Supportive care in clinical Toxicology

Resuscitation in Toxicology

Supportive care
Initial resuscitation should be based on the assessment of the patient and not the particular toxin involved and standard advanced life support (ALS) guidelines should be followed.Specific instances where treatment may differ are indicated below.

The majority of patients taking overdoses or with drug toxicity are young and healthy, so cardiac and respiratory support should be continued for much longer periods of time in patients with a toxicity-related cardiorespiratory arrest.

If there is any doubt, cardiac compression and ventilatory support should be continued until the situation has been discussed with a clinical toxicologist. There has been survival with normal neurological function in patients receiving cardiopulmonary resuscitation (CPR) for hours.

There are no specific differences from Resuscitation except for caustic and corrosive ingestions . CNS depression is a common effect of drugs, so regular and careful assessment of airway protection and patency is important. 

Toxicology patients rarely have hypoxia unless they develop aspiration pneumonitis. The commonest problem is hypoventilation secondary to respiratory depression.

Inotropic support
The use of intravenous fluid therapy and inotropic support should be based on patient haemodynamics and the specific toxins ingested.
Although specific inotropes or or other drugs are suggested in toxicology patients, the initial management of cardiogenic shock should be the same as for any other cause  unless there are specific contraindications to particular inotropes. The initial inotrope of choice is adrenaline unless its vasopressor actions are contraindicated, such as in beta blocker overdose. Administration of an inotrope should only be undertaken in consultation with a toxicologist or cardiologist.

Other inotropes are used in toxicology, but should usually be used in consultation with a clinical toxicologist. Usual doses of these are given in Box below

Prolonged cardiopulmonary resuscitation is essential because unlike in arrests due to cardiovascular disease, the majority of patients are healthy prior to the overdose, and survival with normal neurological function after long periods (hours) of cardiopulmonary resuscitation is well documented.

Adult doses of other inotropes used in toxicology.
Milrinone (phosphodiesterase inhibitor)

milrinone 50 micrograms/kg IV, slowly over 10 minutes, followed by 0.375 to 0.75 micrograms/kg/minute IV, adjusting according to clinical and haemodynamic response, up to a maximum of 1.13 mg/kg daily.
Insulin euglycaemia
short-acting insulin 1 unit/kg  IV bolus, followed by 1 unit/kg/hour. The dose can be increased to 2 units/kg/hour or further but this should be discussed with a clinical toxicologist


glucose 10% or 50% IV infusion


glucagon 5 to 10 mg (= 5 to 10 units) IV bolus, then continue at 5 to 10 mg/hour.

dobutamine 2.5 to 10 micrograms/kg/minute IV.

Drug-induced arrhythmias
QT prolongation and torsades de pointes: QT prolongation should be monitored and any other precipitating factors should be determined and treated if possible. Electrolytes, including magnesium and calcium, should be checked and deficiencies corrected.

Patients with hypomagnesaemia should have magnesium replacement. [Note 1]
In adults, use:

magnesium sulfate 50% 5 to 10 mL (= 2.5 to 5 g or 10 to 20 mmol) IV over 30 to 60 minutes.

In children, use:

magnesium sulfate 50% 0.1 mL/kg (= 50 mg/kg or 0.2 mmol/kg) IV over 20 minutes [Note 2], followed by 0.06 mL/kg/hour (= 30 mg/kg/hour or 0.12 mmol/kg/hour) IV infusion.

Patients with hypocalcaemia should have calcium replaced. Use:
In adults, use:

calcium gluconate 10% 10 to 20 mL (= 1 to 2 g or 2.2 to 4.4 mmol) IV, over 10 to 30 minutes.

In children, use:

calcium gluconate 10% 2 to 5 mL/kg/day (= 200 to 500 mg/kg/day) IV infusion.

Patients with hypokalaemia should have potassium replaced. If the patient is able to take and absorb oral potassium, use:

potassium chloride 14 to 16 mmol orally, 3 times daily (child: 1 mmol/kg/day in 2 to 4 doses) [Note 3].

If the serum potassium is less than 3 mmol/L or the patient is unable to take or absorb oral potassium, use:

potassium chloride 10 to 20 mmol (= 0.75 to 1.5 g) IV, over 1 to 2 hours (child: 0.6 mmol/kg IV over 3 hours) preferably as a pre-mixed solution of the appropriate intravenous fluid. [Note 4].

Isoprenaline or transvenous pacing should be considered in patients with a prolonged QT interval and bradycardia. In adults, use:

isoprenaline 20 micrograms IV, repeat according to clinical response, and commence an infusion at 1 to 4 micrograms/minute, but the rate may need to be rapidly increased to give double, quadruple or higher doses as required to overcome the beta blockade.

Torsades de pointes may resolve spontaneously within a minute but if not, first-line treatment is a 200 J DC shock or equivalent. If there is no response to an initial DC shock this can be repeated with increasing voltage shocks. Magnesium should also be given (except in torsades de pointes resulting from beta blocker overdose, see Toxicology: beta blockers).
In adults, use:

magnesium sulfate 50% 2 to 4 mL (= 1 to 2 g or 4 to 8 mmol) IV as a slow injection over 2 to 5 minutes.

In children, use:

magnesium sulfate 50% 0.05 to 0.1 mL/kg to a maximum of 4 mL (= 0.025 to 0.05 g/kg or 0.1 to 0.2 mmol/kg to a maximum of 8 mmol/dose) IV as a slow injection over 10 to 15 minutes.

If there is deterioration to ventricular fibrillation or asystole, standard advanced life support protocols should be followed, see Figure 14.4 and Figure 14.5.
Note 1: In toxicology patients, the correction of magnesium deficiency, if required, needs to be done rapidly while the patient has a prolonged QT interval and is at risk of torsades de pointes.
Note 2: Magnesium can be given intramuscularly in infants or children if urgent IV access not possible.
Note 3: Effervescent immediate-release tablets of potassium contain 14 mmol potassium per tablet, and slow-release tablets contain 8 mmol potassium. The slow-release formulations of potassium are almost completely absorbed within one hour.
Note 4: If pre-mixed IV solution is unavailable, potassium chloride concentrate injection must be added to a large volume of parenteral fluid and mixed thoroughly before infusion. The usual maximum concentration is 40 mmol/L.