This is the current release of the guideline.

Grades of recommendation (A-D, Z) and levels of evidence (1a-6) are defined at the end of the "Major Recommendations" field.

Recommendations

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 or dermal exposure, determination of the precise dose ingested, and the presence of co-ingestants (Grade D).
3. Patients experiencing any changes in behavior other than mild drowsiness or mild stimulation should be referred to an emergency department. Examples of moderate to severe symptoms that warrant referral include (but are not limited to) agitation, staring spells, inconsolable crying, hallucinations, abnormal muscle movements, loss of consciousness, seizures, or respiratory depression (Grade D).
4. For patients referred to the 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 the patient to arrive at the emergency department (Grade D).

Diphenhydramine

5. If the patient has no symptoms, and more than 4 hours have elapsed between the time of ingestion and the call to the poison center, referral to an emergency department is not recommended. For dermal exposures, if the patient has no symptoms and it has been more than 8 hours since the diphenhydramine was thoroughly removed from the skin, referral to an emergency department is not recommended (Grade D).
6. Patients with acute ingestions of less than a toxic dose, or chronic exposures to diphenhydramine with no or mild symptoms, can be observed at home with instructions to call the poison center back if symptoms develop or worsen. The poison center should consider making a follow-up call at approximately 4 hours after ingestion (Grade D).

Acute Exposures in Children Less than 6 Years of Age

7. Children less than 6 years of age who ingest at least 7.5 mg/kg should be referred to an emergency department (Grade D).

Acute Exposures in Patients 6 Years of Age and Older

8. Patients ingesting at least 7.5 mg/kg or 300 mg (whichever is less) should be referred to an emergency department (Grade D).

Dimenhydrinate

9. If the patient has no symptoms, and more than 6 hours has elapsed between the time of ingestion and the call to the poison center, referral to an emergency department is not recommended (Grade D).
10. Patients with acute ingestions of less than a toxic dose, or chronic exposures to dimenhydrinate with no or mild symptoms, can be observed at home with instructions to call the poison center back if symptoms develop or worsen. The poison center should consider making a follow-up call at approximately 6 hours after ingestion (Grade D).

Acute Exposures in Children Less than 6 Years of Age

11. Children ingesting at least 7.5 mg/kg should be referred to an emergency department (Grade D).

Acute Exposures in Patients 6 Years of Age and Older

12. Patients ingesting at least 7.5 mg/kg or 300 mg (whichever is less) should be referred to an emergency department for evaluation (Grade D).

Other Out-of-Hospital Management

13. For oral exposures, do not induce emesis. Because of the potential for diphenhydramine or dimenhydrinate to cause loss of consciousness or seizures, activated charcoal should not be administered at home or en route to an emergency department (Grade D).
14. For chronic dermal exposures, skin decontamination (with water or soap and water) should be attempted prior to transporting a patient to an emergency department unless hallucinations, loss of consciousness, seizures, and/or arrhythmias are already present. In this circumstance, transportation should not be delayed and emergency medical services (EMS) personnel should attempt skin decontamination en route to the emergency department (Grade D).
15. Intravenous sodium bicarbonate may be administered by EMS personnel if QRS widening (QRS >0.10 msec) is present and if authorized by EMS medical direction expressed by written treatment protocol or policy, or direct medical oversight (Grade D).
16. Physostigmine should be reserved for administration in a hospital. The lack of literature describing its use in the prehospital setting and the limited literature describing its efficacy and safety in patients with diphenhydramine toxicity preclude its use in the out-of-hospital setting (Grade D).
17. Benzodiazepines may be administered by EMS personnel if agitation or seizures are present and if authorized by EMS medical direction expressed by written treatment protocol or policy, or direct medical oversight (Grade D).

Definitions:

Grades of Recommendation and Levels of Evidence

An algorithm is provided in Appendix 4 of the original guideline document for the triage of patients with diphenhydramine or dimenhydrinate poisoning.

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2005 Aug 26

American Association of Poison Control Centers - Professional Association

Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services

Not stated

Primary Authors: Elizabeth J. Scharman, PharmD; Andrew R. Erdman, MD; Paul M. Wax, MD; Peter A. Chyka, PharmD; E. Martin Caravati, MD, MPH; Lewis S. Nelson, MD; Anthony S. Manoguerra, PharmD; Gwenn Christianson, MSN; Kent R. Olson, MD; Alan D. Woolf, MD, MPH; Daniel C. Keyes, MD, MPH; Lisa L. Booze, PharmD; William G. Troutman, PharmD

Panel Members: Lisa L. Booze, PharmD, Certified Specialist in Poison Information, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, Maryland; E. Martin Caravati, MD, MPH, FACMT, FACEP, Professor of Surgery (Emergency Medicine), University of Utah, Medical Director, Utah Poison Center, Salt Lake City, Utah; Gwenn Christianson, RN, MSN, Certified Specialist in Poison Information, Indiana Poison Center, Indianapolis, Indiana; Peter A. Chyka, PharmD. FAACT, DABAT, Professor, Department of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee; Daniel C. Keyes, MD, MPH, Medical Director, Pine Bluff Chemical Demilitarization Facility, Associate Professor, Southwestern Toxicology Training Program, Dallas, Texas; Anthony S. Manoguerra, PharmD, DABAT, FAACT, Professor of Clinical Pharmacy and Associate Dean, School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, Former Director, California Poison Control System, San Diego Division, San Diego, California; Lewis S. Nelson, M.D., FACEP, FACMT, Associate Medical Director, New York City Poison Control Center, New York, New York; Kent R. Olson, MD, FACEP, FAACT, FACMT, Medical Director, California Poison Control System, San Francisco Division, Clinical Professor of Medicine & Pharmacy, University of California, San Francisco, San Francisco, California; Elizabeth J. Scharman, PharmD, DABAT, BCPS, FAACT, Director, West Virginia Poison Center, Professor, West Virginia University School of Pharmacy, Dept. Clinical Pharmacy, Charleston, West Virginia; Paul M. Wax, MD, FACMT, Managing Director, Banner Poison Center, Professor of Clinical Emergency Medicine, University of Arizona School of Medicine, Phoenix, Arizona; Alan D. Woolf, MD, MPH, FACMT, Director, Program in Environmental Medicine, Children's Hospital, Boston, Associate Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts

There are no potential conflicts of interest reported by the expert consensus panel or project staff regarding this guideline.

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on October 31, 2005. The information was verified by the guideline developer on November 28, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.