Poisoning Management

General Principles

The initial management of a poisoning case should follow standard guidelines, including airway assessment, administration of 100% oxygen, identification of the poison, and seeking advice from poison control centers, as recommended by the American Medical Association and American Thoracic Society 1, 2
Ensure patent airway and adequate ventilation, and administer 100% oxygen via mask or endotracheal tube 2
Look for toxidromes and assess mental status, vital signs, pupil size, skin condition, bowel sounds, considering specific toxins based on presentation, as recommended by the American College of Medical Toxicology 1
Healthcare providers should use appropriate personal protective equipment and be aware of specific risks with certain toxins, such as hydrogen cyanide and hydrogen sulfide, as suggested by the National Institute for Occupational Safety and Health 1

Decontamination methods include activated charcoal for drugs that can be adsorbed (within 1-2 hours of ingestion) and dermal decontamination for external exposure, as recommended by the American Heart Association and American Academy of Emergency Medicine 3, 4
The American Heart Association recommends performing dermal decontamination while wearing protective equipment to prevent secondary contamination of healthcare providers 3

Specific antidotes for suspected poisonings include:
The following antidotes and dosages are recommended:
For β-blocker poisoning, high-dose insulin and vasopressors are recommended; glucagon may be reasonable, according to the American Heart Association 3
For calcium channel blocker poisoning, vasopressors, high-dose insulin, and calcium administration are recommended, as suggested by the American College of Cardiology 3
For life-threatening poisoning with cardiogenic shock refractory to pharmacological interventions, VA-ECMO may be reasonable, according to the American Heart Association 3
For metal toxicity, cardiac manifestations include QT prolongation, heart blocks, and ventricular arrhythmias, and treatment should focus on supportive care with cardiac monitoring and chelation therapy based on the type of metal toxicity, as suggested by the American Heart Association and American College of Cardiology 5, 3

Pregnant women should be managed with prompt diagnosis and treatment, and the general principles of poisoning management apply, with special consideration for the pregnancy status, as recommended by the American College of Obstetricians and Gynecologists 6
Children may be more susceptible to pesticide exposure due to higher minute ventilation and lower body mass, and require adjusted activated charcoal dosing and closer monitoring for respiratory depression, as recommended by the American Society of Anesthesiologists 7

Extracorporeal treatment (ECTR) should be considered in cases of toxic alcohol poisoning based on specific clinical indications, including coma, seizures, acute kidney injury (KDIGO stage 2 or 3), and chronic kidney disease (eGFR <45 mL/min/1.73m²), as recommended by the American Society of Nephrology 8
Laboratory indicators for ECTR include:
Indication Threshold
Anion gap >27 mmol/L
Glycolate concentration >12 mmol/L
eGFR <45 mL/min/1.73m²
KDIGO stage 2 or 3

Patients should be monitored for at least 24-36 hours after ingestion, with continuous cardiac monitoring due to the risk of dysrhythmias, and serial assessment of vital signs and mental status, as recommended by the American Heart Association 3
Ensure source of poisoning is eliminated before discharge, as recommended by the American Academy of Emergency Medicine 2
Patients with neurotoxic poison should be monitored for delayed neurological sequelae, as suggested by the American Academy of Emergency Medicine 2