C H AP T E R e5 0

Poisoning and Drug

Overdosage
Mark B. Mycyk

EPIDEMIOLOGY
More than 5 million poison exposures occur in the United States
each year. Most are acute, accidental (unintentional), involve a
single agent, occur in the home, result in minor or no toxicity, and
involve children younger than 6 years of age. Pharmaceuticals are
involved in 47% of exposures and 84% of serious or fatal poisonings. Unintentional exposures can result from the improper use of
chemicals at work or play; label misreading; product mislabeling;
mistaken identification of unlabeled chemicals; uninformed selfmedication; and dosing errors by nurses, pharmacists, physicians,
parents, and the elderly. Excluding the recreational use of ethanol,
attempted suicide (deliberate self-harm) is the most common
reported reason for intentional poisoning. Recreational use of prescribed and over-the-counter drugs for psychotropic or euphoric
effects (abuse) or excessive self-dosing (misuse) are increasingly
common and may also result in unintentional self-poisoning.
About 2025% of exposures require bedside health professional evaluation, and 5% of all exposures require hospitalization.
Poisonings account for 510% of all ambulance transports, emergency department visits, and intensive care unit admissions. Up to
30% of psychiatric admissions are prompted by attempted suicide
via overdosage. Overall, the mortality rate is low: <1% of all exposures. It is much higher (12%) in hospitalized patients with intentional (suicidal) overdose, who account for the majority of serious
poisonings. Acetaminophen is the pharmaceutical agent most often
implicated in fatal poisoning. Overall, carbon monoxide is the
leading cause of death from poisoning, but this is not reflected in
hospital or poison center statistics because patients with such poisoning are typically dead when discovered and are referred directly
to medical examiners.
DIAGNOSIS
Although poisoning can mimic other illnesses, the correct diagnosis can usually be established by the history, physical examination,
routine and toxicologic laboratory evaluations, and characteristic

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CHAPTER e50 Poisoning and Drug Overdosage

Poisoning refers to the development of dose-related adverse effects

following exposure to chemicals, drugs, or other xenobiotics. To
paraphrase Paracelsus, the dose makes the poison. In excessive
amounts, substances that are usually innocuous, such as oxygen
and water, can cause toxicity. Conversely, in small doses, substances
commonly regarded as poisons, such as arsenic and cyanide, can be
consumed without ill effect. Although most poisons have predictable dose-related effects, individual variability in the response to a
given dose may occur because of genetic polymorphism, enzymatic
induction or inhibition in the presence of other xenobiotics, or
acquired tolerance. Poisoning may be local (e.g., skin, eyes, or
lungs) or systemic depending on the route of exposure, the chemical
and physical properties of the poison, and its mechanism of action.
The severity and reversibility of poisoning also depend on the functional reserve of the individual or target organ, which is influenced
by age and preexisting disease.

clinical course. The history should include the time, route, duration,
and circumstances (location, surrounding events, and intent) of
exposure; the name and amount of each drug, chemical, or ingredient involved; the time of onset, nature, and severity of symptoms;
the time and type of first-aid measures provided; and the medical
and psychiatric history.
In many cases the patient is confused, comatose, unaware of
an exposure, or unable or unwilling to admit to one. Suspicious
circumstances include unexplained sudden illness in a previously
healthy person or a group of healthy people; a history of psychiatric problems (particularly depression); recent changes in health,
economic status, or social relationships; and onset of illness while
working with chemicals or after ingesting food, drink (especially
ethanol), or medications. Patients who become ill soon after arriving from a foreign country or being arrested for criminal activity
should be suspected of body packing or body stuffing (ingesting
or concealing illicit drugs in a body cavity). Relevant history may
be available from family, friends, paramedics, police, pharmacists,
physicians, and employers, who should be questioned regarding the
patients habits, hobbies, behavior changes, available medications,
and antecedent events. A search of clothes, belongings, and place of
discovery may reveal a suicide note or a container of drugs or chemicals. The imprint code on pills and the label on chemical products
may be used to identify the ingredients and potential toxicity of a
suspected poison by consulting a reference text, a computerized
database, the manufacturer, or a regional poison information center
(800-222-1222). Occupational exposures require review of any
available material safety data sheet (MSDS) from the worksite.
The physical examination should focus initially on the vital signs,
cardiopulmonary system, and neurologic status. The neurologic
examination should include documentation of neuromuscular
abnormalities such as dyskinesia, dystonia, fasciculations, myoclonus, rigidity, and tremors. The patient should also be examined
for evidence of trauma and underlying illnesses. Focal neurologic
findings are uncommon in poisoning, and their presence should
prompt evaluation for a structural central nervous system (CNS)
lesion. Examination of the eyes (for nystagmus, pupil size and
reactivity), abdomen (for bowel activity and bladder size), and skin
(for burns, bullae, color, warmth, moisture, pressure sores, and
puncture marks) may reveal findings of diagnostic value. When the
history is unclear, all orifices should be examined for the presence
of chemical burns and drug packets. The odor of breath or vomitus
and the color of nails, skin, or urine may provide important diagnostic clues.
The diagnosis of poisoning in cases of unknown etiology primarily relies on pattern recognition. The first step is to assess the
pulse, blood pressure, respiratory rate, temperature, and neurologic
status and characterize the overall physiologic state as stimulated,
depressed, discordant, or normal (Table e50-1). Obtaining a
complete set of vital signs and reassessing them frequently are
critical. Measuring core temperature is especially important, even
in difficult or combative patients, since temperature elevation is
the most reliable prognosticator of poor outcome in poisoning or
drug withdrawal. The next step is to consider the underlying causes
of the physiologic state and attempt to identify a pathophysiologic
pattern or toxic syndrome (toxidrome) based on the observed
findings. Assessing the severity of physiologic derangements
(Table e50-2) is useful in this regard and also for monitoring
the clinical course and response to treatment. The final step is to
attempt to identify the particular agent involved by looking for
unique or relatively poison-specific physical or ancillary test abnormalities. Distinguishing among toxidromes based on the physiologic state is summarized below.

50-1

TABLE e50-1 Differential Diagnosis of Poisoning Based on Physiologic State

PART 18
Poisoning, Drug Overdose, and Envenomation

Stimulated

Depressed

Discordant

Normal

Sympathetics
Sympathomimetics
Ergot alkaloids
Methylxanthines
Monoamine oxidase inhibitors
Thyroid hormones
Anticholinergics
Antihistamines
Antiparkinsonian agents
Antipsychotics
Antispasmodics
Belladonna alkaloids
Cyclic antidepressants
Muscle relaxants
Mushrooms and plants
Hallucinogens
Cannabinoids (marijuana)
LSD and analogues
Mescaline and analogues
Mushrooms
Phencyclidine and analogues
Withdrawal syndromes
Barbiturates
Benzodiazepines
Ethanol
Opioids
Sedative-hypnotics
Sympatholytics

Sympatholytics
1-Adrenergic antagonists
2-Adrenergic agonists
ACE inhibitors
Angiotensin receptor blockers
Antipsychotics
-Adrenergic blockers
Calcium channel blockers
Cardiac glycosides
Cyclic antidepressants
Cholinergics
Acetylcholinesterase
inhibitors
Muscarinic agonists
Nicotinic agonists
Opioids
Analgesics
GI antispasmodics
Heroin
Sedative-hypnotics
Alcohols
Anticonvulsants
Barbiturates
Benzodiazepines
GABA precursors
Muscle relaxants
Other agents
GHB products

Asphyxiants
Cytochrome oxidase inhibitors
Inert gases
Irritant gases
Methemoglobin inducers
Oxidative phosphorylation
inhibitors
AGMA inducers
Alcohol (ketoacidosis)
Ethylene glycol
Iron
Methanol
Salicylate
Toluene
CNS syndromes
Extrapyramidal reactions
Hydrocarbon inhalation
Isoniazid
Lithium
Neuroleptic malignant
syndrome
Serotonin syndrome
Strychnine
Membrane-active agents
Amantadine
Antiarrhythmics
Antihistamines
Antipsychotics
Carbamazepine
Cyclic antidepressants
Local anesthetics
Opioids (some)
Orphenadrine
Quinoline antimalarials

Nontoxic exposure
Psychogenic illness
Toxic time-bombs
Slow absorption
Anticholinergics
Carbamazepine
Concretion formers
Extended-release phenytoin
sodium capsules (Dilantin
Kapseals)
Drug packets
Enteric-coated pills
Diphenoxylate-atropine (Lomotil)
Opioids
Salicylates
Sustained-release pills
Valproate
Slow distribution
Cardiac glycosides
Lithium
Metals
Salicylate
Valproate
Toxic metabolite
Acetaminophen
Carbon tetrachloride
Cyanogenic glycosides
Ethylene glycol
Methanol
Methemoglobin inducers
Mushroom toxins
Organophosphate insecticides
Paraquat
Metabolism disruptors
Antineoplastic agents
Antiviral agents
Colchicine
Hypoglycemic agents
Immunosuppressive agents
MAO inhibitors
Metals
Salicylate
Warfarin

Abbreviations: ACE, angiotensin-converting enzyme; AGMA, anion-gap metabolic acidosis; CNS, central nervous system; GABA, -aminobutyric acid; GHB, -hydroxybutyrate;
GI, gastrointestinal; LSD, lysergic acid diethylamide; MAO, monoamine oxidase.

Increased pulse, blood pressure, respiratory rate, temperature,

and neuromuscular activity characterize the stimulated physiologic
state: sympathetic, antimuscarinic (anticholinergic), hallucinogen
poisoning, and drug withdrawal (Table e50-1). Other features
are noted in Table e50-2. Mydriasis, a characteristic feature of all
stimulants, is most marked in antimuscarinic (anticholinergic)

50-2

poisoning since pupillary reactivity relies on muscarinic control;

in sympathetic poisoning (e.g., cocaine), pupils are also enlarged,
but some reactivity to light is observed. The antimuscarinic (anticholinergic) toxidrome is also distinguished by the presence of hot,
dry, flushed skin; decreased bowel sounds; and urinary retention
(Table e50-1). Other stimulant syndromes increase sympathetic

Copyright 2012 The McGraw-Hill Companies, Inc. All rights reserved.

TABLE e50-2 Severity of Physiologic Stimulation

and Depression in Poisoning and
Drug Withdrawal
Physiologic Stimulation
Anxious, irritable, tremulous; vital signs normal;
diaphoresis, flushing or pallor, mydriasis, and
hyperreflexia may be present

Grade 2

Agitated; may have confusion or hallucinations but is able

to converse and follow commands; vital signs mildly to
moderately increased

Grade 3

Delirious; unintelligible speech, uncontrollable motor

hyperactivity; moderately to markedly increased vital
signs; tachyarrhythmias possible

Grade 4

Coma, seizures, cardiovascular collapse

Physiologic Depression
Grade 1

Awake, lethargic, or sleeping but arousable by voice

or tactile stimulation; able to converse and follow
commands; may be confused

Grade 2

Responds to pain but not voice; can vocalize but not

converse; spontaneous motor activity present; brainstem
reflexes intact

Grade 3

Unresponsive to pain; spontaneous motor activity absent;

brainstem reflexes depressed; motor tone, respirations,
and temperature decreased

Grade 4

Unresponsive to pain; flaccid paralysis; brainstem reflexes

and respirations absent; cardiovascular vital signs
decreased

activity and cause diaphoresis, pallor, and increased bowel activity with varying degrees of nausea, vomiting, abnormal distress,
and occasionally diarrhea. The absolute and relative degree of vital
sign changes and neuromuscular hyperactivity can help distinguish
among stimulant toxidromes. Since sympathetics stimulate the
peripheral nervous system more directly than do hallucinogens or
drug withdrawal, markedly increased vital signs and organ ischemia
suggest sympathetic poisoning. Findings helpful in suggesting the
particular drug or class causing physiologic stimulation include
reflex bradycardia from selective -adrenergic stimulants (e.g.,
decongestants), hypotension from selective -adrenergic stimulants
(e.g., asthma therapeutics), limb ischemia from ergot alkaloids,
rotatory nystagmus from phencyclidine and ketamine (the only
physiologic stimulants that cause this finding), and delayed cardiac
conduction from high doses of cocaine and some anticholinergic
agents (e.g., antihistamines, cyclic antidepressants, and antipsychotics). Seizures suggest a sympathetic etiology, an anticholinergic
agent with membrane-active properties (e.g., cyclic antidepressants,
orphenadrine, phenothiazines), or a withdrawal syndrome. Close
attention to core temperature is critical in patients with grade 4
physiologic stimulation (Table e50-2).
Decreased pulse, blood pressure, respiratory rate, temperature,
and neuromuscular activity are indicative of depressed physiologic
state caused by functional sympatholytics (agents that decrease
cardiac function and vascular tone as well as sympathetic activity),
cholinergic (muscarinic and nicotinic) agents, opioids, and sedativehypnotic -aminobutyric acid (GABA)-ergic agents (Tables e50-1
and e50-2). Miosis is also common and most pronounced in
opioid and cholinergic poisoning. The latter is distinguished from
other depressant syndromes by the presence of muscarinic and

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CHAPTER e50 Poisoning and Drug Overdosage

Grade 1

nicotinic signs and symptoms (Table e50-1). Pronounced cardiovascular depression in the absence of significant CNS depression
suggests a direct or peripherally acting sympatholytic. In contrast,
in opioid and sedative-hypnotic poisoning, vital sign changes are
secondary to depression of CNS cardiovascular and respiratory
centers (or consequent hypoxemia), and significant abnormalities
in these parameters do not occur until there is a marked decrease
in the level of consciousness (grade 3 or 4 physiologic depression,
Table e50-2). Other clues that suggest the cause of physiologic
depression include cardiac arrhythmias and conduction disturbances
(due to antiarrhythmics, -adrenergic antagonists, calcium-channel
blockers, digitalis glycosides, propoxyphene, and cyclic antidepressants),
mydriasis [due to tricyclic antidepressants, some antiarrhythmics,
meperidine, and diphenoxylate-atropine (Lomotil)], nystagmus
(due to sedative-hypnotics), and seizures (due to cholinergic agents,
propoxyphene, cyclic antidepressants).
The discordant physiologic state is characterized by mixed vital
sign and neuromuscular abnormalities as observed in poisoning
by asphyxiants, CNS syndromes, membrane-active agents, and
anion-gap metabolic acidosis (AGMA) inducers (Table e50-1). In
these conditions, manifestations of physiologic stimulation and
physiologic depression occur together or at different times during
the clinical course. For example, membrane-active agents can cause
simultaneous coma, seizures, hypotension, and tachyarrhythmias.
Alternatively, vital signs may be normal but the patient has altered
mental status or is obviously sick or clearly symptomatic. Early,
pronounced vital sign and mental status changes suggest asphyxiant
or membrane-active agent poisoning; the lack of such abnormalities
suggests an AGMA inducer; and marked neuromuscular dysfunction without significant vital sign abnormalities suggests a CNS
syndrome.
A normal physiologic status and physical examination may be
due to a nontoxic exposure, psychogenic illness, or poisoning by
toxic time-bombs, agents that are slowly absorbed, slowly distributed to their sites of action, require metabolic activation, or disrupt
metabolic processes (Table e50-1). Because so many medications
are now reformulated in a once-a-day form for patient convenience
and adherence, toxic time-bombs are increasingly common.
Diagnosing a nontoxic exposure requires that the identity of the
exposure agent be known or that a toxic time-bomb exposure has
been excluded and that the time since exposure exceeds the longest
known or predicted interval between exposure and peak toxicity.
Psychogenic illness (fear of being poisoned, mass hysteria) may also
occur after a nontoxic exposure and should be considered when
symptoms are inconsistent with the exposure history. Anxiety reactions resulting from a nontoxic exposure can cause mild physiologic
stimulation (Table e50-2) and be indistinguishable from toxicologic
causes (Table e50-1) without ancillary testing or a suitable period
of observation.
Laboratory assessment may be helpful in the differential diagnosis. An increased AGMA is most common in advanced methanol,
ethylene glycol, and salicylate intoxication but can occur in any
poisoning that results in hepatic, renal, or respiratory failure;
seizures; or shock. The serum lactate concentration is more commonly low (less than the anion gap) in the former and high (nearly
equal to the anion gap) in the latter. An abnormally low anion gap
can be due to elevated blood levels of bromide, calcium, iodine,
lithium, or magnesium. An increased osmolal gapa difference
between the serum osmolality (measured by freezing point depression) and that calculated from the serum sodium, glucose, and
blood urea nitrogen of >10 mmol/Lsuggests the presence of a
low-molecular-weight solute such as acetone; an alcohol (benzyl,
ethanol, isopropanol, methanol); a glycol (diethylene, ethylene,
propylene); ether (ethyl, glycol); or an unmeasured cation
(calcium, magnesium) or sugar (glycerol, mannitol, sorbitol).

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PART 18
Poisoning, Drug Overdose, and Envenomation
50-4

Ketosis suggests acetone, isopropyl alcohol, salicylate poisoning,

or alcoholic ketoacidosis. Hypoglycemia may be due to poisoning
with -adrenergic blockers, ethanol, insulin, oral hypoglycemic
agents, quinine, and salicylates, whereas hyperglycemia can occur
in poisoning with acetone, -adrenergic agonists, caffeine, calcium
channel blockers, iron, theophylline, or N-3-pyridylmethyl-N-pnitrophenylurea [PNU (Vacor)]. Hypokalemia can be caused by
barium, -adrenergic agonists, caffeine, diuretics, theophylline,
or toluene; hyperkalemia suggests poisoning with an -adrenergic
agonist, a -adrenergic blocker, cardiac glycosides, or fluoride.
Hypocalcemia may be seen in ethylene glycol, fluoride, and oxalate
poisoning.
The electrocardiogram (ECG) can be useful for rapid diagnostic purposes. Bradycardia and atrioventricular block may occur
in patients poisoned by -adrenergic agonists, antiarrhythmic
agents, beta blockers, calcium channel blockers, cholinergic agents
(carbamate and organophosphate insecticides), cardiac glycosides,
lithium, or tricyclic antidepressants. QRS- and QT-interval prolongation may be caused by hyperkalemia, various antidepressants,
and other membrane-active drugs (Table e50-1). Ventricular tachyarrhythmias may be seen in poisoning with cardiac glycosides,
fluorides, membrane-active drugs, methylxanthines, sympathomimetics, antidepressants, and agents that cause hyperkalemia or
potentiate the effects of endogenous catecholamines (e.g., chloral
hydrate, aliphatic and halogenated hydrocarbons).
Radiologic studies may occasionally be useful. Pulmonary edema
[adult respiratory distress syndrome (ARDS)] can be caused by
poisoning with carbon monoxide, cyanide, an opioid, paraquat,
phencyclidine, a sedative-hypnotic, or salicylate; by inhalation
of irritant gases, fumes, or vapors (acids and alkali, ammonia,
aldehydes, chlorine, hydrogen sulfide, isocyanates, metal oxides,
mercury, phosgene, polymers); or by prolonged anoxia, hyperthermia, or shock. Aspiration pneumonia is common in patients
with coma, seizures, and petroleum distillate aspiration. The
presence of radiopaque densities on abdominal x-rays suggests
the ingestion of calcium salts, chloral hydrate, chlorinated hydrocarbons, heavy metals, illicit drug packets, iodinated compounds,
potassium salts, enteric-coated tablets, or salicylates.
Toxicologic analysis of urine and blood (and occasionally of
gastric contents and chemical samples) can sometimes confirm
or rule out suspected poisoning. Interpretation of laboratory data
requires knowledge of the qualitative and quantitative tests used
for screening and confirmation (enzyme-multiplied, fluorescence
polarization, and radio-immunoassays; colorimetric and fluorometric assays; thin-layer, gas-liquid, or high-performance liquid
chromatography; gas chromatography; mass spectrometry), their
sensitivity (limit of detection) and specificity, the preferred biologic specimen for analysis, and the optimal time of specimen
sampling. Personal communication with the hospital laboratory
is essential to understand institutional testing capabilities and
limitations.
Rapid qualitative hospital-based urine tests for drugs of abuse
are only screening tests that cannot confirm the exact identity of
the detected substance and should not be considered diagnostic or
used for forensic purposes: False-positive and false-negative results
are common. A positive screen may result from other pharmaceuticals that interfere with laboratory analysis (e.g., fluoroquinolones
commonly cause false-positive opiate screens). Confirmatory
testing with gas chromatography/mass spectrometry (GC/MS) can
be requested, but often takes weeks to obtain a reported result. A
negative screening result may mean the substance is not detectable
by the test used or that its concentration is too low for detection
at the time of sampling. In the latter case, repeating the test at a
later time may yield a positive result. Patients symptomatic from
drugs of abuse often require immediate management based on the

history, physical examination, and observed toxidrome without

laboratory confirmation (e.g., apnea from opioid intoxication).
When the patient is asymptomatic, or when the clinical picture is
consistent with the reported history, several studies have shown
qualitative screening is neither clinically useful nor cost-effective.
Thus, qualitative drug screens are of greatest value when evaluating
patients with severe or unexplained toxicity such as coma, seizures,
cardiovascular instability, metabolic or respiratory acidosis, and
nonsinus cardiac rhythms. In contrast to qualitative drug screens,
quantitative serum tests are useful for evaluating patients poisoned
with acetaminophen (Chap. 305), alcohols (including ethylene
glycol and methanol), anticonvulsants, barbiturates, digoxin, heavy
metals, iron, lithium, salicylate, and theophylline, as well as for
carboxyhemoglobin and methemoglobin. The serum concentration
in these cases guides clinical management, and results can often be
available within an hour.
The response to antidotes is sometimes useful for diagnostic
purposes. Resolution of altered mental status and abnormal vital
signs within minutes of IV administration of dextrose, naloxone,
or flumazenil is virtually diagnostic of hypoglycemia, narcotic
poisoning, and benzodiazepine intoxication, respectively. The
prompt reversal of dystonic (extrapyramidal) signs and symptoms
following an IV dose of benztropine or diphenhydramine confirms
a drug etiology. Although complete reversal of both central and
peripheral manifestations of anticholinergic poisoning by physostigmine is diagnostic of this condition, physostigmine may cause
some arousal in patients with CNS depression of any etiology.

TREATMENT

Poisoning and Drug Overdose

GENERAL PRINCIPLES Treatment goals include support of vital

signs, prevention of further poison absorption (decontamination),
enhancement of poison elimination, administration of specific
antidotes, and prevention of reexposure (Table e50-3). Specific
treatment depends on the identity of the poison, the route and
amount of exposure, the time of presentation relative to the
time of exposure, and the severity of poisoning. Knowledge of
the offending agents pharmacokinetics and pharmacodynamics
is essential.
During the pretoxic phase, prior to the onset of poisoning,
decontamination is the highest priority, and treatment is based
solely on the history. The maximum potential toxicity based
on the greatest possible exposure should be assumed. Since
decontamination is more effective when accomplished soon
after exposure, and when the patient is asymptomatic, the initial
history and physical examination should be focused and brief.
It is also advisable to establish IV access and initiate cardiac
monitoring, particularly in patients with potentially serious
ingestions or unclear histories.
When an accurate history is not obtainable and a poison causing delayed toxicity (toxic time-bomb) or irreversible damage
is suspected, blood and urine should be sent for appropriate
toxicologic screening and quantitative analysis. During absorption and distribution, blood levels may be greater than those in
tissue and may not correlate with toxicity. However, high blood
levels of agents whose metabolites are more toxic than the parent
compound (acetaminophen, ethylene glycol, or methanol) may
indicate the need for additional interventions (antidotes, dialysis).
Most patients who remain or become asymptomatic 6 h after
ingestion are unlikely to develop subsequent toxicity and can
be discharged safely. Longer observation will be necessary for
patients who have ingested toxic time-bombs, agents that are
slowly absorbed, slowly distributed to their sites of action,

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TABLE e50-3 Fundamentals of Poisoning

Management
Supportive Care
Airway protection
Oxygenation/ventilation
Treatment of arrhythmias
Hemodynamic support

Treatment of seizures
Correction of temperature abnormalities
Correction of metabolic derangements
Prevention of secondary complications

Prevention of Further Poison Absorption

Decontamination of other sites
Eye decontamination
Skin decontamination
Body cavity evacuation

Enhancement of Poison Elimination

Multiple-dose activated
charcoal
Alteration of urinary pH
Chelation

Extracorporeal removal
Hemodialysis
Hemoperfusion
Hemofiltration
Plasmapheresis
Exchange transfusion
Hyperbaric oxygenation

Administration of Antidotes
Neutralization by antibodies
Neutralization by chemical
binding

Metabolic antagonism
Physiologic antagonism

Prevention of Reexposure
Adult education
Child-proofing

Notification of regulatory agencies

Psychiatric referral

require metabolic activation, or disrupt metabolic processes

(Table e50-1). During the toxic phase, the time between the onset
of poisoning and the peak effects, management is based primarily on clinical and laboratory findings. Effects after an overdose
usually begin sooner, peak later, and last longer than they do after
a therapeutic dose. A drugs published pharmacokinetic profile
in standard references such as the Physicians Desk Reference
(PDR) is usually different from its toxicokinetic profile in
overdose. Resuscitation and stabilization are the first priority.
Symptomatic patients should have an IV line, oxygen saturation
determination, cardiac monitoring, and continuous observation. Baseline laboratory, ECG, and x-ray evaluation may also
be appropriate. Intravenous glucose (unless the serum level is
documented to be normal), naloxone, and thiamine should be
considered in patients with altered mental status, particularly
those with coma or seizures. Decontamination should also be
considered, but it is less likely to be effective during this phase
than during the pretoxic one.
Measures that enhance poison elimination may shorten the
duration and severity of the toxic phase. However, they are not
without risk, which must be weighed against the potential benefit.

SUPPORTIVE CARE The goal of supportive therapy is to maintain physiologic homeostasis until detoxification is accomplished
and to prevent and treat secondary complications such as aspiration, bedsores, cerebral and pulmonary edema, pneumonia,
rhabdomyolysis, renal failure, sepsis, thromboembolic disease,
coagulopathy, and generalized organ dysfunction due to hypoxemia or shock.
Admission to an intensive care unit is indicated for the
following: patients with severe poisoning (coma, respiratory
depression, hypotension, cardiac conduction abnormalities, cardiac arrhythmias, hypothermia or hyperthermia, seizures); those
needing close monitoring, antidotes, or enhanced elimination
therapy; those showing progressive clinical deterioration; and
those with significant underlying medical problems. Patients
with mild to moderate toxicity can be managed on a general
medical service, intermediate care unit, or emergency department observation area, depending on the anticipated duration
and level of monitoring needed (intermittent clinical observation versus continuous clinical, cardiac, and respiratory monitoring). Patients who have attempted suicide require continuous
observation and measures to prevent self-injury until they are no
longer suicidal.

CHAPTER e50 Poisoning and Drug Overdosage

Gastrointestinal
decontamination
Gastric lavage
Activated charcoal
Whole-bowel irrigation
Dilution
Endoscopic/surgical
removal

Diagnostic certainty (usually via laboratory confirmation) is generally a prerequisite. Intestinal (or gut) dialysis with repetitive
doses of activated charcoal (also termed multidose activated
charcoal) can enhance the elimination of selected poisons such
as theophylline or carbamazepine. Urinary alkalinization may
enhance the elimination of salicylates and a small number of other
poisons. Chelation therapy can enhance the elimination of selected
metals. Extracorporeal elimination methods are effective for many
poisons, but their expense and risk make their use reasonable only
in patients who would otherwise have an unfavorable outcome.
During the resolution phase of poisoning, supportive care
and monitoring should continue until clinical, laboratory,
and ECG abnormalities have resolved. Since chemicals are
eliminated sooner from the blood than from tissues, blood
levels are usually lower than tissue levels during this phase
and again may not correlate with toxicity. This is particularly
true when extracorporeal elimination procedures are used.
Redistribution from tissues may cause a rebound increase in
the blood level after termination of these procedures. When
a metabolite is responsible for toxic effects, continued treatment might be necessary in the absence of clinical toxicity or
abnormal laboratory studies.

Respiratory Care Endotracheal intubation for protection

against the aspiration of gastrointestinal contents is of paramount importance in patients with CNS depression or seizures
as this complication can increase morbidity and mortality rates.
Mechanical ventilation may be necessary for patients with
respiratory depression or hypoxemia and to facilitate therapeutic
sedation or paralysis in order to prevent or treat hyperthermia,
acidosis, and rhabdomyolysis associated with neuromuscular
hyperactivity. Since clinical assessment of respiratory function
can be inaccurate, the need for oxygenation and ventilation is
best determined by continuous pulse oximetry or arterial bloodgas analysis. The gag reflex is not a reliable indicator of the need
for intubation. A patient with CNS depression may maintain airway patency while being stimulated but not if left alone. Druginduced pulmonary edema is usually noncardiac rather than
cardiac in origin, although profound CNS depression and cardiac conduction abnormalities suggest the latter. Measurement
of pulmonary artery pressure may be necessary to establish the
cause and direct appropriate therapy. Extracorporeal measures

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50-5

(membrane oxygenation, venoarterial perfusion, cardiopulmonary bypass) and partial liquid (perfluorocarbon) ventilation
may be appropriate for severe but reversible respiratory failure.

PART 18
Poisoning, Drug Overdose, and Envenomation

Cardiovascular Therapy Maintenance of normal tissue perfusion is critical for complete recovery to occur once the offending
agent has been eliminated. If hypotension is unresponsive to
volume expansion, treatment with norepinephrine, epinephrine,
or high-dose dopamine may be necessary. Intraaortic balloon
pump counterpulsation and venoarterial or cardiopulmonary
perfusion techniques should be considered for severe but reversible cardiac failure. Bradyarrhythmias associated with hypotension generally should be treated as described in Chap. 232.
Glucagon, calcium, and high-dose insulin with dextrose may be
effective in beta blocker and calcium channel blocker poisoning. Antibody therapy may be indicated for cardiac glycoside
poisoning.
Supraventricular tachycardia associated with hypertension
and CNS excitation is almost always due to agents that cause
generalized physiologic excitation (Table e50-1). Most cases are
mild or moderate in severity and require only observation or
nonspecific sedation with a benzodiazepine. In severe cases
or those associated with hemodynamic instability, chest pain,
or ECG evidence of ischemia, specific therapy is indicated.
When the etiology is sympathetic hyperactivity, treatment
with a benzodiazepine should be prioritized. Further treatment
with a combined alpha and beta blocker (labetalol), a calcium
channel blocker (verapamil or diltiazem), or a combination of
a beta blocker and a vasodilator (esmolol and nitroprusside)
may be considered for cases refractory to high doses of benzodiazepines. Treatment with an -adrenergic antagonist (phentolamine) alone may sometimes be appropriate. If the cause is
anticholinergic poisoning, physostigmine alone can be effective.
Supraventricular tachycardia without hypertension is generally
secondary to vasodilation or hypovolemia and responds to fluid
administration.
For ventricular tachyarrhythmias due to tricyclic antidepressants and other membrane-active agents (Table e50-1),
sodium bicarbonate is indicated, whereas class IA, IC, and III
antiarrhythmic agents are contraindicated because of similar
electrophysiologic effects. Although lidocaine and phenytoin
are historically safe for ventricular tachyarrhythmias of any
etiology, sodium bicarbonate should be considered first for any
ventricular arrhythmia suspected to have a toxicologic etiology.
Beta blockers can be hazardous if the arrhythmia is due to sympathetic hyperactivity. Magnesium sulfate and overdrive pacing
(by isoproterenol or a pacemaker) may be useful in patients with
torsades des pointes and prolonged QT intervals. Magnesium
and anti-digoxin antibodies should be considered in patients
with severe cardiac glycoside poisoning. Invasive (esophageal
or intracardiac) ECG recording may be necessary to determine
the origin (ventricular or supraventricular) of wide-complex
tachycardias (Chap. 233). If the patient is hemodynamically
stable, however, it is reasonable to simply observe him or her
rather than to administer another potentially proarrhythmic
agent. Arrhythmias may be resistant to drug therapy until
underlying acid-base, electrolyte, oxygenation, and temperature
derangements are corrected.
Central Nervous System Therapies Neuromuscular hyperactivity and seizures can lead to hyperthermia, lactic acidosis, and
rhabdomyolysis and should be treated aggressively. Seizures
caused by excessive stimulation of catecholamine receptors
(sympathomimetic or hallucinogen poisoning and drug withdrawal) or decreased activity of GABA (isoniazid poisoning)

50-6

or glycine (strychnine poisoning) receptors are best treated

with agents that enhance GABA activity, such as benzodiazepine or barbiturates. Since benzodiazepines and barbiturates
act by slightly different mechanisms (the former increases the
frequency, and the latter increases the duration of chloride
channel opening in response to GABA), therapy with both may
be effective when neither is effective alone. Seizures caused
by isoniazid, which inhibits the synthesis of GABA at several
steps by interfering with the cofactor pyridoxine (vitamin B6),
may require high doses of supplemental pyridoxine. Seizures
resulting from membrane destabilization (beta blocker or
cyclic antidepressant poisoning) require GABA enhancers
(benzodiazepines first, barbiturates second). Phenytoin is
contraindicated in toxicologic seizures: Animal and human
data demonstrate worse outcomes after phenytoin loading,
especially in theophylline overdose. For poisons with central dopaminergic effects (methamphetamine, phencyclidine)
manifested by psychotic behavior, a dopamine receptor antagonist, such as haloperidol, may be useful. In anticholinergic and
cyanide poisoning, specific antidotal therapy may be necessary. The treatment of seizures secondary to cerebral ischemia
or edema or to metabolic abnormalities should include correction of the underlying cause. Neuromuscular paralysis is
indicated in refractory cases. Electroencephalographic monitoring and continuing treatment of seizures are necessary to
prevent permanent neurologic damage. Serotonergic receptor
overstimulation in serotonin syndrome may be treated with
cyproheptadine.
Other Measures Temperature extremes, metabolic abnormalities, hepatic and renal dysfunction, and secondary complications
should be treated by standard therapies.
PREVENTION OF POISON ABSORPTION
Gastrointestinal Decontamination Whether or not to perform
gastrointestinal decontamination, and which procedure to use,
depends on the time since ingestion; the existing and predicted
toxicity of the ingestant; the availability, efficacy, and contraindications of the procedure; and the nature, severity, and risk of
complications. The efficacy of all decontamination procedures
decreases with time, and there are insufficient data to support
or exclude a beneficial effect when they are used >1 h after
ingestion. The average time from ingestion to presentation for
treatment is >1 h for children and >3 h for adults. Most patients
will recover from poisoning uneventfully with good supportive
care alone, but complications of gastrointestinal decontamination, particularly aspiration, can prolong this process. Hence,
gastrointestinal decontamination should be performed selectively, not routinely, in the management of overdose patients.
It is clearly unnecessary when predicted toxicity is minimal
or the time of expected maximal toxicity has passed without
significant effect.
Activated charcoal has comparable or greater efficacy, fewer
contraindications and complications, and is less aversive and
invasive than ipecac or gastric lavage; thus it is the preferred
method of gastrointestinal decontamination in most situations. Activated charcoal suspension (in water) is given orally
via a cup, straw, or small-bore nasogastric tube. The generally
recommended dose is 1 g/kg body weight because of its convenience, although in vitro and in vivo studies have demonstrated charcoal adsorbs 90% of most substances when given
in an amount equal to 10 times the weight of the substance.
Palatability may be increased by adding a sweetener (sorbitol)
or a flavoring agent (cherry, chocolate, or cola syrup) to the
suspension. Charcoal adsorbs ingested poisons within the gut

Copyright 2012 The McGraw-Hill Companies, Inc. All rights reserved.

obstruction, ileus, hemodynamic instability, and compromised

unprotected airways.
Cathartics are salts (disodium phosphate, magnesium citrate
and sulfate, sodium sulfate) or saccharides (mannitol, sorbitol)
that historically have been given with activated charcoal to promote the rectal evacuation of gastrointestinal contents. However,
no animal, volunteer, or clinical data have ever demonstrated any
decontamination benefit from cathartics. Abdominal cramps,
nausea, and occasional vomiting are side effects. Complications
of repeated dosing include severe electrolyte disturbances and
excessive diarrhea. Cathartics are contraindicated in patients
who have ingested corrosives and in those with preexisting diarrhea. Magnesium-containing cathartics should not be used in
patients with renal failure.
Dilution (i.e., drinking 5 mL/kg of body weight of water,
another clear liquid, or milk) is recommended only after the
ingestion of corrosives (acids, alkali). It may increase the dissolution rate (and hence absorption) of capsules, tablets, and other
solid ingestants and should not be used in these circumstances.
Endoscopic or surgical removal of poisons may be useful in
rare situations, such as ingestion of a potentially toxic foreign
body that fails to transit the gastrointestinal tract, a potentially lethal amount of a heavy metal (arsenic, iron, mercury,
thallium), or agents that have coalesced into gastric concretions
or bezoars (heavy metals, lithium, salicylates, sustained-release
preparations). Patients who become toxic from cocaine due to
its leakage from ingested drug packets require immediate surgical
intervention.
Decontamination of Other Sites Immediate, copious flushing with water, saline, or another available clear, drinkable
liquid is the initial treatment for topical exposures (exceptions
include alkali metals, calcium oxide, phosphorus). Saline is
preferred for eye irrigation. A triple wash (water, soap, water)
may be best for dermal decontamination. Inhalational exposures should be treated initially with fresh air or oxygen. The
removal of liquids from body cavities such as the vagina or
rectum is best accomplished by irrigation. Solids (drug packets,
pills) should be removed manually, preferably under direct
visualization.

CHAPTER e50 Poisoning and Drug Overdosage

lumen, allowing the charcoal-toxin complex to be evacuated

with stool. Charged (ionized) chemicals such as mineral acids,
alkalis, and highly dissociated salts of cyanide, fluoride, iron,
lithium, and other inorganic compounds are not well adsorbed
by charcoal. In animal and human volunteer studies, charcoal
decreases the absorption of ingestants by an average of 73%
when given within 5 min of ingestant administration, 51%
when given at 30 min, and 36% at 60 min. Side effects of charcoal include nausea, vomiting, and diarrhea or constipation.
Charcoal may also prevent the absorption of orally administered therapeutic agents. Complications include mechanical
obstruction of the airway, aspiration, vomiting, and bowel
obstruction and infarction caused by inspissated charcoal.
Charcoal is not recommended for patients who have ingested
corrosives because it obscures endoscopy.
Gastric lavage should be considered for life-threatening
poisons that cannot be treated effectively with other decontamination, elimination, or antidotal therapies (e.g., colchicine). Gastric
lavage is performed by sequentially administering and aspirating ~5 mL fluid per kilogram of body weight through a no. 40
French orogastric tube (no. 28 French tube for children). Except
for infants, where normal saline is recommended, tap water is
acceptable. The patient should be placed in Trendelenburg
and left lateral decubitus positions to prevent aspiration (even
if an endotracheal tube is in place). Lavage decreases ingestant
absorption by an average of 52% if performed within 5 min of
ingestion administration, 26% if performed at 30 min, and 16%
if performed at 60 min. Significant amounts of ingested drug
are recovered in <10% of patients. Aspiration is a common
complication (occurring in up to 10% of patients), especially
when lavage is performed improperly. Serious complications
(esophageal and gastric perforation, tube misplacement in the
trachea) occur in ~1% of patients. For this reason, the physician should personally insert the lavage tube and confirm its
placement, and the patient must be cooperative during the procedure. Gastric lavage is contraindicated in corrosive or petroleum distillate ingestions because of the respective risks of
gastroesophageal perforation and aspiration pneumonitis. It is
also contraindicated in those with a compromised unprotected
airway and those at risk for hemorrhage or perforation due to
esophageal or gastric pathology or recent surgery. Finally, gastric lavage is absolutely contraindicated in combative patients
or those who refuse, as most published complications involve
patient resistance to the procedure.
Syrup of ipecac, an emetogenic agent that was once the most
commonly used decontamination procedure, no longer has a
role in poisoning management. Even the American Academy
of Pediatrics (AAP), traditionally the strongest proponent
of ipecac, issued a policy statement in 2003 recommending
that ipecac should no longer be used in poisoning treatment.
Chronic ipecac use (by patients with anorexia nervosa or
bulimia) has been reported to cause electrolyte and fluid abnormalities, cardiac toxicity, and myopathy.
Whole-bowel irrigation is performed by administering a
bowel-cleansing solution containing electrolytes and polyethylene glycol (Golytely, Colyte) orally or by gastric tube at a
rate of 2 L/h (0.5 L/h in children) until rectal effluent is clear.
The patient must be in a sitting position. Although data are
limited, whole-bowel irrigation appears to be as effective as
other decontamination procedures in volunteer studies. It is
most appropriate for those who have ingested foreign bodies,
packets of illicit drugs, slow-release or enteric-coated medications, and agents that are poorly adsorbed by charcoal (e.g.,
heavy metals). It is contraindicated in patients with bowel

ENHANCEMENT OF POISON ELIMINATION Although the elimination of most poisons can be accelerated by therapeutic interventions, the pharmacokinetic efficacy (removal of drug at a
rate greater than that accomplished by intrinsic elimination)
and clinical benefit (shortened duration of toxicity or improved
outcome) of such interventions are often more theoretical than
proven. Hence, the decision to use such measures should be
based on the actual or predicted toxicity and the potential efficacy, cost, and risks of therapy.
Multiple-Dose Activated Charcoal Repetitive oral dosing
with charcoal can enhance the elimination of previously
absorbed substances by binding them within the gut as they
are excreted in the bile, secreted by gastrointestinal cells, or
passively diffuse into the gut lumen (reverse absorption or
enterocapillary exsorption). Doses of 0.51 g/kg body weight
every 24 h, adjusted downward to avoid regurgitation in
patients with decreased gastrointestinal motility, are generally
recommended. Pharmacokinetic efficacy approaches that of
hemodialysis for some agents (e.g., phenobarbital, theophylline). Multiple-dose therapy should be considered only for
selected agents (theophylline, phenobarbital, carbamazepine,
dapsone, quinine). Complications include intestinal obstruction, pseudoobstruction, and nonocclusive intestinal infarction

Copyright 2012 The McGraw-Hill Companies, Inc. All rights reserved.

50-7

in patients with decreased gut motility. Sorbitol and other

cathartics are absolutely contraindicated when administering
multiple doses of activated charcoal because of electrolyte and
fluid shifts.

PART 18
Poisoning, Drug Overdose, and Envenomation

Urinary Alkalinization Ion trapping via alteration of urine pH

may prevent the renal reabsorption of poisons that undergo
excretion by glomerular filtration and active tubular secretion.
Since membranes are more permeable to nonionized molecules
than to their ionized counterparts, acidic (low-pKa) poisons
are ionized and trapped in alkaline urine, whereas basic ones
become ionized and trapped in acid urine. Urinary alkalinization
(producing a urine pH 7.5 and a urine output of 36 mL/kg
body weight per hour by adding sodium bicarbonate to an IV
solution) enhances the excretion of chlorophenoxyacetic acid
herbicides, chlorpropamide, diflunisal, fluoride, methotrexate,
phenobarbital, sulfonamides, and salicylates. Contraindications
include congestive heart failure, renal failure, and cerebral
edema. Acid-base, fluid, and electrolyte parameters should be
monitored carefully. While making theoretical sense for some
overdoses (amphetamines), acid diuresis is never indicated and
is potentially harmful.
Extracorporeal Removal Hemodialysis, charcoal or resin
hemoperfusion, hemofiltration, plasmapheresis, and exchange
transfusion are capable of removing any toxin from the
bloodstream. Agents most amenable to enhanced elimination
by dialysis have low molecular mass (<500 Da), high water
solubility, low protein binding, small volumes of distribution
(<1 L/kg body weight), prolonged elimination (long half-life),
and high dialysis clearance relative to total-body clearance.
Molecular weight, water solubility, or protein binding do
not limit the efficacy of the other forms of extracorporeal
removal.
Dialysis should be considered in cases of severe poisoning due
to carbamazepine, ethylene glycol, isopropyl alcohol, lithium,
methanol, theophylline, salicylates, and valproate. Although
hemoperfusion may be more effective in removing some of these
poisons, it does not correct associated acid-base and electrolyte
abnormalities, and most hospitals no longer have hemoperfusion cartridges readily available. Fortunately, recent advances in
hemodialysis technology make it effective for removing poisons
such as caffeine, carbamazepine, and theophylline. Both techniques require central venous access and systemic anticoagulation and may result in transient hypotension. Hemoperfusion
may also cause hemolysis, hypocalcemia, and thrombocytopenia.
Peritoneal dialysis and exchange transfusion are less effective but
may be used when other procedures are either not available, contraindicated, or technically difficult (e.g., in infants). Exchange
transfusion may be indicated in the treatment of severe arsineor sodium chlorateinduced hemolysis, methemoglobinemia,
and sulfhemoglobinemia. Although hemofiltration can enhance
elimination of aminoglycosides, vancomycin, and metal-chelate
complexes, the roles of hemofiltration and plasmapheresis in the
treatment of poisoning are not yet defined.
Candidates for extracorporeal removal therapies include
patients with severe toxicity who deteriorate despite aggressive
supportive therapy; those with potentially prolonged, irreversible, or fatal toxicity; those with dangerous blood levels of toxins;
those who lack the capacity for self-detoxification because of
liver or renal failure; and those with a serious underlying illness
or complication that will adversely affect recovery.
Other Techniques The elimination of heavy metals can be
enhanced by chelation, and the removal of carbon monoxide can
be accelerated by hyperbaric oxygenation.

50-8

ADMINISTRATION OF ANTIDOTES Antidotes counteract the

effects of poisons by neutralizing them (e.g., antibody-antigen
reactions, chelation, chemical binding) or by antagonizing
their physiologic effects (e.g., activation of opposing nervous
system activity, provision of competitive metabolic or receptor substrate). Poisons or conditions with specific antidotes
include acetaminophen, anticholinergic agents, anticoagulants,
benzodiazepines, beta blockers, calcium channel blockers, carbon monoxide, cardiac glycosides, cholinergic agents, cyanide,
drug-induced dystonic reactions, ethylene glycol, fluoride,
heavy metals, hypoglycemic agents, isoniazid, membrane-active agents, methemoglobinemia, opioids, sympathomimetics,
and a variety of envenomations. Intravenous lipid emulsion
has been shown to be a successful antidote for poisoning from
various anesthetics and membrane-active agents, but the exact
mechanism of benefit is still under investigation. Antidotes
can significantly reduce morbidity and mortality rates but are
potentially toxic if used for inappropriate reasons. Since their
safe use requires correct identification of a specific poisoning
or syndrome, details of antidotal therapy are discussed with
the conditions for which they are indicated (Table e50-4).
PREVENTION OF REEXPOSURE Poisoning is a preventable illness. Unfortunately, some adults and children are poison-prone,
and recurrences are common. Unintentional polypharmacy
poisoning has become especially common among adults with
developmental delays, among the growing population of geriatric
patients who are prescribed a large number of medications,
and among adolescents and young adults experimenting with
pharmaceuticals for recreational euphoria. Adults with unintentional exposures should be instructed regarding the safe use of
medications and chemicals (according to labeling instructions).
Confused patients may need assistance with the administration
of their medications. Errors in dosing by health care providers
may require educational efforts. Patients should be advised to
avoid circumstances that result in chemical exposure or poisoning. Appropriate agencies and health departments should
be notified in cases of environmental or workplace exposure.
The best approach with young children and patients with
intentional overdose (deliberate self-harm or suicide) is to limit
their access to poisons. In households where children live or visit,
alcoholic beverages, medications, household products (automotive,
cleaning, fuel, pet-care, toiletry products), inedible plants, and
vitamins should be kept out of reach or in locked or child-proof
cabinets. Depressed or psychotic patients should receive psychiatric assessment, disposition, and follow-up. They should
be given prescriptions for a limited supply of drugs and with a
limited number of refills and be monitored for compliance and
response to therapy.
SPECIFIC TOXIC SYNDROMES AND POISONINGS
Table e50-4 summarizes the pathophysiology, clinical features, and
treatment of toxidromes and poisonings that are common, produce
life-threatening toxicity, or require unique therapeutic interventions. In all cases, treatment should include attending to the general
principles discussed above, particularly supportive care. Details
regarding specific therapies can be found in the references cited
here and at www.harrisonsonline.com. Poisonings not covered in
this chapter are discussed in the referenced texts.
Alcohol, cocaine, hallucinogen, and opioid poisoning and
alcohol and opioid withdrawal are discussed in Chaps. 392 to 395;
acetaminophen poisoning is discussed in Chap. 305; the neuroleptic malignant syndrome is discussed in Chap. 372; and heavy
metal poisoning is discussed in Chap. e49.

Copyright 2012 The McGraw-Hill Companies, Inc. All rights reserved.

TABLE e50-4 Pathophysiologic Features and Treatment of Specific Toxic Syndromes and Poisonings
Physiologic
Condition, Causes

Examples

Mechanism of Action

Clinical Features

Specific Treatments

Sympathomimetics 1-Adrenergic agonists (decongestants):

phenylephrine, phenylpropanolamine
2-Adrenergic agonists (bronchodilators):
albuterol, terbutaline
Nonspecific adrenergic agonists: amphetamines, cocaine,
ephedrine

Stimulation of central and

peripheral sympathetic
receptors directly or indirectly (by promoting the
release or inhibiting the
reuptake of norepinephrine
and sometimes dopamine)

Physiologic stimulation
(Table e50-2); reflex
bradycardia can occur
with selective 1 agonists; agonists can
cause hypotension and
hypokalemia.

Phentolamine, a nonselective
1-adrenergic receptor antagonist,
for severe hypertension due to
1-adrenergic agonists; propranolol, a
nonselective blocker, for hypotension
and tachycardia due to 2 agonists;
labetalol, a blocker with -blocking
activity, or phentolamine with esmolol,
metoprolol, or other cardioselective blocker for hypertension with
tachycardia due to nonselective agents
( blockers, if used alone, can exacerbate hypertension and vasospasm
due to unopposed stimulation);
benzodiazepines; propofol.

Ergot alkaloids

Ergotamine, methysergide, bromocriptine, pergolide

Stimulation and inhibition of serotonergic and

-adrenergic receptors;
stimulation of dopamine
receptors

Physiologic stimulation
(Table e50-2); formication; vasospasm with limb
(isolated or generalized),
myocardial, and cerebral
ischemia progressing to
gangrene or infarction;
hypotension, bradycardia,
and involuntary movements
can also occur.

Nitroprusside or nitroglycerine for

severe vasospasm; prazosin (an
1 blocker), captopril, nifedipine,
and cyproheptadine (a serotonin
receptor antagonist) for mild-tomoderate limb ischemia; dopamine
receptor antagonists (antipsychotics)
for hallucinations and movement
disorders

Methylxanthines

Caffeine, theophylline

Inhibition of adenosine
synthesis and adenosine
receptor antagonism;
stimulation of epinephrine and norepinephrine
release; inhibition of
phosphodiesterase resulting in increased intracellular cyclic adenosine and
guanosine monophosphate

Physiologic stimulation
(Table e50-2); pronounced
gastrointestinal symptoms
and agonist effects (see
above). Toxicity occurs at
lower drug levels in chronic
poisoning than in acute
poisoning.

Propranolol, a nonselective blocker,

for tachycardia with hypotension;
any blocker for supraventricular
or ventricular tachycardia without
hypotension; elimination enhanced by
multiple-dose charcoal, hemoperfusion, and hemodialysis; indications for
hemoperfusion or hemodialysis include
unstable vital signs, seizures, and a
theophylline level of 80100 g/mL
after acute overdose and 4060 g/mL
with chronic exposure.

Monoamine
oxidase inhibitors

Phenelzine, tranylcypromine, selegiline

Inhibition of monoamine oxidase resulting in

impaired metabolism
of endogenous catecholamines and exogenous
sympathomimetic agents

Delayed or slowly progressive physiologic stimulation

(Table e50-2); terminal
hypotension and bradycardia in severe cases.

Short-acting agents (e.g., nitroprusside,

esmolol) for severe hypertension
and tachycardia; direct-acting sympathomimetics (e.g., norepinephrine,
epinephrine) for hypotension and
bradycardia

Antihistamines

Diphenhydramine,
doxylamine,
pyrilamine

Inhibition of central and

postganglionic parasympathetic muscarinic cholinergic receptors. At high
doses, amantadine, diphenhydramine, orphenadrine,
phenothiazines, and
tricyclic antidepressants
have additional nonanticholinergic activity (see below).

Physiologic stimulation
(Table e50-2); dry skin
and mucous membranes,
decreased bowel sounds,
flushing, and urinary retention; myoclonus and picking
activity. Central effects may
occur without significant
autonomic dysfunction.

Physostigmine, an acetylcholinesterase inhibitor (see below)

for delirium, hallucinations, and
neuromuscular hyperactivity.
Contraindications include asthma,
nonanticholinergic cardiovascular
toxicity (e.g., cardiac conduction
abnormalities, hypotension, and
ventricular arrhythmias).

Antiparkinsonian
agents

Amantadine,
trihexyphenidyl

Stimulated
Sympathetics (see also Chap. 394)

CHAPTER e50 Poisoning and Drug Overdosage

Anticholinergics

(continued )

Copyright 2012 The McGraw-Hill Companies, Inc. All rights reserved.

50-9

TABLE e50-4 Pathophysiologic Features and Treatment of Specific Toxic Syndromes and
Poisonings (Continued )
Physiologic
Condition, Causes

Examples

PART 18
Poisoning, Drug Overdose, and Envenomation

Antipsychotics

Chlorpromazine,
olanzapine,
quetiapine,
thioridazine

Antispasmodics

Clidinium,
dicyclomine

Belladonna
alkaloids

Atropine,
hyoscyamine,
scopolamine

Cyclic
antidepressants

Amitriptyline,
doxepin, imipramine

Muscle relaxants

Cyclobenzaprine,
orphenadrine

Mushrooms and
plants

Amanita muscaria
and A. pantherina,
henbane, jimson
weed, nightshade

Mechanism of Action

Clinical Features

Specific Treatments

Depressed
Sympatholytics
2-Adrenergic
agonists

Clonidine, guanabenz,
tetrahydrozoline and
other imidazoline
decongestants,
tizanidine and other
imidazoline muscle
relaxants

Stimulation of
2-adrenergic receptors
leading to inhibition of CNS
sympathetic outflow; activity at nonadrenergic imidazoline binding sites also
contributes to CNS effects.

Physiologic depression
(Table e50-2), miosis.
Transient initial hypertension may be seen.

Dopamine and norepinephrine for

hypotension. Atropine for symptomatic
bradycardia. Naloxone for CNS
depression (inconsistently effective).

Antipsychotics

Chlorpromazine,
clozapine,
haloperidol, risperidone, thioridazine

Inhibition of -adrenergic,
dopaminergic, histaminergic,
muscarinic, and serotonergic receptors. Some
agents also inhibit sodium,
potassium, and calcium
channels.

Physiologic depression
(Table e50-2), miosis,
anticholinergic effects (see
above), extrapyramidal
reactions (see below),
tachycardia. Cardiac conduction delays (increased
PR, QRS, JT, and QT
intervals) with ventricular
tachydysrhythmias, including torsades des pointes,
can sometimes develop.

Sodium bicarbonate for ventricular

tachydysrhythmias associated with
QRS prolongation. Magnesium, isoproterenol, and overdrive pacing for
torsades des pointes. Avoid class IA,
IC, and III antiarrhythmics. Intravenous
lipid emulsion therapy may be beneficial in some cases.

-Adrenergic
blockers

Cardioselective (1)
blockers: atenolol,
esmolol, metoprolol
Nonselective (1 and
2) blockers: nadolol,
propranolol, timolol
Partial agonists:
acebutolol, pindolol
1 Antagonists:
carvedilol, labetalol
Membrane-active
agents: acebutolol,
propranolol, sotalol

Inhibition of -adrenergic
receptors (class II antiarrhythmic effect). Some
agents have activity at
additional receptors or have
membrane effects (see
below).

Physiologic depression
(Table e50-2), atrioventricular block, hypoglycemia, hyperkalemia,
seizures. Partial agonists
can cause hypertension and
tachycardia. Sotalol can
cause increased QT interval
and ventricular tachydysrhythmias. Onset may be
delayed after sotalol and
sustained-release formulation overdose.

Glucagon for hypotension and

symptomatic bradycardia. Atropine,
isoproterenol, dopamine, dobutamine,
epinephrine, and norepinephrine may
sometimes be effective. High-dose
insulin (with glucose and potassium
to maintain euglycemia and
normokalemia), electrical pacing, and
mechanical cardiovascular support for
refractory cases.

(continued )

50-10

Copyright 2012 The McGraw-Hill Companies, Inc. All rights reserved.

TABLE e50-4 Pathophysiologic Features and Treatment of Specific Toxic Syndromes and
Poisonings (Continued )
Physiologic
Condition, Causes

Mechanism of Action

Clinical Features

Specific Treatments

Calcium channel
blockers

Diltiazem, nifedipine
and other dihydropyridine derivatives,
verapamil

Inhibition of slow (type L)

cardiovascular calcium
channels (class IV antiarrhythmic effect).

Physiologic depression
(Table e50-2), atrioventricular block, organ ischemia
and infarction, hyperglycemia, seizures. Hypotension
is usually due to decreased
vascular resistance rather
than to decreased cardiac
output. Onset may be
delayed for 12 h after
overdose of sustainedrelease formulations.

Calcium and glucagon for hypotension and symptomatic bradycardia.

Dopamine, epinephrine, norepinephrine, atropine, and isoproterenol are
less often effective but can be used
adjunctively. High-dose insulin (with
glucose and potassium to maintain
euglycemia and normokalemia),
intravenous lipid emulsion therapy,
electrical pacing, and mechanical
cardiovascular support for refractory
cases.

Cardiac glycosides

Digoxin, endogenous
cardioactive steroids,
foxglove and other
plants, toad skin
secretions
(Bufonidae sp.)

Inhibition of cardiac
Na+, K+-ATPase membrane
pump.

Physiologic depression
(Table e50-2); gastrointestinal, psychiatric, and visual
symptoms; atrioventricular
block with or without concomitant supraventricular
tachyarrhythmia; ventricular tachyarrhythmias.
Hyperkalemia in acute
poisoning. Toxicity occurs
at lower drug levels in
chronic poisoning than in
acute poisoning.

Digoxin-specific antibody fragments

for hemodynamically compromising
dysrhythmias, Mobitz II or third-degree
atrioventricular block, hyperkalemia
(>5.5 meq/L; in acute poisoning only).
Temporizing measures include atropine,
dopamine, epinephrine, and external
cardiac pacing for bradydysrhythmias
and magnesium, lidocaine, or phenytoin,
for ventricular tachydysrhythmias.
Internal cardiac pacing and cardioversion
can increase ventricular irritability and
should be reserved for refractory cases.

Cyclic
antidepressants

Amitriptyline,
doxepin, imipramine

Inhibition of -adrenergic,
dopaminergic, GABA-ergic,
histaminergic, muscarinic,
and serotonergic receptors;
inhibition of sodium channels
(see membrane-active
agents); inhibition of norepinephrine and serotonin
reuptake.

Physiologic depression
(Table e50-2), seizures,
tachycardia, cardiac
conduction delays
(increased PR, QRS, JT,
and QT intervals; terminal
QRS right-axis deviation)
with aberrancy and ventricular tachydysrhythmias.
Anticholinergic toxidrome
(see above).

Hypertonic sodium bicarbonate (or

hypertonic saline) and lidocaine for
ventricular tachydysrhythmias associated with QRS prolongation. Use of
phenytoin is controversial. Avoid class
IA, IC, and III antiarrhythmics.

Acetylcholinesterase inhibitors

Carbamate insecticides (aldicarb, carbaryl, propoxur) and

medicinals (neostigmine, physostigmine,
tacrine); nerve gases
(sarin, soman, tabun,
VX) organophosphate
insecticides (diazinon,
chlorpyrifos-ethyl,
malathion)

Muscarinic
agonists

Bethanechol, mushrooms (Boletus,

Clitocybe, Inocybe
spp.), pilocarpine

Nicotinic agonists

Lobeline, nicotine
(tobacco)

Physiologic depression
(Table e50-2). Muscarinic
signs and symptoms: seizures, excessive secretions
(lacrimation, salivation,
bronchorrhea and wheezing, diaphoresis), and
increased bowel and bladder activity with nausea,
vomiting, diarrhea,
abdominal cramps, and
incontinence of feces and
Stimulation of CNS and posturine. Nicotinic signs and
ganglionic parasympathetic
symptoms: hypertencholinergic (muscarinic)
sion, tachycardia, muscle
receptors
cramps, fasciculations,
Stimulation of preganglionic weakness, and paralysis. Death is usually due
sympathetic and parato respiratory failure.
sympathetic and striated
Cholinesterase activity in
muscle (neuromuscular
plasma and red cells <50%
junction) cholinergic
of normal in acetylcholin(nicotine) receptors
esterase inhibitor poisoning.

CHAPTER e50 Poisoning and Drug Overdosage

Examples

Cholinergics
Inhibition of acetylcholinesterase leading to
increased synaptic acetylcholine at muscarinic and
nicotinic cholinergic receptor sites

Atropine for muscarinic signs and

symptoms. Pralidoxime (2-PAM),
a cholinesterase reactivator, for
nicotinic signs and symptoms due to
organophosphates, nerve gases, or an
unknown anticholinesterase.

(continued )
Copyright 2012 The McGraw-Hill Companies, Inc. All rights reserved.

50-11

TABLE e50-4 Pathophysiologic Features and Treatment of Specific Toxic Syndromes and
Poisonings (Continued )
Physiologic
Condition, Causes

Examples

Mechanism of Action

Clinical Features

Specific Treatments

Physiologic depression
(Table e50-2), nystagmus.
Delayed absorption can
occur with carbamazepine,
phenytoin, and valproate.
Myoclonus, seizures,
hypertension, and
tachyarrhythmias can
occur with baclofen,
carbamazepine, and
orphenadrine.

Benzodiazepines , barbiturates, or
propofol for seizures.

Sedative-hypnotics (see also Chap. 393)

Anticonvulsants

PART 18

Barbiturates

Poisoning, Drug Overdose, and Envenomation

Benzodiazepines

GABA precursors

Muscle relaxants

Other agents

Potentiation of the inhibitory effects of GABA by

binding to the neuronal
GABA-A chloride channel receptor complex and
increasing the frequency or
duration of chloride channel opening in response to
GABA stimulation. Baclofen
Short-acting: butand, to some extent, GHB
abarbital, pentobarbiact at the GABA-B receptor
tal, secobarbital
complex; meprobamate,
Long-acting: phenoits metabolite carisopbarbital, primidone
rodol, felbamate, and
orphenadrine antagonize
Ultrashort-acting:
N-methyl-D-aspartate
estazolam, mida(NDMA) excitatory recepzolam, temazepam,
tors; ethosuximide, valtriazolam
proate, and zonisamide
Short-acting: alpradecrease conduction
zolam, flunitrazepam, through T-type calcium
lorazepam, oxazepam channels; valproate
Long-acting: chlordi- decreases GABA degradaazepoxide, clontion, and tiagabine blocks
azepam, diazepam,
GABA reuptake; carbamflurazepam
azepine, lamotrigine,
oxcarbazepine, phenytoin,
Pharmacologically
topiramate, valproate, and
related agents:
zonisamide slow the rate
zaleplon, zolpidem
of recovery of inactivated
-Hydroxybutyrate
sodium channels. Some
(sodium oxybate;
agents also have agoGHB), -butyrolactone nist, anticholinergic,2 and
(GBL), 1,4-butanediol. sodium channel-blocking
activity (see above and
Baclofen, carisoprodol, below).
cyclobenzaprine,
etomidate, metaxalone, methocarbamol, orphenadrine,
propofol, tizanidine
and other imidazoline
muscle relaxants.
Carbamazepine,
ethosuximide,
felbamate, gabapentin,
lamotrigine, levetiracetam, oxcarbazepine,
phenytoin, tiagabine,
topiramate, valproate,
zonisamide

Hemodialysis and hemoperfusion may

be indicated for severe poisoning by
some agents (see Extracorporeal
Removal, in text).

Tachyarrhythmias can also See above and below for treatment of

occur with chloral hydrate. anticholinergic and sodium-channel
(membrane) blocking effects.
AGMA, hypernatremia,
hyperosmolality, hyperammonemia, chemical hepatitis, and hypoglycemia can
be seen in valproate poisoning. Carbamazepine and
oxcarbazepine may produce
hyponatremia from SIADH.

Some agents can cause

anticholinergic and sodium
channel (membrane)
blocking effects (see above
and below).

Chloral hydrate,
ethchlorvynol, glutethimide, meprobamate, methaqualone,
methyprylon
(continued )

50-12

Copyright 2012 The McGraw-Hill Companies, Inc. All rights reserved.

TABLE e50-4 Pathophysiologic Features and Treatment of Specific Toxic Syndromes and
Poisonings (Continued )
Physiologic
Condition, Causes

Examples

Mechanism of Action

Clinical Features

Specific Treatments

Cytochrome
oxidase inhibitors

Cyanide, hydrogen
sulfide

Inhibition of mitochondrial cytochrome oxidase,

thereby blocking electron
transport and oxidative metabolism. Carbon
monoxide also binds to
hemoglobin and myoglobin
and prevents oxygen binding, transport, and tissue
uptake (binding to hemoglobin shifts the oxygen
dissociation curve to the
left).

Signs and symptoms of

hypoxemia with initial
physiologic stimulation
and subsequent depression (Table e50-2); lactic
acidosis; normal PO 2 and
calculated oxygen saturation but decreased oxygen
saturation by co-oximetry
(that measured by pulse
oximetry is falsely elevated
but is less than normal and
less than the calculated
value). Headache and
nausea are common with
carbon monoxide. Sudden
collapse may occur with
cyanide and hydrogen
sulfide exposure. A bitter
almond breath odor may be
noted with cyanide ingestion, and hydrogen sulfide
smells like rotten eggs.

High-dose oxygen. IV hydroxocobalamin or IV sodium nitrite and sodium

thiosulfate (Lilly cyanide antidote kit)
for coma, metabolic acidosis, and
cardiovascular dysfunction in cyanide
poisoning.

Methemoglobin
inducers

Aniline derivatives,
dapsone, local
anesthetics, nitrates,
nitrites, nitrogen
oxides, nitro- and
nitrosohydrocarbons,
phenazopyridine,
primaquine-type
antimalarials,
sulfonamides.

Oxidation of hemoglobin
iron from ferrous (Fe2+) to
ferric (Fe3+) state prevents
oxygen binding, transport,
and tissue uptake (methemoglobinemia shifts oxygen
dissociation curve to the
left). Oxidation of hemoglobin protein causes hemoglobin precipitation and
hemolytic anemia (manifest
as Heinz bodies and bite
cells on peripheral blood
smear).

Signs and symptoms of

hypoxemia with initial
physiologic stimulation and
subsequent depression
(Table e50-2), gray-brown
cyanosis unresponsive to
oxygen at methemoglobin
fractions >1520%, headache, lactic acidosis (at
methemoglobin fractions
>45%), normal PO 2 and
calculated oxygen saturation but decreased oxygen
saturation and increased
methemoglobin fraction by
co-oximetry (oxygen saturation by pulse oximetry
may be falsely increased or
decreased but is less than
normal and less than the
calculated value).

High-dose oxygen. Intravenous methylene blue for methemoglobin fraction

>30%, symptomatic hypoxemia, or
ischemia (contraindicated in G6PD
deficiency). Exchange transfusion
and hyperbaric oxygen for severe or
refractory cases.

Ethylene glycol

Ethylene glycol causes

CNS depression and
increased serum osmolality. Metabolites (primarily
glycolic acid) cause AGMA,
CNS depression, and renal
failure. Precipitation of
oxalic acid metabolite as
calcium salt in tissues and
urine results in hypocalcemia, tissue edema, and
crystalluria.

Initial ethanol-like intoxication, nausea, vomiting,

increased osmolar gap,
calcium oxylate crystalluria.
Delayed AGMA, back pain,
renal failure. Coma, seizures, hypotension, ARDS
in severe cases.

Sodium bicarbonate to correct

acidemia. Thiamine, folinic acid,
magnesium, and high-dose pyridoxine to facilitate metabolism. Ethanol
or fomepizole for AGMA, crystalluria
or renal dysfunction, ethylene glycol
level >3 mmol/L (20 mg/dL), and for
ethanol-like intoxication or increased
osmolal gap if level not readily obtainable. Hemodialysis for persistent
AGMA, lack of clinical improvement,
and renal dysfunction. Hemodialysis
also useful for enhancing ethylene
glycol elimination and shortening
duration of treatment when ethylene
glycol level >8 mmol/L (50 mg/dL).

Discordant
Asphyxiants

CHAPTER e50 Poisoning and Drug Overdosage

AGMA inducers

(continued )
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50-13

TABLE e50-4 Pathophysiologic Features and Treatment of Specific Toxic Syndromes and
Poisonings (Continued )
Physiologic
Condition, Causes
AGMA inducers

Examples

Mechanism of Action
3+

Clinical Features

Specific Treatments

PART 18
Poisoning, Drug Overdose, and Envenomation

Iron

Hydration of ferric (Fe )

ion generates H+. Nontransferrin-bound iron
catalyzes formation of
free radicals that cause
mitochondrial injury, lipid
peroxidation, increased
capillary permeability,
vasodilation, and organ
toxicity.

Initial nausea, vomiting,

abdominal pain, diarrhea.
AGMA, cardiovascular and
CNS depression, hepatitis,
coagulopathy, and seizures in severe cases.
Radiopaque iron tablets
may be seen on abdominal
x-ray.

Whole-bowel irrigation for large ingestions. Endoscopy and gastrostomy if

clinical toxicity and large number of
tablets still visible on x-ray. IV hydration. Sodium bicarbonate for acidemia.
IV deferoxamine for systemic toxicity,
iron level >90 mol/L (500 g/dL).

Methanol

Methanol causes ethanollike CNS depression and

increased serum osmolality.
Formic acid metabolite
causes AGMA and retinal
toxicity.

Initial ethanol-like intoxication, nausea, vomiting,

increased osmolar gap.
Delayed AGMA, visual
(clouding, spots, blindness)
and retinal (edema, hyperemia) abnormalities. Coma,
seizures, cardiovascular
depression in severe cases.
Possible pancreatitis.

Gastric aspiration for recent ingestions. Sodium bicarbonate to correct

acidemia. High-dose folinic acid or
folate to facilitate metabolism. Ethanol
or fomepizole for AGMA, visual symptoms, methanol level >6 mmol/L
(20 mg/dL), and for ethanol-like
intoxication or increased osmolal
gap if level not readily obtainable.
Hemodialysis for persistent AGMA,
lack of clinical improvement, and renal
dysfunction. Hemodialysis also useful
for enhancing methanol elimination
and shortening duration of treatment
when methanol level >15 mmol/L
(50 mg/dL).

Salicylate

Increased sensitivity of
CNS respiratory center to
changes in PO 2 and PCO 2
stimulates respiration.
Uncoupling of oxidative
phosphorylation, inhibition
of Krebs cycle enzymes,
and stimulation of carbohydrate and lipid metabolism
generate unmeasured
endogenous anions and
cause AGMA.

Initial nausea, vomiting,

hyperventilation, alkalemia,
alkaluria. Subsequent
alkalemia with both respiratory alkalosis and AGMA,
and paradoxical aciduria.
Late acidemia with CNS
and respiratory depression.
Cerebral and pulmonary
edema in severe cases.
Hypoglycemia, hypocalcemia, hypokalemia, and
seizures can occur.

IV hydration and supplemental glucose.

Sodium bicarbonate to correct
acidemia. Urinary alkalinization for
systemic toxicity. Hemodialysis for
coma, cerebral edema, seizures, pulmonary edema, renal failure, progressive acid-base disturbances or clinical
toxicity, salicylate level >7 mmol/L
(100 mg/dL) following acute overdose.

Antipsychotics (see
above), some cyclic
antidepressants and
antihistamines.

Decreased CNS dopaminergic activity with relative

excess of cholinergic
activity.

Akathisia, dystonia,
parkinsonism

Oral or parenteral anticholinergic

agent such as benztropine or
diphenhydramine.

Interference with activation

and supply of pyridoxal5-phosphate, a cofactor
for glutamic acid decarboxylase, which converts
glutamic acid to GABA,
results in decreased levels
of this inhibitory CNS neurotransmitter; complexation
with and depletion of
pyridoxine itself; inhibition of nicotine-adenine
dinucleotidedependent
lactate and hydroxybutyrate
dehydrogenases resulting
in substrate accumulation.

Nausea, vomiting, agitation,

confusion; coma, respiratory depression, seizures,
lactic and ketoacidosis in
severe cases.

High-dose intravenous pyridoxine

(vitamin B6 ) for agitation, confusion,
coma, and seizures. Diazepam or
barbiturates for seizures.

CNS syndromes
Extrapyramidal
reactions

Isoniazid

(continued )

50-14

Copyright 2012 The McGraw-Hill Companies, Inc. All rights reserved.

TABLE e50-4 Pathophysiologic Features and Treatment of Specific Toxic Syndromes and
Poisonings (Continued )
Physiologic
Condition, Causes

Examples

Lithium

Clinical Features

Specific Treatments

Interference with cell

membrane ion transport,
adenylate cyclase and
Na+, K+-ATPase activity, and
neurotransmitter release.

Nausea, vomiting, diarrhea,

ataxia, choreoathetosis,
encephalopathy, hyperreflexia, myoclonus, nystagmus, nephrogenic diabetes
insipidus, falsely elevated
serum chloride with low
anion gap, tachycardia.
Coma, seizures, arrhythmias,
hyperthermia, and prolonged
or permanent encephalopathy and movement disorders
in severe cases. Delayed
onset after acute overdose,
particularly with delayedrelease formulations. Toxicity
occurs at lower drug levels
in chronic poisoning than in
acute poisoning.

Whole-bowel irrigation for large ingestions. IV hydration. Hemodialysis for

coma, seizures, severe, progressive,
or persistent encephalopathy or
neuromuscular dysfunction, peak
lithium level >4 meq/L
following acute overdose.

Serotonin
syndrome

Amphetamines,
cocaine, dextromethorphan,
meperidine, MAO
inhibitors, selective
serotonin (5-HT)
reuptake inhibitors,
tricyclic antidepressants, tramadol, triptans, tryptophan.

Promotion of serotonin
release, inhibition of serotonin reuptake, or direct
stimulation of CNS and
peripheral serotonin receptors (primarily 5-HT-1a and
5-HT-2), alone or in
combination.

Altered mental status (agita- Serotonin receptor antagonist cyproheptadine, discontinue the offending
tion, confusion, mutism,
coma, seizures), neuromus- agent(s).
cular hyperactivity (hyperreflexia, myoclonus, rigidity,
tremors), and autonomic
dysfunction (abdominal pain,
diarrhea, diaphoresis, fever,
flushing, labile hypertension,
mydriasis, tearing, salivation,
tachycardia). Complications
include hyperthermia, lactic
acidosis, rhabdomyolysis,
and multisystem organ
failure.

Membrane-active
agents

Amantadine, antiarrhythmics (class I

and III agents;
some blockers),
antipsychotics (see
above), antihistamines
(particularly
diphenhydramine),
carbamazepine, local
anesthetics (including
cocaine), opioids
(meperidine, propoxyphene), orphenadrine,
quinoline antimalarials
(chloroquine,
hydroxychloroquine,
quinine), cyclic
antidepressants (see
above).

Blockade of fast sodium

membrane channels prolongs
phase 0 (depolarization)
of the cardiac action potential, which prolongs the QRS
duration and promotes
reentrant (monomorphic)
ventricular tachycardia. Class
Ia, Ic, and III antiarrhythmics
also block potassium
channels during phases
2 and 3 (repolarization) of
the action potential,
prolonging the JT interval
and promoting early afterdepolarizations and polymorphic (torsades des pointes)
ventricular tachycardia.
Similar effects on neuronal
membrane channels
cause CNS dysfunction.
Some agents also block
-adrenergic and cholinergic
receptors or have opioid
effects (see above and
Chap. 393).

QRS and JT prolongation

(or both) with hypotension,
ventricular tachyarrhythmias, CNS depression,
seizures. Anticholinergic
effects with amantadine,
antihistamines, carbamazepine, disopyramide,
antipsychotics, and cyclic
antidepressants (see
above). Opioid effects with
meperidine and propoxyphene (see Chap. 393).
Cinchonism (hearing loss,
tinnitus, nausea, vomiting,
vertigo, ataxia, headache,
flushing, diaphoresis) and
blindness with quinoline
antimalarials.

CHAPTER e50 Poisoning and Drug Overdosage

Mechanism of Action

Hypertonic sodium bicarbonate

(or hypertonic saline) for cardiac
conduction delays and monomorphic
ventricular tachycardia. Lidocaine for
monomorphic ventricular tachycardia
(except when due to class Ib
antiarrhythmics). Magnesium,
isoproterenol, and overdrive pacing for
polymorphic ventricular
tachycardia. Physostigmine for
anticholinergic effects (see above).
Naloxone for opioid effects (see
Chap. 393). Extracorporeal removal for
some agents (see text).

Abbreviations: AGMA, anion-gap metabolic acidosis; ARDS, adult respiratory distress syndrome; ATPase, adenosine triphosphatase; CNS, central nervous system; GABA,
-aminobutyric acid; GHB, -hydroxybutyrate; 5-HT, 5-hydroxytryptamine (serotonin); MAO, monoamine oxidase; PCO 2, partial pressure of carbon dioxide; PO 2, partial pressure of
oxygen; SIADH, syndrome of inappropriate antidiuretic hormone; VX, extremely toxic persistent nerve agent (no common chemical name).

Copyright 2012 The McGraw-Hill Companies, Inc. All rights reserved.

50-15

ACKNOWLEDGMENT
The author acknowledges the contributions of Christopher H. Linden
and Michael J. Burns to this chapter in previous editions of this text.
FURTHER READINGS
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gastric decontamination: A state-of-the-art review. Ann Emerg
Med 39:273, 2002
Brent J: Fomepizole for ethylene glycol and methanol poisoning.
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Bronstein AC et al: 2008 Annual Report of the American Association
of Poison Control Centers National Poison Data System (NPDS):
27th Annual Report. Clin Toxicol (Phila) 48:979, 2010

PART 18

Dart RC et al: Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Ann Emerg Med
54:386, 2009

Erickson TB et al: The approach to the patient with an unknown

overdose. Emerg Med Clin North Am 25:249, 2007
Felice K et al: Intravenous lipid emulsion for local anesthetic toxicity:
a review of the literature. J Med Toxicol 4:184, 2008
Ford MD et al (eds): Clinical Toxicology. Philadelphia, Saunders,
2001
Greenberg MI et al (eds): Occupational, Industrial, and
Environmental Toxicology. St. Louis, Mosby, 2003
Heard KJ: Acetylcysteine for acetaminophen poisoning. N Engl J
Med 359:285, 2008
Kosten TR, OConnor PG: Management of drug and alcohol
withdrawal. N Engl J Med 348:1786, 2003
Nelson LS et al (eds): Goldfranks Toxicologic Emergencies, 9th ed.
New York, McGraw-Hill, 2010.

Poisoning, Drug Overdose, and Envenomation

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