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Feb 2024
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Acute Medication Poisoning

Irbert L. Vega, MD
Matthew K. Griswold, MD
Dayne Laskey, PharmD

American Family Physician. 2024;109(2):143-153.

Author disclosure: No relevant financial relationships.

Poisoning is the leading cause of injury-related morbidity and mortality in the United States. The highest rates of exposure to poisons occur in children five years and younger, but opioid overdoses in young adults account for most deaths from poisonings in recent years. Intentional or accidental medication poisoning should be considered when evaluating patients with mental status changes, vital sign abnormalities, seizures, and gastrointestinal or cardiovascular problems. For all poisoned patients, a comprehensive history and physical examination are needed. Knowledge of toxidromes may help identify the cause in unknown ingestions; however, their usefulness may be limited when multiple toxins are ingested. Electrocardiography is indicated in patients reporting chest pain and dyspnea and in overdoses of beta blockers, tricyclic antidepressants, and antidysrhythmics. Measurement of electrolyte, serum creatinine, and serum bicarbonate levels and calculation of the anion gap may be helpful based on the clinical presentation. Treatment of a patient with acute poisoning is based on resuscitation and stabilization with a focus on airway, breathing, and circulation. When poisoning is suspected, the Poison Control provides health care workers and the public with access to a specialist 24 hours a day.

More than 2 million poisoning exposure cases are reported annually in the United States, according to the American Association of Poison Control Centers. Most poisonings are unintentional and nonfatal.1,2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Single-dose activated charcoal administered orally or by nasogastric tube may be considered if a patient has ingested a potentially toxic amount of a medication known to be adsorbed by charcoal up to one hour previously. Administration of activated charcoal is contraindicated if a patient does not have an intact or protected airway.34,38 C Expert opinion and consensus guidelines
No clinical data support cathartics, including ipecac syrup, in poisoning because they have not been proven to reduce the bioavailability or toxicity of drugs and do not affect outcomes in the poisoned patient.39 C Expert opinion and consensus guideline in the absence of clinical trials
N-acetylcysteine (oral or intravenous) should be administered to patients at risk of acetaminophen toxicity based on the ingested dose, serum acetaminophen concentration above the threshold using an acetaminophen nomogram at four hours after ingestion and later, abnormal liver biochemistry, or evidence of liver failure attributable to an overdose.20,21 B Results from randomized controlled trials showing reduction in hepatotoxicity and mortality

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Epidemiology

Poisoning is the primary cause of injury-related deaths in the United States, accounting for 102,001 deaths in 2021 and exceeding motor vehicle collision deaths yearly since 2013.3 The number of deaths from poisonings increased 36% between 2019 and 2021, likely because of the public health crises of the opioid epidemic and worsening of mental health associated with the COVID-19 pandemic.4 Mortality attributable to opioid overdose deaths increased by 41% from 2019 to 2020, with an additional 18% increase in 2021. Adults 35 to 44 years of age account for the most deaths from opioid overdoses of any age group.3

IRBERT L. VEGA, MD, FAAFP, is a resident physician in the Department of Emergency Medicine at the University of Connecticut School of Medicine, Farmington.

MATTHEW K. GRISWOLD, MD, is an assistant professor in the Department of Emergency Medicine and Traumatology at Hartford Hospital, University of Connecticut School of Medicine, Hartford.

DAYNE LASKEY, PharmD, is an associate professor in the Department of Pharmacy Practice at the University of Saint Joseph School of Pharmacy, West Hartford, Conn.

Address correspondence to Irbert L. Vega, MD, FAAFP, University of Connecticut School of Medicine, 80 Seymour St., Conklin Bldg., Room 130, Hartford, CT 06102 (irbertvega@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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