Evidence-based guideline for recognition, decontamination, specific antidote therapy, and enhanced elimination in acute poisoning and overdose presentations.
A comprehensive, evidence-based clinical guideline for the recognition, stabilization, decontamination, specific antidote therapy, enhanced elimination, and supportive management of acute poisoning and drug overdose in the emergency department. This resource synthesizes recommendations from the major toxicology societies, extracorporeal treatment workgroups, resuscitation organizations, and landmark clinical evidence into a single integrated reference for emergency physicians, toxicologists, intensivists, pharmacists, and all clinicians who manage poisoned patients.1 2 3 4 5 6 7 8 9 10
Poisoning and drug overdose account for over 2 million calls to United States poison centers annually, with over 100,000 resulting in significant clinical effects and more than 3,000 fatalities each year. Intentional self-harm remains the leading indication, followed by therapeutic errors, unintentional pediatric exposures, and substance abuse. The emergency physician must be proficient in toxidrome recognition, the nuances of gastrointestinal decontamination, the indications and dosing of specific antidotes, the criteria for enhanced elimination techniques including hemodialysis, and the management of toxicologic cardiac arrest. This guideline provides comprehensive, protocol-level guidance for each of these domains, organized into five parts covering the full spectrum from initial approach through specific poisonings, pediatric considerations, and substance abuse emergencies.
Contents:
| Part | Title | Coverage |
|---|---|---|
| Part 1 | General Approach, Toxidrome Recognition & GI Decontamination | Toxidrome recognition table (sympathomimetic, anticholinergic, cholinergic, opioid, sedative-hypnotic, serotonin syndrome, NMS); initial stabilization (ABCs, coma cocktail, glucose, naloxone, thiamine); diagnostic workup (toxicology screen limitations, osmol gap, anion gap, universal screening with acetaminophen and salicylate levels); activated charcoal (dosing, timing, contraindications); whole bowel irrigation; gastric lavage; multi-dose activated charcoal (MDAC) |
| Part 2 | Analgesic, Opioid, Benzodiazepine & Sedative Poisonings | Acetaminophen (Rumack-Matthew nomogram, NAC 21-hour IV and 72-hour oral protocols, massive ingestion, extended-release); salicylate (alkalinization protocol, hemodialysis criteria, Done nomogram limitations); opioids (naloxone titration, infusion, observation periods); benzodiazepines (flumazenil indications and contraindications); ethanol; GHB; barbiturates |
| Part 3 | Cardiovascular Drug, Antidepressant & Psychotropic Poisonings | Tricyclic antidepressants (sodium bicarbonate protocol, QRS criteria); calcium channel blockers (high-dose insulin euglycemia therapy); beta-blockers (glucagon, high-dose insulin); digoxin (DigiFab dosing); serotonin syndrome (Hunter criteria, cyproheptadine); neuroleptic malignant syndrome (dantrolene, bromocriptine); lithium; SSRI/SNRI; antipsychotics |
| Part 4 | Toxic Alcohols, Metals, Organophosphates, Environmental & Chemical Poisonings | Methanol and ethylene glycol (fomepizole, hemodialysis); carbon monoxide (HBO criteria); cyanide (hydroxocobalamin, sodium thiosulfate); organophosphates and nerve agents (atropine, pralidoxime); iron (deferoxamine); caustic ingestions; LAST (lipid emulsion protocol); sympathomimetics (cocaine, methamphetamine); enhanced elimination (urinary alkalinization, EXTRIP hemodialysis indications) |
| Part 5 | Pediatric Poisoning, Antidote Reference Table, Toxicologic Arrest & Substance Abuse Emergencies | “One pill can kill” list; weight-based pediatric antidote dosing; comprehensive antidote dosing reference table; toxicologic cardiac arrest algorithms by agent; alcohol withdrawal (CIWA, benzodiazepines, phenobarbital); synthetic cannabinoids; novel psychoactive substances; poison center consultation |
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One pill can kill agents, weight-based pediatric antidote dosing, comprehensive antidote dosing reference table, toxicologic cardiac arrest management by agent, alcohol withdrawal protocols, synthetic cannabinoids, novel psychoactive substances, and poison center consultation guidance.
Complete management of methanol and ethylene glycol poisoning (fomepizole, hemodialysis), carbon monoxide, cyanide, organophosphates and nerve agents, iron poisoning, caustic ingestions, local anesthetic systemic toxicity (LAST), sympathomimetic toxicity, and enhanced elimination techniques including urinary alkalinization and EXTRIP hemodialysis indications.
Complete management of TCA poisoning (sodium bicarbonate protocol), calcium channel blocker overdose (high-dose insulin), beta-blocker toxicity, digoxin poisoning (DigiFab), serotonin syndrome, neuroleptic malignant syndrome, lithium toxicity, and antipsychotic overdose.
Complete management of acetaminophen overdose (NAC protocols), salicylate poisoning (alkalinization, hemodialysis), opioid overdose (naloxone titration), benzodiazepine reversal (flumazenil), and sedative-hypnotic poisonings.
Initial approach to the poisoned patient including toxidrome recognition, diagnostic workup, toxicology screen interpretation, and gastrointestinal decontamination strategies including activated charcoal, whole bowel irrigation, gastric lavage, and multi-dose activated charcoal.