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CONTENTS Rapid Reference Overview Causes of serotonin syndrome Clinical presentation Differential diagnosis Lab evaluation Diagnostic criteria Treatment Cyproheptadine? Dexmedetomidine Overall treatment strategy Podcast Questions & discussion Pitfalls diagnosis Hunter diagnostic criteria are shown below. ⚠️ Criteria are not 100% specific, so you also need to pay attention to the The objective of this review is to provide a repository of standard and emerging treatment modalities for loperamide, gabapentin and modafinil for the emergency medicine team. Expert opinion: Loperamide, gabapentin, and modafinil are becoming drugs of abuse, and as such, should be on the radar of healthcare providers. Recognizing their unique Between 1999-2017, ~400,000 people died from opioid overdose. That’s over half the number of Americans who have ever died from HIV. It is increasingly clear that opioid use disorder (OUD) is a chronic psychological disease involving persistent changes in neurobiology. Opioids are often coingested with acetaminophen when patients overdose on combination pills (e.g., Percocet or Vicodin). Opioids may be coingested with a sympathomimetic such as cocaine or amphetamine (a combination known as a “speedball”). Toxicity from gabapentin and pregabalin overdose is commonly encountered. Treatment is supportive, and the use of extracorporeal treatments (ECTRs) is controversial. The EXTRIP workgroup conducted systematic reviews of the literature and summarized findings following published methods. Gabapentinoids are commonly ingested in self-harm attempts and often misused for their sedative and euphoric properties. These medications can cause lethargy or agitation in overdose, increase risk of death combined with opioids, and manifest a withdrawal syndrome. Dexmedetomidine is an intravenous alpha-2 agonist used as a sedative infusion. It has some uniquely useful properties, particularly that it doesn’t suppress respiration (allowing it to be safely used in non-intubated patients). The main drawbacks of dexmedetomidine are logistic: it is expensive and can be administered only as an IV infusion within an ED or ICU. Oral clonidine offers some I’ve had excellent success with 2400-3200mg of gabapentin PO or via OG in the first 24 hours with a fixed taper of 400mg/day. Gabapentin has more RCTs than phenobarb, and even beats phenobarb in an RCT. I wish gabapentin came in IV form. CONTENTS Anticholinergic agents Epidemiology Clinical presentation Differential diagnosis Evaluation Management Physostigmine Treatment of agitation Other management issues Management of combined anticholinergic & sodium channel blocker toxicity Podcast Questions & discussion Pitfalls There are hundreds of substances with anticholinergic activity. Below are some of the most common and notable Isoniazid overdose or Gyromitra mushroom poisoning should be treated with high-dose IV pyridoxine (e.g., 5 grams). The newer anticonvulsant agents include: Gabapentin, Lamotrigine, Levetiracetam, Oxcarbazepine, Pregabalin, Tiagabine, Topiramate and Vigabatrin. These are generally less toxic in overdose causing sedation and non-specific neurological symptoms and patients do well with supportive care. Signs and Symptoms of Gabapentin Overdose. A gabapentin overdose can be dangerous or even deadly. Some factors can increase the risk of a fatal overdose, such as taking several substances at once. Gabapentin overdose symptoms can include: Drowsiness; Movement difficulties; Dizziness; Nausea or vomiting; Rapid heartbeat; Low blood pressure CONTENTS spectrum of medications available Pure analgesics Acetaminophen Ketamine, pain-dose ️ Methocarbamol (Lidocaine) (NSAIDs) Analgosedatives (analgesia > sedation) Opioids Opioid PCA Gabapentinoids Tizanidine Sedalgesics (sedation > analgesia) Dexmedetomidine Clonidine Ketamine, high-dose infusion ️ Pure sedatives Propofol ️ Guanfacine Phenobarbital ️ Melatonin (Benzodiazepines Gabapentin and pregabalin are structurally similar to gamma aminobutyric acid (GABA) but have little to no activity on the GABAergic system. Instead, they inhibit the α 2-δ subunit of P/Q-type voltage-gated calcium channels, thereby reducing presynaptic calcium influx and thus subsequent release and activity of excitatory neurotransmitters such as glutamate and substance P. 9 Gabapentin was Common symptoms of gabapentin overdose are drowsiness, fast heartbeat, dizziness, low blood pressure, nausea, vomiting, and impaired coordination. In severe cases, lethargy, coma, and death may occur. relationship of renal failure with baclofen toxicity. Renal dysfunction is the major risk factor for inadvertent baclofen intoxication. Kidney failure causes the half-life of baclofen to extend in an unpredictable fashion, so baclofen should be avoided in patients with GFR <30 ml/min. Even relatively low doses may precipitate encephalopathy among patients with renal insufficiency (graphical Gabapentin and pregabalin are commonly prescribed medications for the treatment of seizure disorders, neuropathic pain (eg, postherpetic neuralgia), fibromyalgia, anxiety, post-traumatic stress disorder, and restless leg syndrome. Gabapentinoids are commonly ingested in self-harm attempts and often misused for their sedative and euphoric For years our patient tolerated 4,800mg daily, became critically ill after an overdose of approximately 24,000 mg, and finally was briefly encephalopathic after 7,500mg. Although further prescribing is banned by marking her EMR as “allergic”, we hope to alert others of the potential for serious GBP-induced toxicity. Toxicity from gabapentin and pregabalin overdose is commonly encountered. Treatment is supportive, and the use of extracorporeal treatments (ECTRs) is controversial. The EXTRIP workgroup conducted systematic reviews of the literature and summarized findings following published methods. CONTENTS Pathophysiology Epidemiology Clinical features Laboratory abnormalities Differential diagnosis & evaluation Diagnostic criteria Management Supportive care Bromocriptine Dantrolene Electroconvulsive therapy Podcast Questions & discussion Pitfalls As its name implies, NMS is often related to neuroleptic agents (i.e., antipsychotic medications) and is manifest by mental status changes
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