(L)-Ephedrine

CAS RN: 299-42-3

Treatment Overview

0.4.2 ORAL/PARENTERAL EXPOSURE
  • A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    • 1) Simple symptomatic care is all that is required in the vast majority of overdoses. Hydration and benzodiazepines may be used as needed for agitation and mild vital sign abnormalities.
  • B) MANAGEMENT OF SEVERE TOXICITY
    • 1) VITAL SIGNS: Fluid resuscitation should be the first-line treatment for hypotension. Hyperthermia should be treated with benzodiazepines, cooled fluids, and external cooling measures if mild, however, for temperatures over 40 degrees Celsius, intubation and paralysis is recommended.
    • 2) CARDIOVASCULAR: Antihypertensives can be used for severely elevated blood pressure associated with end organ effects such as myocardial ischemia or cerebrovascular ischemia. In the hypertensive tachycardic patient, one should avoid using beta-blockers in isolation due to the possibility of unopposed alpha effects worsening vasospastic ischemia. Nicardipine or labetalol are good antihypertensive choices because they have effects on both heart rate and blood pressure. Treat ventricular dysrhythmias with lidocaine or amiodarone, and cardioversion if hemodynamically unstable.
    • 3) NEUROLOGIC: Large doses of benzodiazepines may be needed to control profound agitation and seizures. If benzodiazepines are ineffective, propofol or phenobarbital can be used to control the symptoms. Management of cerebrovascular hemorrhage should focus on blood pressure control and airway management as appropriate.
    • 4) RENAL: Fluid resuscitation is the key to maintaining urine output. Acidosis can be treated with normal saline (and sedation to control agitation) until euvolemia is achieved, followed by bicarbonate for persistent severe acidosis.
    • 5) MUSCULOSKELETAL: Sedation to control agitation; fluid resuscitation and maintenance of urine output will limit progression of rhabdomyolysis.
  • C) DECONTAMINATION
    • 1) PREHOSPITAL: Generally not recommended due to the possibility for seizures in moderate to severe toxicity.
    • 2) HOSPITAL: Administer activated charcoal to patients with recent significant overdose. Do not administer activated charcoal to patients that have a declining mental status, severe toxicity, or those that are at risk for seizures without first protecting the airway.
  • D) AIRWAY MANAGEMENT
    • 1) Altered mental status, pulmonary edema, or profound agitation with resultant hyperthermia and acidosis are all indications for active airway management.
  • E) ANTIDOTE
    • 1) None
  • F) ENHANCED ELIMINATION
    • 1) There is little data to support hemodialysis for oral sympathomimetics, and symptomatic management is almost always sufficient.
  • G) PATIENT DISPOSITION
    • 1) HOME CRITERIA: Mild restlessness and insomnia can be managed at home if the exposure is inadvertent and medication is withdrawn.
    • 2) OBSERVATION CRITERIA: Patients with mild tachycardia, hypertension, and agitation can be treated with benzodiazepines and observed until symptoms and vital signs normalize.
    • 3) ADMISSION CRITERIA: Patients with moderate to severe toxicity should be admitted until symptoms have improved. Seizures, delirium, cardiac dysrhythmias, cardiac or cerebral ischemia, rhabdomyolysis or persistently abnormal vital signs are all indications for admission to an intensive care unit.
    • 4) CONSULT CRITERIA: A toxicologist or poison center should be consulted for all patients with severe toxicity or patients that require hospital admission.
  • H) PITFALLS
    • 1) Under-dosing of benzodiazepines in patients with significant agitation or seizures can lead to complications such as rhabdomyolysis, metabolic acidosis, or status epilepticus. Failure to maintain urine output with adequate hydration can lead to worsening acidosis and renal failure.
  • I) PHARMACOKINETICS
    • 1) EPHEDRINE: Well absorbed; onset within 1 hour; duration 3 to 5 hours; minimal hepatic metabolism; primarily renally excreted (less renal excretion in alkaline urine); half-life 3 to 6 hours. CLENBUTEROL: Onset within 1 hour; duration 8 to 12 hours; well absorbed; 90% protein bound; slight hepatic metabolism; 30% renal excretion; half-life 25 to 39 hours. PHENYLEPHRINE: Onset within 15 minutes; moderate absorption; volume of distribution more than 40 L; moderate hepatic metabolism; renal elimination; half-life 2 to 3 hours.
  • J) DIFFERENTIAL DIAGNOSIS
    • 1) Illicit drugs of abuse such as cocaine, amphetamines, or PCP should be considered. If symptoms occur following induction of general anesthesia, malignant hyperthermia must be considered. Neuroleptic malignant syndrome can lead to similar vital sign abnormalities, altered mental status, and muscular rigidity, though a history of temporal exposure to antipsychotics should be elicited. Medical disorders such as thyroid storm, hypertensive emergency, and pheochromocytoma can cause a similar clinical picture.
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