Exact Post–Gastric-Lavage Prescription for Acute Toxin Ingestion (prioritizing morbidity, mortality, QoL)
Bolded items = firm recommendations to initiate now; doses are exact and weight-based where needed.
1) Universal immediate orders (all ingestions, after lavage)
- IV access x2; continuous pulse oximetry; cardiac monitor; strict I&O.
- Fluids: Balanced crystalloid 20 mL/kg IV bolus once if hypotensive; then 1–2 mL/kg/h; add vasopressors per shock protocols as needed (do not use bicarbonate to treat lactic acidosis unless pH <7.15) 3.
- VTE prophylaxis if not bleeding: Enoxaparin 40 mg SC daily (or UFH 5000 U SC q8h if contraindications to LMWH) 3.
- Stress ulcer prophylaxis if bleeding risk: Pantoprazole 40 mg IV daily (or H2RA) 3.
- Nausea: Ondansetron 4 mg IV q6h PRN.
- Seizure control: Lorazepam 2 mg IV q5 min PRN seizures.
- Glucose checks q2–4h; treat hypoglycemia with D10W bolus 250 mL, then infusion as needed 3.
2) Targeted antidotes/support based on most lethal/common toxidromes
Use this exact algorithm immediately after lavage; choose all that apply.
A) Suspected or possible acetaminophen exposure (unknown cocktail or any risk of ALF)
- Labs stat and q6–8h: acetaminophen level, AST/ALT, INR, bilirubin, lactate, BMP, ABG/venous gas, ammonia 1.
- Start N‑acetylcysteine (NAC) now, without waiting for levels, if ingestion time uncertain or ALF possible.
- IV regimen: 150 mg/kg in 5% dextrose over 15 min, then 50 mg/kg over 4 h, then 100 mg/kg over 16 h; continue beyond 21 h if LFTs/INR not improving 1.
- If able to take enterally: 140 mg/kg PO/NG once, then 70 mg/kg q4h x17 doses 1.
- Manage anaphylactoid reactions by pausing infusion, antihistamines, and epinephrine if bronchospasm; then restart when controlled 1.
- Rationale: early NAC reduces mortality in ALF and is indicated even >48 h after ingestion if liver injury evolving 1.
- Pitfall to avoid: a low or zero acetaminophen level does not exclude toxicity in delayed/unknown timing—do not stop NAC prematurely if LFTs/INR rising 1.
B) Opioid co-ingestion suspected (miosis, respiratory depression; common with sedative overdoses)
- Naloxone 0.2–2 mg IV now; repeat q2–3 min to restore ventilation; then infusion at two-thirds of the wake-up dose per hour if recurrent depression; IN option: 2–4 mg, repeat q2–3 min as needed 4.
- Give naloxone before considering flumazenil if mixed benzo–opioid possible 4.
C) Life-threatening benzodiazepine poisoning (pure, low-risk scenario only)
- Consider only if no seizure risk, no co-ingestants, and no benzo dependence:
- Flumazenil 0.2 mg IV, titrate up to 1 mg if indicated. Avoid if seizure/dysrhythmia risk—can be harmful 4.
- Pitfall: Do not use in unknown/mixed overdoses or chronic benzo users (seizure risk) 4.
D) Sodium-channel blocker cardiotoxicity (e.g., TCA, cocaine; wide QRS, hypotension)
- Sodium bicarbonate 50–150 mEq IV boluses to narrow QRS and improve perfusion; prepare infusion: 150 mEq/L at 1–3 mL/kg/h, titrate; monitor for hypernatremia/alkalemia/hypokalemia 4.
E) Beta-blocker or calcium-channel blocker shock
- Glucagon 2–10 mg IV bolus, then infusion 1–15 mg/h if responsive 4.
- High-dose insulin euglycemia therapy: regular insulin 1 U/kg IV bolus, then 1–10 U/kg/h with dextrose to maintain euglycemia; monitor K+ closely; add vasopressors as needed 4.
- Consider methylene blue 1–2 mg/kg IV (max 5–7 mg/kg) for refractory vasodilatory shock in CCB toxicity 4.
- Caveat: anticipate vomiting with glucagon; protect airway 4.
F) Organophosphate/carbamate features (SLUDGE, bradycardia, miosis, bronchorrhea)
- Airway first.
- Atropine: 2 mg IV q5 min, doubling dose as needed until bronchial secretions dry and oxygenation improves; then infusion to maintain.
- Pralidoxime: 1–2 g IV bolus, then 400–600 mg/h infusion (adults); pediatrics 20–50 mg/kg bolus, 10–20 mg/kg/h infusion 4.
- Monitor for coagulopathy only if superwarfarin co-ingestion suspected; vitamin K1 per INR.
G) Digoxin (or yellow oleander) toxicity with life-threatening signs (significant arrhythmias, hyperkalemia, hemodynamic instability)
- Digoxin immune Fab:
- Manage K+ cautiously; avoid calcium in digoxin toxicity.
H) Local anesthetic systemic toxicity (LAST: seizures, refractory hypotension, wide QRS)
- 20% intralipid emulsion: 1.5 mL/kg IV bolus (max 100 mL), then 0.25 mL/kg/min up to 30 min; may repeat bolus for instability 4.
I) Cyanide (house fire, nitroprusside, labs suggest severe lactic acidosis)
- Hydroxocobalamin (preferred if available) per local protocol; if not:
- Sodium nitrite 300 mg IV, then sodium thiosulfate 12.5 g IV 4.
- Watch for hypotension with nitrite 4.
J) Amanita (mushroom) ingestion suspected with GI prodrome progressing to ALF
- Early decontamination already performed; now:
- Penicillin G IV 300,000–1,000 units/kg/day (continuous or divided), and
- Consider silibinin/silymarin 30–40 mg/kg/day IV or PO for 3–4 days where available.
- Combine with NAC as above; aggressive fluids 1.
- Early transplant listing if ALF evolves; this can be lifesaving 1.
- Caveat: Silibinin IV availability varies; US herbal products have variable content 1.
K) Barbiturate (e.g., phenobarbital) with coma/respiratory depression
- Protect airway, optimal supportive care first.
- Consider multiple-dose activated charcoal (MDAC) 15–20 g PO/NG q6h after airway secured; monitor for ileus/aspiration risk 5.
- Urinary alkalinization is not first-line; consider extracorporeal therapy (hemodialysis/hemoperfusion) for severe phenobarbital toxicity per EXTRIP 5.
3) Gastrointestinal decontamination after lavage (what to add/avoid)
- If within window and airway protected:
- Activated charcoal 1 g/kg (adult typical 50 g) via NG once unless toxin is not adsorbed (e.g., iron, lithium, alcohols) or GI contraindications exist 1, 6.
- Consider MDAC for enterohepatic/slow-release agents (carbamazepine, theophylline, dapsone, quinine, phenobarbital) once bowel sounds present 7, 5.
- Whole-bowel irrigation only for sustained-release, enteric-coated, metals (iron, lithium), or body packers; avoid if ileus/instability 7, 6.
- Avoid ipecac; avoid routine milk/water dilution 2.
4) Laboratory/monitoring protocol (start now)
- Stat and q6–8h: CMP (including K+, Ca2+, Mg2+), glucose, VBG/ABG, lactate; CBC; PT/INR; troponin if cardiotoxic agents; acetaminophen level in all ALF-risk ingestions; tox screen as available; pregnancy test in females 1.
- Specific levels when relevant: digoxin, salicylate, phenobarbital, valproate, lithium, theophylline, iron, carboxyhemoglobin, methemoglobin.
- Urine output goal ≥0.5 mL/kg/h; Foley if unstable.
5) Common pitfalls and how to avoid them
- Do not delay NAC while awaiting acetaminophen level if ALF possible or timing unclear 1.
- Do not give flumazenil in mixed/unknown overdoses or benzo-dependent patients (seizure risk) 4.
- Use sodium bicarbonate for sodium-channel blockade arrhythmias, not for routine lactic acidosis (if pH ≥7.15) 4, 3.
- Start naloxone first in suspected opioid–benzo mixtures to rapidly reduce mortality from respiratory arrest 4.
- After lavage, give charcoal only with protected airway and appropriate indication; aspiration risk is substantial 5, 6.
6) Disposition and escalation
- ICU level care, early transplant center discussion for evolving ALF; transfer if criteria met 1.
- Consider extracorporeal therapies per toxin (e.g., phenobarbital, severe organophosphate with shock, massive salicylate/lithium/valproate per local protocols and EXTRIP guidance) 5.
Bottom-line, start now: NAC IV 150 mg/kg → 50 mg/kg/4 h → 100 mg/kg/16 h for any possible acetaminophen/ALF; naloxone titrated for respiratory depression; sodium bicarbonate for wide QRS; glucagon ± high-dose insulin for BB/CCB shock; digoxin immune Fab for life-threatening digoxin; atropine + pralidoxime for organophosphates; lipid emulsion for LAST; and consider penicillin G ± silibinin for Amanita—while maintaining ICU monitoring and supportive care. 1, 4, 1, 5, 3