Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Feb 2014
ReviewPediatric toxicology: specialized approach to the poisoned child.
The poisoned child presents unique considerations in circumstances of exposure, clinical effects, diagnostic approach, and therapeutic interventions. The emergency provider must be aware of the pathophysiologic vulnerabilities of infants and children and substances that are especially toxic. ⋯ Considerations in treatment include the need for attentive supportive care, pediatric implications for antidotal therapy, and extracorporeal removal methods such as hemodialysis in children. In this article, each of these issues and emerging poison hazards are discussed.
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Central nervous system toxicity caused by xenobiotic exposure is a common reason for presentation to the emergency department. Sources of exposure may be medicinal, recreational, environmental, or occupational; the means of exposure may be intentional or unintended. Toxicity may manifest as altered thought content resulting in psychosis or confusion; may affect arousal, resulting in lethargy, stupor, or coma; or may affect both elements of consciousness. Seizures may also occur.
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The effects of chemotherapy in multiple organ systems may be challenging to discern from the sequelae of malignancy and systemic illnesses with concomitant immunocompromise. Chemotherapeutic agents typically affect multiple organ systems. ⋯ Intrathecal medication errors and specific antidotes are discussed in pertinent management sections. Emergency department management should focus on rapid patient assessment, immediate intervention following intrathecal medication errors, exclusion of infection, and excellent supportive care.
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Acid-base disorders may complicate the presentation of patients with poisoning. This article summarizes an approach to acid-base disorders from a toxicologic perspective. It aims to assist the reader in identifying underlying acid-base processes, generating a differential diagnosis for each, and approaching that differential diagnosis in a systematic fashion. Understanding these processes will help to guide management and interventional strategies.
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Although warfarin and heparin have been mainstays of anticoagulation for almost 50 years, the recent introduction of multiple oral anticoagulants has led some practitioners to shift away from warfarin as the anticoagulant of choice for various diseases. Major advances have been made in targeting downstream clotting factors in the coagulation cascade, resulting in two major new classes of drugs: direct thrombin inhibitors and factor Xa inhibitors. Developed partially with the patient in mind, these drugs are taken orally and, because of their target specificity, have eliminated the need for routine blood monitoring, making them attractive to patients currently on warfarin.