyanocobalamin, 2739, 2819 Deadly nightshade, 521, 2164, 2170, 2725 Cyanogenic glycosides, 2166 Death Cyanogens, 1930, 1943–1945 adders, 2308 Cyanomethemoglobin, 2739 camass, 2190 Cyclic antidepressants (CAs) cap, 2129 low therapeutic index, 975 Decorporation, 2937 poor metabolizers, 976 Deferoxamine, 175, 1319, 1320 serotonergic medications, 976 administration, 2775–2776 Cyclic coma, 430, 443 adverse effects, 2774–2775 3030 Index

Deferoxamine (cont.) Diazinon, 1831, 1832 contraindications, 2774 2, 4-Dichlorophenoxyacetic acid (2, 4-D), 1789–1790 history, 2771 Dichlorvos, 1830, 1832 pharmacodynamics, 2772–2773 Diclofenac, 1222, 1223, 1225, 1226 pharmacokinetics, 2773 Dicobalt edetate, 2737, 2739, 2742 pregnant and breast-feeding patients, 2773–2774 Diethylene glycol, 1753–1755, 2834 properties, 2772 Diethylenetriaminepentaacetic acid (DTPA), 2937 Delayed neuropathy (OPIDN), 2663 administration, 2938–2940 Delayed sequence intubation, 46 administration, adverse effects, 2940 Deliberate self-harm (DSH), 118, 134, 137, 144 children, 2940 Deliberate self-poisoning (DSP), 118, 146 elements chelated, 2939 Delirium, 117, 124–126, 128, 130, 132, 137, 425, lacating mothers, 2940 428–430, 441, 716–720, 2726, 2728, 2729 pharmacokinetics, 2938 Delirium Rating Scale (DRS), 126 properties, 2938 , 596 renal failure patients, 2940 Dendroaspis, 2325 Diethylpropion, 550 , 2293, 2296 Diffenbachia, 2165 Dependence, 591 Diffusion, 269, 1222 Dermal and inhalational absorption, chlorophenoxy Digitalis, 479, 494, 501, 2188–2189, 2192, 2194, 2196 herbicides, 1792 delirium, 2718 Dermatitis, 2122 poisoning, 807, 809, 810, 812, 816, 2715, 2717, Designer drugs, 1416 2719, 2721 clinical presentation, complications, 1426–1427 purpurea, 807, 2164, 2188 , 521 Digitalis glycosides Desomorphine, 1722, 1723 biochemistry of, 808 Desvenlafaxine, 1032, 1034 clinical presentation and life-threatening complication, Dexamethasone, 1202 809–811 Dexchlorpheniramine, 870 diagnosis, 811–812 Dexmedetomidine (DXM), 131, 443, 720, 940 elderly patients, 816–817 clinical toxicology of, 758 management, 812–816 and , 753–755 pediatric patients, 816 pharmacokinetics, 756 pharmacology and mechanisms of toxicity, 808–809 , 1203, 1242, 1243 pregnant patients, 816 Dextrose, 436 renal dysfunction patients, 817 , 2807 Digitoxin, 807, 808, 810, 811, 815, 2164, 2190, 2197, 2199 infusions, 2806 Digoxin, 2851, 2852 150 gram, 2807 Diguanides, 1368 pharmacokinetics of, 2805–2806 Dihydrofolate reductase (DHFR), 1178, 1180, 2153 polypharmacy overdoses, 2801 Dihydropteroate synthase, 1303 therapy, 2808 Dihydropyridine, 788 Diabetes, 1364, 1368, 1375 Dilantin, 1044 Diagnosis Dilated cardiomyopathy, 1533 arterial blood gases, 38 Diltiazem, 492, 496, 794 biochemical analysis, 38–39 , 870 clinical signs, 32–33 Dimercaprol, 1626, 1653, 1654, 1658, 1660, 1688, CT imaging, 40 1689, 1691, 1692, 1715, 1815, 1823, 3006 EKG, 37–38 adverse effects, 2793 history, 30 antidotal treatment, 1713–1716 osmolal gap, 39–40 contraindication and precautions, 2792 toxicology testing, 39 generic term, 2791 toxidromes (see Toxidromes) history, 2791–2792 vital signs, 31 pharmacodynamics, 2792 Dialysis kinetics, fomepizole, 2833 pharmacokinetics, 2792 Diamine oxidase, 2152 properties, 2792 2,4-Diamino-N10-methylpteroic acid, 1175, 1196 Dimercaptopropanesulfonic acid (DMPS), 1655, 1656, Diazepam, 1134, 1135, 2671–2673, 2675 1658, 1661, 1672, 1688, 1714–1715, 3005 pharmacokinetics and metabolism, 1134–1135 2,3-Dimercaptosuccinic acid (DMSA), 1626, 1627, 1672, toxic effects pathophysiology, 1137 1655, 1656, 1658, 1659, 1714, 1715, 1813, uses, 1274, 1275 1815, 1823, 2791 Index 3031

Dimethoate, 2920 discovery, 2929 4-Dimethylaminophenol (4-DMAP), 2737, 2741, 2743, pharmacodynamics, 2931 2788 pharmacokinetics, 2930–2931 adverse effects, 2787–2788 precautions, 2932 clinical experience, 2784 properties, 2930 contraindications, 2783–2784 side effects, 2932 dose effect, 2784–2786 DPP-4 inhibitors, 1370, 1374 erythrocytes metabolism, 2782 DRESS. See Drug reaction with eosinophilia and systemic history, 2780 symptoms (DRESS) liver metabolism, 2783 Driving pressures, 369, 375 patients administration, 2785–2786 , 130, 442 pharmacodynamics, 2780–2782 Dropwort, 2225, 2231 pharnacokinetics, 2782–2783 Drug allergy, 578, 583 precautions, 2786 Drug-drug interactions, 745–746 properties, 2780 Drug-facilitated sexual assault, 527 toxicity, 2783 Drug eruptions, 582 treatment, adverse effect, 2788 Drug hypersensitivity, 577 Dimethylarsinic acid (DMA), 1641, 1642, 1649, 1650 Drug induced hypersensitivity syndrome (DiHS), 572, 576 , 1711, 1714 Drug induced liver injury (DILI), 1226 Dimethyltryptamine, 1590, 1592, 1594, 1596–1597 definitions, 386–387 Dioxins, 1816 diagnosis and complications, 395–399 Diphenhydramine, 869, 870, 873, 876, 2972 diagnostic studies, 399 exposure routes, 526 etiology diagnosis, 388 toxicologic analyses, 531 frequency causes, 388 Diphenoxylate, 1242 history, 386 Disintegrins, 2299 incidence, 391 Disopyramide, 2973 nontoxic causes, 393–395 Disseminated intravascular coagulation (DIC), 2295, pathogenesis, 387–388 2309, 2314 prognosis, 402–403 Distributive shock, 298 toxic causes, 388–393 Disulfiram, 1632, 2118–2120 treatment, 399–402 Dithiocarbamates Drug-induced , 682 chemical structure, 1821 Drugs, high clearance in cirrhosis, 258 clinical presentation, 1821–1822 Drug mediated hypersensitivity, 695 diagnosis, 1822 Drug overdoses, 6, 7, 17, 23 ICU conditions, 1822 Drug related eosinophilia and systemic symptoms pathophysiology, 1821 (DRESS), 698, 1069, 1070 toxicity, 1820–1821 Dulaglutide, 1369 treatment, 1822 Duloxetine, 1033, 1034 Diuretics, 194, 198, 200 Dumbcane, 2165, 2167 Divalproex, 1084 Duvernoy’s gland, 2320, 2456 DMA. See Dimethylarsinic acid (DMA) Dysesthesias, 2036, 2038 4-DMAP. See 4-Dimethylaminophenol (4-DMAP) Dysrhythmias, 211–214, 558, 980, 983, 987 DMPS. See Dimercaptopropanesulfonic acid (DMPS); Sodium, 2,3-dimercaptopropane-1-sulfonate DMSA. See 2,3-Dimercaptosuccinic acid E Dobutamine, 705, 779, 781, 798, 2261 Eastern coral snake, 2493, 2850 Dopamine, 57, 106, 705, 709, 798, 852, 854, 855, 857, 861 ECG. See Electrocardiogram (ECG) agonists, 1112–1114 Ecgonine methyl ester, 1527 antagonists, 914 ECMO. See Extracorporeal membrane oxygenation Dopamine-β-hydroxylase, 551 (ECMO) -induced effect, 1422 Ecstasy, 1416, 1417. See also 3,4- hyperthermia treatment, 1424 Methylenedioxymethamphetamine (MDMA) receptors, 854 Edetic acid, 2733. See also EDTA Doxepin, 521, 975, 979 Edoxaban, 1326, 1328, 1331, 1335, 1337 , 683 EDTA. See Calcium disodium ethylenediaminetetraacetic D-penicillamine, 2932 acid (EDTA) adminstration, 2932 EEG. See Electroencephalography (EEG) contraindications, 2932 Effusions, 1175 3032 Index

EKG changes, 1279 control, 2519, 2521 Elapidae, 2280, 2282–2283, 2296, 2298, 2300, 2321, diagnosis, 2273 2326, 2368–2377, 2406, 2408, 2422, 2423, effects, 2507, 2518 2425, 2433, 2454, 2456, 2493, 2494 grading system, 2273 Elapids, 2406, 2493, 2499, 2500 mortality, 2270–2271 Elderly toxicokinetic study, 2271 adverse drug-related events (ADE), 198 treatment, 2273–2274, 2517 anticholinergic poisoning, 199 2-en-VPA, 1084, 1086, 1087 atherosclerotic cerebrovascular disease, 199–200 4-en-VPA, 1084, 1087, 1091 clinical presentation, 198–199 Ephedra, 1414 diagnosis, 200 Ephedrine, 854, 856, 858, 862 drug interations, 197 Epinephrine, 106, 697, 705, 798, 852, 854, 855, 857, 861 drug poisoning, 193–194 ERG potassium channels, 2271 geriatric pharmacology, 194 Erythrocytes, 645, 653 hemodialysis, 201 Erythromelalgic syndrome, 2122–2123 neurobehavioral dysfunction, 199 Erythroxylon , 1526 pharmaceutical drug, exposure reactions, 197 Escitalopram, 1030, 1032 pharmacokinetic and pharmacodynamic changes, 194, Esmolol, 863, 894, 895 196–197 Esophageal strictures, 1882 pharmacokinetic considerations, 195–196 Ethanol, 389, 599–600, 1747, 1749, 1757, 1776–1777, pulmonary edema, 200 2795 treatment, 201 clinical practice, 2798 Electrocardiogram (ECG), 53 dosing of, 2798 abnormalities, 981 effect, 2796 identification, 983 elimmimation, 2797 QT interval prolongation, 980 therapy, 2797, 2834–2836 abnormalities, 981 treatment option, 2795 identification, 983 Ethchlorvynol, 944 QT interval prolongation, 980 Ethylene dibromide, 1800–1801, 1805 Electroencephalogram (EEG), 110, 111, 282, 283, 285, Ethylene glycol, 333, 341, 343, 344, 1744 435, 449, 460–461, 1200, 2141 alchol dehydrogenas, 2798 Elemental mercury, 1706 biochemistry, 1744 clinical presentation, 1710 clinical presentation, 1746–1747 compounds and resources, 1706 diagnosis, 1747–1748 decontamination, 1713 ethanol concentration, 2798 radiography and diagnostic procedures, 1712 metabolites of, 2795 toxic effects pathophysiology, 1708–1709 pathophysiology of toxicity, 1744–1746 toxicokinetics, 1707 in special populations, 1752 Elephants ear, 2165 toxicity, 2795 Elimination enhancement techniques, 267 treatment, 1748–1751 Elimination kinetics, fomepizole, 2832–2833 Ethylene glycol butyl , 1757 Emetic, 1623, 1624 Ethylene glycol monoethyl ether, 1757 Empagliflozin, 1370 Ethylene oxide, 1801 Empirical Bayesian geometric mean (EBGM), 695, 696, Ethylenediaminetetraacetate, 2733 699 Ethylenediaminetetraacetic acid (EDTA), 1819, 1823 Encainide, 823, 832, 2974 Etodolac, 1222, 1230 Encephalopathy, 250, 253, 255, 256, 395–396, 400, 402, Etomidate, 753–755 1151, 1162, 2123 Etoricoxib, 1222, 1226 Endocannabinoid system, 1609, 1610 Eucalyptus oil, 2173 Endotracheal intubation European snakes equipment, 216 circumstances, 2442–2444 indications, 212 clinical presentation, 2445–2447 pharmacologic agents, 215 composition and pathophysiology, 2444 End tidal capnography (EtCO2), 2909 diagnosis, 2447 Enterohepatic circulation, 2132, 2139 European non-front fanged colubrids, 2450–2451 Envenomation, 2509, 2510, 2516, 2522 special populations, 2449–2450 animal studies, 2271 toxicokinetics, 2444 anti-venom, 2274 treatment, 2447–2449 clinical presentation, 2272–2273 zoology and distribution, 2441–2442 Index 3033

European Viper venom antiserum, 2448 Fasciotomy, 2353, 2384, 2397 Evoked potentials, 283, 285 Fatty liver, 250, 251, 257 Exchange transfusion, 273, 1654, 1659, 1660, 1816, 1817 Fc chain, 2845 Excitation-contraction coupling, 793 Fecal pophyrins, 1819 Exenatide, 1369, 1374 , 1066 Exogenous lipoid pneumonia (ELP), 1953, 1956 Felodipine, 788 Extracorporeal drug elimination, 93 Fenoprofen, 1222, 1223 Extracorporeal life support (ECLS), 80, 108, 492, 800. , 1244 See also Extracorporeal membrane oxygenation Fer-de-lance, 2456 (ECMO) Ferrihemate, 685 Extracorporeal liver assist devices, 273 Ferrioxamine, 1319, 2771, 2775 Extracorporeal membrane oxygenation (ECMO), 60, Ferritin, 1314 108–109, 219, 371–374, 492, 496, 497, 500, Ferrous fumarate, 1314 1882, 1997 Ferrous gluconate, 1314 antidepressants, 90 Ferrous sulfate, 1314, 1319 anti-inflammatory drugs, 90 Fetal demise, 162, 172 antimalarials, 88 FFC. See Front-fanged colubroids (FFC) case report, 84–86 FFP. See Fresh frozen plasma (FFP) case series, 87–92 Fibrin, 1342, 1352 chemotherapeutic agents, 90 Fibrinogen compatibility, 92–94 medically significant hazard features, 2474 complications, 81, 91 replacement therapy indications, 2486–2487 components, 80 File snakes, 2406 description, 80–81 Filgrastim, 613 direct-acting cardioactive agents, 88 Fire-related inhalational injury, 1989, 1990 direct pulmonary toxins, 88–90 Flecainide, 2974 experimental evidence, 83 Floxglove, 2164 analgesics, 90 , 9, 129, 131, 396, 439–440, 1126, organ donation, 91 1139–1140, 2811 , 91 adminstration, 2815 plants, 91 clinical uses, 2814–2815 use, 1276–1277 contraindications, 2815 veno-arterial, 82–83 pharmacodynamics, 2811–2813 veno-venous, 81–82 pharmacokinetics, 2813 in xenobiotic-induced cardiopulmonary failure, 83 Fluoride, 2022, 2024, 2027 xenobiotic toxicity, 94–95 Fluoroacetamide, 1888 Extracorporeal removal, 1866 biochemistry, 1891 Extracorporeal treatments (ECTRs), 267 clinical presentation, 1897 adsorption, 269 diagnosis, 1899 continuous renal replacement therapies, 272 pathophysiology, 1894 convection, 269 treatment, 1902–1903 diffusion, 269 , 1027, 1030, 1031 ECTR-related factors, 269 , 520 exchange transfusion, 273 Flurbiprofen, 1222, 1223, 1225 extracorporeal liver assist devices, 273 Fly agaric, 2114 indications, 273–275 Folate, 1177 peritoneal dialysis, 272 Folic acid poison-related factors, 268–269 adminstration, 2825 therapeutic plasma exchange, 273 benefits, 2820 therapy-specific factors, 268 chemical structure, 2821 Extrapyramidal manifestations, 1105 contraindications, 2824–2825 Extrinsic allergic alveolitis, 232, 234 description, 2819 history of use, 2819–2820 in neonatal patients, 2823–2824 F in pediatric patients, 2823–2824 Facies latrodectismica, 2598 pharmacodynamics, 2820–2823 False hellebore, 2164, 2169 pharmacokinetics, 2823 Famotidine, 870, 876 in pregnant women, 2823–2824 , 2293, 2296, 2328 properties, 2820 3034 Index

Folinic acid, 1176, 1191, 1775, 1778, 2155 methyl , 1799 actual oral overdose, 1193 phosphides, 1799 adverse effects, 1194 properties of, 1798 and glucarpidase interaction, 1194 sulfuryl fluoride, 1800 chemical structure, 2821 treatment, 1803–1805 contraindications, 2824–2825 uses of, 1797 high-dose methotrexate, 1192–1193 Fungicides, 1812. See also Copper compounds; mechanism of action, 1192 Dithiocarbamates; Hexachlorobenzene (HCB); errors of low dose methotrexate, 1193 Methylmercury; Organomercury compounds; pharmacodynamics, 2822–2823 Pentachlorophenol (PCP) pharmacokinetic parameters, 2823 classification, 1812 pharmacokinetics, 1191 organic, trade names, 1812 properties, 2820 Funnel-web spiders, 2559–2560, 2566 synthesis, 2153 antivenom, 2574–2575 Folypolyglutamate synthetase (FPGS), 1180 bite complications, 2571 Fomepizole, 1748–1749, 1776, 2795, 2798 diagnosis of bite, 2571 adminstration, 2838 taxonomy and distribution, 2566–2567 adverse effects, 2837–2838 treatment for bite, 2572–2575 chemical properties, 2830 venom, 2567–2569 in children, 2836 clinical use, 2833–2834 contraindications, 2837 G description, 2830 Gabapentin, 1066–1068 . ethanol, 2834–2836 GABA. See Gamma-aminobutyric acid (GABA) inititation of, 2798 Gaboon viper, 2323 pharmacodynamics, 2831 Gacyclidine, 2673 pharmacokinetics, 2831–2833 Galega officinalis, 1368 physical properties, 2831 , 2130 precautions, 2837 G. autumnalis, 389, 2110 in pregnant patients, 2836 Gallium arsenide, 1640 Food and Drug Administration (FDA), 2076 Gambierol, 2033, 2035 Fondaparinux, 1344–1347 Gamma-aminobutyric acid (GABA), 426, 593, Forced diuresis, 2975 1555, 1559, 1571, 2115, 2151–2152, Formaldehyde, 1976, 1981, 1984, 1995 2812, 2963 clinical presentation, 1782 agonist, 1120 diagnosis, 1782 γ-aminobutyric acid receptor, types, 1119 liquid form of, 1781 (see also Baclofen pathophysiology, 1781–1782 (β-(4-chlorophenyl)-γ-aminobutyric acid)) treatment, 1782 chemical structure, 1120 Formalin, 1781, 1782 chlorine channel binding, 2156–2157 Fosphenytoin, 1050–1051 GABAA receptor(s), 426, 451, 452, 593, 1120–1121, Foxglove, 2188, 2190 2115, 2812 Fractional inspired oxygen, 369 antagonists, 2168–2169 Freebase, 1526, 1527, 1533 synthesis, 2152 Free radicals, 607, 1314 Gamma-butyrolactone (GBL), 1555, 1557, 1560, 1562, Fresh frozen plasma (FFP), 1329, 1333, 1343, 2476. 1572, 1576–1578 See also Cryoprecipitate; Platelets; Fibrinogen abuse, 592 medically significant hazard features, 2476 Gamma-glutamyl hydrolase (GGH), 1180 replacement therapy indications, 2486–2487 Gamma-hydroxybutyrate (GHB), 441, 592, 593, 596, 600, Front-fanged colubroids (FFC), 2454, 2456, 2459 2951 Fugu, 2086 acute toxicity, 1562–1566 Fulminant hepatic failure, 386, 400 alcohol-dependent patients, 1557 Fumigants, 1875 animal studies, 1557, 1559 acrylonitrile, 1801–1802 baclofen, 1578–1580 carbon disulfide, 1802–1803 , 1576–1577 chlorine dioxide, 1803 chronic administration, 1559 chloropicrin, 1800 chronic dependency and withdrawal, 1559 ethylene dibromide, 1800–1801 decision making criteria, 1575 ethylene oxide, 1801 diagnosis, 1571–1572 Index 3035

and GBL, 1577–1578 Glycolaldehyde, 1745 intravenous administration, 1557 Glycolate, 1747, 1750 mean residence time, 1558 Glycolic acid, 1746 metabolism, 1558 Glycolysis, 2996 physical restraints, 1576 Glycoprotein IIb/IIIa receptor, 1352–1353 prevalence of use, 1560–1562 Glyoxylate, 1745 respiratory effects, 1559 Gout, 1388 special populations, 1581 Grade III recommendation, 761, 762 Gamma rays, 606, 609, 615 Grayanotoxins, 831, 2164, 2169, 2190, 2192, 2194, Garter snakes (thamnophis), 2285, 2481 2195, 2197, 2199 Gas eye, 1966 Guanfacine, 759 Gas solubility, and toxic effects, 1980 Guillain-Barre syndrome, 2616, 2618 Gastric lavage/emesis, 1865 , 1288, 2150 Gastric outlet obstruction, 1315, 1317 antidotes, 2155–2156 Gastrointestinal decontamination, 67–69, 893, 1188 clinical presentation, 2153–2154 Gastrointestinal hemorrhage, 1315 common errors in treatment, 2158 GBL. See Gamma-butyrolactone (GBL) ICU conditions, 2157, 2158 Genin, 2190, 2191 toxic effects, 2151–2153 Geriatric poisoning treatment, 2155–2157 clinical presentation, 198–200 diagnosis, 200–201 clinical findings, 2153–2154 drug clearance, 196 embryotoxicity, 2153 iatrogenic medication errors, 198 , 2150 iatrogenic poisoning, 195 hydrazine acetylation, 2152 medical disorders, 198 patient observation, 2157 pharmacodynamic factors, 197 pregnant patients, 2157 pharmacokinetic and pharmacodynamic changes, properties, 2150 196–197 tetrahydrofolate synthesis inhibition, 2153 pharmacokinetic and pharmacodynamic interactions, toxicity, 2150 197–198 toxins, 2150–2151 pharmacokinetic considerations, 195 treatment, 2155–2156 pharmacology, 194 Gyromitrin, 2150, 2151 pulmonary edema, 200 diagnosis, 2150, 2154–2155 serum albumin levels, 196 GI effects of, 2154 treatment, 201–202 hemodialysis, 2156 Germander, 392 hepatotoxicity, vitamin K treatment, 2157 GHB. See Gamma-hydroxybutyrate (GHB) individual threshold dose, 2153 Ghost cells, 1654 metabolism, 2151 Glibenclamide, 1368 mortality, 2150 Gliclazide, 1368 oxidase inhibition, 2153 Glimepiride, 1368 , 2152 Glipizide, 1368 poisoning, 2157 Glitazones, 1369 pyridoxine, 2156 Globus pallidus, 1917 seizures treatment, 2156–2157 Glomerular filtration rate (GFR), 410–411 syndrome, 2153–2154 Gloriosa superba, 1387, 2164, 2171 common errors in treatment, 2158 Glory lilly, 1387, 2164, 2171 GLP-1 agonists, 1369, 1370, 1374 Glucagon, 487, 496, 779, 781, 800, 2898, 2899 H Glucarpidase, 1194–1198, 1202 H2S. See Hydrogen sulfide (H2S) Glucose-6-phosphate dehydrogenase deficiency, 1306, Haber-Weiss reaction, 1314 2155, 2157 Hadronyche, 2552 α-Glucosidase inhibitors, 1369, 1374 bite effects, 2571 Glutamate, 593, 594, 2151 taxonony and distribution, 2566 decarboxylase, 2151 venom, 2567 , 645, 649, 2879, 2881, 2883 , 2180 peroxidase, 1983 Hallucinogenic amphetamines, 549, 564, 1414, , 430, 437, 943, 944 1416–1417, 1423, 1425, 1426 Glyburide, 1367 Halogenated anesthetics, 390 3036 Index

Halogenated hydrocarbons, 240–241, 389, 392, Hepatotoxicity, 388, 390, 392, 1086–1088, 1091, 1155, 1952, 1955 1226, 1317, 1319, 1728, 1955 , 126, 129, 130, 430, 442, 910, 915, 919, Heptavalent botulinum antitoxin (HBAT), 2618–2620 921, 923 , 1238, 1244 , 392 Hexachlorobenzene (HCB) Haptoglobin, 646 chemical structure, 1818 Harber’s rule, dose-effect, 1975 diagnosis, 1819 Hazard index, 1 ICU conditions, 1820 envenoming pathophysiology, 2470–2472 pathophysiology, 1819 important considerations, 2484 pharmacokinetics, 1818 management features, 2472–2477 poisoning, common misconceptions, 1820 packed red blood cells, 2487 toxicity, 1818 prognosis, 2489 treatment, 1820 replacement therapy indications, 2486–2487 Hexafluorine, 2024 Hazard index 2-3, well-documented bites features, 2477 Hexose monophosphate shunt, 645 Hazard index 3, well-documented bites features, 2479 HHHFNC. See Humidified high flow nasal cannula Hazard index 4, well-documented bites features, 2481 (HHHFNC) Heart block, 481, 486, 487, 501 HI-6, 2663, 2670–2672, 2914, 2921, 2922 Heinz bodies, 645, 646, 1303 High-dose insulin, 797–798 Hellebore, 2189, 2190, 2196 High-frequency ventilation, 217 Hemiscorpiidae, 2244–2245 Hippocampus, 1916 Hemiscorpius, 2244–2245 Histaminase. See Diamine oxidase H. lepturus, 2258, 2260, 2264 Histamine, 2075–2080 Hemlock, poisonous. See Poison hemlock fish poisoning, 2075 Hemlock water dropwort, 2169, 2231 Histidine decarboxylase, 2076 Hemodialysis (HD), 268, 418, 420, 1000, 1089, 1090, Homocysteine, 1199 1262–1263, 1265, 1294–1295, 1749–1751, Honeybees, 2627, 2628, 2632, 2633 1765, 1777–1778, 1783, 2138, 2143, Horned desert vipers, 2323 2833, 2835 Hottentotta, 2243 Hemofiltration, 269 House spider, 2553 Hemoglobin, 1313, 1314, 1912–1913, 1921 Huffing, 1954 Hemoglobinuria, 1648, 1655 Human Botulism Immune Globulin (H-BIG), 2619 , 241, 244, 1303, 1304, 1306, 1648, 1654, 1655, Humidified high flow nasal cannula (HHHFNC), 218 1657, 1660, 2123 Humidifier fever, 232, 233 clinical presentation and diagnosis, 646 Hunter serotonin toxicity criteria, 543 intravascular, 2470, 2475, 2484 Hunting spider, 2553 pathophysiology and etiology, 645–646 Hura crepitans, 2214 treatment, 646 Hurin, 2214 Hemoperfusion, 269, 2138, 2674 Hyaluronidase, 2629, 2633 and hemodialysis, 1794 Hydantoins. See Phenytoin Hemorrhage, 1342, 2530 Hydralazine, 860, 861, 863 bilateral adrenal, 1345 Hydrazines, 1288, 2963, 2965 intracranial, 1343 diagnosis, 1292 retroperitoneal, 1345 hepatotoxicity, 1290 Hemorrhagic toxin, 2495 industrial hydrazines, 1292 Hemorrhagins, 2295, 2296, 2304–2305, 2349, 2356, 2361, medical management, 1293 2367, 2413 and poisoning, 1294 Henbane pharmacokinetics, 1288–1289 malicious use, 527 skin and eye decontamination, 1292–1293 recreational abuse, 526 Hydrocarbon(s), 1951, 1952 Heparin, 1996, 1997 physical properties, 1952 Heparin-induced , 706, 1347–1351 physical state, 1952 unfractionated and low-molecular weight, 1344–1347 pneumonitis, 1953, 1955, 1957 Hepatic encephalopathy, 1086, 2140 saturated, 1953 Hepatic necrosis, 1086 volatile, 1954 Hepatic steatosis, 1086, 1087 Hydrofluoric acid (HF), 1974, 1995, 2021 Hepatocyte growth factor (HGF), 387 biochemistry, 2021 , 253 burns, 2022 renal failure and, 254 complications, 2022–2023 Index 3037

diagnosis, 2024 amphetamines effects, 1425 enzyme inhibition, 2022 amphetamines toxicity, ICU conditions, 1431, 1432 hypocalcemia, 2022 amphetamines toxicity treatment, common errors, 1433 in pediatric patients, 2028 liver injury, amphetamines effects, 1425 pharmacokinetics of, 2021 MDMA toxicity, 1426 treatment, 2024–2027 toxicity, treatment, 1430, 1431 Hydrogen cyanide (HCN), 1930–1934, 1938, 1939, phenylethylamine effects, 1424 1941, 1944 PMA caused, 1417 (see also Malignant Hydrogen sulfide (H2S) hyperthermia (MH)) American Association of Poison Control, 1967 Hypertonic saline, 833 antidotes, 1968 Hypertonic sodium bicarbonate, 832 cellular asphyxiants, 1967 , 955, 957, 962 concentration of, 1965 Hypocalcemia, 685, 1751, 2022 cytochrome c oxidase, 1968 Hypochlorite, 2669–2670 definition, 1963–1964 Hypoglycemia, 1162, 1372, 1374–1377, 1379 experiment, 1964 Hypoinsulinemia, 2802 gasotransmitter, 1964 Hypomagnesemia, 892, 894 hazards of, 1969 Hyponatraemia, 1060 methemoglobin therapy, 1968 Hypotension, 51–53, 702, 703, 705, 720, 777, 794, oxidative phosphorylation, 1967 834–835, 891, 894, 895, 898, 1762, 1766 respiratory rate, 1965 and shock 700–1,000 ppm, 1966 antidotal therapy, 302–303 smoke inhalation treatment, 1995 cardinal findings, 298 survive exposure, 1967 chest compression devices, 313–314 three major pathways, 1964 definition, 296–297 toxic effects, 1976 echocardiography, 300 ventilation medicated, 1966 epidemiology, 296 Hydromorphone, 1238 extracorporeal life support, 314–317 Hydroxocobalamin, 1933, 1939–1943, 1945, 1968, 2167, fluid resuscitation, 303–304 2737, 2739–2741, 2743, 2893 hemodynamic variables, 300–302 Hydroxychloroquine, 1820, 2972 high dose insulin, 312 Hydroxycobalamin, 177 inotropes, 307, 308, 311 Hydroxyethyl starch, 56 intravenous lipid emulsion therapy, 311–312 4-Hydroxymethylpyrazole (4-OHMP), 2831 laboratory tests, 300 5-Hydroxytryptamine (5-HT), 540–541 levosimendan, 308–309 , 870, 873 MAP >65 mmHg, 304–305 Hydrozoa, 2052 , 312–313 clinical presentation and life-threatening pathophysiology, 297–299 complications, 2052–2053 physical examination, 298 diagnosis, 2053 vasopressin, 309–311 pharmacology, 2052 vasopressors, 305–308, 311 treatment, 2053–2054 Hypothyroidism, 996 Hymenoptera, 2627, 2629 Hypovolemic shock, 297, 298 Hyoscine, 2164, 2170 Hypoxemia, 81, 82, 104, 109 , 520, 525, 2725 Hyoscyamus niger, 2178 Hyperadrenergic toxidrome, 1014, 1017 I Hyperammonemia, 1086, 1088 Iatrogenic medication errors, 198 Hyperbaric oxygen, 1968, 2741 , 1588, 1590, 1597–1598 therapy, 2140 , 1588, 1591, 1593, 1596, 1598, 2114. Hyperdynamic changes, 252 See also Hypernatremia, 2968, 2975, 2976 Ibuprofen, 1222, 1223, 1225, 1227, 1229, 1232 Hyperreflexia, 541, 543, 545 ICU. See Intensive care unit (ICU) Hypersensitivity Idarucizumab, 2848 reactions, 195, 2498 IFE. See Intravenous fat emulsion (IFE) syndrome, 1228 IgE. See Immunoglobulin E (IgE) Hypertension, 50–51, 845, 847 Illawarra, 2567 Hypertensive crisis, 1015 Illudin, 2121 Hyperthermia, 529, 531, 533, 559, 562, 1529–1530 Imidazolines, 483, 484 3038 Index

Imipramine, 521 pathophysiology, 1371–1372 Immune system, 569, 571, 572, 580 positive inotropic effects, 2802 Immunoglobulin E (IgE) regular human, 2803 antibodies, 572 titrating, 2806 dependent anaphylaxis, 573 Intensive care planning, CBRN events, 2642 independent anaphylaxis, 574 biologic agents, 2647–2652 Inamrinone, 780, 799 cyanide, 2645 Indolealkylamines (IAAs), 1587, 1589, 1590, nerve agents, 2643–2645 1593, 1594, 1599 vesicants, 2645 chemical structure, 1589 Intensive care unit (ICU), 252, 253, 260, 742 differential diagnosis, 1598 Interleukin-1, 387 origin, 1588 Interleukin-6, 387 uses, 1587 Intermediate syndrome, 1832, 1835, 1841, 1843, Indomethacin, 1222, 1224, 1233 2663, 2669 Infant botulism, 2614–2615 Intraaortic balloon counterpulsation (IABC), 316 Infection, 251–253, 2533, 2536 Intraaortic balloon pump (IABP), 220, 316 Infliximab, 391 Intracranial hemorrhage, 1343 Infusion pumps for intravenous medications, 744 Intracranial hypertension, 435 Infusion reactions, 695–696 Intracranial pressure, 2141 toxic gases Intralipid use, 1276 clinical presentation, 1986–1988 Intrauterine growth retardation, 162 health effect quantitation, 1982–1983 Intravenous fat emulsion (IFE), 93, 986 inhalational fevers, 1984 Intravenous lipid emulsion (ILE), 107–108, 442, 835–836, mass and dose, 1975 1070, 2860, 2862, 2864 oxidant-related injury, 1983 therapy, 311–312, 780 patient evalution, 1988–1989 Intrinsic renal failure, 411, 417 smoke inhalation, 1986 Intubation solubility, 1984 awake, 47 toxic effects pathophysiology, 1983–1986 delayed sequence, 46 toxicokinetics, 1975–1982 nasotracheal, 46 treatment, 1990–1997 orotracheal, 46 aminophylline and terbutaline, 1992 rapid sequence, 46 corticosteroids, 1991–1992 Ionizing radiation exogenous surfactant, 1994 biological effects, 606–607 ibuprofen, 1993 definition, 605 N-, 1992–1993 types, 605–606 penotoxifylline, 1992 Iron, 174–175, 2772, 2775 perfluorocarbons, 1994 biochemistry and pharmacokinetics, 1313–1314 Inhalant(s), 1952, 1954 clinical presentation, 1316–1317 of choice in liver disease, 259 complications, 1316–1317 Inhalational botulism, 2615–2616 overdose, 2771, 2775 Inhalational fevers, 232–239 pathophysiology, 1314–1316 inhalant gas toxic effects, 1984 poisoning, 1319 Inhalational injury managing strategies, 1991 circulatory shock, 1315 In-hospital mortality, 280 coagulopathy, 1315 Inky cap, 2118 errors in, 1321 , 2112, 2113 free radicals, 1314 Insulin, 107, 110, 781, 1882 metabolic acidosis, 1316 adverse effects, 2805 stages of, 1316 amorphous, 2803 special populations, 1320–1321 beneficial effects, 2802 toxicity, diagnosis of, 1317–1318 chemistry and pharmacokinetics, 1364–1366 treatment, 1318–1320 discontinuing, 2808 Irukandji syndrome, 2047, 2049, 2051 exogenous and endogenous, 1379 , 449, 452, 466, 2963, 2965 facilitates, 2803 clinical presentation, 1289–1290 formulation of, 2801 food and drug interactions, 1291–1292 high-dose therapy, 2801 hemodialysis, 1294–1295 infusion, 2803, 2805, 2808 hepatotoxicity, 1290–1291 mechanism, 2802 pathophysiology, 1289 Index 3039

, 1290 Kraits, 2285, 2291, 2344, 2375–2377, 2456, 2470 pharmacokinetics, 1288–1289 Kreb’s cycle, 2996 treatment, 1292–1295 Krokodil, 1722, 1723 Isonicotinic acid hydrazide (INH). See Isoniazid Isopropanol, 1761 L characteristics, 1761 Labetalol, 861 poisoning, 1765, 1766 Lachesis, 2529, 2536–2537 toxicity, 1763 Lactic acidosis, 1377 Isoproterenol, 487, 494, 496, 498, 515, 779, 781, 798, Lactulose, 400, 2141 856, 858 Lamotrigine, 1068–1071, 2972 Isotretinoin, 163 Lamprophiidae, 2280, 2282–2284 Itai-itai disease, 1671 Lanreotide, 2898 Larkspur, 2164 Lathyrogens, 2014–2015 J , 2552, 2560, 2595 Jack-o-lantern mushroom, 2121 clinical presentation, 2597–2598 Japan incident, 2643 diagnosis, 2598 Jatropha in elderly patients, 2604 curcas, 2214 pathophysiology, 2597 multifida, 2214 pediatric population, 2603 Jellyfish, 2046–2047 in pregnant patients, 2603 clinical presentation and life-threatening treatment, 2598–2603 complications, 2049–2050 , 2552, 2560, 2849, 2850 diagnosis, 2050 L. hasseltii, 2572 pathophysiology, 2048–2049 L. hasseltii antivenom, 2601 pharmacology, 2047–2048 L. indistinctus, 2601 treatment, 2050–2052 Lead, 1676, 2931, 2933 Jequirity pea, 2215 colic, 1679, 1680, 1682, 1685, 1686, 1688, 1689, Jerk nystagmus, 430 1692, 1693 Jimson weed, 527, 532, 2164, 2170, 2177, 2725 encephalopathy, 1676–1681, 1683, 1684, 1687, 1689 Jumping spider, 2554 lines, 1681, 1684 poisoning, 1676 Legionaire’s disease, 233 K Legionella, 233 , 392 Leiurus, 2243 K-cramps, 1456 quinquestriatus, 2256, 2258, 2259, 2262 keratoconjunctivitis, 1966 , 392, 2130 Kerner, Julius, 2610 Lethargy, 425 Ketamine, 131 Leucovorin, 2820. See also Folinic acid analgesic effects, 1451 calcium powder, 2825 bladder effects, 1455 l-isomer, 2823 complications, 1464–1465 with methotrexate, 2824 drug abuse, 1445 rescue concept, 2820 onset and duration of effects, 1447 uses, 2820 pathway metabolism, 1447 Leukoencephalopathy, 242, 1184 pharmacodynamics, 1448 Levamisole, 559 and phencyclidine, 1446 Level of evidence III, 760, 762 recreational doses, 1458 Levetiracetam, 1071–1073 recreational use, 1441, 1444–1445 Levodopa/carbidopa, 1100–1105 on urogenital system, 1455 Levosimendan, 60, 308–309 in veterinary medicine, 1441 Lewisite, 1643, 1658, 2646, 2791, 2793 Ketoprofen, 1222, 1223 Lidocaine, 987 Ketorolac, 1222 Ligand-gated ion channel, 554 K factor, 608 Lily of the valley, 808, 2164, 2188, 2197 Khat, 1486, 1488 Linagliptin, 1370 K-hole, 1462 , 242 Killer bees, 2628 Linear energy transfer(LET), 606 King cobras, 2370, 2375 Lionfish, 2057, 2059 3040 Index

Lipid emulsion, 1817, 2674 surgical management, 2590–2591 therapy, 60, 442 taxonomy of, 2578 Lipid peroxidation, 1314, 1916, 1918, 1919 venom and histopathophysiological effects, 2581–2582 Lipid rescue, 93 Loxoscelism, 2552, 2558, 2578, 2582, 2584, 2587, Lipid resuscitation therapy (LRT) 2589, 2591 administration, 2863 L-type calcium channel, 790, 791 adverse effects, 2863–2864 Lumaricoxib, 1222 contraindications, 2863 Lung-damaging , 360–362, 364 definition, 2859 non-pulmonary absorption of, 364 in human toxicity, 2860 Lung fibrosis, prevention, 1866–1867 pharmacodynamics, 2861–2862 Lung injury determinants, 1980 pharmacokinetics, 2862 Lymphoproliferative diseases, 1186 properties, 2860–2861 Lysergic acid diethylamide (LSD), 1587, 1592, 1594, Lipid sink, 2861, 2862 1598, 1600 α-. See Thioctic acid Liquefactive necrosis, 2022 Liraglutide, 1369 M Lispro, 1364 Magic mushrooms, 2109 Lithium , 515, 813, 834, 1875, 1880 biochemistry and clinical pharmacology, 992–993 sulfate, 179–183 carbonate, 992 Ma Huang, 2173. See also Ephedra clinical presentation, intoxication, 994–996 Maitotoxin, 2033, 2035 diagnosis, of toxicity, 997–998 Malayan pit viper, 2348, 2351, 2363, 2374 intoxication, 994–995 Malignant hyperthermia (MH), 544–545, 2765 pathophysiology, 993–994 biopsy centers, 627 in special populations, 1003–1004 cardiac arrest, 630 treatment, 998–1003 clinical diagnosis, 627 Liver transplant, 2141–2143 clinical presentations, 625 Liver transplantation, 386, 388, 392, 393, 395, 399, diagnostic test, 625, 627 401, 403 differential diagnosis, 633–635 Local anesthetics, 821, 822, 980 exertional heat , 632 , 521, 2177 histologic examination, 627 Locus caeruleus, 552, 555, 757 history, 619–621 Long-acting anticoagulant rodenticides (LAAR), 1888 hypokalemic periodic , 625 Loratadine, 520, 870 incidence, 621 Lorazepam, 130, 442, 600, 894 infection, 632 Low-molecular weight heparin, 1344–1347 late-onset, 629 Low platelet counts, 251 molecular genetic testing, 627 Loxosceles, 2552 muscle rigidity, 628 analgesics, 2590 myopathies, 630 antibiotics, 2590 non-anesthetic drugs, 631 antihistamines, 2590 pathophysiology, 622 antivenom, 2589 prevalence, 621 complications, 2586–2587 rhabdomyolysis, 628, 632–633 corticosteroids, 2589 ryanodine receptor, 624 differential diagnosis, 2588 safe anesthesia, 635 epidemiology, 2581 signs, 629 forms, 2582–2586 tachycardia, 628 geographic distribution, 2580 treatment, 635–637 histopathological alterations, 2587–2588 Malignant Hyperthermia Association of the United hydration, 2591 States (MHAUS), 627, 637 laboratory tests, 2588 Malo kingi, 2047, 2048 metalloproteinase inhibitors, 2590 Mamba(s), 2285, 2296, 2325, 2456, 2493 packed transfusion, 2591 Mandragora species, 2178 plasma exchange, 2591 Mandrake, 2178 PMN inhibitors, 2589–2590 Manganese, 238, 244 renal replacement therapy, 2591 Mannitol, 400, 2038–2039 spider description and biology, 2578–2580 MAOIs. See Monoamine oxidase inhibitors (MAOIs) Index 3041

MAO. See Monoamine oxidase (MAO) , 430, 437, 944 Marijuana, 1609, 1612 clinical presentation, centrally acting muscle relaxants, MARK1, 2677 1137–1138 Massasauga, 2289, 2300 concentration, 1138 Mast cell degranulating peptide, 2629 extracorporeal removal techniques, 1139 Matsumoto, 2656, 2661, 2667, 2675 pharmacokinetics and metabolism, 1135 May apple, 1398 toxic effects pathophysiology, 1137 MDMA. See 3,4-Methylenedioxymethamphetamine withdrawal, 1140 (MDMA) Mercuric chloride, 1707, 1710 Mean arterial pressure (MAP), 105 antidotal treatments, 1713–1716 Mechanical Circulatory Support/Ecmo, 219 inorganic mercury salts, compounds and resources, Mechanical ventilation, 215–217, 1997 1706–1707 , 520, 870 Mercuric ion, 1706, 1708, 1710 Meclofenamic acid, 1222, 1230 Mercurous chloride, 1706 Mecoprop, 1790–1794 Mercurous ion, 1706, 1710 Medical toxicology, 3, 5 Mercury, 238, 244, 1706, 2933, 3006 fellowship training, 14–16 clinical presentation, 1710–1711 health care professionals, 16 compounds and resources, 1706–1707 journal, 15 diagnosis, 1711–1713 medical students training, 14 specific treatment, 1713–1716 medical toxicologists, 16 toxic effects pathophysiology, 1708–1710 residency training, 14 toxicokinetics, 1707–1708 services, 10 , 1415 standard practice, 17–18 Meso-2,3-dimercaptosuccinic acid (DMSA), 2987, training, 13–17 2988 Medication errors, 194, 195, 741. See also Iatrogenic Mesobuthus, 2243–2244 medication errors Metabolic acidosis, 1229, 1252, 1253, 1258–1260, Medication use process, 743 1316, 1317, 1319, 1748, 1750, 1773, , 450, 1222, 1229, 1231 1775, 1778, 1877, 1933, 1935, 1937, 1943, Meglitinides, 1367, 1372 1944, 2968, 2980 Meixner’s test, 2112, 2135 phosphide poisoning treatment, 1880–1882 MELD. See Memorial Delirium Assessment Scale phosphide toxicity diagnosis, 1879–1880 (MDAS) Metabolic alkalosis, 327, 349 , 2629, 2633 fume fever (MFF), 223 Meloxicam, 1222, 1223 Metalloprotease(s), 2460, 2471, 2495, 2506, 2508 Melzer’s solution, 2135 Metallothionein, 1671 Memorial Delirium Assessment Scale (MDAS), 126, 250, Metam-sodium, 1820, 1822 253, 256, 257, 261 Metaraminol, 308 score, 1161 Metaxalone, 1134, 1135 Meperidine, 1242, 1243 pharmacokinetics and metabolism, 1135 Mephedrone toxic effects pathophysiology, 1137 analytically confirmed case reports, 1505 Metformin, 1368–1369 cardiovascular effects, 1498–1499 , 600, 1246, 2909 chemical structure, 1491 , 549, 556, 562, 564 clinical toxicity, 1502 commmon names, 1416 diagnosis, 1514 gastrointestinal treatment, 1430 dosage and route of adminstration, 1489–1490 hepatocytes, 1425 emergency department case reports, 1502–1505 hyperthermia treatment, 1430 legal status, 1490–1491 illegal synthesis, 1420–1422 locomotor activity, 1499 illegal usage, 1414–1416 neurochemistry, 1495–1497 immunoassay, 1428–1429 neuro-cytotoxicity, 1497 infants, 1432 pharmacokinetics, 1491–1493 laboratory analysis, 1428 prevalence and pattern of use, 1487–1488 oral effects, 1426 reported death, 1505–1507 pharmacokinetics, 1420 synthesis, 1491 pharmacology, 1418–1419 thermoregulation, 1499–1500 pregnant women, 1432 wastewater analysis, 1488 serotonin effects, 1423 3042 Index

Methamphetamine (cont.) , 856, 859, 860 toxicity, treatment, 1429–1430 Methoxetamine Methanol, 1749, 2821, 2825, 2979 cardiovascular pressor effects, 1461 biochemistry, 1770 clinical toxicity, 1461 clinical pharmacology, 1770 complications, 1465–1466 clinical presentation and complications, 1771–1772 onset and duration of effects, 1447 diagnosis, 1772–1774 and phencyclidine, 1447 formation of, 2798 Methyl alcohol. See Methanol half life of, 2798 Methyl bromide, 1799, 1805 pathophysiology, 1770–1771 N-Methyl-N-formylhydrazine (MFH), 2150–2151 poisoning, 1769, 1771, 1772, 1774, 1775, 1778, 1780 Methyl isocyanate, 1974, 1984 prognosis, 1779 4-Methylpyrazole. See Fomepizole sodium bicarbonate treatment, toxicity, 2979–2980 Methyl salicylate (oil of wintergreen), 1252, 1254 special population, 1780 Methylene blue (MB), 312–313, 649, 652–654, 801, 1305, toxicity, 2795 2155, 2158, 2788 treatment, 1774–1778, 2798 chemical properties, 2870 , 945 glucose-6-phosphate dehydrogenase deficiency, 2874 , 1415, 1486 methemoglobinemia, 2868–2870 Methemoglobin (MetHb), 1931, 1932, 1937–1939, 1942, in neonates, 2873 2152, 2154, 2870, 2871, 2891, 2892 nontoxicologic medical uses, 2868 4-DMAP blood level test, 2787 pharmacodynamics, 2870–2871 formation, 2786 pharmacokinetics, 2871–2873 inducers, 2739 physical properties, 2870 reductase, 2871 Methylene chloride (MeCl), 242, 1955, 1981 Methemoglobinemia, 244, 706–707, 1303–1305, 1968, Methylene disocyanate, 1982 2868–2870 3,4-Methylenedioxymethamphetamine (MDMA), 120, adverse effect treatment, 2787–2788 549, 556, 559, 563, 1155 animal study effects, 2781–2782 adverse rection, classes, 1426–1427 diagnosis, 650–651 commmon names, 1416 differential diagnosis, 651–652 diagnosis, 1429 4-DMAP cooxidation, 2782 gastrointestinal treatment, 1431 etiology, 649–650 hallucinogenic amphetamine, 1416 hemoglobin conversion, 2780–2781 hyperthermia treatment, 1430 in vitro test, 2787 pharmacokinetics, 1420 nitrite usage, 2779 pregnant women, 1433 pathophysiology, 648–649 renal complications, 1425 treatment, 652–654 serotonin effects, 1423 Methionine synthase reductase (MTRR), 1181 toxicity effects, 1426 Methionine synthetase (MS), 1181 Methylenedioxypyrovalerone, 1417. See also Bath salts Methocarbamol, 1134, 1135 associated, 1512–1514 pharmacokinetics and metabolism, 1135 cardiovascular parameters, 1501 toxic effects pathophysiology, 1137 chemical structure, 1491 Meth mouth, 1426 diagnosis, 1514 Methotrexate, 183, 2822, 2824, 2978 dosage and route of adminstration, 1489–1490 embryopathy, 1204 emergency department case reports and case series, Methotrexate-induced , 1179 1508–1512 clinical presentation, 1182–1187 legal status, 1490–1491 diagnosis, 1187–1188 locomotor activity, 1500 high-dose, 1172 neurochemistry, 1500 low-dose, 1172 neuro-cytotoxicity, 1500 management, 1173 pharmacokinetics, 1493–1495 molecular structure, 1173 prevalence of use, 1488–1489 pathoohysiology, 1177–1179 prognosis, 1516 pharmacogenetics, 1179–1181 thermoregualtion, 1501 pharmacokinetics, 1173–1176 treatment, 1514–1515 toxic doses and concentrations, 1181–1182 wastewater analysis, 1489 treatment, 1188–1205 Methylenetetrahydrofolate reductase (MTHFR), 1180 uses, 1172 Methylmercury, 244, 1706, 1707, 1709 Index 3043

antidotal treatments, 1713–1716 pharmacokinetics, 1013 blood mercury concentration, 1712 seizures, 1020–1021 clinical presentation, 1813 tyramine reaction, 1015–1017, 1021–1022 common misconceptions, 1815 Monoamine oxidase (MAO), 852, 853, 855, 857, 863, diagnosis, 1814 1418, 1422, 1433. See also Monoamine oxidase fungicide, 1812 inhibitors (MAOIs) infants, 1815 Monomethylarsonic acid (MMA), 1641, 1643, 1649, maternal exposure, 1716 1650, 1658 organic mercury, toxicokinetics, 1708 Monomethylhydrazine (MMH), 2151–2152, 2963 pathophysiology, 1813 boiling point, 2150 pharmacokinetics, 1813 gyromitrin metabolism, 2150 treatment, 1814–1815 non-mushroom source, 2155 , 1417. See also Bath salts Montpellier snake, 2450 , 550 Mood disorders, 992 Methylxanthines Morels, 2117 clinical presentation, 890–892 , 132, 1238, 1244, 1247, 2674, 2908 complications, 890–892 Mortality, ARDS, 367, 369, 374 pathophysiology, of toxic effects, 887–889 Mountain laurel, 2190, 2192 pharmaceutically active, 883 Mouse spider(s), 2553, 2566, 2567 treatment, 892–898 Moxonidine, 752, 753 Metoprolol, 861 Mu receptor, 2907, 2908 Mexiletine, 2973 Multidrug resistance-associated protein 2 (MRP2), M-hole, 1462 1180 Mianserin, 1035 Multiple-dose activated charcoal, 1305 Microtubules, 1389–1390 Munchausen syndrome, 121, 137 Micruroides, 2493 Murray score, 366, 373 M. euryxanthus, 2493, 2495 , 2112–2114 Micrurus, 2494, 2497, 2499, 2529, 2531, 2540, 2542, Muscarinic acetylcholine receptors, 2725 2543 Muscimol, 1588, 1591, 1593, 1596, 1598, 2114 antivenin, 2845 biochemistry, 2115–2116 M. fulvius, 2494, 2496, 2498, 2845 clinical presenation, 2116 Midazolam, 2673, 2676 treatment, 2117 Miglitol, 1369 Muscle pain, 1138 Military doctrine, 2640 muscle relaxants, 1134, 1136 Milrinone, 780 centrally acting (see Centrally acting muscle Minamata disease, 244 relaxants) Miosis, 430–432, 2661, 2662, 2676–2663 Muscle wasting, 257 Mirtazapine, 1035 Missulena , 2114–2117 bite effects, 2571 cholinergic neurotoxic, 2112–2114 taxonony and distribution, 2567 cytotoxic, 2105–2109 venom, 2568 encephalopathy, 2123 MMA. See Monomethylarsonic acid (MMA) erythromelalgic syndrome, 2122–2123 Monkshood, 2164, 2169, 2189 gastrointestinal irritant, 2120–2122 Monoamine oxidase, 551, 555, 562, 563 hallucinogenic neurotoxic, 2109–2112 Monoamine oxidase inhibitors (MAOIs), 1010, 1027, metabolic pathway toxicity, 2118–2120 1031, 1033, 1112 morel neurologic syndrome, 2109–2112 admission criteria, 1021 myotoxic, 2117–2118 biochemistry, pathophysiology and clinical Paxillus syndrome, 2123 pharmacology, 1011–1013 shiitake dermatitis, 2122 clinical presentation, 1013–1015 Mushrooms, 2130. See also Amanita diagnosis, 1017 Mustard gas, 2685, 2694 drug interactions, 1022–1023 keratopathy, 2695 dysrhythmias, 1019 Mustargen, 2687 extracorporeal removal techniques, 1021 MXE. See Methoxetamine (MXE) hypertension, 1019 Myasthenia gravis, 2616, 2618 hyperthermia, 1021 Mydriasis, 430, 433–435, 524, 2180 hypotension, 1019 Myelosuppression, 1183, 1186 3044 Index

Mygalomorphs, 2554 (s), 2684 Myocardial infarction, 239, 1225, 1529, 1532, 1537, 1539 poisoning, 2725, 2728 Myoglobin, 680, 1913, 1914 Nerve gases, 2643 Myonecrosis, 2530 Neuroleptic malignant syndrome (NMS), 37, 120, Myopathies, 1163 130, 146, 533, 544–545, 560, 633, 637, Myotoxins, 2293–2294, 2297, 2411 661, 1103, 1104 agents, 662 clinical course, 666 N clinical features, 666 Nabumetone, 1222 complications and mortality, 667 N-acetylcysteine (NAC), 171, 696, 1156–1160, 1714, 1882, diagnosis, 667–669 1983, 1992, 2136, 2137, 2139, 2697, 2879 differential diagnosis, 669–670 concentrations, 2881 epidemiology, 662–664 cysteine, 2881 evaluation, 670 dose, 2885 laboratory findings, 666–667 glutathione, 2881 pathophysiology, 664–666 oral absorption, 2881 treatment, 670–674 overdose, 2883 Neuroleptic(s), 908 pharmacokinetic profile, 2882 Neurologic effects plasma level, 2881 extrapyramidal effects, 875 protein, 2881 sedation, 874 protocol, 2881 , 874 treatment, 2882 Neurologic toxicity, 968–969 N-acetyl-β-D-glucosaminidase (NAG), 1672 Neuromuscular, 2531, 2540, 2542 N-acetyl-D-penicillamine, 2930 blockade, 2531, 2537, 2540 N-acetyl-p-benzoquinoneimine (NAPQI), blocking agents, 65 1149, 1150 endplate, 2495 NADPH methemoglobin reductase, 649, Neuropathy target esterase (NTE), 1832 653, 654 Neurotoxic esterase, 2659 NaHCO3, 985. See also Sodium bicarbonate Neurotoxicity, 1282 (NaHCO3) -α, 2326, 2327 Naja, 2359, 2374, 2456 Neurotoxins, 2291–2293, 2295, 2302, 2313, 2353, , 436, 439 2368–2371, 2380, 2398, 2410, 2495, , 45, 49, 436, 439, 1242, 1244, 1246, 2609–2610, 2617 2908, 2910 Neutrons, 606, 608 , 439, 2909, 2911 Neutrophils, 361, 364, 365 Naphazoline, 752, 764 Newspaper test, 2135 Naproxen, 1222, 1223, 1227, 1229, 1230, 1232 NFFC bites, first aid recommendations applicable, α-Napthylthiourea (ANTU), 1889, 1893, 1896, 2483–2484 1899, 1901 , 863, 1431 Narcotic, 591 Nickel, 1628 Nateglinide, 1367 biochemistry and clinical pharmacology, 1628–1630 National Poison Data System (NPDS), 205, carbonyl, 1628, 1630, 1633 206, 1173 clinical presentation and life-threatening Natricidae, 2280, 2282, 2298 complications, 1630–1631 Nebo, 2245 pathophysiology, 1630 Nebulized heparin therapy, 1997 treatment, 1632–1633 Necrosis, 2533, 2534, 2537, 2689–2690 , 2206, 2208 , 1035, 1036 Nicotinic acetylcholine receptors (nAChRs), 2370 , 597–598 Nicotinic syndrome, 2207 Neostigmine, 534, 2479 Nifedipine, 789, 794 Nephrogenic diabetes insipidus, 994 Night adders, 2323 Nephrotic syndrome, 1711, 1715 Nightshade plants, 521 Nephrotoxicity, 715–716, 2735 Nikolski’s sign, 1819 delayed, 2108–2109 Nimesulide, 1222, 1231 early, 2122–2123 Nitrates, 650 Nerium oleander, 2164, 2188, 2716 , 757, 1913–1915, 1917, 2891 Index 3045

synthase, 2862 NPDS. See National Poison Data System (NPDS) treatment, inhalant toxic gases, 1993 NSAID. See Nonsteroidal anti-inflammatory drugs Nitrile(s), 650, 655, 1943–1945 (NSAID) adminstration, 2893 Nutritional deficiencies, 257 adverse effects, 2893 Nystagmus, 430 contraindications, 2892 methemoglobin formation, 2779–2780 pharmacodynamics, 2890–2892 O pharmacokinetics, 2890 OATP1B3. See Organic anion transporting protein 1B3 precautions, 2893 (OATP1B3) properties, 2890 Obidoxime, 1841–1842, 1847, 2667, 2671–2672, 2913, dioxide, 223, 229 2915–2916, 2924 corticosteroids treatments, 1991–1992 Obtundation, 425 silo filler’s disease, 1987, 1991 Occupational asthma, 224–225 Nitrogen mustards, 2686 Octopuses, 2064–2065 Nitroglycerin, 1431, 1541, 1542 clinical presentation and life-threatening Nitroprusside, 861, 863, 1431. See also Sodium complications, 2065–2066 nitroprusside (SNP) pharmacology, 2065 Nizatidine, 870 treatment, 2066 N-95 mask, 608 Octreotide, 1381, 2897, 2898 N-methyl-D-aspartate (NMDA), 593, 1916 action of, 2899 receptor, 426, 593, 1447, 1449–1450 administration, 2902–2903 Noncardiogenic pulmonary edema, 794 antidotal effects, 2899 Non-front-fanged colubroids (NFFC), 2456 contraindications and adverse effects, 2900 biochemistry, 2460 pharmacokinetics, 2900 envenoming somatostatin, 2898 discharge and follow-up, 2489 sulfonylurea drugs, 2898 long-term considerations/prognosis, 2489 treatment, 2900 management, 2470 adult patients, 2901–2902 risks of, 2466 pediatric patients, 2901 snakes, 2346–2347, 2377 Ocular toxicity, 1278, 1280 toxins, 2459 Odontobuthus, 2244 Non-heart beating poisoned donors, 288 Oenanthe, 2225, 2228, 2231 Non-invasive ventilation, 218–219 O. crocata, 2169 Nonsteroidal anti-inflammatory drugs (NSAIDs), 194, Oenanthotoxin, 2228, 2229 197, 198, 201, 1148, 1176, 1219 O-ethyl S-diisopropylaminomethyl biochemistry, 1220 methylphosphonothiolate, 2643 clinical presentation and compications, , 130, 144, 520, 910, 912, 913, 915, 918, 919, 1220–1229 923, 926 diagnosis, 1229–1231 Old world vipers, 2345 pathophysiology of toxic effects, 1220 Oleander, 808, 814, 2188, 2193, 2195, 2196 in special population, 1233 Oleandrin, 2164 treatment, 1232 Oleoresin capsicum (OC), 1988 Noradrenergic receptors, 554, 557 Olfactory , 1876, 1963, 1964 , 1527 Oligospermia, 1205 Norepinephrine, 57–58, 106, 550, 552, 554, 556, 705, olearius, 2121 710, 779, 781, 798, 852, 854, 857, 861, Ondansetron, 893, 896, 1126 1422, 1423 Ophthalmoplegia, 2994 transporter, 551 Opiates, 1238 North American Coral Snake Antivenin, 2497 OPIDN. See Organophosphate-induced delayed Nortriptyline, 521, 975, 978 neuropathy (OPIDN) Novel oral anticoagulants (NOACs), 1328 Opioid(s), 178, 436–439, 704, 711, 2908–2910 acute overdoses of, 1331 agonist, 2907, 2909 antidotes for, 1332 antagonists, 436–439 direct thrombin inhibitors, 1331–1332 definition, 1238 direct Xa inhibitors, 1331 diagnosis, 1245 therapeutic use of, 1335 pathophysiology and clinical presentation, 1243–1245 3046 Index

Opioid(s) (cont.) oximes effects, 2673 pharmacology, 1243 toxicity, 2659 poisoning, 1237, 1245 toxicokinetics, 2659 receptor, 436, 1238, 1240, 1242 Organophosphate-induced delayed neuropathy (OPIDN), receptor antagonists 2659, 2663 administration, 2910 Organophosphorus compounds, 2914, 2916, 2921 contraindications, 2909 Organophosphorus (OP) insecticides pharmacodynamics, 2907–2909 biochemistry, 1829–1830 pharmacokinetics, 2909 clinical presentation and life–threatening treatment, 2909–2910 complications, 1832–1836 uses of, 2910–2911 clinical toxicology, 1830–1831 special populations, 1246–1247 diagnosis of, 1837 toxidrome, 34, 1243, 1244 neuropsychological effects, 1836–1837 treatment, 1245–1246 pathophysiology of toxic effects, 1831–1832 withdrawal, 178, 1242, 1244, 1246 treatment, 1837–1843 Opium, 1238, 1246 Organotin compounds, 1824 Opsoclonus, 430 chemical strucures, 1824 Oral absorbents, 1865 clinical presentation, 1825 Oral anticoagulants diagnosis, 1825 clinical presentation, diagnosis and treatment, ICU conditions “ 1825 1328–1333 pathophysiology, 1824 drug interactions, 1334–1335 pharmacokinetics, 1824 nonhemorrhagic complications, 1335–1336 treatment, 1825 pathophysiology, 1326–1328 Ornamental tree, 2553 pharmacokinetics, 1326 , 1136, 1140 pregnant patients, 1336–1337 clinical presentation, centrally acting muscle Oral bioavailability of methotrexate, 1173 relaxants, 1137–1138 Oral mucositis, 1183 pharmacokinetics and metabolism, 1135 Orb weaver, 2553 Orthotopic liver transplantation (OLT), 1160 , 2108, 2109 Osmolal gap, 39–40, 1747, 1773, 1774 Organ donation, 91, 220 Osmolality (Om), 1773 heart, 286–287 Osmolar gap, 1763, 1764 kidneys, 288 Osteonecrosis, 1722, 1725 liver, 288 Osteosarcoma, 1191 lung, 287–288 Ouabain, 807, 809 non-heart beating donor, 288 Overdrive pacing, 515 pancreas, 288 Oxalate(s), 1744, 2165, 2167 toxin examination, 286 Oxaprozin, 1222, 1230 Organic anion transporting protein, Oxazolines, 752, 753, 755, 760 1B3(OATP1B3), 2132 Oxcarbazepine Organic mercury, 1706, 1714 overdose, 1060 clinical presentation, 1711 pharmacodynamics, 1060 mercury compounds and sources, 1707 pharmacokinetics, 1060 toxic effects pathophysiology, 1709 therapeutic dosing, 1060 toxicokinetics, 1708 treatment, 1061 Organochlorine insecticides, 242 Oxidant-related injury, inhalant gas toxic effects, Organolead, 1676, 1695 1983 Organomercurials, 1706 Oxidant stress, 644, 646, 648 Organomercury compounds, 1812, 1815. Oxidative stress, 2154 See also Methylmercury; Phenylmercuric Oxime(s), 1832, 1833, 1839–1842, 1847, 2670, 2671 acetate; Sodium, 2,3-dimercaptopropane-1- animal studies, 2919 sulfonate (DMPS); Dimercaptosuccinic acid contraindications, 2924 (DMSA) elderly patients, 2675 Organomercury fungicides, 1813 estimation of, 2667 Organophosphate (OP), 239, 240, 244 human studies, 2919–2921 compounds, 2656 mechanisms of action, 2916–2919 diagnosis, 2657 obidoxime chloride, 2915–2916 insecticides, 2725, 2727 pharmacokinetic data, 2923 nerve agent poisoning, 2668, 2672 pralidoxime, 2914–2915, 2923–2924 Index 3047

self-administration, 2923 neuroprotective agents, 1115–1116 therapy, 2644 selegiline, 1109–1112 treatment, 2672 Paroxetine, 1030 Oximetry, 1989 PARP signaling, 2688–2689 Oxon, 1830, 1831 Partial liver transplantation, 2142 Oxprenolol, 776 Pasireotide, 2898 , 1238 Pathogenesis, lung injury, 1986 Oxygen, 1918, 1920 Patients needing hemodialysis, 1765 Oxyhemoglobin, 1912, 1913 Pattern recognition receptors (PRRs), 365 Oxymetazoline, 484, 752, 763, 764 Pavia protocol, 2140 Oxyphenbutazone, 1222, 1229, 1231 , 2123 Oxytocin, 183 Paxillus syndrome, 2123 Ozone concentration, 1981 PCC. See Poison control center (PCC) PCP. See Phencyclidine Pediatric acute respiratory distress syndrome (PARDS) P definition, 215 P2P. See Phenyl-2-propanone (P2P) Pediatric ICU, 742 Pacemaker cells, 481 Pediatric intensive care unit (PICU), 206 Pacific -1, 2034, 2035 admission to, 206 Packed red blood cell(s), 2487 cardiovascular toxicity management, 209–211 transfusion, 2591 circulatory assist devices, 220 Pancreatic cells, 2898 dysrhthmia management, 211–214 Pancreatic islet beta cells, 2898 high-frequency ventilation, 217 Pancreatitis, 713–715 mechanical circulatory support/ecmo, 219 Pancytopenia, 1645, 1649, 1652 mechanical ventilation, 215–217 Parabuthus, 2244 neurologic toxicity, 208–209 Paracetamol, 386, 390. See also Acetaminophen non-invasive ventilation, 218–219 Paracoxib, 1222, 1223 organ donation, 220 , 592, 593 renal toxicity, 220 Paralysis, 2495, 2496, 2528, 2531, 2542 respiratory support, 214–215 Paralytic shellfish poisoning, 2093 seizure management, 209 Paramethoxymethamphetamine (PMMA), 1417, 1420 treatment in, 206 Paraoxygenase (PON1), 2658 Pediatric transport team, 206 Paraquat, 89 Pelamis, 2529, 2540 chemical structures of, 1856 Pembe yara, 1820 chemistry, 1855–1857 Penicillamine, 1714, 1814, 1823 clinical presentation, 1860–1862 Penicillin, 2132, 2137, 2139 diagnosis, 1862–1863 Pennyroyal, 2165, 2172 elderly patients, 1868 Pentachlorophenol (PCP) formulation, 1856–1857 chemical structure, 1816 incidence of human poisoning, 1857–1858 clinical presentation, 1816 local toxicity, 1860 common misconceptions, 1818 nomograms and outcome, 1864 diagnosis, 1817 pathophysiology, 1859–1860 pathophysiology, 1816 pharmacokinetics, 1858–1859 pharmacokinetics, 1816 pediatric patients, 1868 toxicity, ICU conditions, 1818 pregnant patients, 1868 treatment, 1817–1818 prognosis, 1863–1864 usage, 1815–1816 systemic toxicity, 1860–1862 Pentavalent antimony, 1620, 1622, 1623 treatment, 1864–1867 Pentavalent botulinum toxoid (PBT), 2620 Parasuicide, 118, 123 Pentetic acid. See Diethylenetriaminepentaacetic acid Parathion, 1831, 1842 (DTPA) Parkinson’s disease Pentoxifylline, 885, 887, 898 amantadine, 1107–1109 Peptide 401, 2629 anticholinergic agents, 1105–1107 Perfluorocarbon, 1994 catechol-O-methyltransferase inhibitors, 1114–1115 Peripheral neuropathy, 244, 1290, 1645, 1649, 1651, 1653, clinical features of, 1098 1657, 1661 dopamine agonists, 1112–1114 Peritoneal dialysis, 272 levodopa/carbidopa, 1100–1105 , 1916 3048 Index

Persian Gulf War, 527 diluent effects, 1047 Persistent nerve agent, 2657 overdose, 1049 Pesticides, 1829, 1832, 1840, 1843 pathophysiology, 1045–1047 , 2131 pharmacokinetics, 1044–1045 Pharmacokinetics toxicity, 1047–1048 brompheniramine, 870, 873, 876 treatment, 1049–1050 chlorpheniramine, 870, 873 Philodendron, 2165 cimetidine, 870, 875, 876, 878 Phoneutria, 2552 cyproheptadine, 873 P. nigriventer, 2598 dexchlorpheniramine, 870 Phoneutrism, 2552 dimenhydrinate, 870 Phosgene, 1983, 1988–1989 diphenhydramine, 869, 870, 873, 876 clinical presentation, 1986 famotidine, 870, 876 low water solubility, 1985 hydroxyzine, 870, 873 Phosphate, 1720, 1722, 1723 loratadine, 870 Phosphides, 1723, 1728, 1799, 1804, 1875, 1890–1891, meclizine, 870 1896. See also Aluminium phosphide; Calcium nizatidine, 870 phosphide; phosphide , 870, 873 clinical presentation, 1878–1879 ranitidine, 870, 875, 876 history, 1876 , 870 physical properties, 1876 Phenazopyridine, 650, 657 poisioning Phencyclidine clinical features, 1879 complications, 1457–1458 electrocardiographic changes, 1879 detection, 1466 treatment, 1880–1882 and ketamine, 1446 toxicity diagnosis, 1879–1880 McCarron clinical classification, 1459 toxicokinetics, 1876–1877 and methoxetamine, 1447 Phosphine, 1876, 1880, 1882, 1888, 1891, 1893, onset and duration of effects, 1447 1896–1897, 1899, 1902 recreational use, 1444–1445 history, 1876 synthesis, 1440 pathophysiology and toxicodynamics, 1877–1878 Phenethylamine phosphide toxicity diagnosis, 1879–1880 alpha-methylphenethylamine, 1418 physical properties, 1876 chemical structure, 1415 toxic dose, 1878 diagnosis, 1427–1428 toxicokinetics, 1876–1877 dimethoxy-4-ethylphenethylamine, 1417 Phosphodiesterase inhibitors, 780, 889, 2893 gastrointestinal treatment, 1430–1431 Phospholipase A2 (PLA2), 1220, 2291, 2293, 2296, 2349, hyperthermia treatment, 1430 2350, 2368, 2494, 2628, 2629 immunoassay, 1428–1429 Phospholipase D, 2578, 2581 β-phenethylamine, 1418 Phosphorothioate, 1830, 1831, 1833 PiHKAL, 1417 Phosphorus pregnant women, 1433 biochemistry, 1722–1723 rhabdomyolysis treatment, 1431–1432 cardiovascular effects, 1726 seizures treatment, 1431 dermal effects, 1724 toxicity, clinical presentation, 1424 dermal exposures, 1728–1729 treatment, 1429–1430 diagnosis, 1727 , 599, 895, 2156, 2977–2978 gastrointestinal effects, 1724–1725 Phenothiazines, 822 GI decontamination, 1727–1728 Phentermine, 550 health care workers, 1727 Phentolamine, 861, 863, 1431, 1532, 1541, 1542 hepatic effects, 1726 Phenylbutazone, 1222, 1224, 1229, 1231 inhalational effects, 1725 Phenylephrine, 106, 550, 799, 857, 859, 860, 895 neurologic effects, 1726 Phenylethylamine, 966, 1486 nomenclature, 1720–1722 Phenylmercuric acetate, 1813, 1814 prognosis, 1727 Phenylmercury, 1707, 1708 renal effects, 1725 Phenylpiperazines, 1035–1036 special populations, 1729 Phenyl-2-propanone (P2P), 1420–1421 supportive care, 1728 Phenytoin, 163, 178, 181, 390, 1294, 2156–2157, 2973 toxicokinetics, 1724 anticonvulsant hypersensitivity syndrome, 1048 uses, 1723–1724 diagnosis, 1048 Phossy jaw, 1720, 1722, 1725 Index 3049

Physalia physalis, 2048, 2050 ICU conditions, 2210 Physostigma venenosum. See Calabar beans pathophysiology, 2207–2208 Physostigmine, 4, 129, 430, 436, 440–442, 531–532, 979, pharmacokinetics, 2207 986, 1139, 1140, 2182, 2670–2671, 2944–2946 treatment, 2209–2210 adult administration, 2951 Poison treatment centers, 15, 19, 22–23 anticholinergic-induced seizures, 2950–2951 Poison control center, 15 asthma, 2949 Poisoning, 1275, 1277, 1281, 1283 cardiotoxicity, 2947–2948 deaths, 279–280 chemical and physical properties, 2946 Polonium, 608, 609, 615 dosing regimens, 2951–2952 Polyethylene glycol (PEG), 400, 1755 metabolism, 2946 Polyglutamation, 1178 pediatric administration, 2951 Polymer fume fever, 233 pharmacodynamics, 2947 Polymorphic ventricular arrhythmia, 509, 515 physiologic effects, 2945 Polymorphic ventricular tachycardia (PVT), 488, seizures, 528, 2948 492, 502 sodium bisulfite sensitivity, 2949 Polymycin B, 2144 uses, 2944 Polyneuropathy, 1736 PICU. See Pediatric intensive care unit (PICU) Pontiac fever, 233 “Ping-Pong” gaze, 430 Porphobilinogen, 1819 Pink disease. See Acrodynia Porphyria cutanea tarda (PCT) Pink sore. See Pembe yara clinical representation, 1819 Pioglitazone, 1369 diagnostic patterns, 1819 Piperidinic alkaloids, 2206 hexachlorobenzene (HCB) toxicity, 1818, 1820 Piroxicam, 1222, 1223, 1227 infants affected, 1820 Pit viper(s), 2281, 2284, 2285, 2292, 2294, 2313, 2346, treatment, 1819–1820 2350, 2363, 2503, 2513 Portal hypertension, 251, 255 envenomation, 2509, 2510 Positive end-expiratory pressure (PEEP), 368 local tissue effects, 2510–2511 Positron emission tomography, 283 Placenta, 163, 172 Posterior reversible encephalopathy syndrome (PRES), Placental abruption, 162 435 Plague, 2649 Postrenal failure, 411, 416, 419 Plaquenil. See Hydroxychloroquine Postsynaptic neurotoxins, 2370, 2375, 2398 Plasma Post-traumatic stress disorder (PTSD), 125, 127 cholinesterase, 1837, 2657 Potassium channels, 476, 478, 482, 501 exchange, 2591 Potassium permanganate, 1880 methotrexate, 1175 Potassium shifts, 1272 Plasmapheresis, 273 Pralidoxime, 1839, 1841, 1843, 1847, 2667, Plasmin, 1342 2669–2672, 2675, 2913–2915, 2922–2924 Plasminogen, 1341–1342 Pralidoxime chloride, 2644 Platelets, 1342, 1343, 1347, 1351–1352, 2475 Prasugrel, 1351 medically significant hazard features, 2476 Pregnancy prophylactic provision threshold, 2487 death reports, 160 replacement therapy indications, 2486–2487 physiologic changes, 162–164 Platelets, 2487 poisoning agents, 168–179 Plutonium (Pu), 2937, 2938 , 161–162 Pneumoconiosis, 1623, 1630 toxicity of medications, 179–185 Podophyllin treatment of poisoning, 164–168 clinical presentation, 1400–1401 Premature delivery, 162, 176 diagnosis, 1401 Prerenal failure, 411, 419 pathophysiology, 1399–1400 PRES. See Posterior reversible encephalopathy pharmacokinetics, 1399 syndrome (PRES) treatment, 1402 Prevention strategies, medication errors, 743–745 Podophyllotoxin, 1398 Prilocaine, 650 Poison control center, 7, 10, 16, 18, 21 PRIS. See related infusion syndrome (PRIS) Poison hemlock, 2165, 2168, 2227, 2231, 2233 Procainamide, 2969, 2971, 2973 biochemistry, 2206–2207 , 520 clinical presentation, 2208–2209 Procoagulants, 2412 common misconceptions, 2210 Prognostic And Ethical Considerations, 260–261 diagnosis, 2209 Proinsulin, 1364, 1379 3050 Index

Promethazine, 870, 873 Pyridoxine, 1293, 1751, 2151–2152, 2156 Promiscuous permeability, 2192 adverse effects, 2964–2965 Prone positioning, 368, 370 contraindications, 2964 Propafenone, 823, 830, 835, 2974 pharmacodynamics, 2963 Propofol, 600, 684, 704–705, 753, 895, 940, 2673 pharmacokinetics, 2964 Propofol related infusion syndrome (PRIS), 704 treatment and administration, 2965 Proportional reporting ratios (PRRs), 695, 696, 699 Pyrrolizidine alkaloids, 2165, 2172 Propoxyphene, 2972, 2975 Pyruvate dehydrogenase, 2996 Propranolol, 776, 777, 783, 823, 861, 894, 895, 2974 Python(s), 2281, 2322, 2406 Propylene glycol, 1047, 1756 , 550, 1414 Prostaglandins, 1220, 1221, 1227 Q Protective ventilation, 368, 375 QT interval nomogram, 513, 514 Prothrombin complex concentrates, 1329, 1330 QT prolongation, 510, 512, 514, 699–702 Prothrombin concentrate complex, 1344 gene causing, 1030 Prothrombin time (PT), 395, 1154–1155 hypocalcemia, 1032 Proton pump inhibitors, 2140 Ikr current channel, 1036 Protoporphyrin IX, 1677, 1683 ingestions, 1031 Prunus, 2164, 2166 normalizes, 1031 Pruritus, 2694, 2698 takosubo cardiomyopathy, 1034 Prussian Blue, 615, 1736, 1737 trazodone, 1036 administration, 2960 Quality of life, 374 adverse effects, 2959 , 911, 913, 918, 919, 921, 924 cesium, 2958 Quinidine, 823, 830, 832, 2969, 2971–2974 pharmacodynamics, 2958 syncope, 830 pharmacokinetics, 2958 Quinine, 2972 pregnancy category, 2959 chemistry and pharmacology, 1272 thallium, 2958 clinical presentation and life-threatening treatment, 2959–2960 complications, 1279–1280 Pseudoallergy, 569, 580, 582 diagnosis, 1280–1281 Pseudocholinesterase, 1837, 2657 pathophysiology, 1278–1279 Pseudoephedrine, 550, 563, 856, 858, 1415, 1421–1422, special populations, 1283 1428 treatment, 1281–1283 Pseudotumor cerebri, 435 , 1588, 1590, 1592, 1595, 2110, 2112 , 1588, 1590, 1595, 2109, 2111 R P. semilanceata,2110 Racers. See Whipsnakes , 1588, 1590, 1592, 1595, 1597, 1598, Radiation 2109–2111 absorbed dose, 607 Psychosis, 120, 126 injury treatment network, 614 Pterosis spp., 2057 weighting factor, 607 Ptosis, 2610, 2614, 2616, 2618 Radionuclides, 2937–2940 PTSD. See Post-traumatic stress disorder (PTSD) RAD. See Right-axis deviation (RAD) Puff adder, 2322, 2323 RADS. See Reactive airways dysfunction syndrome Puffer fish, 2085, 2088, 2090, 2091, 2093 (RADS) poisoning, 2085, 2087 Ramelteon, 940 Pulmonary abnormalities, 255–256 Ranitidine, 870, 875, 876 Pulmonary arterial hypertension (PAH), 709–711 Rapid and sustained clinically important reduction Pulmonary artery catheter, 61, 62 (RSCIR), 1195 Pulmonary artery catheterization (PAC), 301 Rattlesnakes, 2289, 2294, 2299, 2314, 2503, 2505, 2507, Pulmonary aspergillosis, 253 2512 Pulmonary capillary wedge pressure (PCWP), 298 envenomation, 2509, 2519 Pulmonary edema, 1244 neuromuscular effects, 2512–2513 and toxic gases, 1985–1986 Reactive airways dysfunction syndrome (RADS), 224, Pulmonary function tests, 1990 229–239, 2979 Pulmonary injury, 1953 Reactive skin decontamination lotion, 2697 Pulmonary toxicity, 1186 α1-receptors, 554, 852, 854 Pyridostigmine, 2670–2671 α2 receptors, 554 Pyridoxal phosphate, 2151 β3 receptors, 483, 554 Index 3051

μ receptors, 1240, 1243 pharmacokinetics, 1300 Recluse spiders, 2552, 2558, 2559. See also Loxosceles in pregnant patients, 1302 Red back spiders, 2572 structure, 1300 Red man syndrome, 1307 treatment, 1301–1302 Red phosphorus, 1421–1422, 1722, 1723 Rifaximin, 400 Reduced folate carrier protein (RFC1), 1173, 1180 Right-axis deviation (RAD), 983 Reentrant arrhythmias, 890 Rilmenidine, 752, 753, 760 Renal dysfunction in cirrhosis, 253 Riot control agents. See oleoresin capsicum (OC) Renal failure, 386, 392, 395, 397–398, 401, 559, Risk factors for TdP 1161–1162, 1223, 1232 clinical management of TdP, 509 in cirrhosis, 254 poisoned patients, 512 Renal insufficiency, 1186 Ritodrine, 550 Renal papillary necrosis, 1227 Rivaroxaban, 1326, 1328, 1331, 1335, 1337 Renal replacement therapy (RRT), 411, 420, 687, 2591 Robinia pseudoacacia, 2215 Renal toxicity, 220 Rodenticides, 1733, 1875 Renal tubular necrosis, 2630 biochemistry, 1889–1892 Repaglinide, 1367 clinical presentation, 1896–1898 Reperfusion injury, 104 diagnosis, 1898–1900 Respiratory alkalosis, 327, 1252, 1258–1260 pathophysiology, 1892–1895 Respiratory burns treatment, 1997 special populations, 1904 Respiratory depression, 1289, 2908, 2909 treatment, 1900–1904 Respiratory failure, 80, 89, 1763 Rofecoxib, 1222, 1225 causes, 47 Ropivicaine, 822 classification, 47–48 Rosary pea, 2164, 2171, 2214, 2215 Respiratory support, 214–215 Rosiglitazone, 1369 Respiratory tract, 361, 363 RTX ventilator, 219 Resuscitation and supportive care, 1865 Rubbing alcohol, 1761 Reteplase, 1342 Running spider, 2553 Reticular activating system, 426 Russell’s viper, 2285, 2288, 2290, 2296, 2299, 2304, Rhabdomyolysis, 241, 413, 415, 419, 529, 531, 533, 2311, 2345, 2353, 2355–2360 559, 875, 876, 1530, 1535–1536, 2117, Ryanodine receptor, 622, 624, 625, 2758. 2210, 2232, 2234, 2531, 2537, 2539, See also Dantrolene 2542, 2543 of anesthesia, 621 amphetamines effects, 1425 S amphetamines toxicity, 1423, 1425 Sac spider, 2553 clinical and laboratory manifestations, 684–686 Sacred Datura, 2177 description, 679 Salicylate intoxication, 1254 diagnosis, 1428 Salicylates, 172–174, 327, 332, 349, 432, 438, illicit drug development, 1418 1251–1265, 2977 MDMA toxicity, 1426 Salicylic acid, 1252, 1254 pathophysiology, 680–684 Sarafotoxins, 2326 signs, 2209 Sarcoplasmic reticulum, 622, 624, 635 treatment, 686–688, 1431–1432 Sargramostim–Leukine®, 613 urinary acidification, amphetamines, 1432 Saw-scaled vipers, 2360–2362 Rhodanese, 1932, 2891, 3002 Saxagliptin, 1370 Rhododendron, 2169 SBP, trigger sever complications, 256 Rhubarb, 2165, 2167 SCN5A gene, 823 , 2214 Scombroid poisoning, 2075 apoptosis, 2215 biochemical basis, 2076 detection, 2219 clinical presentation, 2079 inhalation, 2218 diagnosis, 2079–2080 oral ingestion, 2216 pathophysiology, 2078–2079 weight, 2215 in pregnancy, 2081 Ricinus communis, 2164, 2171, 2213–2215 prevalence, 2075 Rifampin, 1300 signs and symptoms, 2076 clinical presentation, 1300–1301 treatment of, 2080–2081 diagnosis, 1301 Scombrotoxin, 2079 pathophysiology, 1300 , 521, 527, 2164, 2170, 2179 3052 Index

Scopolamine (cont.) illicit drug development, 1418 clinical presentation, 525 phenethylamine toxicity, diagnosis, 1428 exposure routes, 526 synthetic cathinones, 1417 malicious use, 527 treatment, 1429–1431 Scorpaenidae, 2056–2057 Selective serotonin reuptake inhibitors (SSRI), 540, clinical presentation and life-threatening 1027–1033, 1035, 2971 complications, 2058 Selegiline, 1109–1112 pharmacology, 2057–2058 Sensitizer-induced asthma (SIA), 224 treatment, 2058–2059 Sensory neuropathy, 2964 SCORPIFAV, 2262 Septicemia, 2534, 2535 Scorpion Septicemic plague, 2649 , 2249 Sernyl, 1440 clinical presentation, 2273 Serotonergic antidepressants, 1028 envenomation, 2257 Serotonin, 427, 442, 540, 541, 976, 978, 980, 1589, 1594, biochemistry and pathophysiology, 2256–2258 1598, 1599 Buthidae, 2241–2244 receptors, 540, 541, 544, 545, 1589, 1590 clinical manifestation, 2258–2259 syndrome, 37, 120, 146, 530, 560, 562, 1015, 1023, clinical presentation, 2246–2247 1030–1033, 2748–2749, 2752 diagnosis, 2259 benzodiazepines, 545 Hemiscorpiidae, 2244–2245 clinical presentation, 541–542 laboratory abnormalities, 2259 cyproheptadine, 545 long toxins, 2245 dexmedetomidine, 546 Scorpionidae, 2245 diagnosis, 542–543 short toxins, 2245 differential diagnosis, 544–545 special populations, 2265 laboratory testing, 544 species, regions and characteristic toxicity, 2256 5-hydroxytryptamine, 540 taxonomy, 2240–2241 hyperthermia, 546 treatment, 2247–2249, 2260–2265 prevention of, 546 size and habitat, 2269–2270 regulation of serotonin, 541 stings, 2255, 2259, 2261 serotonergic xenobiotics, 541 venom, 2256, 2257 toxicity, 1031, 1035 Scorpionidae, 2245 Serotonin-dopamine antagonists, 914 Sea cucumbers cases of seizures, 1035 clinical presentation and life-threatening designer drugs toxicity, 1423 complications, 2064 efficacy, 1027 diagnosis, 2064 hyperthermia treatment, 1424 pharmacology, 2063–2064 MDMA effects, 1423 treatment, 2064 phenylethylamine effects, 1423 Sea snakes, 2284, 2285, 2296, 2297, 2377, 2409, 2422, reuptake inhibition, 1030 2425, 2433, 2456 synaptic, 1033 Sea urchins, 2068 syndrome, 1031, 1427, 1433 clinical presentation and life-threatening toxicity, 1028, 1423 complications, 2068–2070 transmission, 1027 diagnosis, 2070 venlafaxine poisoning, 1033 pharmacology, 2068 Serotonin noradrenergic reuptake inhibitors (SNRI), 1027, treatment, 2070 1028, 1032–1035 Second-line therapy for anaphylaxis, 2603 Sertraline, 1030, 1036 Sedation, 1162 Serum albumin, 196 Sedative-hypnotics, 427, 430, 432, 595, 599, 955, 957, Serum alkalization, 2673–2674 959, 962 Serum antiviperinum, 2448 Seizure(s), 109, 110, 209, 242, 244, 425, 439, 441, 719, Serum iron concentration, 1317 721, 836, 891, 895, 955, 962, 963, 971, 979, Serum sickness, 570, 575, 581, 2310, 2311, 2313, 2396, 981, 982, 985, 986, 1066, 1068, 1071, 1073, 2498, 2850, 2852 1075, 1229, 1231, 1529–1531. Sewer gas, 1963, 1967 See also -induced seizures SGLT2 inhibitors, 1364, 1370, 1374 amphetamines , 1414 Shock, 51. See also Hypotension and shock amphetamines toxicity, ICU conditions, 1431, 1432 SILENT. See Syndrome of irreversible lithium-effectuated CNS, 1424 neurotoxicity Index 3053

Silibinin, 402, 2132, 2137 Sodium arsenite, 1640, 1661 Sistrurus, 2503 Sodium bicarbonate (NaHCO3), 487, 490, 495, 498, 500, S. spp., 2289, 2300 985, 986, 2673 Sitagliptin, 1370 administration, 2982 Slip-mode conductance, 2192 antidepressant toxicity treatment, 2971 Slow calcium channel, 788 antihistamines toxicity treatment, 2972 Smallpox, 2651 Brugada syndrome, 2975 Smoke inhalation, 1931, 1939, 1940, 1943 bupropion toxicity treatment, 2971 inhalant gas toxic effects, 1986 chlorine gas inhalation, treatment, 2978 treatments, 1995–1997 cocaine toxicity treatment, 2973 Snake bites, 2503, 2504, 2507 effectiveness, 980 antivenom, 2517 lamotrigine toxicity treatment, 2972 diagnosis, 2513–2514 methanol toxicity treatment, 2979–2980 toxic effects, 2507–2509 methotrexate toxicity treatment, 2978 treatment, 2514–2516 neuroleptics toxicity treatment, 2972 Snake envenoming, 2378, 2384, 2385, 2388 pediatric patients, 2981 antivenom therapy, 2310–2313 pharmacodynamics, 2968 basic treatment, 2310 pulmonaery edema, 987 biochemical classification of, 2294 quinine toxicity treatment, 2972 blood coagulation, 2294–2296 selective serotonin reuptake inhibitors (SSRIs), 2971 clinical effects of, 2299–2305 sodium channel antagonist treatment, 2969–2970, complications of, 2313–2315 2975 elderly patients, 2316 therapy, 985 epidemiology of , 2284–2287 uranium nephrotoxicity treatment, 2980 first aid, 2305–2306 Vaughan Williams class agents toxicity treatment, follow-up, 2315 2973–2974 hemorrhagins, 2296 xenobiotics, urinary elimination, 2975–2976 hospital treatment, 2307–2309 Sodium bicarbonate use, 1275, 1282 medical classification of, 2294 Sodium bisulfite sensitivity, 2949 multiple functions, 2288 Sodium calcium edetate, 1688 myotoxins, 2293–2294 Sodium channel(s), 476, 480, 481, 490, 495, 500, 501, necrotoxins, 2296 1054, 1056, 1057, 1068, 1069, 1072, 2035, nephrotoxins, 2296 2039, 2089 neurotoxins, 2291–2293 antagonism, 88, 822, 823, 830 non-antivenom therapies, 2313 anesthetic, 2972 pediatric patients, 2316 Brugada syndrome, 2974 pregnant patients, 2316 cardiac, 2971, 2973 psychological issues, 2315 myocardial, 2972 types of, 2280–2284 toxicity treatment, 2969–2970 venom toxicodynamics, 2297–2299 xenobiotic, 2975 metalloproteinases (SVMPs), 2471, 2505, bicarbonate therapy, 2973 2506 blockade, 480, 490, 499, 500, 980, 987, 2947–2948, Snake venom proteases (SVSPs), 2506 2950, 2970, 2971, 2973 Snake . See Snake envenoming treatment, 2973 Snakebite(s), 2328, 2441, 2449 Sodium diethyldithiocarbamate, 1632 in children, 2338 Sodium monofluoroacetate, 1888 envenomation, 2528 biochemistry, 1891 economic evaluation, 2329 clinical presentation, 1897 management, 2333 diagnosis, 1899 in pregnant women, 2338 pathophysiology, 1894 SNAP-25, 2612, 2613 treatment, 1902–1903 SNARE proteins, 2612 Sodium nitrite, 177, 1937–1939, 1942, 1945, 2737, 2739, Sniffing, 1954 2740, 2742, 2743 SNRI. See Serotonin noradrenergic reuptake inhibitors absorption, 2890 (SNRI) adminstration, 2893 Soaking, 1915 properties, 2890 Sodium, 2,3-dimercaptopropane-1-sulfonate (DMPS), Sodium nitroprusside (SNP) 1813, 1814 chemistry and pathophysiology, 843–845 3054 Index

Sodium nitroprusside (SNP) (cont.) Stimulants, 12 clinical findings and toxic doses, 845 Stingrays, 2054–2055 diagnosis, 846 clinical presentation and life-threatening pharmacokinetics, 845 complications, 2055 prevention, 846–847 pharmacology, 2055 special populations, 848–849 treatment, 2055–2056 thiocyanate toxicity, 847–848 Stonefish, 2056, 2059 treatment, 847 Streptokinase, 1342, 1344 Sodium polystyrene sulfonate (SPS), 999 Strictures, 2007, 2008, 2013–2015 Sodium-potassium adenosine triphosphatase Strong ion, 327, 335–339, 344 (Na/K-ATPase) pump, 680 , 4, 1891, 1894–1895, 1897–1900, 1903 Sodium thiosulfate, 177, 2737, 2740, 2742, 2743, 3002, , 425, 427 3003 Subarachnoid hemorrhage, 1531, 1540 Sodium valproate, 1084 α2-agonist, clonidine (see Clonidine) SOFA score, 261 β1-receptors, 853, 858, 859 Solanaceae, 521, 527 β2-receptors, 853, 856, 858, 859 Solubility, inhalant gas toxic effects, 1984 β3-receptors, 853, 859 Solvents, 239, 241, 242 Substance misuse, 147 , 2913, 2918 Substantia nigra, 1917 Somatostatin, 2897, 2899 Succimer, 1653, 1655, 1656, 1658, 1659, 1688, 1689, membrane receptors, 2899 1691, 1693, 1696 Somnolence, 425 administration, 2990 Sonoran coral snake, 2493 adverse effects, 2989 Sotolol, 775 chemical properties, 2988 Sour gas, 1963 contraindication and precautions, 2988 Special populations, 877–878 history, 2987 Speedball, 1244 pharmacokinetics, 2988 Sphingomyelinases-D (SMases D), 2581 Succinylcholine, 2658, 2674 Spider(s), 2551 Sudden sniffing death, 1954 bite Sudden unexplained death in epilepsy (SUDEP) clinical effects, 2556–2559 diagnosis, 1058 diagnosis, 2559–2560 other effects, 1058 first aid, 2559 risk factors, 1058 treatment, 2560 treatment, 1058–1060 Loxosceles (see Loxosceles) SUDEP. See Sudden unexplained death in epilepsy medically important, 2552 (SUDEP) taxonomy, 2552–2555 Suicide, 117, 118, 120, 121, 123, 136, 138, 140, 141, venom, 2555 145–146 Spontaneous bacterial peritonitis, 256 Sulfanegen, 2741 Spore print, 2104, 2122 Sulfane sulfur, 1932, 1933, 1939 Spotted hemlock, 2206 Sulfasalazine, 1222. See also Sulfhemoglobin Spreading factor, 2629 Sulfhemoglobin SPS. See Sodium polystyrene sulfonate (SPS) background and characteristics, 654–655 Spurges, 2165, 2167 clinical presentation, 656–657 Squill, 2189, 2197 diagnosis, 655–656 SSRI. See Selective serotonin reuptake inhibitors (SSRI) formation and etiology, 655 Starfish, 2063–2064 treatment, 657 Statin-associated rhabdomyolysis, 681 Sulfhemoglobinemia, 1303, 1305, 1965 (SE) Sulfone syndrome, 1304, 1305 definition, 448 Sulfonylureas, 1366–1367, 1372 incidence, 448 drugs, 2898, 2900, 2902 intermittent drug dosing, 463 poisoning, 2899, 2902 mortality rate, 449 Sulfur dioxide, 1984 refractorySE, 463, 467 Sulfur mustard, 2645, 2676 Steatosis, 391, 392 alkylating properties, 2686–2688 Sternbach criteria, 543 apoptosis and necrosis, 2689–2690 Steven-Johnson syndrome (SJS), 575, 698–699, 1228 chemistry, 2685–2686 Stibine, 1627, 1655 clinical presentation, 2692–2697 clinical presentation and life-threatening effects, 1627 detector, 2702 treatment, 1627–1628 DNA damage, 2688 Index 3055

inflammation, 2690 (TTX) PARP signaling, 2688–2689 biochemistry and pharmacology, 2088–2089 pathophysiology, 2686 clinical presentation, 2091–2093 poisoning, 2664 diagnosis, 2093 reactive oxygen and nitrogen species, 2690–2691 history, 2085–2088 skin decontamination lotion, 2670 pathophysiology, 2089–2091 toxicokinetics, 2691–2692 treatment, 2094–2096 treatment, 2697–2702 Texas coral snake, 2493 in World War I, 2684 Thalidomide, 163 Sulfuryl fluoride, 1800 Thallium, 615 Sulindac, 1222, 1224 clinical pharmacology, 1734 Superwarfarins, 1888, 1896, 1898 clinical presentation, 1734–1736 Suprofen, 1222 diagnosis, 1736 Suvorexant, 940 discovery, 1733 Sympathomimetic(s), 851, 852, 854, 856, 860, 863, 1015, pathophysiology, 1734 1016, 1020, 1023 in pregnant patients, 1738 agents, 550, 861, 863 treatment, 1736–1738 beverages and drugs, 550 Theobromine, 883, 887 definition, 551 Theophylline, 884, 885, 887, 888, 890, 893, 895, 896, 899 kindling, 558 drug-interactions, 2674 syndrome, 560, 564 Therapeutic hypothermia (TH), 109–111 toxicity, 544, 1503, 1514 Therapeutic plasma exchange, 273 toxidrome, 36–37, 550, 558, 852 Thevetin, 2164 Symphytum, 2165, 2172 Thiabendazole, 1812 Synaptic cleft, 551 Thiamine, 436, 443, 1751 Synaptobrevin, 2612, 2613 adverse effects, 2996 Syndrome of irreversible lithium-effectuated description, 2993 neurotoxicity, 996, 1002 dosing and administration, 2997 Synephrine, 857, 860 during pregnancy and lactation, 2996 Syntaxin, 2612 in infants, 2997 Synthetic , 1611 pharmacodynamics, 2995 Systemic inflammatory response syndrome pharmacokinetics, 2996 (SIRS), 1162 Thiamine deficiency, 2993. See also Beriberi Thiazolidinediones, 1369, 1373 Thimerosal, 1711 T Thioctic acid, 2136, 2140, 2155–2156 , 2913, 2918, 2921 Thiocyanate (SCNÀ), 1932, 1936–1937, 1939, 2740, 2742 Tachyarrhythmias, 212, 480, 483, 487–488, 491, 494, 495, toxicity, 847–848 498–502 Thiodiglycol, 2691, 2700 Taipans, 2285, 2296, 2298, 2407 , 520, 908, 915, 917, 919, 921, 925, 929, 2971 Takosubo cardiomyopathy, 1034 Thiosulfate, 1932, 1937–1940, 1942, 1943 Tarantula, 2558, 2559 administration, 3003 Targeted temperature management (TTM), 109, 111 adverse effects, 3003 Taxine(s), 86, 91, 2164 history, 3001 Taxus, 2164, 2169 pharmacodynamics, 3002 TdP. See Torsade de pointes (TdP) pharmacokinetics, 3002 Teflon, 2646 properties, 3002 Tenecteplase, 1342 in special population, 3002 Tensilon test, 2394 sulfurtransferase, 1932 Teratogenicity, 161, 1088 Thiothixene, 520 Teratology, 161–162 Thiram, 1820–1822 Terbutaline, 550, 862 Thorn apple, 521, 2177 Terrorism, 2640 Three-finger toxins (3FTXs), 2370, 2495 Tetracyclic antidepressants, 1028 Thrombin-like enzymes (TLEs), 2506, 2508 Tetracycline(s), 391, 2582, 2590 Thrombocytopenia, 706, 2470, 2484 , 1610, 1611, 1613 medically significant hazard features, 2474–2475 Tetrahydrofolate, 2821 platelets, 2487 Tetrahydrozoline, 484, 752, 761, 764 Thromboelastography (TEG), 251 Tetramethylene, 1891 Thrombotic microangiopathies (TMAs), 414–415, 419 Tetramine, 1891–1892, 1895, 1898, 1900, 1903 Thrombotic thrombocytopenic purpura, 1351 3056 Index

Thromboxanes, 1221 systemic complications, 457 , 2165 treatment, 461–468 Thymidilate synthetase, 1178 Toxic encephalopathy, 242 Thymidine, 1196 Toxic epidermal necrolysis (TEN), 698–699, 1228 Thymidylate synthetase (TS), 1181 Toxic gases dangerous levels, 1977–1980 Tiagabine, 1066 Toxicity, 1272, 1278, 1280 Ticagrelor, 1351 Toxic load, Baxter, 1976 Ticlopidine, 1352 Toxicodendron, 2165, 2167 Tiger snakes, 2283, 2285, 2296, 2298, 2407 Toxicofera hypothesis, 2281 Tityus, 2244 Toxicokinetics, 1283 Tizanidine, 759 inhalant toxic gases, 1975–1982 Tocainide, 2973 Toxicology, 1620 Tolazamide, 1367 Toxic polyneuropathy, 1836 Tolazoline, 762 Toxidromes, 33, 35 Tolerance, 591, 595 antimuscarinic toxidrome, 34–36 Toll-like receptors (TLRs), 365 cholinergic syndrome, 36 Tolmetin, 1222, 1225 in clinical practice, 33 , 240, 242, 1954, 1955, 1957, 1958 neuroleptic malignant syndrome, 37 Toluidine blue, 2788 opioid toxidrome, 34 Topiramate, 1073–1077 sedative-hypnotic toxidrome, 34 Torsade de pointes (TdP), 53–54, 213, 479, 482, 493, 502, , 37 699, 830, 834, 1030, 1031, 1624, 1626 sympathomimetic toxidrome, 36–37 bouts of, 509 Toxins, 10, 18 cases with drug, 514 study, 4 controversial, 514 fatalities, 12–13 development of, 512 TRALI. See Transfusion related acute lung injury (TRALI) genetic susceptibilities, 513 , 450, 1243 magnesium therapy, 515 Tranexamic acod, 1343 management of toxicant-induced, 515 Transcranial doppler, 282, 283 pulseless polymorphy, 509 Transferrin, 1314, 1316, 2772 several drugs, 512 Transfusion related acute lung injury (TRALI), 710 serve side effects, 510 Transjugular intrahepatic portosystemic shunt (TIPS), Tourniquets, 2380 253, 255 , 2164, 2213 Trapdoor spider, 2553 biochemistry and pharmacology, 2215–2216 Trazodone, 1036 clinical presentation, 2216–2217 Treatments for alcohol withdrawal, 260 complications, 2218–2219 Trelagliptin, 1370 in children, 2221 Triazolopyridines, 1035–1036 diagnosis and detection, 2219 Tributyltin oxide (TBTO), 1824, 1825 pathophysiology, 2217–2218 , 240, 241, 432 treatment, 2220–2221 2,4,5-Trichlorophenoxy acetic acid (2,4,5-T), 1790 Toxicant-induced alterations, 208 Tricholoma equestre, 683 Toxicant-induced convulsions. See Toxicant-induced Tricyclic antidepressant (TCA) poisoning, 498, 500 seizures Trimeresurus, 2351, 2363–2368 Toxicant-induced seizures Trimethadione, 163 acetylcholine agonism, 453 Tripelennamine, 870 adenosine antagonism, 454–455 Triphenyltin, 1824 bedside evaluation, 459 Trivalent antimony, 1620, 1622, 1623, 1627 clinical features, 457–459 Trogia venenata,2118 differential diagnosis, 461 Troglitazone, 1369 electroencephalography, 460–461 Troponins, 1532, 1537, 1538 epidemiology, 449–450 TTX. See Tetrodotoxin (TTX) GABA antagonism, 451–453 Tubulin, 1389–1390 glutamate agonism, 453 Tularemia, 2650 agonism, 453 Tumor necrosis factor (TNF-α), 387, 1992 laboratory evaluation, 460 Tweaking, 556 neurologic sequelae, 457 Type A lactic acidosis, 52 patient history, 459 Type B lactic acidosis, 52 proconvulsant agents, 448 Type IA antiarrhythmics, 501, 502 Index 3057

Type III hypersensitivity, 2498 Venomous snakes. See also Snake envenoming Typhlopidae, 2406 apparatus, 2505 Tyramine, 550, 551 biochemistry, 2271 Tyramine reaction, 1015–1017, 1021–1022 effects, 2514, 2517, 2519, 2521 Tyrosine hydroxylase, 551, 553 glands, 2269, 2503 pathophysiology, 2271 Ventilator-induced lung injury, 368, 369 U Ventricular assist device (VAD), 220 Umbelliferae, 2205, 2225, 2227 Ventricular tachycardia (VT), 479, 490, 492, 559 Unithiol, 1658, 1688, 1692, 1693 Ventriculolumbar perfusion, 1201 administration, 3007 Verapamil, 492, 496, 794, 799, 800 adverse effects, 3007 Veratridine, 831, 2164, 2169 chemical properties, 3005–3006 Veratrum, 2164, 2169, 2189, 2190, 2192, 2194, 2197 contraindications and precautions, 3007 Versutoxin, 2567 history, 3005 Vesicant(s), 2645, 2692 pharmacokinetics, 3006 Vesicular monoamine transporter (VMAT2), 540 Uranium nephrotoxicity, sodium bicarbonate Vietnamese program, 745 treatment, 2980 Vigabatrin, 1066 Urinary alkalinization, 1190 Vildagliptin, 1370 chlorophenoxy compounds excreation, 2978 Vinblastine, 1390, 1394, 1396 methotrexate elimination, 2978 Vinca alkaloids, 1394 phenobarbital elimination, 2977 acute toxicity, 1395–1396 salicylate toxicity, 2977 chronic adverse effects, 1396 urinary elimination enhancement, 2975–2976 pathophysiology, 1395 Urinary retention, 529, 530 pharmacokinetics, 1395 toxic mechanism, 524 special populations, 1397 Urine alkalinization, 1793, 1794 treatment, 1396–1397 Urokinase, 1342 Vincristine, 1394–1397 Uroporphyrinogen, 1819 Vinorelbine, 1396 Urticaria, 575 Violet phosphorus, 1722 Violin spiders, 2552 Vipera V V. ammodytes, 2442, 2448, 2449 Valdecoxib, 1222, 1228 V. aspis, 2442, 2448 Valproic acid (VPA), 163, 390, 391 V. berus, 2442, 2448 biochemistry and clinical pharmacology, Tab, 2449 1084–1086 Viperfav, 2448 clinical presentation and life-threatening Viperidae, 2280, 2284, 2296, 2300, 2321, 2346, complications, 1088–1089 2349–2368, 2441, 2503 diagnosis of, 1089 Vipers, 2284, 2285, 2294, 2313, 2345, 2349, 2350, gastrointestinal decontamination, 1089–1091 2353, 2358, 2360–2368, 2441–2445, toxic effect, pathophysiology of, 1086–1088 2447–2449, 2456 treatment, 1089 Viral hemorrhagic fevers, 2651–2652 Vancomycin Virol A, 2228, 2230 clinical presentation, 1307 Vitamin diagnosis, 1307 A, 430 in neonates, 1308 B1 (see Thiamine) pathophysiology, 1307 B6, 2151, 2156 pharmacology and pharmacokinetics, 1306 B12, 2740, 2819 in pregnant patients, 1308 K, 1326, 1330, 1331, 1333, 1335, 2140, 2157 treatment, 1308 Vitamin K antagonists (VKA), 1327 uses, 1306 acute overdose, 1329–1330 Vapors and gases, 1974–1975 blood products for, 1333 Vasopressin, 309–311, 799 chronic toxicity, 1328–1329 Vasopressors, 102, 106, 705, 781, 798, 894 nonhemorrhagic complications of, 1335–1336 Vasospasm, 1529, 1531, 1544 pharmacologic properties of, 1334 Vaughan Williams Class, 823, 2973, 2974 and warfarin, 1326 Venlafaxine, 1032–1034 Voltage-gated sodium channels, 790, 824, 2271, 2272 Venom, 2505, 2507, 2511, 2515, 2517, 2519, 2522 Volatile solvents, 1952 3058 Index

Volume of distribution (Vd), 195–196 diagnosis, 598 , 1792 differential diagnosis, 598 VPA. See Valproic acid (VPA) toxic effects, 595–598 treatment, 599–601 Wolf spiders, 2553 W Wolfsbane, 2164, 2169 Wandering spider, 2558 Wood alcohol. See Methanol Warfarin, 163, 1325, 1326, 1329, 1330, 1333, 1334 Work-exacerbated asthma (WEA), 224 in pregnant women, 1337 World Health Organization, 1287 R and S stereoisomers of, 1334 World War I, 2684, 2696 skin necrosis, 1335 Wound botulism, 2615 Water hemlock (Cicuta maculata), 683, 2165, 2168, 2169, 2206, 2225, 2227, 2231 poisoning X clinical presentation, 2231–2232 oxidase, 1916 diagnosis, 2232–2233 X-ray, 606, 607 pathophysiology, 2229–2231 Xylazine, 751, 761 treatment, 2233–2234 Water moccasin, 2482 Weeverfish, 2062 Y clinical presentation and life-threatening Yellow oleander, 2164, 2166 complications, 2062–2063 poisoning, 2720, 2721 diagnosis, 2063 Yellow phosphorus, 1722, 1729 pathophysiology, 2062 Yersinia pharmacology, 2062 Y. enterocolitica, 2775 treatment, 2063 Y. pestis, 2649 Welding, 1670 Y. sepsis, 2774, 2775 Well-water methemoglobinemia, 650 Yew, 2164, 2169 Wernicke-, 2994 Yohimbe, 2173 Wernicke’s encephalopathy, 2993 White phosphorus, 1721, 1728 Whole blood clotting test, 2304, 2309, 2330, 2333 Z Whole-bowel irrigation (WBI), 45, 69, 166, 893, 1059, , 2812 1318, 1686, 1692 Zebrafish, 2057 Widow spiders, 2552, 2559 Zinc phosphide description, 2595 toxic dose, 1878 female, 2596 uses, 1876 male, 2596 Zinc protoporphyrin (ZPP), 1683 Wild carrot, 2206 , 130, 144, 442, 913, 915, 921 Wilson’s disease, 388, 394, 1823 , 2812 Withdrawal, 591 Zonisamide, 1066 opioid, 2908, 2910 , 2812 syndromes Zygandenus, 2190