Toxicologic Emergencies and Critical Care Management
Resuscitation first
Approach every poisoned patient with ABCDE, remembering that toxins kill through hypoventilation, hypotension, arrhythmia, seizures, and hyperthermia. Airway management may require rapid sequence intubation with hemodynamic awareness; many toxins ( opioids, benzodiazepines, alcohols ) cause hypoventilation that responds to simple support or a titrated antidote. Do not delay ventilation to give an antidote.
Hemodynamic and neurologic crises
Undifferentiated hypotension is treated with fluids and norepinephrine while the toxidrome is identified. Wide-complex tachycardia suggests sodium-channel blockade and warrants sodium bicarbonate; avoid class IA and IC antiarrhythmics. Refractory cardiogenic shock from lipophilic drugs or local anesthetics may respond to intravenous lipid emulsion. High-dose insulin with dextrose treats calcium channel blocker and beta blocker poisoning. Hyperthermia requires aggressive cooling and benzodiazepines; dantrolene helps malignant hyperthermia but not serotonin syndrome.
Distinguishing the hyperthermic syndromes
Serotonin syndrome: clonus, hyperreflexia, mydriasis, onset within hours of a serotonergic agent. Neuroleptic malignant syndrome: rigidity, bradyreflexia, elevated CK, onset over days. Anticholinergic toxicity: dry skin, flushing, urinary retention, delirium.
Prolonged support
The poisoned patient who arrests may warrant prolonged resuscitation, especially with local anesthetic systemic toxicity, where lipid emulsion and extended CPR can achieve good outcomes. ECMO is an option for refractory cardiogenic shock (e.g., massive ingestion of cardiotoxic drugs).
Rule of thumb: treat the patient, not the lab value - an asymptomatic, well-perfused patient with an abnormal screening result generally needs observation rather than heroic intervention.