Poisoning and drug toxicity
In adolescents and young adults, intoxication events leading to cardiac arrest are notably prevalent, primarily due to the misuse of prescription medications and illicit substances. Currently, opioid overdose stands as a predominant etiological factor for cardiac arrest within this demographic on a global scale. Numerous substances possess the potential to induce cardiac arrest or cause profound cardiopulmonary depression. Table 1 delineates substances for which specific antidotes are available. The detrimental effects of these substances can potentially be reversed if interventions are promptly instituted. In scenarios where an antidote is not available, it is essential to provide supportive care and maintain vital functions artificially until the substance undergoes renal elimination, hepatic elimination or is removed by means of dialysis.
| Substance | Antidote |
| Paracetamol (Acetaminophen) | N-Acetylcysteine |
| Anticholinergics | Physostigmine |
| Anticoagulants (apixaban) | Andexanet alpha |
| Benzodiazepines | Flumazenil |
| The Black Widow, Spider Bett | Lactrodectus antivenom |
| Botulism (botulinum toxin) | Botulism Ininum antitoxin |
| Beta-blocker | Glucagon IV |
| Calcium flow inhibitor (calcium blocker) | Calcium iv High dose insulin with glucose IV |
| Carbamates | Atropine Pralidoxime chloride |
| Cyanide | hydroxocobalamin Cyanide antidote kit (includes amyl nitrate, sodium nitrite, and sodium thiosulfate) |
| Dabigatran | Idarucizumab |
| Digitalis glycosides (digoxin, digitoxin, oleander) | Digoxin-specific Fab fragments |
| Ethylene glycol | Fomepizo|121:Ethylene Glycol||122:leethanol |
| Heavy metals | Chelating substances |
| Ionizing radiation | Potassium iodide |
| Iron | Deferoxamine |
| Isoniazid | Pyridoxine (Vitamin B6) |
| Methanol | Fomepizoleethanol |
| Methemoglobin-forming substances | Methylene blue |
| Methotrexate | Leucovorin (folinic acid) Glucarpidase (carboxypeptidase-G2) |
| Opioids | Naloxone |
| Organophosphates | Atropine Pralidoxime |
| Sulfonylurea | Octreotide |
| Thallium | Prussian blue |
| Tricyclic Antidepressants | Sodium Bicarbonate |
| Unfractionated Heparin | Protamine |
| Valproic acid | L-carnitine (limited evidence) | |
| Warfarin | Vitamin K Fresh frozen plasma Prothrombin complex concentrate |
Actions in suspected poisoning and cardiac arrest
Promptly contact the closest intensive care unit (ICU) possessing expertise in toxicological management. Severe poisoning mandates intricate care, often encompassing hemodialysis, intubation, and prolonged ICU admissions. Pending the correct level of care, the following actions can be performed.
- CPR
- Initiate CPR in adherence to standard guidelines. However, refrain from rescue breaths to mitigate the risk of potential contaminants endangering the rescuer.
- Contact expertise
- Contact the nearest poison center (or call 911 US, 112 EU).
- Contact the nearest intensive care unit with expertise in toxicological emergencies.
- Antidote
- Administer the specific antidote promptly upon suspicion of poisoning.
- Decontamination
- Disrobe the patient of any attire possibly contaminated with the toxicant.
- Irrigate skin and eyes using saline solution (NaCl) if suspected of toxin exposure.
- Gastrointestinal lavage is infrequently employed due to aspiration risks and inconclusive evidence. However, in cases of iron, lithium, or potassium intoxication where lavage might prove beneficial, the procedure should be conducted post-intubation. Avoid lavage if gastrointestinal perforation or obstruction is suspected.
- If the patient is intubated, administer activated charcoal through a gastric tube at a dose of 0.5 g/kg. Refrain from using activated charcoal if more than one hour has elapsed post-ingestion unless the ingested substance has the propensity to form bezoars or is a sustained-release formulation. Note: activated charcoal is ineffective against alcohols, lithium, and heavy metals.
- Enhance elimination
- Induce diuresis through urine alkalinization, contingent upon renal elimination of the toxicant. This can be accomplished using an infusion of sodium bicarbonate combined with furosemide at a dose of 1 mg/kg.
- Advanced elimination
- Hemodialysis
- Hemofiltration
- Plasmapheresis
References
DeBehnke DJ, Hilander SJ, Dobler DW, Wickman LL, Swart GL. The hemodynamic and arterial blood gas response to asphyxiation: a canine model of pulseless electrical activity. Resuscitation 1995;30:16975.
Safar P, Paradis NA, Weil MH. Asphyxial cardiac arrest. In: Paradis NA, Halperin HR, Kern KB, Wenzel V, Chamberlain DA, editors. Cardiac arrest—the science and practice of resuscitation medicine.
Kitamura T, Kiyohara K, Sakai T, et al. Epidemiology and outcome of adult out-of-hospital cardiac arrest of non-cardiac origin in Osaka: a population-based study. BMJ Open 2014;4:e006462.
Deasy C, Bray J, Smith K, et al. Hanging-associated out-of-hospital cardiac arrests in Melbourne, Australia. Emerg Med 2013;30:3842.
Luna GK, Pavlin EG, Kirkman T, Copass MK, Rice CL. Hemodynamic effects of external cardiac massage in trauma shock. J Trauma 1989;29:1430-3.
Jeffcoach DR, Gallegos JJ, Jesty SA, et al. Use of CPR in hemorrhagic shock, a dog model. J Trauma Acute Care Surg 2016;81:27-33.
Watts S, Smith JE, Gwyther R, Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhageinduced traumatic cardiac arrest. Resuscitation 2019;140: 37-42.
Endo A, Kojima M, Hong ZJ, Otomo Y, Coimbra R. Open-chest versus closed-chest cardiopulmonary resuscitation in trauma patients with signs of life upon hospital arrival: a retrospective multicenter study. Crit Care 2020;24:541.
Ebo DG, Clarke RC, Mertes PM, et al. Molecular mechanisms and pathophysiology of perioperative hypersensitivity and anaphylaxis: a narrative review. Br J Anaesth 2019;123:e3849.
Wallmuller C, Meron G, Kurkciyan I, et al. Causes of in-hospital cardiac arrest and influence on outcome. Resuscitation 2012;83:120611.
Wang CH, Huang CH, Chang WT, et al. The effects of calcium and sodium bicarbonate on severe hyperkalaemia during cardiopulmonary resuscitation: a retrospective cohort study of adult in-hospital cardiac arrest. Resuscitation 2016;98:10511.
Saarinen S, Nurmi J, Toivio T, et al. Does appropriate treatment of the primary underlying cause of PEA during resuscitation improve patients’ survival? Resuscitation 2012;83:81922.
Mroczek T, Gladki M, Skalski J. Successful resuscitation from accidental hypothermia of 11.8 degrees C: where is the lower bound for human beings? Eur J Cardiothorac Surg 2020;58:10912.
Stephen CR, Dent SJ, Hall KD, Smith WW. Physiologic reactions during profound hypothermia with cardioplegia. Anesthesiology 1961;22:87381.
Frei C, Darocha T, Debaty G, et al. Clinical characteristics and outcomes of witnessed hypothermic cardiac arrest: a systematic review on rescue collapse. Resuscitation 2019;137:418.
Wood S. Interactions between hypoxia and hypothermia. Annu Rev Physiol 1991;53:7185.
Podsiadlo P, Darocha T, Svendsen OS, et al. Outcomes of patients suffering unwitnessed hypothermic cardiac arrest rewarmed with extracorporeal life support: a systematic review. Artif Organs 2020.
