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Toronto Notes 2019
Toxicology Emergency Medicine ER53
Table 34. Specific Antidotes and Treatments for Common Toxins*
Toxin
Acetaminophen
Acute Dystonic Reaction
Anticholinergics ASA
Benzodiazepines
β-blockers
Calcium Channel Blockers
Cocaine
CO Poisoning
Cyanide Digoxin
Ethanol
Ethylene Glycol/ Methanol
Heparin
Insulin IM/SC/ Oral Hypoglycemic
MDMA
Opioids TCAs
Treatment
Decontaminate (activated charcoal) N-acetylcysteine
Benztropine: 1-2 mg IM/IV then 2 mg PO x 3 d OR Diphenhydramine 1-2 mg/kg IV, then25mgPOqidx3d
Consider decontamination (activated charcoal) Supportive care
Consider decontamination (activated charcoal) Alkalinize urine; want urine pH >7.5
Consider decontamination (activated charcoal) Flumazenil
Supportive care
Consider decontamination (activated charcoal, consider whole bowel irrigation for extended-release ingestion) IV glucagon, IV calcium chloride, IV high-dose insulin (with dextrose), IV intralipid
Consider decontamination (activated charcoal, consider whole bowel irrigation for extended-release ingestion) IV glucagon, IV calcium chloride, IV high-dose insulin (with dextrose), IV intralipid
Decontaminate (activated charcoal) if oral Aggressive supportive care
See Inhalation Injury, ER47 Supportive care
100% O2 ; may require hyperbaric O2
Hydroxocobalamin
Consider decontamination (activated charcoal) Digoxin-specific Ab fragments
10-20 vials IV if acute; 3-6 if chronic
1 vial (40 mg) neutralizes 0.5 mg of toxin
Thiamine 100 mg IM/IV
Manage airway and circulatory support
Fomepizole (4-methylpyrazole)
15 mg/kg IV load over 30 min,
then 10 mg/kg q12h OR
Ethanol (10%) 10 mL/kg over 30 min, then 1.5 mL/h
Protamine sulfate 25-50 mg IV
Glucose IV/PO/NG tube
Glucagon: 1-2 mg IM (if no access to glucose)
Consider decontamination (activated charcoal) Supportive care
See Universal Antidotes, ER49
Consider decontamination (activated charcoal)
Aggressive supportive care
NaHC03 bolus for wide QRS/seizures
Considerations
Often clinically silent; evidence of liver/renal damage delayed >24 h
Toxic dose >200 mg/kg (>7.5 g adult)
Monitor drug level 4 h post-ingestion; also liver enzymes, INR, PTT, BUN, Cr Hypoglycemia, metabolic acidosis, encephalopathy poor prognosis Dialysis may be required to manage in very high overdoses
Benztropine (Cogentin®) has euphoric effect and the potential for misuse
Special antidotes available; consult Poison Information Centre
Monitor serum pH and drug levels closely
Monitor K+ level; may require supplement for urine alkalinization
Hemodialysis may be needed if intractable metabolic acidosis, very high levels, or end-organ damage (i.e. unable to diurese)
Order ECG, electrolytes (especially Ca2+, Mg2+, Na+, K+)
β-blockers are contraindicated in acute cocaine toxicity Intralipid for life-threatening symptoms
Order ECG, VBG. Consider lactate and troponin depending on specific presentation
Use for life-threatening dysrhythmias unresponsive to conventional therapy, 6 h serum digoxin >12 nmol/L, initial K+ >5 mmol/L, ingestion >10 mg (adult)/>4 mg (child)
Common dysrhythmias include VFib, VTach, and conduction blocks
Mouthwash = 70% EtOH; perfumes and colognes =
40-60% EtOH
Order serum EtOH level and glucose level; treat glucose level appropriately
CBC, electrolytes, glucose, ethanol level Consider hemodialysis
For unfractionated heparin overdose only
Glyburide carries highest risk of hypoglycemia among oral agents
Consider octreotide for oral hypoglycemics (50-100 μg SC q6h) in these cases; consult local Poison Information Centre
Monitor CK; treat rhabdomyolysis with high flow fluids: aggressive external cooling for hyperthermia Review medical history if possible for serotonergic use
Flumazenil antidote contraindicated in combined TCA and benzodiazepine overdose Also consider cardiac and hypotension support, seizure control
Intralipid therapy
* Call local Poison Information Centre for reporting of cases, specific doses, and treatment recommendations. Most toxicology cases should involve communication with your local Poison Information Centre.