Pediatric emergency medicine trisk 4568 4568
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mg of atropine). In this setting, atropine is typically delivered IM via an
autoinjector. However, in severe cases, both atropine and pralidoxime should be
administered IV once the patient has been decontaminated and delivered to the
ED. Animal data suggest that hypoxia should be corrected, if possible, prior to IV
atropine use, to prevent arrhythmias; otherwise, IM use might be safer initially.
Pralidoxime cleaves OP away from the cholinesterase and regenerates the
intact enzyme if aging has not yet occurred. The beneficial effect is observed
predominantly as improved muscle strength. Pralidoxime is dosed initially at 25
mg/kg, with maximum doses of 1 g IV or 2 g IM ( Table 132.5 ). Pediatric
experience with OP pesticide poisoning suggests that the continuous infusion of
pralidoxime may be optimal. However, the IM route is acceptable if IV access is
not readily available. In practice, atropine and pralidoxime are often given
concurrently because of the availability of autoinjector kits containing separate
vials of 2 mg atropine and 600 mg 2-PAM. Recently, combination autoinjectors
containing 2.1 mg atropine and 600 mg pralidoxime in a single vial have also
become available (Duodote). Additionally, pediatric-sized autoinjectors of pure
atropine are now available in 0.25 mg, 0.5 mg, and 1 mg doses. Of note, during
the Gulf War, 240 Israeli children were evaluated for accidental autoinjection of
atropine. None had been exposed to nerve agents and systemic anticholinergic
effects occurred in many, but seizures, severe dysrhythmias, and deaths were not
observed.
2-PAM autoinjectors that deliver a proper dose for children are not currently
available. However, in dire circumstances, the adult autoinjectors with 600 mg
pralidoxime might find utility in children older than ages 2 to 3 years or who
weigh more than 13 kg (suggested guidelines and weight-based dosing for
children of all sizes are detailed in Table 132.5 ). For infants, one might consider
using the pediatric-sized atropine autoinjectors, along with conventionally
administered IM 2-PAM. This can be effected by the discharge of one or several
autoinjectors’ contents into an emptied 10 cc sterile saline vial ( Fig. 132.7 ). The
300 mg/mL solution may then be withdrawn through a filter needle into one or
several syringes suitable for small-volume IM injections.
Finally, the routine administration of anticonvulsant doses of benzodiazepines
is recommended in significant cases, even without observed convulsive activity.
Diazepam is available in autoinjectors for IM administration, but midazolam
absorption from muscle is more rapid than for diazepam.
Because the latent periods of fourth-generation agents (FGAs) can be up to two
days or longer and because it may be difficult to treat FGA-poisoned patients if
one simply waits for signs and symptoms to arise, the approach to the
