Unconventional Toxicology Resuscitation

TABLE 1.2.2 Specific resuscitation situations in toxicology where conventional algorithms or approaches may not apply

Life-threat	Mechanism	Agent(s)	Comments
Airway compromise	Corrosive injury to oropharynx	Alkalis Acids Glyphosate Paraquat	Stridor, dysphagia and dysphonia indicate airway injury and potential for imminent airway compromise Early endotracheal intubation or surgical airway often required
Acidosis Acidaemia	Various	Ethylene glycol Methanol Salicylates	Until late in the clinical course there is usually prominent respiratory compensation Intubation and ventilation at standard settings may worsen acidaemia and precipitate rapid clinical deterioration, if not death. Avoid normo- or hypoventilation Maintain hyperventilation and consider bolus IV NaHCO3 1-2 mmol/kg to prevent worsening of acidaemia
Hypoventilation	Opioid mu receptor stimulation	Opioids	Prompt administration of naloxone may obviate need for intubation and ventilation
Respiratory failure	Cholinergic crisis	Carbamates Nerve agents Organophosphates	Rapid administration of atropine by serial doubling of atropine dose to achieve dry respiratory secretions may restore adequate oxygenation
Acidosis Hypoxaemia Multiple organ failure	Oxygen-free radical mediated cellular injury, particularly type II pneumocytes	Paraquat	Avoid supplemental oxygen If hypoxia occurs, titrate supplemental oxygen to maintain oxygen saturation of ~90% or PaO2 60 mmHg
Ventricular fibrillation	Hypocalcaemia	Hydrofluoric acid ingestion Massive cutaneous burn	Defibrillation alone unlikely to be efficacious Bolus IV calcium (e.g. 60-90 mL 10% calcium gluconate) repeated as required every 2 minutes until defibrillation restores perfusing rhythm
Ventricular tachycardia	Fast Na⁺ channel blockade	Chloroquine Cocaine Flecainide Local anaesthetic agents Procainamide Propranolol Quinine Tricyclic antidepressants	Cardioversion or defibrillation unlikely to be efficacious Urgently intubate and hyperventilate Bolus IV NaHCO3 1-2 mmol/kg repeated every 1-2 minutes until restoration of perfusing rhythm. Do not await determination of serum pH prior to intubation and NaHCO3 boluses Lignocaine is third line therapy when pH is established at > 7.5 Amiodarone and Vaughan Williams Type Ia antiarrhythmic agents (e.g. procainamide) are contraindicated
Ventricular ectopy Ventricular tachycardia	Halogen-induced myocardial sensitisation to catecholamines	Chloral hydrate Organochlorines	Cardioversion or defibrillation unlikely to be efficacious Administer IV beta-blockers, titrate to ectopy response
Refractory hypotension	Various	Beta-blockers Calcium channel blockers Local anaesthetic agents	High-dose insulin-dextrose therapy
Tachycardia	Central and peripheral sympathomimetic response	Amphetamines Cocaine	Beta-blockers contraindicated Administer IV benzodiazepines, titrated to gentle sedation and heart rate control
Supraventricular tachycardia	Adenosine antagonism	Theophylline	Urgent haemodialysis indicated
Hypertension	Central and peripheral sympathomimetic response	Amphetamines Cocaine	Beta-blockers contraindicated Administer IV benzodiazepines, titrated to gentle sedation and heart rate control If further therapy necessary use agents that can be given by titratable intravenous infusion Glycerol trinitrate (GTN) Phentolamine Nitroprusside
Asystole Bradycardia Tachycardia	Na⁺/K⁺ATPase pump inhibition	Digoxin	Usual resuscitation interventions futile Digoxin-specific antibodies
Bradycardia Hypotension Cardiac conduction defects	Calcium channel blockade	Calcium channel-blockers	Atropine and pacing unlikely to be efficacious Bolus IV calcium (e.g. 60 mL 10% calcium gluconate) may provide temporary haemodynamic stability by increasing HR and BP, while other treatments are organised High-dose insulin-dextrose therapy
Acute coronary syndrome	Central and peripheral sympathomimetic response	Amphetamines Cocaine	Beta blockers contraindicated Benzodiazepines GTN Antiplatelet and anticoagulation therapy if no neurological deficits (otherwise cranial CT first) Reperfusion therapy along conventional lines
Hyperkalaemia	Na⁺/K⁺ATPase pump inhibition	Digoxin	Calcium salts are contraindicated Digoxin-specific antibodies
Hypoglycaemia	Hyperinsulinaemia	Sulphonylureas	Difficult to maintain euglycaemia with dextrose supplementation alone Octreotide administration obviates need for dextrose supplementation
Refractory seizures	Inhibition of GABA production	Isoniazid	IV Pyridoxine 1 g per gram of isoniazid ingested, up to 5 g
Seizures	Adenosine antagonism	Theophylline	Urgent haemodialysis indicated