Continuous cardiac monitoring and a 12-lead electrocardiogram are cardinal management features. Ventricular dysrhythmias should be managed with type Ib antidysrhythmic agents (e.g., lidocaine), avoiding class Ia agents (e.g., quinidine, disopyramide, and procainamide), which may worsen cardiac toxicity. Wide-complex tachycardias should be treated with intravenous sodium bicarbonate due to the potential quinidine-like effect of certain agents, especially thioridazine. 13,14,15 and 16,» Torsade de pointes, if it occurs, should be managed with cardiac pacing, isoproterenol, or magnesium infusion. «I7,2,2
Gastrointestinal decontamination should be instituted as soon as the patient is stabilized; in most cases, orally administered activated charcoal (1 g/kg) will suffice. Gastric lavage should be considered in patients who present to the emergency department very soon after a life-threatening ingestion. 21 Multidose activated charcoal is theoretically indicated due to partial metabolism by enterohepatic circulation. High protein binding and a large volume of distribution, general characteristics of this drug class, render hemodialysis and forced diuresis ineffective management techniques.3,4,!1,!5
In addition to stabilization of the airway and cardiovascular status, and attention to gastrointestinal decontamination, other therapy may be given as needed. Intravenous benzodiazepines, phenobarbital, and phenytoin should be considered for control of seizures. 1 14 Electrolyte disturbances have been reported sporadically; serum chemistries should be obtained in serious ingestions, especially to exclude other causes of altered mental status and dysrhythmia, which may occur. Specific drug levels are not readily available and are not helpful in the acute management of these patients. 24 Acute extrapyramidal disorders should be treated as described above.
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