The management of poisoning requires a systematic approach that prioritizes stabilization of vital functions, followed by careful assessment, gastrointestinal decontamination when indicated, enhanced elimination when possible, and appropriate supportive care. Poisoning is a common medical emergency, accounting for over two million reported exposures annually in the United States alone. The general principles of poison management apply across a diverse range of toxic agents, with specific modifications based on the particular substance involved, the route and timing of exposure, and the clinical condition of the patient.
Initial assessment and stabilization follow the ABCDE approach with focus on the airway, breathing, circulation, and disability. Airway compromise is a leading cause of death in poisoned patients, particularly those with depressed consciousness from sedative-hypnotic or opioid overdose. Endotracheal intubation may be required to protect the airway and provide ventilatory support. Breathing assessment includes pulse oximetry, capnography, and arterial blood gas analysis. Respiratory depression is the primary cause of death in opioid and benzodiazepine overdose, and prompt ventilatory support is life-saving. Circulation assessment focuses on heart rate, blood pressure, and perfusion, with specific attention to dysrhythmias that may require antiarrhythmic therapy or electrical cardioversion.
Gastrointestinal decontamination aims to reduce the absorption of ingested poisons. Activated charcoal is the most widely used decontamination method and is most effective when administered within one hour of ingestion. It adsorbs a wide range of drugs and toxins within the gastrointestinal tract, preventing systemic absorption. The dose is typically 50 to 100 grams for adults or 1 gram per kilogram for children. Charcoal should not be used in patients with an unprotected airway, ileus, or ingestion of corrosives or hydrocarbons. Gastric lavage is rarely indicated but may be considered for life-threatening ingestions performed within 60 minutes of exposure. Whole bowel irrigation with polyethylene glycol solution is used for sustained-release or enteric-coated preparations, iron overdose, and body packers who have ingested packets of illicit drugs.
Enhanced elimination techniques increase the removal of already absorbed toxins. Multiple-dose activated charcoal (MDAC) enhances elimination of drugs that undergo enterohepatic recirculation or that are actively secreted into the gastrointestinal tract, including phenobarbital, theophylline, carbamazepine, and dapsone. Urinary alkalinization with sodium bicarbonate increases the urinary excretion of weak acids such as salicylates and phenobarbital by trapping ionized drug in the urine. Hemodialysis effectively removes substances with low protein binding, small volume of distribution, and water solubility, including lithium, ethylene glycol, methanol, and salicylates. The decision to use enhanced elimination depends on the specific toxin, the severity of poisoning, and the anticipated clinical course.
Supportive care is the cornerstone of poison management and is sufficient as sole treatment for the majority of poisoning cases. It includes intravenous fluids, temperature management, seizure control, correction of metabolic abnormalities, and prevention of secondary complications such as aspiration pneumonia, rhabdomyolysis, and pressure ulcers. In severe cases, advanced organ support including mechanical ventilation, vasopressors, and renal replacement therapy may be required for extended periods until the toxin is eliminated and organ function recovers.
Toxicologic investigations include a thorough history, physical examination focused on identifying toxidromes — constellations of signs and symptoms characteristic of specific poisoning classes — and laboratory testing. The cholinergic toxidrome presents with salivation, lacrimation, urination, defecation, gastrointestinal upset, and emesis. The anticholinergic toxidrome features hyperthermia, flushing, dry skin, dilated pupils, urinary retention, and delirium. The sympathomimetic toxidrome presents with hypertension, tachycardia, hyperthermia, mydriasis, and agitation. The opioid toxidrome is characterized by respiratory depression, miosis, and CNS depression. Comprehensive toxicology screening may confirm the suspected agent but rarely alters acute management.
Poison control centers serve as essential resources for healthcare professionals and the public, providing 24-hour access to specialized toxicology expertise. These centers improve patient outcomes, reduce unnecessary healthcare utilization, and play a critical role in surveillance for emerging poisoning patterns and public health threats. Clinicians managing poisoned patients should contact their regional poison control center early in the course of treatment for guidance on specific management decisions.
