General Approach

  • Determine the toxic substance

    Obtain a thorough history of the possible toxic substances and co-ingestions. Note the route of administration and time of ingestion or last known normal. If possible, try to obtain a sample of the ingested substance.

  • Assess & Stabilize

    Obtain a thorough medical history, including any medications the patient is taking and any underlying medical conditions. Assess the patient's level of consciousness, airway, breathing, and circulation. If the patient is unstable, provide immediate treatment to stabilize their condition. If altered, consider dextrose for hypoglycemia and naloxone for possible opiate overdose.

  • Consult Poison Control: 1-800-222-1222

    Remember, the management of toxic ingestions can be complex and require specialized knowledge and resources. Don't hesitate to reach out to poison control centers, toxicology experts, or other medical providers for guidance and assistance in managing these patients.

Common Toxidromes

Diagnostic Workup 

Routine studies should include:

  • Complete blood count (CBC) to assess for anemia or infection

  • Comprehensive metabolic panel (CMP) and POC glucose to monitor for electrolyte changes and assess renal and liver function tests

  • Arterial blood gas (ABG) and lactate to evaluate acid-base balance.

  • Measurement of serum osmolarity and methanol level may be helpful if poisoning with methanol, ethylene glycol or isopropanol is suspected.

  • Acetaminophen, salicylate, and ethanol level

  • Urine and/or serum drug screen

  • An electrocardiogram (ECG) may be ordered to monitor for any arrhythmias, especially in cases where the patient has ingested a cardiac toxin.

  • Consider a chest X-ray (CXR) if concern for aspiration or an abdominal X-ray (AXR) if concern for foreign body ingestion, battery, or radiopaque ingestion such as iron  

Gastric Decontamination

Gastric decontamination is a process of removing toxic substances from the stomach in cases of a toxic ingestion. It is an important part of the initial management of toxic ingestions, but the specific method of gastric decontamination depends on the substance ingested, the patient's condition, and the time since ingestion.

  • (1 g/kg; max 50 g) every 4 hours until symptoms resolve or plasma salicylate concentration is <40 mg/dL. 

    Works by binding to toxic substances in the stomach and preventing their absorption into the bloodstream. Activated charcoal should be given within 1-2 hours of ingestion and can be given orally or through a nasogastric tube.

    Ineffective for heavy metals, inorganic ions (iron, lead, phosphorus, lithium, K, Na), alcohols, and hydrocarbons.

    Although activated charcoal can decrease gastrointestinal absorption of drugs, its administration is contraindicated in those with mental status depression; aspiration of activated charcoal can result in chemical pneumonitis and respiratory distress. It also interferes with visualization during endoscopy, so it should not be used for caustic ingestions.

  • Polyethylene glycol 500 ml/hr

    Involves administering large volumes of a polyethylene glycol solution to flush out the entire gastrointestinal tract. This method can be effective in removing toxic substances that have already left the stomach and are in the intestines.

    Effective for ingestions of iron, heavy metals, sustained-release medications, or illicit drug packets.

  • Involves inserting a tube through the mouth or nose and into the stomach to remove the contents. This procedure can be effective in removing toxic substances from the stomach, but it is not recommended for routine use due to the risk of complications such as aspiration or esophageal injury. Effective within 1 hour of ingestion and if the patient has not had emesis.