Overdose and poisoning: management

Answer 1

Paracetamol Management
activated charcoal if ingested < 1 hour ago
N-acetylcysteine (NAC)
liver transplantation

Salicylate Management
urinary alkalinization with IV bicarbonate
haemodialysis

Opioid/opiates Naloxone

Benzodiazepines Flumazenil
The majority of overdoses are managed with supportive care only due to the risk of seizures with flumazenil. It is generally only used with severe or iatrogenic overdoses.

Tricyclic antidepressants Management
IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity
arrhythmias: class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation. Class III drugs such as amiodarone should also be avoided as they prolong the QT interval. Response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in management of tricyclic induced arrhythmias
dialysis is ineffective in removing tricyclics

Lithium Management
mild-moderate toxicity may respond to volume resuscitation with normal saline
haemodialysis may be needed in severe toxicity
sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion

Warfarin Vitamin K, prothrombin complex

Heparin Protamine sulphate

Beta-blockers Management
if bradycardic then atropine
in resistant cases glucagon may be used

Ethylene glycol Management has changed in recent times
ethanol has been used for many years
works by competing with ethylene glycol for the enzyme alcohol dehydrogenase
this limits the formation of toxic metabolites (e.g. Glycoaldehyde and glycolic acid) which are responsible for the haemodynamic/metabolic features of poisoning
fomepizole, an inhibitor of alcohol dehydrogenase, is now used first-line in preference to ethanol
haemodialysis also has a role in refractory cases

Methanol poisoning Management
fomepizole or ethanol
haemodialysis

Organophosphate insecticides Management
atropine
the role of pralidoxime is still unclear - meta-analyses to date have failed to show any clear benefit

Digoxin Digoxin-specific antibody fragments

Iron Desferrioxamine, a chelating agent

Lead Dimercaprol, calcium edetate

Carbon monoxide Management
100% oxygen
hyperbaric oxygen

Cyanide Hydroxocobalamin; also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate