- Airway with specific care on cervical spine immobilization (unless trauma has been excluded)
- Breathing, oxygenation, and need for intubation
- Circulation—fluid resuscitation and continuous cardiac monitoring
- Decontamination of GI—only if ingestion within 1 hour
- Elimination of toxin—antidotes, charcoal hemoperfusion, hemodialysis
- History—past medical and psychiatric history, prescription drugs, empty bottles found and pill count, time of ingestion
- Examination—a quick, but detailed exam focusing at identifying a toxidrome to narrow on the toxin ingested (multiple drug ingestion common)
Always check pupils, temperature, and GCS along with vitals to identify toxic syndrome.
Most Common Toxic Syndromes
|Organophosphates, nerve agents||Cholinergic|
- Constricted pupils
|Antidote: pralidoxime, atropine|
|Atropine, benztropine, tricyclic antidepressants, antihistamines||Anticholinergic||Flushed dry skin, fever, dilated pupils, psychosis, seizures, HTN, tachycardia, urinary retention, ileus|
- Antidote: physostigmine (do not use if EKG changes or seizures occur)
- Seizures: benzodiazepines
|Cocaine, MDMA (Ecstasy), phencyclidine (PCP), amphetamines, caffeine, decongestants (ephedrine), theophylline||Sympathomimetic (adrenergic)||Fever, HTN, tachycardia, dilated pupils, seizures, diaphoresis|
- Sedation: benzodiazepines
- HTN control: labetalol (avoid beta-blockers)
|Morphine, fentanyl, Percocet, heroin, methadone||Opiate||Hypothermia, constricted pupils, bradycardia, hypotension, respiratory and CNS depression||Antidote: naloxone|
|Benzodiazepines, barbiturates, Ambien, chloral hydrate, diphenhydramine, antipsychotics||Sedative–hypnotic||Slurred speech, altered mental status, respiratory and CNS depression—apnea, hypotension, hypothermia|
- Alkaline diuresis for barbiturates
- Flumazenil only for acute BZD overdose
|Neuroleptic malignant syndrome (NMS)||T >40°C, rigidity, delirium, seizures, autonomic instability, elevated CPK||Overdose of neuroleptic drugs, metoclopramide, haloperidol||Treatment: bromocriptine|
|Malignant hyperthermia (MH) (see Chapter 223)||Hyperthermia, rigidity||Anesthetic agents—succinylcholine, halothane||Treatment: dantrolene|
|Serotonin syndrome||Irritability, flushing, tremor, myoclonus, diarrhea, diaphoresis||Overdose of SSRI or SSRI with MAO inhibitor||Treatment: cyproheptadine, and benzodiazepines if seizure|
- Laboratory investigations: CBC, Chem-7, blood glucose, anion gap, osmolar gap, PT/PTT/INR, LFTs, drug levels (acetaminophen, salicylate, digoxin, phenytoin, valproate, phenobarbital, lithium, theophylline as per history; quantitative levels useful for these drugs as they will change management), urine tox screen, alcohol level
- EKG—rate, rhythm, ORS duration, QTc interval
- CXR and abdominal x-ray to look for radio-opaque drugs (iron, heavy metals, and enteric-coated drugs) or packets of illicit drugs
- Sodium bicarbonate 1–2 mEq/kg for QRS >120 ms
- Diazepam 2 mg/kg
|Cyanide (sodium nitroprusside drip)|
- Hydroxocobalamin (converts cyanide and forms cynocobalamin)
- Sodium thiosulfate (enhances conversion to sodium thiocyanite)
- Sodium nitrite (induces methemoglobinemia)
|Oral hypoglycemic medications|
- Dextrose IV (D50 50 mL IV) + glucagon (1–2 mg IV/IM/SQ)
- Octreotide (2–10 μg/kg IV q12 h), diazoxide (oral)
|Methemoglobinemia||Methylene blue (1–2 mg/kg IV over 5 min, q30 min PRN)|
|Organophosphates/carbamate||Pralidoxime + atropine|
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