Such as any field of medicine, it is imperative to stay current with the latest advances and treatment modalities in toxicology. With the absence of rigorous randomized controlled trials, many updated guidelines are created by expert consensus and/or case reports and clinical experience. Over the past 10 years, there have been several changes in the management of drug overdoses in light of new data available. Although this is not a comprehensive review of all available antidotes, this article will focus on several important interventions including the use of gastrointestinal decontamination, hyperinsulinemic–euglycemic therapy, methylene blue, intravenous lipid emulsion, hemodialysis, and extracorporeal membrane oxygenation.
GumminDDMowryJBSpykerDA. 2016 Annual Report of the American Association of poison control centers’ national poison data system (NPDS): 34th annual report. Clin Toxicol (Phila). 2017;55(10):1072–1252.
3.
CaravatiEMMégarbaneB. Update of position papers on gastrointestinal decontamination for acute overdose. Clin Toxicol (Phila). 2013;51(3):127.
4.
ThanacoodyRCaravatiEMTroutmanB. Position paper update: whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol (Phila). 2015;53(1):5–12.
5.
BensonBEHoppuKTroutmanWG. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila). 2013;51(3):140–146.
6.
MintegiSDalzielSRAzkunagaB. International variability in gastrointestinal decontamination with acute poisonings. Pediatrics. 2017;140(2):pii:e20170006.
7.
CorcoranGChanBChiewA. Use and knowledge of single dose activated charcoal: a survey of Australian doctors. Emerg Med Australas. 2016;28(5):578–585.
8.
LivshitsZSampsonBAHowlandMA. Retained drugs in the gastrointestinal tracts of deceased victims of oral drug overdose. Clin Toxicol (Phila). 2015;53(2):113–118.
9.
MiyauchiMHayashidaMYokotaH. Evaluation of residual toxic substances in the stomach using upper gastrointestinal endoscopy for management of patients with oral drug overdose on admission: a prospective, observational study. Medicine (Baltimore). 2015;94(4):e463.
10.
HolgerJSStellpflugSJColeJB. High-dose insulin: a consecutive case series in toxin-induced cardiogenic shock. Clin Toxicol (Phila). 2011;49(7):653–658.
11.
GraudinsALeeHMDrudaD. Calcium channel antagonist and beta-blocker overdose: antidotes and adjunct therapies. Br J Clin Pharmacol. 2015;81(3):453–461.
12.
St-OngeMAnseeuwKCantrellFL. Experts consensus recommendation for the management of calcium channel blocker poisoning in adults. Crit Care Med. 2017;45(3):e306–e315.
13.
GreeneSLGawarammanaIWoodDM. Relative safety of hyperinsulinaemia/euglycaemia therapy in the management of calcium channel blocker overdose: a prospective observational study. Intensive Care Med. 2007;33(11):2019–2024.
14.
EspinozaTRBryantSMAksSE. Hyperinsulin therapy for calcium channel antagonist poisoning: a seven-year retrospective study. Am J Ther. 2013;20(1):29–31.
15.
EngebretsenKMKaczmarekKMMorganJ. High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning. Clin Toxicol (Phila). 2011;49(4):277–283.
16.
BartlettD. B-blocker and calcium channel blocker poisoning: high-dose insulin/glucose therapy. Crit Care Nurse. 2016;36(2):45–50.
17.
DoepkerBHealyWCortezE. High-dose insulin and intravenous lipid emulsion therapy for cardiogenic shock induced by intentional calcium-channel blocker and beta-blocker overdose: a case series. J Emerg Med. 2014;46(4):486–490.
18.
StellpflugSJHarrisCREngebretsenKM. Intentional overdose with cardiac arrest treated with intravenous fat emulsion and high-dose insulin. Clin Toxicol. 2010;48(3):227–229.
19.
PageCBRyanNMIsbisterGK. The safety of high-dose insulin euglycaemia therapy in toxin-induced cardiac toxicity. Clin Toxicol (Phila). 2018;56(6):389–396.
20.
LydenAECooperCParkE. Beta-blocker overdose treated with extended duration high dose insulin therapy. Pharmacol Clin Toxicol. 2014;2(1):1015.
21.
JangDHNelsonLSHoffmanRS. Methylene blue in the treatment of refractory shock from an amlodipine overdose. Ann Emerg Med. 2011;58(6):565–567.
22.
WarrickBJTataruAPSmolinskeS. A systemic analysis of methylene blue for drug-induced shock. Clin Toxicol (Phila). 2016;54(7):547–555.
23.
HardingSA. Letter to the editor—In response to: “A systematic analysis of methylene blue for drug-induced shock. Clin Toxicol. 2017;55(3):227.
24.
GrahamRECartnerMWinearlsJ. A severe case of vasoplegic shock following metformin overdose successfully treated with methylene blue as a last line therapy. BMJ Case Rep. 2015. Accessed September 15, 2018. doi:10.1136/bcr-2015-210229.
25.
LaesJRWilliamsDMColeJB. Improvement in hemodynamics after methylene blue administration in drug-induced vasodilatory shock: a case report. J Med Toxicol. 2015;11(4):460–463.
26.
FisherJTaoriGBraitbergG. Methylene blue used in the treatment of refractory shock resulting from drug poisoning. Clin Toxicol (Phila). 2014:52(1):63–65.
27.
FrenchDSmollinCRuanW. Partition constant and volume of distribution as predictors of clinical efficacy of lipid rescue for toxicological emergencies. Clin Toxicol. 2011;49(9):801–809.
28.
GosselinSHoegbergLCHoffmanRS. Evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning. Clin Toxicol (Phila). 2016;54(10):899–923.
29.
American College of Medical Toxicology. ACMT position statement: guidance for the use of intravenous lipid emulsion. J Med Toxicol. 2017;13(1):124–125.
30.
HayesBDGosselinSCalelloDP. Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration. Clin Toxicol (Phila). 2016;54(5):365–404.
31.
LevineMSkolnikABRuhaAM. Complications following antidotal use of intravenous lipid emulsion therapy. J Med Toxicol. 2014;10(1):10–14.
32.
GrunbaumAMGilfixBMHoffmanRS. Review of the effect of intravenous lipid emulsion on laboratory analyses. Clin Toxicol (Phila). 2016;54(2):92–102.
33.
AbelJJRowntreeLGTurnerBB. On the removal of diffusible substances from the circulating blood by dialysis. Trans Assoc Am Physicians. 1913;58:51–54.
34.
GhannoumMHoffmanRGosselinS. Use of extracorporeal treatments in the management of poisonings. Kidney Int. 2018;94(4):682–688.
35.
JuurlinkDNGosselinSKielsteinJT. Extracorporeal treatment for salicylate poisoning: systematic review and recommendations from the EXTRIP workgroup. Ann Emerg Med. 2015;66(2):165–181.
36.
LamYWBanerjiSHatfieldC. Principles of drug administration in renal insufficiency. Clin Pharmacokinet. 1997;32(1):30–57.
CalelloDPLiuKDWiegandTJ. Extracorporeal treatment for metformin poisoning: systematic review and recommendations from the extracorporeal treatments in poisoning workgroup. Crit Care Med. 2015;43(8):1716–1730.
39.
WolleyMJardineMHutchisonCA. Exploring the clinical relevance of providing increased removal of large middle molecules. Clin J Am Soc Nephrol. 2018;13(5):805–814.
40.
GatchalianRAPopliAEjazAA. Management of hypophosphatemia induced by high-flux hemodiafiltration for the treatment of vancomycin toxicity: intravenous phosphorus therapy versus use of a phosphorus-enriched dialysate. Am J Kidney Dis. 2000;36(6):1262–1266.
41.
HicksLKMcFarlanePA. Valproic acid overdose and hemodialysis. Nephrol Dial Transplant. 2001;16(7):1483–1486.
MeyerRJFlynnJTBrophyPD. Hemodialysis followed by continuous hemofiltration for treatment of lithium intoxication in children. Am J Kidney Dis. 2001;37(5):1044–1047.
44.
DaviesJGKingswoodJCSharpstoneP. Drug removal in continuous haemofiltration and haemodialysis. Br J Hosp Med. 1995;54(10):524–528.
45.
SenSDaviesNAMookerjeeRP. Pathophysiological effects of albumin dialysis in acute-on-chronic liver failure: a randomized controlled study. Liver Transpl. 2004;10(9):1109–1119.
46.
SchmidtLESvendsenLBSorensenVR. Cerebral blood flow velocity increases during a single treatment with the molecular adsorbents recirculating system in patients with acute on chronic liver failure. Liver Transpl. 2001;7(8):709–712.
47.
LalemanWWilmerAEvenepoelP. Effect of the molecular adsorbent recirculating system and Prometheus devices on systemic haemodynamics and vasoactive agents in patients with acute-on-chronic alcoholic liver failure. Crit Care. 2006;10(4):R108.
48.
BanaresRNevensFLarsenFS. Extracorporeal albumin dialysis with the molecular adsorbent recirculating system in acute-on-chronic liver failure: the RELIEF trial. Hepatology. 2013;57(3):1153–1162. doi:10.1002/hep.26185.
49.
KribbenAGerkenGHaagS. Effects of fractionated plasma separation and adsorption on survival in patients with acute-on-chronic liver failure. Gastroenterology. 2012;142:782–789.e3. doi:10.1053/j.gastro.2011.12.056.
50.
LeeWM. Drug-induced hepatotoxicity. N Engl J Med. 1995;333(17):1118–1127.
51.
BronsteinACSpykerDACantilenaLRJr. 2010 Annual report of the American association of poison control centers’ national poison data system (NPDS): 28th annual report. Clin Toxicol (Phila). 2011;49(10):910–941.
52.
JohnsonNJGaieskiDFAllenSR. A review of emergency cardiopulmonary bypass for severe poisoning by cardiotoxic drugs. J Med Toxicol. 2013;9(1):54–60.
53.
SchuererDJKolvosNSBoydKV. Extracorporeal membrane oxygenation: current clinical practice, coding, and reimbursement. Chest. 2008;134(1):179–184.
WangGSLevitanRWiegandTJ. Behalf of the Toxicology Investigators Consortium. Extracorporeal Membrane Oxygenation (ECMO) for severe toxicological exposures: review of the Toxicology Investigators Consortium (ToxIC). J Med Toxicol. 2016;12(1):95–99.
56.
WangGSLevitanRWiegandTJ. Extracorporeal membrane oxygenation (ECMO) for severe toxicological exposures: review of the Toxicology Investigators Consortium (ToxIC). J Med Toxicol. 2016;12(1):95–99.
57.
MassonRColasVParientiJJ. A comparison of survival with and without extracorporeal life support treatment for severe poisoning due to drug intoxication. Resuscitation. 2012;83(11):1413–1417.
58.
ChengRHachamovitchRKittlesonM. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg. 2014;97(2):610–616.
59.
LeeHMArcherJRDarganPI. What are the adverse effects associated with the combined use of intravenous lipid emulsion and extracorporeal membrane oxygenation in the poisoned patient?Clin Toxicol (Phila). 2015;53(3):145–150.
