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Toxic Ingestion — EKG — Clinical Pathway: Emergency Department, ICU and Inpatient

Toxic Ingestion Clinical Pathway — Emergency Department, ICU and Inpatient

EKG

General Recommendations

  • Not required for every pediatric poisoning.
  • An EKG is recommended in the following cases:
    • Any symptomatic poisoning
    • Known or suspected exposure to drugs with myocardial effects
  • Consider EKG in the following cases:
    • Known or presumed polysubstance exposure
    • Presumed exposure to an unknown substance
    • Clinical concerns are present

EKG Interpretation and Cardiotoxic Substances

  • There are numerous cardiotoxic substances and medications.
  • A non-inclusive list of EKG changes with exemplar toxicants is provided below.

Note

A non-inclusive list of EKG changes with associated substances is provided below.

Sinus Bradycardia
  • Alpha 2-agonists
    • Clonidine
  • Beta-blockers
  • Calcium channel blockers (CCBs)
  • Class IA, IC antiarrhythmics
  • Digoxin
  • Lithium
  • Opioids
  • Organophosphates
Sinus Tachycardia
  • Amphetamines
  • Anticholinergics
  • Antihistamines
  • Beta-agonists
  • Caffeine, theophylline
  • Carbon monoxide
  • Cocaine
  • Nicotine
  • SSRIs/SNRIs
  • Tricyclic antidepressants
Prolonged PR
Can progress to complete heart block
  • Beta-blockers
  • Calcium channel blockers
  • Digoxin
Prolonged QTc
Can progress to Torsades de Pointes
  • Antihistamines
  • Antipsychotics
    • Haloperidol
    • Olanzapine
    • Quetiapine
  • Class IA, 1C, III antiarrhythmics
  • Macrolides
  • Quinolones
  • Antidepressants
    • Citalopram
    • Escitalopram
    • TCAs
Prolonged QRS
Can progress to wide complex ventricular tachycardia
  • Bupropion
  • Carbamazepine
  • Class IA and IC antiarrhythmics
  • Diphenhydramine
  • Lamotrigine
  • Phenothiazines
  • Tricyclic antidepressants
ST Elevation or Depression
  • Carbon monoxide
  • Cocaine
  • Digoxin
    • Primarily ST depression
  • Any overdose that impairs myocardial perfusion
    • Severe hypoxemia or hypotension
AV Block
  • Alpha-agonists
  • Beta-blockers
  • Calcium channel blockers
  • Class IA, IC antiarrhythmics
  • Digoxin
PVCs
Can progress to wide complex ventricular tachycardia
  • Digoxin
Tall, wide R wave, S in I and aVL
  • Class IA, IC antiarrhythmics
  • Tricyclic antidepressants

 

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