Methylphenidate poisoning: An evidence-based consensus guideline for out-of-hospital management*
Methylphenidate poisoning: An evidence-based consensus guideline for out-of-hospital management*
复制标题
哌醋甲酯中毒：基于证据的院外管理共识指南*
作者：
E. Scharman;A. Erdman;D. J. Cobaugh;Alan D. Woolf;Lisa L. Booze;G. Christianson;W. Troutman;E. Scharman
一项对2004年美国毒物中心数据的审查显示，超过8000人摄入了哌醋甲酯。一项确定急诊科转诊和院前护理条件的指南可能会潜在地优化患者的结局，避免不必要的急诊科就诊，降低医疗成本，并减少对患者和照顾者生活的干扰。以证据为基础的专家协商一致过程被用来制定该指南。相关文章由一位训练有素的内科研究员摘录。该准则的初稿是由主要作者编写的。整个小组讨论并完善了指南，然后分发给二级评审员征求意见。然后，专家小组根据二次审查意见进行了修改。本指南的目的是帮助中毒中心人员对疑似摄入了哌醋甲酯的患者进行适当的院外分诊和初步院外管理，方法是：1)描述中毒信息专家评估暴露于哌醋酸甲酯的过程；2)确定管理哌醋甲酯摄入病例的关键决策要素；3)提供反映当前知识状况的清晰和实用的建议；4)确定研究需求。这篇综述基于对当前科学和临床信息的评估，重点讨论了超过一种治疗性剂量的哌醋酸甲酯的摄取和过量的影响。专家共识小组认识到，考虑到涉及的所有情况，具体的患者护理决定可能与本指南不一致，是患者和提供护理的卫生专业人员的特权。本指南不能替代临床判断。建议按可能的临床应用的时间顺序排列。推荐等级在括号中。1)所有有自杀意图、故意虐待或怀疑有恶意(例如虐待儿童或疏忽照顾)的病人应转介至急诊科(D级)。2)对于没有自我伤害、虐待或恶意意图的患者，毒物中心的工作人员应该获得额外的信息，包括摄入的时间、准确的摄入剂量和是否存在共摄入物(D级)。3)长期服用单胺氧化酶抑制剂和摄入任何剂量的哌醋甲酯的患者需要转诊到急诊科(D级)。4)除轻度刺激或激动外，患者的任何行为改变都应转诊至急诊科。需要转诊的中到重度症状包括中到重度躁动、幻觉、异常肌肉运动、头痛、胸痛、意识丧失或抽搐(D级)。5)对于转诊到急诊科的病人，应根据病人的情况和病人到达急诊科(D级)的时间长短等几个因素来考虑使用救护车进行运送。6)如果患者没有任何症状，并且从摄入到呼叫中毒中心的时间超过3个小时，则不建议转诊到急诊科(D级)。7)急性或急性-慢性摄入低于中毒剂量(参见建议8、9和10)或慢性暴露于哌醋甲酯且无症状或轻微症状的患者，可以在家中观察到，并指示如果症状发展或恶化，可致电中毒中心。对于慢性急性摄入，应指示呼叫者在接下来的24小时内不要给患者服用哌醋甲酯。中毒中心应考虑在摄入后约3小时(D级)进行随访。8)患者摄入速释制剂(或已咀嚼的等量改良释放制剂)的剂量超过2毫克/公斤或60毫克(以较少者为准)，应转介至急诊科(C级)。9)如果一个贴片已被吞下，则认为该贴片的全部内容物(而不仅仅是贴片的标签剂量)已被摄入。摄入量超过2毫克/公斤或60毫克的患者，以较少者为准，应转诊至急诊科。如果知道贴片只被短暂咀嚼过，并且贴片保持完好，则不太可能出现重大毒性，不需要急诊科转诊(D级)。10)患者摄入完整的改良释放制剂超过4毫克/公斤或120毫克，以较少者为准，应转介至急诊科(D级)。11)对于口腔暴露，不要引起呕吐(D级)。12)院前给药，如果有的话，只应由卫生专业人员进行，并且只有在没有禁忌症的情况下才能进行。不要为了管理活化炭(D级)而耽误运输。13)如果出现激动、肌张力障碍或抽搐，且经EMS医疗指示书面治疗方案或政策或直接医疗监督(C级)授权，EMS人员可使用苯二氮卓类药物。14)如果存在呼吸骤停、心律失常或心脏骤停，并且如果得到EMS的授权，则应由EMS人员实施标准的高级心脏生命支持(ACLS)措施，并通过书面治疗方案或政策或直接医疗监督(C级)表示的医疗指示。
A review of US poison center data for 2004 showed over 8,000 ingestions of methylphenidate. A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce health care costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial out-of-hospital management of patients with suspected ingestions of methylphenidate by 1) describing the process by which a specialist in poison information should evaluate an exposure to methylphenidate, 2) identifying the key decision elements in managing cases of methylphenidate ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This review focuses on the ingestion of more than a single therapeutic dose of methylphenidate and the effects of an overdose and is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may 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. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) All patients with suicidal intent, intentional abuse, or in cases in which a malicious intent is suspected (e.g., child abuse or neglect) should be referred to an emergency department (Grade D). 2) In patients without evidence of self-harm, abuse, or malicious intent, poison center personnel should elicit additional information including the time of the ingestion, the precise dose ingested, and the presence of co-ingestants (Grade D). 3) Patients who are chronically taking a monoamine oxidase inhibitor and who have ingested any amount of methylphenidate require referral to an emergency department (Grade D). 4) Patients experiencing any changes in behavior other than mild stimulation or agitation should be referred to an emergency department. Examples of moderate to severe symptoms that warrant referral include moderate-to-severe agitation, hallucinations, abnormal muscle movements, headache, chest pain, loss of consciousness, or convulsions (Grade D). 5) For patients referred to an emergency department, transportation via ambulance should be considered based on several factors including the condition of the patient and the length of time it will take for the patient to arrive at the emergency department (Grade D). 6) If the patient has no symptoms, and more than 3 hours have elapsed between the time of ingestion and the call to the poison center, referral to an emergency department is not recommended (Grade D). 7) Patients with acute or acute-on-chronic ingestions of less than a toxic dose (see recommendations 8, 9, and 10) or chronic exposures to methylphenidate with no or mild symptoms can be observed at home with instructions to call the poison center back if symptoms develop or worsen. For acute-on-chronic ingestions, the caller should be instructed not to administer methylphenidate to the patient for the next 24 hours. The poison center should consider making a follow-up call at approximately 3 hours after ingestion (Grade D). 8) Patients who ingest more than 2 mg/kg or 60 mg, whichever is less, of an immediate-release formulation (or the equivalent amount of a modified-release formulation that has been chewed) should be referred to an emergency department (Grade C). 9) If a patch has been swallowed, consider the entire contents of the patch (not just the labeled dose of the patch) to have been ingested. Patients who ingest more than 2 mg/kg or 60 mg, whichever is less should be referred to an emergency department. If it is known that the patch has been chewed only briefly, and the patch remains intact, significant toxicity is unlikely and emergency department referral is not necessary (Grade D). 10) Patients who ingest more than 4 mg/kg or 120 mg, whichever is less, of an intact modified-release formulation should be referred to an emergency department (Grade D). 11) For oral exposures, do not induce emesis (Grade D). 12) Pre-hospital activated charcoal administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activate charcoal (Grade D). 13) Benzodiazepines can be administered by EMS personnel if agitation, dystonia, or convulsions are present and if authorized by EMS medical direction expressed by written treatment protocol or policy or direct medical oversight (Grade C). 14) Standard advanced cardiac life support (ACLS) measures should be administered by EMS personnel if respiratory arrest, cardiac dysrhythmias, or cardiac arrest are present and if authorized by EMS medical direction expressed by written treatment protocol or policy or direct medical oversight (Grade C).
影响因子：
8
作者：
Stein, MA;Sarampote, CS;Newcorn, JH
通讯作者：
Newcorn, JH
影响因子：
17.7
作者：
Volkow, ND;Wang, GJ;Pappas, N
通讯作者：
Pappas, N