## Lithium Lithium excreted renally on sodium transporter, so if serum sodium is decreased, more lithium and sodium will be reabsorbed at proximal tubule, like in states pf dehydration Blocks actions of ADH so leads to DI Hypothyroidism CNS is the major site of toxicity EKG-t wave flattening, ST changes, prolonged QRS and rarely QT If on lithium and c/o GI stuff, it is lithium toxicity until proven otherwise Ther. Levels usually .6-1.2 AC does not bind Dialyse if >4.0 serum. Renal failure, CHF, comatose Fine tremor=side effect, coarse tremor=toxicity Severe toxicity=seizures and coma Whole Bowel Irrigation with PEG if sustained release tabs Hydration Lithium level, repeat in 2 hours for acute, 6 hours for chronic. Best course is to get levels Q 1-2 hrs regardless if first is back yet, if truly suspect. Kayexalate for overdose. The usual dose is 30 grams of SPS in sorbitol orally every four hours. Binds lithium in gut, gut dialysis, and sodium load. Chronic lithium toxicity can occur with even mild renal fx and they can be toxic at near normal levels acute often has GI side effects, chronic not as much [Lithium Poisoning Review](baird-gunning-et-al-2016-lithium-poisoning.pdf) ## Antiseizure Medications Present c CNS effects, sedation, confusion, dizziness, ### Phenytoin (Dilantin) Therapeutic Levels 10-20 Class 1B antidysrhythmic. do not give in patients with bradycardia or heart block Most dysrhythmias are probably from diluent (propylene glycol) ### Carbamazepine (Tegratol) Therapeutic Levels 4-12 Levels above 40 mg/L assoc c adverse effects Nystagmus, ataxia, dysarthria, stupor, encephalopathy, myoclonus, dystonia Seizures and tachycardia ### Valproic Acid (Depakote) Therapeutic Levels 50-120 Has toxic metabolite, so sx of overdose can be present c normal serum levels at presentation. Releases GABA Sedation, ataxia, dizziness, myoclonus, GI sx, Can cause hepatic failure Causes carnitine deficiency and blocks fatty acid metabolism, eventually leading to hyperammonemia VPE (a metabolite of valproate) combines with carnitine and is excreted in the urine. Lacking carnitine, fats must undergo alpha oxidation instead of beta oxidation. This produces ammonia. Ammonia normally metabolized through the urea cycle, but VPE also binds the first enzyme there. Fatty acyl groups also inhibit the urea cycle. All increase ammonia levels. Send ammonia levels, possibly administer carnitine (15-50 mg/kg IV or PO to take VPE out of urea cycle) GABAergic action on CNS also increases endogenous opioids (enkephalen) AC Nalaxalone may reverse CNS depressant effects (JEM 22:1, pp.67-70) In order to clear, need two consecutive valproate levels that are clearing by at least 20% and are three hours apart Onset is 3 hours after ingestion, so first level should be after 3 hours Elimination half life is 6-17 hours | | |