Toxicology
A 38-year-old woman is admitted to the ICU after a
suspected overdose of risperidone. She was initially
hypotensive, but she was stabilized after the admin-
istration of two 500-mL boluses of lactated Ringer
solution. Her BP is now 118/77 mm Hg, HR 75
beats/minute, and RR 16 breaths/minute. A 12-lead
electrocardiogram (ECG) shows QT prolongation
(corrected QT interval [QTc] = 480 milliseconds),
and her chemistry panel is significant for a bicar-
bonate of 24 mEq/L, potassium of 3.1 mEq/L, and
magnesium of 1.8 mg/dL. Which intervention is
most appropriate at this time?
doses.
A 48-year-old man is admitted to the medical floor
for community-acquired pneumonia. His medical
history is significant for hypertension, hyperlipid-
emia, and chronic obstructive pulmonary disease
(COPD), and he reports occasional alcohol use but
no history of alcohol withdrawal. He is initiated
on levofloxacin 750 mg intravenously daily and
nebulizer treatments with albuterol and ipratropium.
Twenty-four hours after admission, he is increas-
ingly more confused and has nausea and vomiting.
His vital signs are stable: BP 115/68 mm Hg, HR
122 beats/minute, RR 21 breaths/minute, and tem-
perature 99.7°F (37.6°C). The team is concerned
about possible alcohol withdrawal and asks for rec-
ommendations for initial therapy. Which is the most
appropriate treatment for this patient?
hours as needed according to the patient’s
Clinical Institute Withdrawal Assessment for
Alcohol Scale (CIWA) score.
needed according to the patient’s CIWA score.
A 57-year-old male patient on the medical floor is
incorrectly administered a dose of methadone 40
mg by mouth that was written for the patient in the
adjoining bed. Two hours later, the nurse finds him
unresponsive with the following vital signs: BP
105/67 mm Hg, HR 61 beats/minute, RR 8 breaths/
minute, and temperature 98.7°F (37.1°C). The nurse
calls for the rapid response team, and, as the team
pharmacist, you are asked for a recommendation.
Which treatment is most appropriate at this time?
Questions 7 and 8 pertain to the following case.
A 56-year-old female patient is admitted to the ED after
an intentional overdose of 25 amlodipine 10-mg tablets.
She is given activated charcoal 50 g, 2 L of 0.9% sodium
chloride, and 3 g of calcium gluconate. Her current vital
signs are as follows: BP 90/50 mm Hg, HR 107 beats/
minute, RR 17 breaths/minute, and temperature 98.7°F
(37.1°C). Serum chemistries are as follows: Na 141
mEq/L, K 2.5 mEq/L, Cl 101 mEq/L, HCO3 24 mEq/L,
blood urea nitrogen (BUN) 19 mg/dL, serum creatinine
(SCr) 0.9 mg/dL, and glucose 215 mg/dL. The ED phy-
sician wants to initiate hyperinsulinemic euglycemic
therapy (HIET).
Which is most appropriate to initiate or do first with
respect to HIET?
intravenously.
to 30 minutes.
nously every hour for four doses.
The patient is not responding to HIET initiation.
Her current infusion rate is 1 unit/kg/hour. Her BP
remains low at 70/40 mm Hg, and her HR is now
58 beats/minute. Her repeat glucose is 186 mg/dL.
Which is most appropriate to initiate at this time?
sion rate and initiate norepinephrine.
therapy.