Poisonings (Intoxications): Drug Therapy

Therapeutic targets

• Toxin removal
• Preservation of vital functions (vital functions while awake, respiration and circulation).
• Recovery

Therapy recommendations

In addition to symptom-based therapy, specific treatments are required for poisoning (where antidotes/counterpoisons are available):

• Primary toxin removal
  • Application of medical charcoal (activated charcoal: see below) – within the first hour after ingestion of a noxious agent that binds to charcoal
    • Delayed administration of activated charcoal is indicated for the following drugs: Citalopram, paracetamol, promethazine, quetiapine.
    • repetitive administration of activated charcoal is indicated with the following medications:
      • Amatoxin, colchicine (marked enterohepatic circulation).
      • Carbamazepine, quinine, dapsone, phenobarbital, theophylline.
      • Digoxin/digitoxin (marked enterohepatic circulation; if no digitalis antidote available/s. u. Antidota).
      • Retarded quetiapine (bezoar-forming drug).
    • See below list: “Drugs/toxins with proven or absent adsorption to activated charcoal”.
• Gastric lavage with isotonic saline (if necessary. under intubation (artificial respiration via a breathing tube inserted through the nose), in case of intoxication with potential effects on the CNS) – within the first hour after ingestion of a potentially life-threatening threatening dose of noxious substance (poisons), which is also absorbed extremely protracted (“delayed”), which is also absorbed extremely protractedContraindications: corrosive substances, and long-chain hydrocarbon compounds (eg, gasoline, lamp oils).

• Secondary toxin removal (urinary alkalinization, hemodialysis/detoxification of blood outside the body or hemoperfusion).
• Administration of antidotes/counterpoisons (see below)Note: Unless there is a specific antidote (e.g., amphetamine intoxication), therapy is symptomatic and supportive.
• Continuous monitoring (intensive care unit).
• See also under “Further therapy“.

Agents (main indication) for absorption inhibition/elimination acceleration

Active ingredients	Dosage	Special features
Activated carbon	0.5-1 g/kg bw (children <1 year) 1 g/kg bw (children > 1 year) 1-2 g/kg bw (adults) but not more than 50 g or Charcoal amount 10 times over the amount of poison	Optimal if poison intake < 1 hour (poison intake > 1 hour: absorption capacity only 20-60 %)Then Glauber’s salt 15-30 g p.o. (diluted)
Sodium hydrogen carbonate	Not specified	No longer recommended (activated carbon superior)

• Mode of action Activated charcoal: absorption reduction based on its large external surface area, which is over 2,000 m 2/g; elimination acceleration of drugs subject to enteropatic circulation (e.g., antiepileptic drugs, theophylline).
• Indications: See below list: “Drugs / toxins with proven or lack of adsorption to activated carbon“.
• Indications for repetitive administration: intoxication with carbamazepine, quinine, dapsone, phenobarbital, theophylline.
• Contraindications:
  • Patient clouded in consciousness without adequate swallowing reflexes without securing airway.
  • Increased risk of aspiration pneumonia (solvents, surfactants).
  • Gastrointestinal burns (e.g., acids, alkalis, iron salts), bleeding, impaired gastrointestinal passage or suspected perforation.
  • Ingestion of gasoline/oil or other non-adsorbable substances/toxins.
  • Recurrent vomiting
  • Administration of activated charcoal against the express will of the patient or child (except in cases of attempted suicide)
• Side effects: Aspiration

• Mode of action sodium bicarbonate: urinary alkalinization.
• Indications: Intoxication with salicylates, barbiturates, dichlorophenoxyacetic acid herbicides.

Drugs / toxins with proven or lack of adsorption to activated carbon.

Drugs that are adsorbed

ACE inhibitor Amphetamines Antidepressants (except lithium) Antiepileptic drugs Antihistamines Acetylsalicylic acid (ASA), salicylates Atropine Barbiturates Benzodiazepines Beta blockers Calcium channel blockers (synonym: calcium blockers or calcium antagonists). Quinine, quinidine Chloroquine, primaquine Dapsone Digoxin, digitoxin (cardiac glycosides) Diuretics (v. a. Furosemide, Torasemide). Non-steroidal anti-inflammatory drugs (NSAIDs) Neuroleptics Oral antidiabetic agents (v. a. glibenclamide, glipizide). Opiates, dextromethorphan (related to morphine). Paracetamol Piroxicam Tetracycline Theophylline

Plant substances/toxins that are absorbed.

Amatoxin (tuberous-leaf fungus) Aconitine (aconitine; aconite) Colchicine (meadow saffron) Cucurbitacin (zucchini, cucurbits [caveat: if pumpkin vegetables please upsets]). Digitalis glycosides (foxglove) Ergotamine, ergot alkaloids Ibotensic acid, muscarinic (fly agaric (Amanita muscaria), panther mushroom). Nicotine (tobacco) Ricin (miracle tree) Strychnine (nux vomica) Taxanes (yew)

Substances/toxins that are not absorbed or not absorbed sufficiently

Alcohols (e.g. ethanol (synonyms: ethyl alcohol, also ethanol or ethyl alcohol), methanol and glycols(e.g. ethylene glycol). Inorganic salts (eg sodium chloride). Metals and their inorganic compounds (e.g., lithium, iron or other heavy metals (e.g., lead, mercury)). Organic solvents (e.g. acetone, dimethyl sulfoxide). Acids and alkalis Cyanides

Antidota

Active substance (antidote)	Mode of action	Intoxications
Atropine	Blockade of muscarinic receptors	OrganophosphatesNerve agents (e.g., sarin (methylfluorophosphonic acid isopropyl ester))Muscarinic syndrome caused by crack fungi
Beclomethasone dipropionate	Sealing of capillary membranes	Flue gasOther pulmonary irritantsIn case of hydrogen cyanide involvement: Sodium thiosulfate, hydroxocobalamin.
Biperiden	Anticholinergic	Neuroleptic-associated extrapyramidal motor disorders.
Calcium gluconate	Calcium ions combine with the free fluoride ions (F-) in the body	Hydrofluoric acid (fluorides), oxalic acid (star fruit, rhubarb).
Calcium trisodium tetate	Complexing agent	Lead, chromium, iron, manganese, zinc salts.
Deferoxamine	Complexing agent	IronIron overload [see also guideline below: secondary iron overload in patients with congenital anemias, diagnosis and therapy].
Diazepam	Benzodiazepine	Chloroquine
Digitalis antidote	Binds free glycoside (digitalis antibody)	Digitalis
Dimeticone	Defoamer for surfactant poisoning	SurfactantsSurfactant-containing hand rinses, shampoos and similar products.
Dimercaptopropane sulfonic acid (DMPS)	Chelating agent	Heavy metalsArsenic, bismuth, lead, chromium, copper, mercury.
Iron(III) hexacyanoferrate (Berlin blue)	Binds thallium in the intestine	Thallium
Flumazenil	GABA receptor antagonist	Benzodiazepine
Fomepizole	Inhibits alcohol dehydrogenase	Alcohol, diethylene glycol, ethylene glycol intoxicationCoolant freeze (hemodialysis here if necessary). NoteIn alcohol withdrawal syndrome (AES): delirium prophylaxis should be started before hospital admission, if necessary.
Hydroxocobalamin	Complexation of cyanide and cobalt	Alternative to 4-DMAP
Methylene blue	Accelerates reduction of Met-Hb to Hb	Methemoglobinemia
N-acetylcysteine	Inactivation of intermediate metabolites (e.g., N-acetyl-p-benzoquinoneimine).	ParacetamolDichloroethane(meta-)acrylonitrileCarbon tetrachloride. Single paracetamol overdose: <150 mg/kg bw is not expected to cause liver injury in healthy individuals without therapy. > 250 mg/kg bw, liver damage is likely. > 350 mg/kg bw, liver damage is expected without therapy in more than 90% of those poisoned.For liver damage or impending acute liver failure, see below liver failure.
Naloxone	Opiate antagonist	Opioids, heroin/diacetylmorphine
Sodium thiosulfate	Detoxification capacity ↑	Hydrogen cyanide (bromates), cyanide, nitrile.
Obidoxime	Reactivation of acetylcholinesterase by dephosphorylation.	Organophosphate intoxication (e.g., sarin).
Penicillamine	Complexing agent	Lead, copper, mercury, zinc
Physiostigmine, Neostigmine	Parasympathomimetic	AtropineIf necessary for severe GHB intoxication.
Oxygen (100%)	Elimination of CO the higher the offered oxygen partial pressure (pO2) is	Carbon monoxide poisoningNote: In case of fire gas exposure, additive cyanide poisoning should be considered in addition to CO → additive administration of the cyanide antidote (hydroxycobolamine, see above ), which has few side effects.
Silibinin	Inhibits amatoxin uptake in the liver	Amatoxin, tuberous-leaved mushroom
Toluidine blue (toluidine chloride)	Accelerates reduction of Met-Hb to Hb	Methemoglobin formers
Vitamin K	Fat-soluble vitamin; cofactor of reactions of γ-glutamyl carboxylase	Phenprocoumon (Marcumar)
4-dimethylaminophenol (4-DMAP)	Methemoglobin formation	Hydrogen cyanide, cyanide, nitrile, hydrogen sulfide.

New therapeutic options

• Insulin – poisoning with beta blockers, calcium antagonists.
• Lipid emulsions – local anesthetic intoxication.

Antidota minimal equipment (“Bremen list”)

• Carbo medicinalis 50 g; administration only after consultation with the poison center.
• Atropine 100 mg ampoule; indication: organophosphate intoxication.
• 4-DMAP (dimethylaminophenol) 250 mg ampoule; indication: cyanidintoxication.
• Naloxone 0.4 mg ampoule; Indication: opioid intoxication.
• Toluidine blue 300 mg ampoule; indication: methemoglobin formers poisoning.