Activated charcoal

(preferred)

Use within 1 h of ingestion of drug poisoning

Decreased level of consciousness or inability to protect airway

Increased risk of gastrointestinal bleeding or perforation

Recent bowel surgery

Ingestion of acids, alkali, alcohols, carbamates, cyanide, organic solvents, hydrocarbons, metals, and organophosphates

Oral/NG:

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  Single dose: 25–100 g

  
  
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  Multidose: 50 g ×1 then 25–50 g q4h

Gastric lavage

Reserve for extraordinary situations involving life-threatening overdoses

Unprotected airway

Increased risk of and severity for aspiration

Ingestion of strong acid or alkali

Increased risk of gastrointestinal bleeding or perforation

Lavage via large-bore OG tube with 200–300 mL of warm saline or water; continue until fluid is free of pills or pill fragments

Cathartics

Not recommended

Conflicting data on decreased transit time in the GI track of drugs that are sustained-release, enteric coated, or poorly absorbed by activated charcoal

Bowel obstruction or perforation

Absent bowel sounds

Recent bowel surgery

Volume depletion

Electrolyte disturbances

Renal insufficiency for magnesium citrate

Hypotension

Sorbitol 70% solution 1–2 mL/kg or

Magnesium citrate 10% solution 240 mL

Whole bowel irrigation

Not recommended for routine use

May consider in potentially life-threatening ingestion of drugs with long half-lives, sustained-release, enteric coated drugs, or drugs that are poorly absorbed by activated charcoal (e.g., lithium, iron)

May be useful in persons who ingest large quantities of illicit drugs for the purpose of smuggling (body packers)

Unprotected airway

Ileus

Recent bowel surgery

Bowel obstruction or perforation

Intractable vomiting

Hemodynamic instability

Polyethylene glycol electrolyte solution 500–2000 mL/h until rectal effluent is clear

Acetaminophen

Anorexia; elevated liver enzymes; jaundice; pallor; lethargy; liver failure; N/V

Treatment based on Rumack-Matthew nomogram (see Fig. 18.1 )

N -acetylcysteine dosage:

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  Oral (72 h): 140 mg/kg (LD), then 70 mg/kg q4h × 17 doses (MD)

  
  
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  IV (21 h): 150 mg/kg (max 15 g) in 200 mL D5W infused over 60 min (LD), then 50 mg/kg (max 5 g) in 500 mL D5W over 4 h then 100 mg/kg (max 10 g) in 1L D5W over 16 h (MD); reduce volume if weight <40 kg

Limitations to using the Rumack-Matthew nomogram: presentation >24 h postingestion, unclear history of ingestion, overdose with extended-release formulations, chronic or repeated overdoses, preexisting hepatic disease, chronic alcohol use, or concurrent medications metabolized by the CYP system

Anticholinergics (antihistamines, antipsychotics, tricyclic antidepressants, skeletal muscle relaxants)

Agitation, hallucinations, abnormal movements, tachycardia, mydriasis, dry membranes, flushed/dry skin, hyperthermia, urinary retention, decreased bowel sounds

Physostigmine IV: 0.5–2 mg over 2–4 min, may repeat q0.5–1h PRN

Benzodiazepines for seizures and agitation: lorazepam 1–4 mg IV push

Avoid phenothiazines (e.g., chlorpromazine) and butyrophenones (e.g., haloperidol)

Benzodiazepines

Anterograde amnesia; ataxia; coma; confusion; drowsiness; lethargy; sedation

Flumazenil: 0.5 mg IV push; repeat 0.5 mg q1min PRN

If no response 5 min after a cumulative dose of 5 mg, consider other causes of sedation

CI: history of seizures, chronic benzodiazepine use, co-ingestion that could induce seizures (e.g., tricyclic antidepressants, cocaine)

Propylene glycol toxicity from lorazepam or diazepam: characterized by hyperosmolarity and anion gap metabolic acidosis. Dialysis may be required for severe cases

β -Blockers (BBs)

Acidosis, bradycardia, bronchospasm, coma, hyper/hypoglycemia, hyperkalemia, hypotension, respiratory depression, seizures, prolonged AV conduction

Same treatment for BB and CCB:

Atropine 0.5 mg IV push

Glucagon 5–10 mg IV push; continuous infusion if symptom response achieved with bolus

Calcium chloride 1–2 g or calcium gluconate 3–6 g IVPB; continuous infusion 0.3–0.7 mEq/kg/h if symptoms persist

Norepinephrine 2–5 mcg/min, titrated to response

Dopamine 5–10 mcg/kg/min, titrated to response

Phenylephrine 20–40 mcg/min, titrated to response

Hyperinsulinemic euglycemic therapy: Regular insulin 1 unit/kg IVP bolus (with dextrose bolus of 1 g/kg), then 0.5 unit/kg/h (with dextrose 0.5 g/kg/h) titrated until hypotension resolved or a maximum of 10 units/kg/h reached (keep serum glucose level at 100–250 mg/dL)

Replete potassium PRN

Sodium bicarbonate for QRS widening, severe acidosis, or dysrhythmia: 1–2 mEq/kg bolus; continuous infusion if symptoms persist

Calcium channel blockers (CCBs)

Non-dihydropyridine CCB: hypotension, prolonged AV conduction, bradycardia, lethargy, hyperglycemia, and depressed consciousness

Dihydropyridine CCB: vasodilation, hypotension, and reflex tachycardia

Clonidine

Apnea; bradycardia; coma; hyper- or hypotension; hypothermia; mental status change; pinpoint pupils

Naloxone: IV bolus: 0.04 mg then increase q2–3min to 0.5 mg, 2 mg, 4 mg, 10 mg, then 15 mg

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  IV infusion: two-thirds the effective bolus dose per hour (0.04–4 mg/h) for patients requiring subsequent naloxone doses to sustain effect

IV preferred, but can be given via endotracheal, intramuscular, intranasal, inhalational, intraosseous, or intrapulmonary route

Atropine: 0.5–1 mg IV push

Dopamine: 5–20 mcg/kg/min

Cholinergics (organophosphates, nerve agent exposure, physostigmine)

Hypersalivation, lacrimation, urinary/fecal incontinence, GI cramping, emesis, bradycardia, miosis, diaphoresis, pulmonary edema, weakness, muscle fasciculations, paralysis, bronchoconstriction

Atropine: 1–2 mg IV push ×1 then doubled dose q3–5min PRN until pulmonary muscarinic signs and symptoms are alleviated

Pralidoxime (in addition to atropine): IV bolus: 30 mg/kg (max 2000 mg) over 30 min, then IV infusion: 8–10 mg/kg/h (max 650 mg/h)

Digoxin

Heart block, tachyarrhythmias, bradyarrhythmias, N/V, lethargy, headaches, confusion, and visual disturbances

Correct electrolyte abnormalities: K, Mg, Ca

Treat symptomatic bradyarrhythmias: atropine 0.5 mg IV push

Digoxin immune antigen-binding fragments (Fab) for life-threatening arrhythmias; asystole, VF/VT, complete heart block, symptomatic bradycardia, end-organ damage, hyperkalemia

Dosing:

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  If amount of digoxin ingested is unknown: 10–20 vials for acute toxicity or 6 vials for chronic toxicity

  
  
• 
  

  If amount of digoxin ingested is known: dose (vials) = [serum digoxin conc (ng/mL) × weight (kg)] / 100

Monitoring: serum digoxin concentrations are not recommended after the administration of Fab as a rapid rise in serum concentrations expected from the Fab-digoxin complex

Iron

N/V/D, hypovolemia, metabolic acidosis, seizures, hepatic/kidney failure, and GI tract scarring/strictures

Deferoxamine IV infusion: 5 mg/kg/h, titrate to 15 mg/kg/h as tolerated, max dose 6 g/day

Opioids

CNS depression, including coma, lethargy, or stupor; constipation, N/V; flushing and pruritus; hypotension; meiosis; pulmonary edema; respiratory depression; seizures

Naloxone: a competitive antagonist at the opioid receptor

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  IV onset: 2 min; IV duration: 30–120 min

  
  
• 
  

  IV bolus: 0.04 mg then increase q2–3min to 0.5 mg, 2 mg, 4 mg, 10 mg, then 15 mg

  
  
• 
  

  IV infusion: two-thirds the effective bolus dose per hour (0.04–4 mg/h) for patients requiring subsequent naloxone doses to sustain effect

IV preferred, but can be give via endotracheal, intramuscular, intranasal, inhalational, intraosseous, or intrapulmonary route

Salicylates

If serum concentration:

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  <30 mg/dL: asymptomatic

  
  
• 
  

  15–30 mg/dL: therapeutic

  
  
• 
  

  30–50 mg/dL: hyperventilation, N/V, tinnitus, dizziness

  
  
• 
  

  50–70 mg/dL: tachypnea, fever, sweating, listlessness, dehydration

  
  
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  >70 mg/dL: coma, seizures, stupor, hallucinations, cerebral edema, oliguria, dysrhythmias, hypotension, renal failure

No antidote for salicylate poisoning

Gastric decontamination with activated charcoal for acute ingestions if the patient is alert without vomiting

IV crystalloids to maintain BP

IV glucose for hypoglycemia or significant neurologic symptoms

Urine alkalinization to enhance renal elimination: 250 mL of sodium bicarbonate 8.4% over 1 h then 50 mL boluses PRN to maintain urine pH 7.5–8.5 or 150 mL of sodium bicarbonate 8.4% in 1L D5W at 2–3 mL/kg/h to maintain urine output 1–2 mL/kg/h to maintain urine pH ≥7.4

Replete serum potassium as necessary

Consider hemodialysis if acute renal insufficiency, end-organ damage, altered mental status, deterioration of clinical status, or severe acid-base abnormalities

Sulfonylureas

Coma, decreased appetite, dizziness, hypoglycemia, lethargy, seizures, weakness

Conscious patients: 8 oz of oral carbohydrate (juice, non-diet sodas, or milk) or oral glucose tablet/gel PRN BG <60 mg/dL

Unconscious patients: IV dextrose 0.5–1 g/kg q15min PRN BG <60 mg/dL

Octreotide: 50 mcg subcutaneous or IV q6h ×4

Glucagon: 1 mg IM, IV, or SubQ q15min PRN

Tricyclic antidepressants

Coma; confusion; delirium; dilated pupils; dry mouth; seizure; hypotension; tachycardia; urinary incontinence

Benzodiazepines for seizures (avoid barbiturates and phenytoin): lorazepam 2–4 mg IV push

Sodium bicarbonate 1 mEq/kg IV push q15min until ECG stabilized or arterial pH goal (7.45–7.55) achieved

Dopamine 5–10 mcg/kg/min, titrated to response

Norepinephrine 2–5 mcg/min, titrated to response