Pseudoephedrine

CAS RN: 90-82-4

Treatment Overview

0.4.2 ORAL/PARENTERAL EXPOSURE
  • A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    • 1) Benzodiazepines can be used for agitation, tachycardia, hypertension and psychosis.
  • B) MANAGEMENT OF SEVERE TOXICITY
    • 1) Supportive care, including IV crystalloid, oxygen and mechanical ventilation may be required. Benzodiazepines can be used for severe agitation and psychosis. Treat seizures and dysrhythmias if they occur. With persistent severe hypertension or myocardial ischemia, alpha-adrenergic antagonists, such as phentolamine may be considered. Patients with focal neurologic deficits should receive a head CT to evaluate for intracranial bleeding.
  • C) DECONTAMINATION
    • 1) PREHOSPITAL: Severe toxicity rarely develops after inadvertent pediatric exposures; prehospital decontamination is probably not necessary.
    • 2) HOSPITAL: Activated charcoal should be considered in large ingestions in patients who are alert and able to protect their airway. Gastric lavage is not warranted as toxicity is rarely life-threatening. Consider activated charcoal if the ingestion is 3 or more times the maximum daily dose.
  • D) ANTIDOTE
    • 1) Benzodiazepines should be used to treat agitation or seizures.
  • E) ENHANCED ELIMINATION
    • 1) Enhanced elimination is unlikely to be effective due to the large volume of distribution.
  • F) PATIENT DISPOSITION
    • 1) HOME CRITERIA: Children less than 6-years-old with a history of ingestion of less than 180 mg (or 11 mg/kg) of pseudoephedrine can be managed at home, provided that they are asymptomatic and that adequate follow-up can be done.
    • 2) OBSERVATION CRITERIA: Any patient with symptoms or a deliberate ingestion should be referred to a health care facility for observation. All symptomatic patients should be sent to a health care facility for observation. Children with ingestions of 180 mg or more (or 11 mg/kg or more) should be referred to a healthcare facility.
    • 3) ADMISSION CRITERIA: Patients who remain persistently symptomatic despite supportive management, or require large amounts of benzodiazepines should be admitted for further observation. A patient in status epilepticus, respiratory failure, significant hemorrhage, or altered mental status should be admitted to an intensive care unit.
    • 4) CONSULT CRITERIA: Consult a poison center or a medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is uncertain.
  • G) PHARMACOKINETICS
    • 1) Topical or absorption. Absorption in the GI tract is rapid, with onset of action as quick as 15 to 30 minutes, and peak serum concentrations within 1 to 4 hours. The duration of action is typically 3 to 4 hours; elimination half-life has a large range of 1.9 to 21 hours. Protein binding is 20% with a volume of distribution of 2.1 to 3.3 L/kg. Pseudoephedrine is incompletely metabolized in the liver and mostly excreted in the urine.
  • H) PITFALLS
    • 1) Failure to recognize signs and symptoms of excessive sympathomimetic release, recognize coingestants in a combination preparation, or delay in supportive care. Also, failure to recognize symptoms of complications of adrenergic excess, such as intracranial hemorrhage, or myocardial infarction or dysrhythmias.
  • I) DIFFERENTIAL DIAGNOSIS
    • 1) Other agents that may produce similar symptoms include: ephedrine, phenylephrine, phenylpropanolamine, cocaine, anticholinergic, methamphetamines, methcathinone, hallucinogenics and sympathomimetic xenobiotics.
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