What is the appropriate treatment for a patient with poisoning?

Treatment of Acute Poisoning

Immediately stabilize the patient with aggressive supportive care focused on airway, breathing, and circulation, contact poison control for toxin-specific guidance, and treat based on clinical toxidrome recognition without waiting for confirmatory testing. 1, 2, 3

Immediate Stabilization (First Priority)

• Implement life-support measures immediately: secure airway, provide respiratory support if needed, and ensure hemodynamic stability with fluid resuscitation and vasopressor support to maintain systolic blood pressure >80 mm Hg 3, 4
• Place unconscious patients in left lateral head-down position and administer glucose if hypoglycemic 4
• For cardiorespiratory arrest, initiate full resuscitation protocols immediately 4
• Contact poison control center or medical toxicologist immediately for expert guidance on toxin-specific therapy, as specialized consultation is critical for optimal management 1, 2, 3

Toxidrome Recognition and Specific Antidotes

Treat based on clinical presentation and exposure history—do not delay treatment while waiting for confirmatory testing 1, 2, 3

Calcium Channel Blocker/β-Blocker Poisoning

• Initiate high-dose insulin therapy immediately (1 U/kg bolus, then 1 U/kg/hr infusion) as first-line treatment to improve myocardial contractility and microcirculatory perfusion 1
• Administer IV calcium chloride 10% at 10-20 mL (1-2 g) every 10-20 minutes or as continuous infusion at 0.2-0.4 mL/kg/hr 1
• Select vasopressors based on shock type: norepinephrine for vasodilatory shock or epinephrine for cardiogenic shock (avoid dopamine as first-line) 1

Sympathomimetic Poisoning (Cocaine, Amphetamines)

• Administer benzodiazepines immediately (diazepam or midazolam) to control severe agitation, hyperthermia, and acidosis—this prevents microcirculatory damage from rhabdomyolysis 1
• Implement rapid external cooling (evaporative or immersive) for life-threatening hyperthermia >41°C 1

Organophosphate/Carbamate Poisoning

• Give atropine 1-2 mg IV immediately, doubling the dose every 5 minutes until bronchorrhea, bronchospasm, and bradycardia resolve 1
• Administer pralidoxime 1-2 g IV slowly, then 400-600 mg/hr continuous infusion to reactivate acetylcholinesterase 1

Cyanide Poisoning

• Administer hydroxocobalamin immediately without waiting for confirmatory testing (5 g IV over 15 minutes for adults) as the preferred antidote 1

Opioid Poisoning

• Administer intravenous naloxone for respiratory depression, but recognize its duration of action is often shorter than opioids, requiring continuous monitoring 4

Paracetamol (Acetaminophen) Poisoning

• Administer acetylcysteine within 24 hours after ingestion to protect against life-threatening hepatocellular necrosis; give empirically when emergency medical intervention is not feasible within 8-10 hours 4

Decontamination

• Remove all contaminated clothing and thoroughly wash exposed skin with soap and water to prevent continued absorption 2, 3
• Healthcare providers must use appropriate personal protective equipment to prevent secondary contamination 2, 3
• Administer activated charcoal as soon as possible (preferably within 2 hours) for drugs known to be adsorbed by charcoal, provided the patient is fully conscious and capable of swallowing safely 5, 4
• Do NOT induce vomiting under any circumstances, as this may worsen the condition and delay definitive care 2, 3, 4
• Gastric lavage carries serious risks and is only justified in rare cases where life is at risk following ingestion of a drug not adsorbed by activated charcoal 4

Symptomatic Management

• Administer benzodiazepines (diazepam or midazolam) for seizures, status epilepticus, or severe agitation 1, 2, 3, 4
• Give atropine for severe bradycardia 4
• Elevate legs for hypotension 4
• For extreme agitation without respiratory depression risk, use diazepam or clorazepate; otherwise use haloperidol 4

Hemodynamic Monitoring and Advanced Support

• Implement advanced hemodynamic monitoring early to assess cardiac function and guide fluid resuscitation, as systemic blood pressure does not reliably reflect microcirculatory perfusion 1
• Titrate fluid repletion based on response, avoiding both hypovolemia (inadequate microcirculatory flow) and volume overload (increased interstitial edema) 1
• Consider VA-ECMO early for refractory shock rather than waiting until the patient is moribund, as outcomes are superior when started before irreversible organ damage occurs 1

Metabolic Management

• Address hypocalcemia and other electrolyte derangements that may develop during the acute phase 3
• Measure electrolyte, serum creatinine, and serum bicarbonate levels and calculate anion gap based on clinical presentation 6

Monitoring Requirements

• Observe all patients for at least 48-72 hours, even if initially stable, due to risk of delayed effects from some pharmacological substances and formulations 2, 3, 4
• Perform electrocardiography in patients with chest pain, dyspnea, or overdoses of beta blockers, tricyclic antidepressants, and antidysrhythmics 6

Critical Pitfalls to Avoid

• Never delay antidote administration while obtaining confirmatory testing—treat based on clinical toxidrome recognition, as microcirculatory damage progresses rapidly 1, 2, 3
• Do not use neuromuscular blockers without adequate sedation if intubation is required, as they can mask seizure activity without treating it 2, 3
• Do not use dopamine as first-line vasopressor in calcium channel blocker poisoning due to inconsistent hemodynamic improvement 1
• In self-poisoning cases, evaluate the risk of short-term relapse and propose hospital admission until acute suicide risk has subsided 4