Toxicology

Gastric decontamination with a single dose of activated charcoal may be considered only if patients

present within 2-4 hours after a large overdose and can protect their airway.

Naloxone

Should be administered in addition to supportive care in patients with respiratory depression

who cannot protect their airway

ii.

The lowest effective dose should be used; repeat doses may be necessary secondary to

loperamide’s slow elimination.

Sodium bicarbonate

May be beneficial in patients with signs and symptoms of cardiac toxicity and QRS interval

widening secondary to sodium channel blockade by loperamide

ii.

Sodium bicarbonate 1-2 mEq/kg intravenously should be administered concomitantly with

magnesium and potassium chloride if electrolyte abnormalities exist.

Patients should be closely monitored for resolution of clinical symptoms, including respiratory status,

vital signs, and return to baseline mental status.

Closely monitor for signs and symptoms of opioid withdrawal.

Alcohol poisonings (methanol and ethylene glycol) are not as common as poisonings with other

substances, accounting for <1% of all cases in 2022 (Clin Toxicol. 2023;61(10):717-939), but they can be

serious and potentially fatal.

carburetor fluids, and cooking products.

Ethylene glycol is commonly found in products such as antifreeze, de-icing solutions, refrigerants, and

brake fluids.

Toxicity of both agents is caused by the breakdown to toxic metabolites by alcohol dehydrogenase and

aldehyde dehydrogenase.

Methanol is converted to formaldehyde and then to formic acid, which results in an anion gap

acidosis and ocular toxicity.

Ethylene glycol is converted to glycoaldehyde and then to glycolic acid, followed by glyoxylic acid,

and, eventually, oxalic acid. Glycolic acid results in an anion gap acidosis and CNS toxicity. Oxalic

acid results in CNS toxicity and renal toxicity because of the formation of calcium oxalate crystals.

Common symptoms include inebriation, altered mental status, nausea, vomiting, hematemesis,

nystagmus, and depressed reflexes. In rare cases of ethylene glycol toxicity, patients may present with

tetany caused by hypocalcemia. Symptoms typically develop over the first 24 hours; however, they can

be delayed for days in the setting of ethanol coingestion.