Drug

Clinical features and Diagnosis

Maternal and fetal effects

Management and antidotes

Acetaminophen

Paracetamol

Calpol

Pacimol

Nausea, vomiting, anorexia; right upper quadrant pain. Icterus, right upper quadrant abdominal tenderness; lethargy; evidence of bleeding

Elevated transaminases LDH, amylase, lipase, creatinine, prolonged PTT

Maternal: oliguria, pancreatitis, hypotension, myocardial ischemia, and necrosis. Premature contractions, potential for premature delivery

Diffuse hepatic necrosis

Fetal: decreased fetal movements, poor beat to beat variability, nonreactive NST, bradycardia

Increased risks of spontaneous abortion and stillbirth

Neonatal hyperbilirubinemia

Gastric lavage

Activated charcoal (1 g/kg in water or sorbitol).

Induced emesis

N-acetylcysteine

150 mg/kg in 200 ml of 5 % dextrose over 15 min or 100 mg/kg in 1000 ml 5 % dextrose over 16 h

Oral: methionine (2.5 g every 4 h × 4 doses) N – acetylcysteine(140 mg/kg stat, then half dose every 4 h × 17 doses)

ICU admission if hepatic failure or encephalopathy

Antidepressants

Imipramine

Amitriptyline

Doxepin

Trimipramine

Fluoxetine

Trazodone

Blurred vision, dysarthria, visual hallucinations, delirium, sedation, coma

Tachycardia, dry skin and mucous membranes, blisters, mydriasis, divergent strabismus, decreased bowel sounds, urinary retention, increased muscular tone, hyperreflexia, myoclonic activity, rapid loss of consciousness, seizures, cardiac dysrhythmias, hypotension, pulmonary edema

Sinus tachycardia with prolonged PR, QRS and QT intervals, AV block, and ventricular tachycardia on ECG

3 major toxidromes: anticholinergic crisis, cardiovascular failure, or seizure activity

Cardiac dysrhythmias, seizures, urinary retention, GI hypomotility, aspiration pneumonitis and ARDS

Rhabdomyolysis, brain damage, and multisystem failure

Fetal: abnormal fetal heart rate [12].Rarely congenital malformations like anencephaly, craniosynostosis, and omphalocele [13, 14]

In neonate tachypnea, cyanosis, irritability, urinary retention, paralytic ileus, seizures as withdrawal syndrome

Maintain airway if necessary with mechanical ventilation. Treatment of agitation, seizures, hyperthermia, hypotension, and arrhythmias

Decontamination with activated charcoal, cathartic, and gastric lavage

IV sodium bicarbonate is indicated, if the patient manifests coma, seizures, QRS greater than 0.1 s, ventricular arrhythmias, or hypotension

Phenytoin 100 mg over 3 min if perfusion is compromised. Norepinephrine or phenylephrine for refractory hypotension

Aspirin

None. Nausea, vomiting, abdominal pain, tinnitus, decreased audition, dyspnea

Hyperventilation; altered mental status, flushing, diaphoresis, hyperpyrexia, GI bleeding, petechiae, bruising, hypovolemia, pulmonary edema, seizures; ARDS, coma

ABGs: respiratory alkalosis, compensated metabolic acidosis or metabolic acidosis, increased anion gap, salicylate levels, creatinine, BUN, electrolytes, glucose, CBC, PT and PTT, urinalysis, specific gravity, volume and ferric chloride test. (Add 1 ml of 10 % FeCl₃ to 1 ml of urine change of color from purple to purple brown indicates salicylate presence) Chest x ray: pulmonary edema

Volume depletion, shock, hemorrhage, seizures, prolonged pregnancy, prolonged labor, higher risk of peripartum hemorrhage.

Fetal: constriction of ductus arteriosus, growth restriction

Neonatal: hyperbilirubinemia, clinical evidence of thrombocytopenia

Generous IV fluid replacement (glucose-containing solutions); if hypotension is refractory, may use plasma or blood

Gastric lavage

Forced alkaline diuresis (3 ampules of 40 % sodium bicarbonate) (50 ml/43 MEq of sodium) in 1 l of 5 % dextrose plus 40 mEQ of KCl at 2–3 ml/kg/h; goal: 5–10 ml/min of urine with pH of 7.5

Administer vitamin K 10 mg IV pH of 7.5 or IM

Hemodialysis may be indicated in severe acidosis, hypotension, seizures, pulmonary edema or renal failure

Barbiturates

FDA class: D

Weakness fatigue, sleepiness. slurred speech, ataxia

Sedation, altered mental status, miosis, bradypnea, respiratory depression, ataxia, nystagmus, extraocular muscle palsies, dysarthria, hyperreflexia, incoordination, decreased bowel sounds, hypothermia, hypotension, cardiovascular collapse

CBC, electrolytes, blood glucose, creatinine and BUN, PT, PTT

Extraocular motor palsies, absent corneal reflexes, sluggish pupillary reaction, mydriasis, absent deep tendon reflexes, absent Babinski sign and coma, a flatline EEG has been reported

Respiratory depression atelectasis, pulmonary edema, bronchopneumonia, hypotension, direct myocardial depression, hypothermia, cutaneous bullae, decreased GI motility. Renal failure

Withdrawal syndrome

Fetal: abnormal BPP, decreased beat to beat variability, bradycardia

Fetal compromise

Fetal and neonatal addiction and neonatal withdrawal complications [15, 16]. Hemorrhagic disease of newborn [17]

Stabilization of maternal cardiopulmonary status. Gradual withdrawal to prevent abrupt withdrawal complications

Respiratory support

O₂ supplementation.

Endotracheal intubation and mechanical ventilation.

Adequate volume expansion and diuresis is critical

Dopamine or norepinephrine for severe hypotension

Gastric emptying followed by charcoal and cathartic agents

Forced alkaline diuresis

Hemoperfusion

Hemodialysis

Folate supplementation and vitamin K administration to mother

Benzodiazepines

Lorazepam

Oxazepam

Clonazepam

Diazepam

Chlordiazepoxide

Librium

Restoril

Drowsiness, ataxia, nystagmus, dysarthria, dizziness, weakness and confusion, paradoxical irritability, excitation, or delirium [18]

Lethargy altered mental status, slurred speech, ataxia, brady- or tachycardia, decreased bowel sounds, respiratory depression, hypotension, dyskinesia, acute dystonic reactions. Respiratory and/or circulatory depression. Coma

CBC, serum electrolytes, blood glucose, toxicology screen

Respiratory depression, hypotension and anoxic encephalopathy

Withdrawal syndrome (anxiety, insomnia, dysphoria, nausea, palpitations, fatigue, confusion, delirium, muscle twitching, seizures, psychosis)

Fetus: decreased beat to beat variability, bradycardia, abnormal biophysical profile

Neonatal hypotonia, impaired temperature regulation, lethargy, and apnea needing resuscitation measures [19]

Respiratory assistance

Crystalloid infusion

Dopamine and norepinephrine infusion for refractory hypotension

Gastric emptying followed by activated charcoal and cathartics repeated every 4 h (the sorbitol added only every 12 h). Induced emesis not recommended

Flumazenil 0.2 mg IV over 30 s dose can be repeated at 1 min interval up to 3–5 mg

Investigate chronic use/abuse of benzodiazepines. Consider drug counselor, psychiatry, and social worker evaluations

Carbon monoxide:

Is a by-product of cigarette smoking automobile exhaust, open fires, kerosene stoves, and heating systems in improperly ventilated areas

Headache, shortness of breath, nausea, dizziness, dim vision, chest pain, weakness

Vasodilation, disturbed judgement, collapse, coma, convulsions, Cheyne-Stokes respiration

ECG changes: sinus tachycardia, ST depression, atrial fibrillation, prolonged PR and QT intervals, AV or bundle branch block. Metabolic acidosis and %COHb on ABG

Myocardial ischemia, infarction, rhabdomyolysis, renal failure, pulmonary edema, blindness, and hearing loss

Delayed CNS toxicity (perivascular infarction, demyelination of basal ganglia) in comatose or acidotic patients on arrival [20–22]

Fetal: decreased variability, decelerations [23]

Fetal brain damage, developmental delays. Premature birth, neurological deficits, and anomalies (CNS, skeletal, clefts) [21, 23–25]

Increased risk of fetal demise with chronic exposure. Fetal death or permanent neurological damage

100 % O₂ for prolonged duration. Hyperbaric oxygen is indicated if COHb is >15 %, presence of signs of non reassuring fetal condition, any neurologic signs in the mother (altered mental status, coma, focal neurologic deficits, seizures) or history of loss of consciousness

Ethanol: most frequently ingested toxin in the world [26]

Acute alcohol overdosage: euphoria, incoordination, impaired judgement, and altered mental status. Social inhibitions are loosened

Aggressive or boisterous behavior is commonly seen

Flushed facies, diaphoresis, tachycardia, hypotension, hypothermia, ataxia, abnormal reflexes, nystagmus, altered mental status, mydriasis, impaired judgement and reflexes, and a characteristic breath smell

CBC, blood glucose, electrolytes, BUN, creatinine, transaminase, lipase, PT, magnesium, calcium, ketones, acetone, ammonia and alcohol level

ABG, drug screen, chest X – ray

Respiratory depression, pulmonary aspiration, hypoglycemia, and coma. GI bleeding, atrial arrhythmias, or rhabdomyolysis are encountered

Organic problems include pancreatitis, hepatitis, cirrhosis, hepatic encephalopathy, portal hypertension, GI Bleeding, anemia, thiamine deficiency, alcoholic ketoacidosis, systemic hypertension, decreased resistance to infection, hypomagnesemia, hypokalemia, and hypophosphotemia. Intracerebral hemorrhage [27], nonischemic cardiomyopathy, malnutrition, isolation, depression, or suicide attempts [28]

Fetal: Nonreactive NST [29]

Poor BPP

Fetal alcohol syndrome [30]

Protection of the airway. Treatment of coma and seizures, hypoxemia, hypoglycemia, and opioid intoxication

Supplemental oxygen, intravenous dextrose (0.5-1 mg/kg); thiamine (100 mg) should be given routinely. Naloxone should be administered

Decontamination, gastric lavage.

Hemodialysis considered in respiratory failure or coma

Iron:

Ferrous gluconate

Indigestion, abdominal pain, nausea, vomiting, hematemesis, diarrhea, hematochezia

Bloody stools, tachycardia, fever, lethargy, shock and acidosis in severe cases. Rarely icterus, hypoglycemic symptoms coagulopathy

Leukocytosis, anemia or hemoconcentration

Serum electrolytes (anion gap metabolic acidosis)

Blood glucose, LFT, KFT, coagulation profile,

ABG

Direct corrosive insult to the intestinal mucosa; systemic organ failure, GI hemorrhage, cardiovascular collapse, severe metabolic acidosis, intestinal scarring [31, 32]

Shock, hemorrhage, hepatic failure, pulmonary edema/hemorrhage, DIC

GI scarring, small intestine infraction, hepatic necrosis achlorhydria

Fetal: uterine contractions may be associated to maternal hypovolemia and shock

Oxygen supplementation, airway assessment, IV access for vigorous hydration

Orogastic intubation

Gastric lavage

Ipecac emesis

Whole bowel irrigation. Endoscopy or surgery to remove iron tablets adherent to the gastric mucosa [33]

Correction of hypovolemia with crystalloids before initiation of chelation with deferoxamine. (15 mg/kg/h as in intravenous infusion for up to 24 h.) [34]

Hemodialysis for toxic renal failure

Organophosphates/carbamates

Muscarinic manifestations

D = Diarrhea

U = Urination

M = Miosis

B = Bronchospasm, bradycardia

E = Emesis

L = Lacrimation

S = Salivation

Nicotinic manifestations

M = Muscle weakness

A = Adrenal medulla activity increases

T = Tachycardia

C = Cramps in muscle

H = Hypertension [39]

CNS effects

Irritability

Apprehension

Restlessness

Convulsions

Coma

Depression of respiratory and circulatory centers

Leukocytosis, hypokalemia, hyperglycemia, elevated amylase, reduced erythrocyte cholinesterase, tachycardia/bradycardia, AV block, QT prolongation, asystole on ECG

Bronchorrhea, bronchospasm and respiratory failure, aspiration pneumonia, ventricular arrhythmias, pancreatitis, ARDS