What is the appropriate management for a case of intoxication?

Management of Intoxication

The appropriate management for intoxication depends on the specific substance involved, with treatment focused on addressing life-threatening symptoms, administering appropriate antidotes when available, and providing supportive care to maintain vital functions until the toxin is eliminated from the body. 1

Initial Assessment and Stabilization

• Ensure proper personal protective equipment (PPE) when caring for patients with potential toxic exposures to prevent contamination of healthcare providers 2
• Assess and stabilize airway, breathing, and circulation (ABCs) as the first priority in any intoxication case 3
• For external contamination, perform immediate dermal decontamination by removing contaminated clothing and copious irrigation with soap and water 2
• Monitor vital signs continuously, including cardiac monitoring for substances that may cause dysrhythmias 1

Substance-Specific Management

Opioid Intoxication

• Administer naloxone for suspected opioid overdose: initial dose 0.4 mg to 2 mg intravenously for adults, may repeat every 2-3 minutes if needed 4
• For children with opioid overdose, administer 0.01 mg/kg body weight IV initially; if inadequate response, may give subsequent dose of 0.1 mg/kg 4
• Titrate naloxone to reversal of respiratory depression and restoration of protective airway reflexes, not complete arousal 4
• If combined opioid and benzodiazepine poisoning is suspected, administer naloxone first before other antidotes 1

Benzodiazepine Intoxication

• Flumazenil can be effective in select patients with respiratory depression caused by pure benzodiazepine poisoning who don't have contraindications 1
• Avoid flumazenil in patients with risk factors for seizures, dysrhythmias, or those with suspected co-ingestion of tricyclic antidepressants 1
• Flumazenil has no role in cardiac arrest related to benzodiazepine poisoning 1

Alcohol Intoxication

• For mild-moderate alcohol intoxication (blood alcohol concentration < 1 g/L), supportive care without medications is typically sufficient 5
• For severe intoxication (blood alcohol concentration > 1 g/L), provide intravenous fluids, treat hypoglycemia, hypotension, hypothermia, and electrolyte imbalances 5
• Administer thiamine (vitamin B1) to prevent Wernicke's encephalopathy, especially in chronic alcohol users 5, 6
• Consider metadoxine to accelerate alcohol elimination in severe cases 5

Local Anesthetic Toxicity

• For local anesthetic toxicity causing cardiovascular instability, administer intravenous lipid emulsion (ILE): 1.5 mL/kg up to 100 mL bolus, followed by 0.25 mL/kg/min for up to 30 minutes 1

Cocaine Toxicity

• Treat hyperthermia aggressively as it increases cocaine toxicity 1
• For coronary vasospasm, consider nitroglycerin, benzodiazepines, and phentolamine 1
• Avoid adrenergic blockers in cocaine toxicity 1
• For ventricular arrhythmias, consider sodium bicarbonate (1-2 mEq/kg) 1

Tricyclic Antidepressants and Sodium Channel Blockers

• Administer sodium bicarbonate 1-2 mEq/kg IV boluses until arterial pH >7.45 1, 3
• Avoid Class IA, IC, and III antiarrhythmics, which may worsen cardiac toxicity 1
• For hypotension, give normal saline boluses (10 mL/kg); if persistent, epinephrine and norepinephrine are more effective than dopamine 1

Calcium Channel Blocker Toxicity

• Treat mild hypotension with small boluses (5-10 mL/kg) of normal saline 1
• Consider calcium administration: 20 mg/kg (0.2 mL/kg) of 10% calcium chloride IV over 5-10 minutes 1
• For severe toxicity, high-dose insulin therapy (1 U/kg bolus followed by 1-10 U/kg/hr infusion) may be effective 1

Beta-Blocker Toxicity

• Glucagon (2-10 mg for adults, 0.05-0.15 mg/kg for children) can be effective 1
• Consider high-dose insulin therapy similar to calcium channel blocker toxicity 1

Organophosphate Poisoning

• Administer atropine immediately at 1-2 mg IV for adults (0.02 mg/kg for children), doubling the dose every 5 minutes until bronchorrhea, bronchospasm, and bradycardia resolve 2
• Administer pralidoxime 1-2 g IV for adults (20-50 mg/kg for children), followed by infusion of 400-600 mg/h for adults or 10-20 mg/kg/h for children 2
• Administer benzodiazepines to treat seizures and agitation 2
• Avoid neuromuscular blockers metabolized by cholinesterase (succinylcholine and mivacurium) 2

General Supportive Care

• Provide supplemental oxygen as needed to maintain adequate oxygenation 3
• Administer intravenous fluids for volume resuscitation and to enhance elimination of toxins 5
• Consider activated charcoal for recent oral ingestions (within 1-2 hours) if the airway is protected 7
• Monitor for and treat complications such as hypoglycemia, electrolyte abnormalities, and acid-base disturbances 5, 6
• Consider hemodialysis for water-soluble substances with small volume of distribution 7

Disposition and Follow-up

• Most intoxicated patients can be managed with observation for 24 hours or less 5, 8
• Temporary observation units in the emergency department are ideal for managing many intoxication cases 5, 8
• Patients with alcohol use disorder should be referred to specialized addiction services for follow-up to reduce relapse risk 5
• For intentional overdoses, psychiatric evaluation is essential before discharge 7

Common Pitfalls and Considerations

• Avoid forced emesis, gastric lavage, or cathartics as primary decontamination methods due to lack of evidence for effectiveness 7
• Be cautious with naloxone administration in opioid-dependent patients as it may precipitate severe withdrawal 4
• Consider multiple drug ingestion in all cases of intoxication, as this is common and may complicate management 7, 8
• Contact a poison control center for guidance on unfamiliar or complex poisonings 7