General Approach to All Patients

Overdose and Poisonings

Determine the agent involved, the time of the ingestion/exposure, and the amount ingested. Bring empty pill bottles, etc., to the receiving facility. Give nothing by mouth unless specified in protocol or directed by the Regional Poison Control Center.

Anticholinergic Poisoning/Organophosphates

Organophosphates cause acetylcholinesterase inhibition, resulting in signs and symptoms such as pinpoint pupils, eye pain, sweating, drooling, tearing, vomiting, seizures, and respiratory distress. Examples of commonly used organophosphate pesticides:

  • Acephate (Orthene®)
  • Azinphos-methyl (Azinphos®, Guthion®)
  • Chlorpyrifos (Govern®, Lorsban®, Nufos®, Warhawk®, Whirlwind®)
  • Diazinon
  • Dimethoate (Cygon®)
  • Disulfoton (Di-Syston®)
  • Ethoprop (Mocap®)
  • Fenamiphos (Nemacur®)
  • Malathion (Fyfanon®)
  • Methamidophos (Monitor®)
  • Methidathion (Supracide®)
  • Methyl parathion (Penncap-M®)
  • Naled (Dibrom®)
  • Oxydemeton-methyl (MSR®)
  • Phorate (Thimet®)
  • Phosmet (Imidan®)
  • Profenofos (Curacron®)

Nerve agent chemical weapons such as Sarin, Soman, Tabun, and VX are also organophosphates and should be treated accordingly

Basic Life Support

  • Initiate HAZMAT Alert if indicated
  • Wear protective clothing including masks, gloves, and eye protection
    • Toxicity to ambulance crew may result from inhalation or topical exposure
    • Remove all clothing and contain run-off of toxic chemicals when flushing
  • Supplemental 100% oxygen

Advanced Life Support

  • Full ALS Assessment and Treatment
  • If signs of severe toxicity, (severe respiratory distress, bradycardia, heavy respiratory secretions – do not rely on pupil constriction to diagnose or to titrate medications):
    • Atropine 2 mg IV every 5 min; titrate dosing by assessing improvement in respiratory/ bronchial secretions
  • For hypotension (systolic BP < 90 mmHg) not improved by fluid boluses, or when fluid boluses are contraindicated:
    • Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP > 90 mm Hg
  • If any of the following conditions occur, refer to the appropriate protocols:
    • Altered Mental Status
    • Seizures

Antipsychotics/Acute Dystonic Reaction

Example of commonly used medications that may result in acute dystonic reactions:

  • Haloperidol
  • Prolixin
  • Thorazine
  • Prochlorperazine (Compazine)
  • Promethazine (Phenergan)
  • Ziprasidone (Geodon)

Advanced Life Support

  • Full ALS Assessment and Treatment
  • For Dystonic reactions administer Diphenhydramine (Benadryl) 1 mg/kg IV (Max. 50 mg)
    • May be administered IM if no IV access available

Beta Blocker Toxicity

Examples of commonly used Beta-Blocker medications:

  • Atenolol (Tenormin)
  • Corzide (Nadolol/bendroflumethlazide)
  • Esmolol (Brevibloc)
  • Inderide (Propranolol/HCTZ)
  • Inderide LA (Propranolol/HCTZ)
  • Labetolol (Trandate)
  • Lopressor HCT (Metoprolol/HCTZ)
  • Metroprolol (Lopressor)
  • Nadolol (Corgard)
  • Propranolol (Inderal)
  • Tenoretic (Atenolol/Chlorthalidone)
  • Timolide (Timolol/HCTZ)
  • Timolol (Blocadren)
  • Ziac (Bisoprolol/HCTZ)

Advanced Life Support

  • Full ALS Assessment and Treatment
  • For patients with cardiovascular toxicity, defined by:
    • SBP < 90 mm Hg
    • Altered mental status
    • Bradycardia
    • 2nd or 3rd degree heart blocks
  • Administer the following agents:
    • NS 250 ml boluses IV
    • If no response, Atropine 0.5 mg IV
      • Repeat every 3 minutes as needed (Maximum 3 mg)
    • Glucagon 5 mg IV
  • If vomiting occurs after Glucagon, administer Ondansetron (Zofran), 4 mg slow IV or 4 mg Oral Disintegrating Tablet (ODT) by mouth
  • If no response, begin Transcutaneous Pacing

Calcium Channel Blockers

Examples of commonly used Calcium Channel Blocker medication:

  • Amlodipine (Norvasc)
  • Nifedipine (Procardia, Adalat)
  • Felodipine (Plendil, Renedil)
  • Verapamil (Calan)
  • Isradipine (DynaCirc)
  • Diltiazem (Cardizem)
  • Nicardipine (Cardene)

Advanced Life Support

  • Full ALS Assessment and Treatment
  • For patients with cardiovascular toxicity, defined by:
      • SBP < 90 mm Hg
      • Altered mental status
      • Bradycardia
      • 2nd or 3rd degree heart blocks
    • Administer the following agents:
      • NS 250 ml boluses IV
      • Atropine 0.5 mg IV
        • Repeat every 3 minutes as needed (Maximum 3 mg)
      • If no response, Calcium Chloride 1 gram IV
        • Contraindicated if patient taking digoxin (Lanoxin)
        • If no response, may repeat Calcium Chloride 1 gram IV
      • If no response, Glucagon 5 mg IV
  • If vomiting occurs after Glucagon, administer Ondansetron (Zofran), 4 mg slow IV or 4 mg Oral Disintegrating Tablet (ODT) by mouth
  • If no response, begin transcutaneous pacing

Carbon Monoxide

Basic Life Support

  • Remove the patient from the contamination source
  • Supplemental 100% oxygen; document time oxygen started

Advanced Life Support

  • Full ALS Assessment and Treatment
  • For smoke inhalation patients also consider Cyanide poisoning (see Hazardous Material- Basic Approach protocol)

Clonidine (Alpha-2 Adrenergic agonist) Overdose

Example of commonly used alpha-2 adrenergic agonists:

  • Clonidine (Catapres)
  • Imidazoline

Advanced Life Support

  • Full ALS Assessment and Treatment
  • Toxidrome includes central nervous system depression, bradycardia, hypotension, respiratory depression, and small pupil size. For severe central nervous system or respiratory depression:
    • Naloxone (Narcan) 2 mg IV (start at 0.4 mg for patients over 65 years old)
      • Naloxone (Narcan) can be given in 0.4 mg increments, titrated to mental status and respiratory drive (monitor respiratory status with continuous capnography)
      • If respiratory depression persists, repeat every 3 minutes to a maximum of 8 mg
      • If IV access has not been established, Naloxone (Narcan) can be given IM or via Mucosal Atomizer Device

Cocaine and Sympathomimetic Overdose

Advanced Life Support

  • Full ALS Assessment and Treatment
  • For patients with sympathomimetic toxidrome (hypertension, tachycardia, agitation):
    • Midazolam (Versed) 5 mg IM or intranasal via MAD OR 2.5 mg IV
      • Repeat Midazolam (Versed) 5 mg IM or intranasal via MAD OR 2.5 mg IV if adequate sedation not achieved on initial dose
  • If seizures occur, refer to Seizure Protocol

Tricyclic and Tetracyclic Antidepressant Overdose

Advanced Life Support

  • Full ALS Assessment and Treatment
  • If wide QRS complex (≥0.10 sec), hypotension, or any arrhythmias:
    • Sodium Bicarbonate 1 mEq/kg IV
    • Repeat Sodium Bicarbonate 1 mEq/kg IV in 5 to 10 minutes
  • For hypotension (systolic BP < 90 mmHg) not improved by fluid boluses, or when fluid boluses are contraindicated:
    • Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP > 90 mm Hg
  • If any of the following conditions occur, refer to the appropriate protocols:
    • Polymorphous Ventricular Tachycardia
    • Altered mental status
    • Seizures