Atypical antipsychotic medication poisoning: An evidence-based consensus guideline for out-of-hospital management

Abstract

American Association of Poison Control Centers, Washington, District of Columbia, USAThe objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and out-of-hospital management of patients with suspected acute ingestions of atypical antipsychotic medications by 1) describing the process by which an ingestion of an atypical antipsychotic medication might be evaluated, 2) identifying the key decision elements in managing cases of atypical antipsychotic medication ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of atypical antipsychotic medications alone. Co-ingestion of additional substances could require different referral and management recommendations depending on the combined toxicities of the substances. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions might be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. The grade of recommendation is in parentheses. 1) Patients with stated or suspected self-harm or the recipient of a potentially malicious administration of an atypical antipsychotic medication should be referred to an emergency department immediately. This activity should be guided by local poison center procedures. In general, this should occur regardless of the dose reported (Grade D). 2) Patients without evidence of self-harm should have further evaluation, including determination of the precise dose ingested, presence of signs or symptoms of toxicity, history of other medical conditions, and the presence of co-ingestants (Grade C). 3) Asymptomatic patients without evidence of attempted self-harm are unlikely to develop symptoms if the interval between the ingestion and the call is greater than 6 hours. These patients do not need referral and should receive follow-up based on local poison center protocols (Grade C). 4) All patients less than 12 years of age who are naïve to atypical antipsychotic medications and are experiencing no more than mild drowsiness (lightly sedated and can be aroused with speaking voice or light touch) can be observed at home unless they have ingested more than four times the initial adult dose for the implicated antipsychotic medication or a dose that is equal to or more than the lowest reported acute dose that resulted in at least moderate toxicity, whichever dose is smaller (i.e., aripiprazole 15 mg, clozapine 50 mg, olanzapine 10 mg, quetiapine 100 mg, risperidone 1 mg, ziprasidone 80 mg) (Grade D). 5) All patients 12 years of age or older who are naïve to atypical antipsychotic medications and are experiencing no more than mild drowsiness can be observed at home unless they have ingested more than five times th...

Pediatric Ziprasidone Overdose

“…4 In pediatric ziprasidone overdose, QTc prolongation and hypotension have also been illustrated, but seizures have not been reported. 9 An interesting aspect of this case is the development of pinpoint pupils unresponsive to naloxone. This phenomenon has been reported before with overdose of olanzapine, 10 a similar atypical antipsychotic.…”

webPOISONCONTROL: can poison control be automated?

“…To reduce the tremendous variability in triage practices [15], 17 US national triage guidelines were published from 2003 to 2008, but address only 107 ingredients [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34]. Most substances are not covered by national guidelines, and most poison centers have only a limited set of additional site-specific guidelines; thus, there is a high degree of triage variability both between and within centers and considerable time spent reassessing toxicity each time an exposure occurs.…”

Compliance with Atypical Antipsychotic Triage Guidelines by Texas Poison Centers

“…However, all poison centers do not have management guidelines for atypical antipsychotic ingestions. In December 2007, a group associated with the AAPCC drafted detailed management guidelines for atypical antipsychotic ingestions [8]. This investigation attempted to evaluate the utility of these guidelines by identifying what proportion of acute atypical antipsychotic ingestions reported to Texas poison centers during 2000-2007 were managed according to a simplified triage algorithm based on the recommended guidelines.…”

“…This includes knowledge of the circumstances of the ingestion, whether the home situation is of concern, the symptoms present when the poison center was first contacted, time since the ingestion, whether the ingestion was acute or chronic, patient age, and dose ingested [8]. All of this information was not necessarily recorded in the TPCN database.…”

“…A group associated with the American Association of Poison Control Centers (AAPCC) published detailed management guidelines for atypical antipsychotic ingestions in December 2007 [8]. However, the utility of these guidelines has not been evaluated.…”