Toxicology

A

• Acetaminophen (Paracetamol) Overdose — ED Management

  Obtain level at ≥4 hours post ingestion; use Rumack-Matthew nomogram; start N-acetylcysteine when indicated or if timing uncertain with elevated level; give activated charcoal within 4 hours in appropriate patients.
• Acetaminophen Overdose — NAC Protocol

  Use timing and level on the Rumack Matthew nomogram for single acute ingestions; start N acetylcysteine immediately if timing unknown, delayed presentation, or high risk.
• Acetaminophen Overdose — NAC Protocols, Risk Nomogram, and Transplant Criteria

  For single acute ingestions, use the Rumack‑Matthew nomogram (≥4 h level) to guide treatment; for staggered or unknown ingestions, start NAC immediately. Prefer IV NAC for severe toxicity, late presenters, or vomiting; monitor LFTs/INR and apply transplant criteria when ALF develops.

B

• Beta Blocker and Calcium Channel Blocker Overdose — High-Dose Insulin

  Treat cardiogenic shock with airway support, fluids, vasopressors, calcium for CCB, glucagon for beta blocker, and high-dose insulin euglycemia therapy; consider lipid emulsion and ECMO in refractory cases.
• Beta Blocker Overdose — Glucagon and High Dose Insulin

  Hypotension and bradycardia respond to glucagon trial, vasopressors, and high dose insulin therapy with dextrose and potassium monitoring.

C

• Calcium Channel Blocker Overdose — High Dose Insulin

  Bradycardia and shock from calcium channel blocker toxicity respond to aggressive supportive care, calcium, vasopressors, and high dose insulin therapy.
• Calcium Channel Blocker Overdose — High‑Dose Insulin Euglycemia and Adjuncts

  Severe hypotension/bradycardia from CCB toxicity requires airway protection, calcium salts, vasopressors, and **high‑dose insulin euglycemia therapy (HIE)** with dextrose and electrolyte monitoring; add lipid emulsion for lipophilic agents and consider ECMO for refractory shock.
• Carbon Monoxide Poisoning — 100% Oxygen, HBOT Criteria, and Disposition

  CO binds hemoglobin and impairs cellular respiration. Treat immediately with 100% oxygen; consider hyperbaric oxygen for severe poisoning (neurologic symptoms, COHb ≥25%—lower thresholds in pregnancy—or cardiac ischemia). Monitor for delayed neurocognitive sequelae.
• Carbon Monoxide Poisoning — 100% Oxygen, Indications for HBOT, and Neuro Follow‑Up

  Headache, dizziness, and flu‑like illness in winter or from fires suggest CO poisoning. Give 100% oxygen immediately and consider hyperbaric oxygen for severe poisoning (e.g., COHb ≥25%, loss of consciousness, pregnancy, neurologic deficits, or cardiac ischemia). Observe for delayed neurologic sequelae.
• Cyanide Poisoning — Hydroxocobalamin Protocol

  Suspect in smoke inhalation with lactic acidosis or industrial exposure; give high-flow oxygen and administer hydroxocobalamin empirically when suspected; avoid nitrites in concurrent CO poisoning.

M

• Methanol Ethylene Glycol Poisoning — Fomepizole and Dialysis

  Suspect in high anion gap metabolic acidosis with osm gap; give fomepizole promptly, correct acidosis, and arrange hemodialysis for standard indications.
• Methemoglobinemia — Methylene Blue

  Suspect with hypoxia unresponsive to oxygen and chocolate colored blood; confirm with co oximetry; treat with methylene blue when symptomatic or levels elevated.
• Methemoglobinemia — Recognition and Treatment

  Functional anemia with cyanosis unresponsive to oxygen; confirm by co-oximetry; treat symptomatic or level >20% with methylene blue unless G6PD deficiency, where alternatives are needed.

O

• Opioid Overdose — ED Management

  Support airway and ventilation; titrate naloxone to restore breathing; monitor for recurrence with long-acting opioids; offer take-home naloxone and buprenorphine initiation when appropriate.
• Opioid Overdose — Naloxone and Supportive Care

  Respiratory depression and pinpoint pupils suggest opioid toxicity; support airway and ventilation and give titrated naloxone; monitor for recurrence from long acting opioids.
• Organophosphate Poisoning — Atropine and Pralidoxime

  Cholinergic toxidrome with salivation, bronchorrhea, and miosis; decontaminate, titrate atropine to dry secretions and adequate ventilation, and start pralidoxime early; benzodiazepines for seizures.

S

• Salicylate Poisoning — Alkalinization and Dialysis

  Recognize tinnitus, tachypnea, and mixed acid–base disorder; start sodium bicarbonate to alkalinize serum and urine; early hemodialysis for severe toxicity.
• Salicylate Toxicity — Alkalinization and Dialysis

  Assess acid base status and symptoms; start sodium bicarbonate infusion for alkalinization and consider hemodialysis for severe toxicity.
• Serotonin Syndrome — Cyproheptadine and Support

  Triad of mental status change, autonomic instability, and neuromuscular hyperactivity after serotonergic drug exposure; stop offending agents, provide supportive care, benzodiazepines, and cyproheptadine for moderate to severe cases.
• Serotonin Syndrome — Recognition and Treatment

  Triad of altered mental status, autonomic instability, and neuromuscular hyperactivity; stop serotonergic agents, give benzodiazepines, and use cyproheptadine for moderate to severe cases.
• Serotonin Syndrome — Recognition, Benzodiazepines, Cooling, and Cyproheptadine

  Triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities (clonus, hyperreflexia). Stop serotonergic agents, give benzodiazepines for agitation, aggressive cooling for hyperthermia, and cyproheptadine for moderate–severe cases. Avoid antipyretics and succinylcholine.

T

• Toxic Alcohol Ingestion — Fomepizole, Adjuncts, and Dialysis Triggers

  Methanol/ethylene glycol ingestions cause high anion gap metabolic acidosis and osmolal gap. Start fomepizole immediately, give cofactors (folinic acid/pyridoxine/thiamine), correct acidosis, and consult poison control; initiate hemodialysis for severe toxicity.
• Toxic Alcohols — Fomepizole and Dialysis

  Recognize high anion gap metabolic acidosis and osm gap; start fomepizole promptly; give cofactor therapy; dialysis for severe poisoning or end-organ toxicity.
• Tricyclic Antidepressant Overdose — Sodium Bicarbonate Protocol

  Life-threatening sodium channel blockade causing wide QRS and arrhythmias; treat with IV sodium bicarbonate boluses/infusion, benzodiazepines for seizures, and supportive care.