Comprehensive Management of Poisoning Cases
The management of poisoning cases requires specialized treatments including antidotes and venoarterial extracorporeal membrane oxygenation (VA-ECMO), in addition to effective basic and advanced life support, with early consultation with a medical toxicologist or regional poison center to facilitate rapid and effective therapy. 1
Initial Assessment and Stabilization
Immediate Life-Saving Measures
- Airway, Breathing, Circulation (ABC)
Critical Interventions for Specific Presentations
- Seizures: Administer benzodiazepines (e.g., diazepam) 1, 3
- Extreme agitation: Use sedatives (diazepam or clorazepate if no risk of respiratory depression; haloperidol if risk exists) 3
- Severe bradycardia: Administer atropine 1, 4, 3
- Hypotension: Elevate legs, administer fluids and vasopressors 1, 2, 3
- Respiratory depression from opioids: Administer naloxone IV (note: its duration of action is often shorter than opioids, requiring continuous monitoring) 1, 3
Toxin Identification and Risk Assessment
Information Gathering
- Question patient and close contacts
- Examine immediate environment
- Assess clinical presentation for toxidromes (constellation of symptoms associated with specific drug classes) 5:
- Anticholinergic: Hyperthermia, dry skin, mydriasis, delirium
- Cholinergic: Salivation, lacrimation, urination, defecation, GI distress, emesis
- Opioid: Respiratory depression, miosis, decreased consciousness
- Sympathomimetic: Hypertension, tachycardia, hyperthermia, agitation
Laboratory Assessment
- Basic metabolic panel to determine electrolyte imbalances, liver and renal function
- Additional testing based on clinical presentation and suspected toxin 5
Gastrointestinal Decontamination
Activated Charcoal
- Administer as soon as possible, preferably within 2 hours of ingestion
- Only for drugs known to be adsorbed by activated charcoal
- Only if patient is fully conscious and capable of swallowing safely 1, 3, 6
Other Decontamination Methods
- Gastric lavage: Only justified in rare cases where patient's life is at risk following ingestion of a drug not adsorbed by activated charcoal 3
- Ipecac syrup: Should not be used under any circumstances 3, 6
- Whole bowel irrigation: Useful for iron, lead, and lithium poisoning and for body packers 6
Antidote Administration
Common Antidotes for Specific Poisonings
- Opioids: Naloxone 1, 3
- Benzodiazepines: Flumazenil (use with caution due to risk of precipitating seizures in patients with benzodiazepine tolerance or mixed overdoses) 1
- Acetaminophen: Acetylcysteine (within 24 hours of ingestion) 3
- Organophosphates: Atropine and pralidoxime 1, 4
- Pralidoxime dosing: Initial dose of 1000-2000 mg IV over 15-30 minutes, with possible second dose after one hour if muscle weakness persists 4
- Cyanide: Hydroxocobalamin (preferred) or sodium nitrite plus sodium thiosulfate 1
- Digoxin: Digoxin-specific immune antibody fragments 1
- Local anesthetic toxicity: 20% intravenous lipid emulsion 1, 7
Enhanced Elimination Techniques
Methods to Increase Toxin Clearance
- Multiple-dose activated charcoal: For drugs that undergo enterohepatic circulation 6
- Hemodialysis: For water-soluble, low-protein-bound toxins (e.g., lithium, salicylates, alcohols) 1, 6, 7
- VA-ECMO: For cardiogenic shock or dysrhythmias refractory to other treatments (start early in patients not responding to other therapies) 1, 2
- Urinary alkalinization: For salicylate poisoning 7
Specific Toxin Management
β-Blocker and Calcium Channel Blocker Poisoning
- First-line: High-dose insulin therapy early in treatment 1
- Additional therapies:
- Vasopressors for hypotension
- Glucagon bolus followed by continuous infusion
- Calcium administration (for calcium channel blockers)
- Atropine for bradycardia
- Consider VA-ECMO for refractory shock 1
Sodium Channel Blocker Toxicity (including cocaine)
- Standard advanced life support plus sodium bicarbonate 1
Sympathomimetic Poisoning
- Sedation to manage hyperthermia, acidosis, prevent rhabdomyolysis and injury 1
- Aggressive cooling for hyperthermia using evaporative or immersive cooling modalities 2
Monitoring and Supportive Care
Ongoing Assessment
- Continuous cardiac monitoring
- Serial assessment of vital signs and mental status
- Monitor myocardial enzymes, renal and hepatic function 2
- Monitor for at least 48-72 hours after organophosphate poisoning 4
Safety Precautions
- Use personal protective equipment when caring for patients with external exposure
- Perform dermal decontamination for external exposure 2
Special Considerations
Pediatric Patients
- Children can experience more profound effects from small amounts of medication
- Symptoms in infants may include drowsiness or unconsciousness with muscle floppiness rather than muscle twitching 4, 5
Psychological Assessment
- Evaluate risk of short-term relapse in cases of self-poisoning
- Consider hospital admission until acute suicide risk has subsided 3
Expert Consultation
Poison Control Centers
- Contact regional poison centers for expert guidance:
- United States: 1-800-222-1222 1, 2
- Canada: Provincial poison centers (https://infopoison.ca) 1
Common Pitfalls to Avoid
- Delayed antidote administration: Don't wait for confirmatory testing in suspected cyanide poisoning 1
- Inappropriate use of flumazenil: Avoid in patients with benzodiazepine tolerance, mixed overdoses, or preexisting seizure disorders 1
- Administering atropine in significant hypoxia: This can cause ventricular fibrillation 4
- Delayed consideration of VA-ECMO: Implementation takes time, so start early in patients not responding to other therapies 1
- Using morphine, theophylline, aminophylline, reserpine, and phenothiazine-type tranquilizers in organophosphate poisoning 4
- Using succinylcholine with caution in patients receiving drugs with anticholinesterase activity due to risk of prolonged paralysis 4
By following this structured approach to poisoning management, clinicians can optimize patient outcomes while minimizing complications from both the poisoning itself and the treatments administered.