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Toxic Agent Acetaminophen Anticholinergics (eg, atropine) Anticholinesterases (eg, organophosphate pesticides) Specific Antidote N-Acetylcysteine Physostigmine Atropine and pralidoxime (2-PAM) Flumazenil (rarely used; see warning in text) Oxygen, hyperbaric oxygen Sodium nitrite, sodium thiosulfate; hydroxocobalamin (Cyanokit) Digoxin-specific Fab antibodies Specific chelating agents Pyridoxine (vitamin B6) Ethanol (ethyl alcohol) or fomepizole (4-methylpyrazole) Naloxone, nalmefene Specific antivenin

Administer pyridoxine May indicate need for hemodialysis Administer pralidoxime (2-PAM) and atropine Seizures are actually spinally mediated muscle spasms and usually require neuromuscular paralysis Seizures indicate need for hemodialysis Hyperthermia and cardiotoxicity are common complications of repeated seizures; paralyze early with neuromuscular blockers to reduce muscular hyperactivity

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Benzodiazepines Carbon monoxide Cyanide Digitalis glycosides Heavy metals (eg, lead, mercury, iron) and arsenic Isoniazid Methanol, ethylene glycol Opioids Snake venom See text for indications and dosages

ever, in certain cases, removal of the toxin may be more important than concern over possible complications Consult a medical toxicologist or regional poison control center (800222-1222) for advice

selves may have serious side effects The indications and dosages for specific antidotes are discussed in the respective sections for specific toxins

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Corrosive agents rapidly injure the skin and eyes and must be removed immediately In addition, many toxins are readily absorbed through the skin, and systemic absorption can be prevented only by rapid action Wash the affected areas with copious quantities of lukewarm water or saline Wash carefully behind the ears, under the nails, and in skin folds For oily substances (eg, pesticides), wash the skin at least twice with plain soap and shampoo the hair Specific decontaminating solutions or solvents (eg, alcohol) are rarely indicated and in some cases may paradoxically enhance absorption For exposure to chemical warfare poisons such as nerve agents or vesicants, some authorities recommend use of a dilute hypochlorite solution (household bleach diluted 1:10 with water)

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Gastric lavage is more effective for liquid poisons or small pill fragments than for intact tablets or pieces of mushroom It is most useful when started within 60 minutes after ingestion However, the lavage procedure may delay administration of activated charcoal and may stimulate vomiting and pulmonary aspiration in an obtunded patient It is no longer used in the routine management of overdose 1 Indications Gastric lavage is sometimes used after very large ingestions (eg, massive aspirin overdose), for collection and examination of gastric contents for identification of poison, and for convenient administration of charcoal and antidotes 2 Contraindications Do not use lavage for stuporous or comatose patients with absent gag reflexes unless they are endotracheally intubated beforehand Some authorities advise against lavage when caustic material has been ingested; others regard it as essential to remove liquid corrosives from the stomach 3 Technique In obtunded or comatose patients, the danger of aspiration pneumonia is reduced by performing endotracheal intubation with a cuffed tube before the procedure Gently insert a lubricated, soft but noncollapsible stomach tube (at least 37 40 F) through the mouth or nose into the stomach Aspirate and save the contents, and then lavage repeatedly with 50- to 100-mL aliquots of fluid until the return fluid is clear Use lukewarm tap water or saline

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Act quickly to prevent serious damage Flush the eyes with copious amounts of saline (preferred) or water (If available, instill local anesthetic drops in the eye before beginning irrigation) Remove contact lenses if present Direct the irrigating stream so that it will flow across both eyes after running off the nasal bridge Lift the tarsal conjunctiva to look for undissolved particles and to facilitate irrigation Continue irrigation for 15 minutes or until each eye has been irrigated with at least 1 L of solution If the toxin is an acid or a base, check the pH of the tears after irrigation, and continue irrigation until the pH is between 65 and 75 After irrigation is complete, perform a careful examination of the eye, using fluorescein and a slit lamp or Wood s lamp to identify areas of corneal injury Patients with serious conjunctival or corneal injury should be immediately referred to an ophthalmologist

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