Overview of Antidotes

An antidote is a substance that counteracts poisoning or toxicity. Substances that can cause poisoning include heavy metals (from occupation, treatments, or diet), alcohols, environmental toxins, and medications. An increase in the concentration of these substances to toxic levels can occur accidentally or intentionally, resulting in both acute and chronic presentations. Some substances can be detected using specific laboratory tests, whereas the detection of others relies on nonspecific findings. Thus, it is important to recognize substance poisoning by history, individual risk factors, and physical examination. Antidotes along with supportive care and monitoring are part of the management.

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Heavy Metal Poisoning

Copper

  • Accumulation seen in Wilson disease; results from high intake (increased absorption or reduced excretion)
  • Toxicity presentation:
    • Abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, vomiting, gastric bleeding (hematemesis), diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
    • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension 
    • Jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice
    • Liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver toxicity 
    • Psychiatric symptoms (behavioral changes)
    • Altered mentation
  • Antidotes:
    • D-penicillamine (primary chelator)
    • Trientine (2nd line)
  • Other treatment: zinc (reduces the absorption of copper)

Iron

  • Accumulation due to accidental ingestion or chronic multiple transfusions
  • Toxicity presentation:
    • Lethargy/ coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma
    • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
    • GI symptoms (nausea, vomiting, abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain)
    • Hematemesis
    • Bowel obstruction
    • Liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver dysfunction
    • Renal dysfunction
    • Anion gap metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis 
    • ↓ HCO3 levels 
  • Antidotes:
    • Deferoxamine 
    • Deferasirox 
    • Deferiprone

Lead

  • Toxicity seen due to ingestion or inhalation of lead (from lead paint, lead bullets, contaminated water)
  • Toxicity presentation:
    • Lead lines on gingiva (Burton lines) 
    • Systemic symptoms (fatigue, irritability, insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia, joint/muscle aches)
    • GI symptoms (abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, anorexia)
    • CNS symptoms (headache, short memory loss, peripheral neuropathy, wrist drop, foot drop)
    • Encephalopathy and mental deterioration in children
    • Dense metaphyseal lines of long bones on X-ray
  • Antidotes:
    • Succimer (2,3-dimercaptosuccinic acid (DMSA))
    • Calcium disodium ethylenediaminetetraacetic acid (EDTA)
    • Dimercaprol

Mercury

  • Toxicity arising from occupational exposure (mining, manufacturing of thermometers), dentistry (tooth fillings), ingestion of contaminated fish
  • Toxicity presentation:
    • Conjunctivitis Conjunctivitis Conjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis
    • Stomatitis Stomatitis Stomatitis is a general term referring to inflammation of the mucous membranes of the mouth, which may include sores. Stomatitis can be caused by infections, autoimmune disorders, allergic reactions, or exposure to irritants. The typical presentation may be either solitary or a group of painful oral lesions. Stomatitis, increased salivation
    • Cough, dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
    • Nausea, vomiting
    • Dermatitis
    • Peripheral neuropathy, paresthesia
    • Chronic changes: neuropsychiatric (depression or mood changes or memory loss, neuropathy, paresthesia), rash, hair loss
  • Antidotes:
    • DMSA
    • Unithiol (2,3-dimercaptopropane-1-sulfonate (DMPS))
    • Dimercaprol
    • Penicillamine

Medication Overdose

Acetaminophen Acetaminophen Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. Acetaminophen

  • Toxicity presentation:
    • Asymptomatic initially (1st 24 hours)
    • Nausea, vomiting, anorexia
    • Liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes
    • Hepatotoxicity
  • Antidotes:
    • N-acetylcysteine 
    • Charcoal if administered < 4 hours of ingestion

Anticholinergic Anticholinergic Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs toxicity (e.g., atropine, diphenhydramine)

  • Toxicity presentation:
    • Dry mouth, dry skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
    • Blurry vision, mydriasis
    • Hyperthermia
    • Urinary retention
    • ↓ Bowel sounds 
  • Antidotes: 
    • Physostigmine
    • Control hyperthermia, IV fluids

Benzodiazepines

  • Toxicity presentation:
    • Slurred speech
    • Unsteady gait
    • Drowsiness
    • Respiratory depression
  • Antidote: Flumazenil (competitive antagonist of benzodiazepine)

Beta-blockers

  • Toxicity presentation:
    • Bradycardia
    • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
    • ↓ Consciousness or delirium Delirium Delirium is a medical condition characterized by acute disturbances in attention and awareness. Symptoms may fluctuate during the course of a day and involve memory deficits and disorientation. Delirium
    • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
    • Bronchospasm
    • Hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia
  • Antidotes:
    • Atropine
    • Glucagon

Digitalis (digoxin)

  • Toxicity presentation:
    • GI symptoms (abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, nausea, vomiting, diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea)
    • Anorexia, fatigue
    • Visual changes (diplopia, blindness, photophobia)
    • CNS symptoms (confusion, weakness)
    • Bradycardia, cardiac arrhythmias
    • Hyperkalemia Hyperkalemia Hyperkalemia is defined as a serum potassium (K+) concentration >5.2 mEq/L. Homeostatic mechanisms maintain the serum K+ concentration between 3.5 and 5.2 mEq/L, despite marked variation in dietary intake. Hyperkalemia can be due to a variety of causes, which include transcellular shifts, tissue breakdown, inadequate renal excretion, and drugs. Hyperkalemia (due to inhibition of the Na+-K+-ATPase)
  • Antidote: Anti-digoxin Fab fragments

Heparin

  • Toxicity presentation: 
    • Bruising
    • Excessive hemorrhage 
  • Antidote: Protamine sulfate

Opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics

  • Toxicity presentation: 
    • CNS symptoms (euphoria, drowsiness, slurred speech, seizures, pinpoint pupils)
    • GI symptoms (nausea, vomiting, constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation)
    • Respiratory depression
  • Antidote: Naloxone

Salicylates

  • Toxicity presentation: 
    • Tinnitus
    • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
    • Nausea and vomiting
    • Early hyperpnea ( respiratory alkalosis Respiratory alkalosis The respiratory system is responsible for eliminating the volatile acid carbon dioxide (CO2), which is produced via aerobic metabolism. When hypoventilation occurs, excess carbon dioxide is blown off and respiratory alkalosis develops. The kidneys respond by decreasing serum bicarbonate (HCO3-) through increased HCO3- excretion or decreased excretion of H+. Respiratory Alkalosis
    • Later develops into anion gap metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis
  • Antidotes: 
    • NaHCO3 (urine alkalinization)
    • Decontamination with activated charcoal if ingestion is within 2 hours
    • Supplemental glucose even if serum glucose is normal (as salicylates decrease cerebral glucose levels)
    • Hemodialysis

Tricyclic antidepressants Tricyclic antidepressants Tricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain. Tricyclic Antidepressants (TCAs)

  • Toxicity presentation:
    • CNS symptoms (mental status changes, seizures)
    • Respiratory depression
    • Cardiovascular symptoms (tachycardia, hypotension, prolonged QT, arrhythmias)
    • Anticholinergic Anticholinergic Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs symptoms (dry mouth, blurred vision, dilated pupils, urinary retention, flushing, hyperthermia)
  • Antidotes: 
    • O2
    • IV fluids
    • IV NaHCO3 for arrhythmias
    • Benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines for seizures
    • Decontamination with activated charcoal if ingestion was within 2 hours

Warfarin

  • Toxicity presentation:
    • Bruising
    • Excessive hemorrhage
    • Skin necrosis
  • Antidotes: 
    • Vitamin K (delayed reversal)
    • Fresh frozen plasma (immediate reversal)
    • Prothrombin complex concentrate

Toxic Alcohol Poisoning

Methanol and ethylene glycol are found in automotive coolants (antifreeze) and deicing solutions, fuel, cleaners, windshield wiper fluids, solvents, and other industrial products.

Methanol

  • Toxicity presentation:
    • Blurred vision with central scotoma
    • Afferent pupillary defect (ominous sign)
    • Headaches
    • Mental status changes
    • Nausea and vomiting
    • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
    • ↑ Anion gap metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis
    • Coma
  • Antidotes: 
    • Fomepizole (preferred)
    • Ethanol
    • Hemodialysis in severe cases (acidosis, end-organ damage)

Ethylene glycol

  • Toxicity presentation:
    • Tetany
    • Flank pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Hematuria
    • Oliguria
    • ↑ Anion gap metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis
    • Calcium oxalate crystals in urine
    • Kidney failure
    • Cranial nerve palsy
  • Antidotes: 
    • Fomepizole (preferred)
    • Ethanol
    • Hemodialysis in severe cases (acidosis, end-organ damage)

Arsenic and Cyanide Poisoning

Arsenic

  • Exposure can be from natural sources (volcanic eruption), occupational sources (smelting), or contaminated medications, water, or animal feeds.
  • Toxicity presentation:
    • Garlic breath
    • Dehydration
    • GI symptoms (vomiting, watery diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea)
    • Cardiovascular symptoms (hypotension, QT prolongation, cardiac arrhythmias)
    • Skin manifestations: pigmentation (↓ or ↑), hyperkeratosis
    • Stocking-glove neuropathy (burning, painful hypersensitivity, distal weakness, and hyporeflexia)
    • Liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver cancer (angiosarcoma)
    • Lung cancer Lung cancer Lung cancer is the malignant transformation of lung tissue and the leading cause of cancer-related deaths. The majority of cases are associated with long-term smoking. The disease is generally classified histologically as either small cell lung cancer or non-small cell lung cancer. Symptoms include cough, dyspnea, weight loss, and chest discomfort. Lung Cancer 
  • Antidotes: 
    • Dimercaprol 
    • DMSA

Cyanide

  • Exposure can be from domestic fires (cyanide released from the combustion of products), occupation (mining, manufacturing), sodium nitroprusside, or diet (pits/seeds of some fruits).
  • Toxicity presentation:
    • Bitter almond breath
    • Pink or cherry red skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin 
    • Nausea and vomiting
    • Metabolic acidosis 
    • Initial hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, then hypotension 
    • Hyperventilation 
    • Headache, vertigo Vertigo Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo, seizures 
    • Renal and hepatic failure
  • Antidotes: 
    • Hydroxocobalamin
    • Sodium thiosulfate
    • Induce methemoglobinemia Methemoglobinemia Methemoglobinemia is a condition characterized by elevated levels of methemoglobin in the blood. Methemoglobin is the oxidized form of hemoglobin, where the heme iron has been converted from the usual ferrous (Fe2+) to the ferric (Fe3+) form. The Fe3+ form of iron cannot bind O2, and, thus, leads to tissue hypoxia. Methemoglobinemia using nitrites (e.g., amyl nitrite, sodium nitrite) if the above medications are unavailable.

Miscellaneous Antidotes

Anticholinesterase poisoning (organophosphate, insecticides)

  • Toxicity presentation (cholinergic):
    • Pinpoint pupils
    • Sweating, salivation
    • Bronchoconstriction
    • Vomiting and diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
    • CNS stimulation followed by CNS depression
    • Muscle fasciculations, weakness, paralysis
    • Death from respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure
  • Antidotes: 
    • Atropine 
    • Pralidoxime

Carbon monoxide

  • From fire-related smoke inhalation; also common in winter months (from fuel-burning devices, vehicles in poorly ventilated areas)
  • Toxicity presentation:
    • Confusion 
    • Rose cheeks and bright cherry lips Lips The lips are the soft and movable most external parts of the oral cavity. The blood supply of the lips originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue 
    • Headache, dizziness
    • Decreased visual acuity 
    • Nausea
    • Malaise 
    • Tachycardia, myocardial ischemia, arrhythmias 
  • Antidotes: 
    • 100% O2
    • Hyperbaric O2

Methemoglobin

  • Methemoglobinemia has genetic and acquired (medications such as dapsone, antimalarials) causes.
  • Toxicity presentation:
    • Cyanosis
    • Chocolate-colored blood
    • Arrhythmias
    • Chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain, palpitations
    • Acidosis
    • Confusion
    • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures, coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma
  • Antidotes: 
    • Methylene blue
    • High dose of vitamin C

Clinical Relevance

  • Methanol poisoning: Methanol is a type of non-consumable alcohol (wood alcohol) mostly used in the manufacture of fuel, solvents, and antifreeze. Methanol ingestion results in symptoms such as visual blurring, central scotoma, afferent pupillary defect, headaches, mental status changes, nausea, vomiting, and anion gap metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis. The most dangerous complications of methanol poisoning are vision loss and coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma. Management is with fomepizole (blocks alcohol dehydrogenase) and ethanol, and hemodialysis.
  • Ethylene glycol poisoning: Ethylene glycol is an alcohol used as a raw material in the manufacture of polyester fibers and antifreeze formulations. Toxicity presentation includes flank pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, hematuria, oliguria, anion gap metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis, calcium oxalate crystals in the urine, and kidney damage. Management involves the administration of fomepizole (blocks alcohol dehydrogenase) and ethanol, and dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Overview and Types of Dialysis.
  • Anticholinergic Anticholinergic Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs toxicity: a condition occurring from the overdose of atropine or diphenhydramine. Anticholinergic Anticholinergic Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs toxicity is characterized by dry mouth, dry skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin, blurry vision, mydriasis, hyperthermia, urinary retention, and decreased bowel sounds. Management involves the administration of physostigmine and the control of hyperthermia.
  • Organophosphate toxicity: Organophosphates irreversibly inhibit the enzyme acetylcholinesterase. Features of toxicity include pinpoint pupils, sweating, salivation, bronchoconstriction, vomiting, diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, CNS stimulation followed by CNS depression, muscle fasciculations, weakness, paralysis, and death from respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure. Management involves the administration of both atropine and pralidoxime.
  • Acetaminophen Acetaminophen Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. Acetaminophen toxicity: occurs when large doses of acetaminophen (> 7.5 g in adults, and > 150 mg/kg in pediatrics) are administered. Many patients remain asymptomatic initially (1st 24 hours). Features of acetaminophen toxicity include nausea, vomiting, anorexia, elevated liver enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes, and hepatotoxicity. Management involves measuring acetaminophen blood levels, administering activated charcoal if the patient presents within 4 hours of intoxication, and administering N-acetylcysteine (to restore glutathione levels).
  • Methemoglobinemia: a condition characterized by elevated levels of methemoglobin in the blood. Methemoglobin is the oxidized form of hemoglobin, where the heme iron has been converted from the usual ferrous (Fe2+) to ferric (Fe3+) form. The Fe3+ form cannot bind oxygen, leading to tissue hypoxia. The condition is fatal in case of significant elevation of methemoglobin (> 70%). Diagnosis is established by measuring methemoglobin levels in blood using co-oximetry. Treatment is using methylene blue or ascorbic acid.
  • Benzodiazepine toxicity: a condition resulting from benzodiazepine overdose (e.g., for anxiety, sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep). Symptoms of benzodiazepine toxicity include slurred speech, unsteady gait, drowsiness, and respiratory depression, especially if co-administered with alcohol or opioids. Patients usually have normal vital signs and pupillary size. Flumazenil is used as an antidote.
  • CO poisoning CO poisoning Carbon monoxide (CO) is an odorless, colorless, tasteless, nonirritating gas formed by hydrocarbon combustion (e.g., fires, car exhaust, gas heaters). Carbon monoxide has a higher affinity to hemoglobin than oxygen, forming carboxyhemoglobin (COHb). Increased levels of COHb lead to tissue hypoxia and brain damage. Carbon Monoxide Poisoning: CO is an odorless, tasteless, colorless, nonirritating gas formed by hydrocarbon combustion (fires, car exhaust, gas heaters). Carbon monoxide poisoning Carbon monoxide poisoning Carbon monoxide (CO) is an odorless, colorless, tasteless, nonirritating gas formed by hydrocarbon combustion (e.g., fires, car exhaust, gas heaters). Carbon monoxide has a higher affinity to hemoglobin than oxygen, forming carboxyhemoglobin (COHb). Increased levels of COHb lead to tissue hypoxia and brain damage. Carbon Monoxide Poisoning results in impaired O2 transport and utilization. Features of CO poisoning CO poisoning Carbon monoxide (CO) is an odorless, colorless, tasteless, nonirritating gas formed by hydrocarbon combustion (e.g., fires, car exhaust, gas heaters). Carbon monoxide has a higher affinity to hemoglobin than oxygen, forming carboxyhemoglobin (COHb). Increased levels of COHb lead to tissue hypoxia and brain damage. Carbon Monoxide Poisoning include confusion, headache, dizziness, decreased visual acuity, rose cheeks, coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma, and death. Management includes the use of 100% O2; hyperbaric O2 is used if O2 therapy fails.

References

  1. Barrueto, F. (2021). Beta blocker poisoning. UpToDate. Retrieved June 20, 2021, from https://www.uptodate.com/contents/beta-blocker-poisoning
  2. Beauchamp, G., Kusin, S., Elinder, C. (2021). Mercury toxicity. UpToDate. Retrieved June 20, 2021, from https://www.uptodate.com/contents/mercury-toxicity
  3. Boyer, E., Weibrecht, K. (2021). Salicylate (aspirin) poisoning in adults. UpToDate. Retrieved June 20, 2021, from https://www.uptodate.com/contents/salicylate-aspirin-poisoning-in-adults
  4. Clardy, P., Perry, H. (2021). Carbon monoxide poisoning Carbon monoxide poisoning Carbon monoxide (CO) is an odorless, colorless, tasteless, nonirritating gas formed by hydrocarbon combustion (e.g., fires, car exhaust, gas heaters). Carbon monoxide has a higher affinity to hemoglobin than oxygen, forming carboxyhemoglobin (COHb). Increased levels of COHb lead to tissue hypoxia and brain damage. Carbon Monoxide Poisoning. UpToDate. Retrieved June 20, 2021, from https://www.uptodate.com/contents/carbon-monoxide-poisoning
  5. Dart, R., Heard, K. (2020). Acetaminophen Acetaminophen Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. Acetaminophen (paracetamol) poisoning in adults: Treatment. UpToDate. Retrieved April 1, 2021, from https://www.uptodate.com/contents/acetaminophen-paracetamol-poisoning-in-adults-treatment
  6. Desai, S., Su, M. (2021). Cyanide Poisoning Cyanide Poisoning Hydrogen cyanide is an extremely poisonous, colorless, flammable liquid used in multiple industries and includes rubber, plastic, and household paints. Exposure to cyanide can occur via inhalation, dermal contact, or intestinal ingestion. Cyanide Poisoning. UpToDate. Retrieved June 20, 2021, from https://www.uptodate.com/contents/cyanide-poisoning
  7. Goldman, R. (2021). Arsenic exposure and poisoning. UpToDate. Retrieved June 20, 2021, from https://www.uptodate.com/contents/arsenic-exposure-and-poisoning
  8. Hu, H., Goldman, R. (2019). Lead exposure and poisoning in adults. UpToDate. Retrieved April 2, 2021, from https://www.uptodate.com/contents/lead-exposure-and-poisoning-in-adults
  9. Levine, M. (2020). General approach to drug poisoning in adults. UpToDate. Retrieved April 1, 2021, from https://www.uptodate.com/contents/general-approach-to-drug-poisoning-in-adults
  10. Liebelt, E. (2021). Acute iron poisoning. UpToDate. Retrieved June 20, 2021, from https://www.uptodate.com/contents/acute-iron-poisoning
  11. Royer, A., Sharman, T. (2021). Copper toxicity. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK557456/
  12. Salhanick, S. (2021). Tricyclic antidepressant Antidepressant Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications poisoning. UpToDate. Retrieved June 20, 2021, from https://www.uptodate.com/contents/tricyclic-antidepressant-poisoning
  13. Sivilotti, M. (2020). Methanol and ethylene glycol poisoning: Management. UpToDate. Retrieved April 1, 2021, from https://www.uptodate.com/contents/methanol-and-ethylene-glycol-poisoning-management

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