Toxicology
Seizure activity should be managed with benzodiazepines, barbiturates, or propofol.
Anticholinergic symptoms can potentially be treated with IV physostigmine (or oral/patch formulations
of centrally acting acetylcholinesterase inhibitors in the setting of a shortage) in select patients (e.g.,
normal ECG); however, substantial controversy exists with this approach, particularly in the setting of
Med 2000;35:374-81). Currently, it is not frequently used and further investigations into its safety and
efficacy are necessary (J Med Toxicol 2015;11:179-84).
Lipid emulsion therapy may be effective because of the high lipophilicity of these agents and may
be considered if more traditional treatment means do not improve the cardiovascular complications
of decreased HR and/or BP (J Emerg Med 2012;43:906-13). Administer an intravenous bolus dose of
1.5 mL/kg of 20% lipid emulsion over 2–3 minutes, followed by a continuous intravenous infusion of
0.25–0.5 mL/kg/min for 60 minutes, if necessary.
Monitor for cardiac toxicity with a 12-lead ECG, CK-MB, and troponins.
Lithium was associated with almost 3341 toxic exposures and seven deaths in 2022.
the phosphatidylinositol cycle, and inhibition of the post-synaptic D2 receptor.
Adverse effects associated with lithium include:
Acute overdose:
GI: Nausea, vomiting, diarrhea
ii.
CNS: Confusion, tremor, myoclonus, seizures, coma
iii.
Cardiovascular: T-wave inversion, ventricular arrhythmias
Chronic adverse effects:
Endocrine: Hypothyroidism, myxedema coma
ii.
Nephrogenic diabetes insipidus
There are no specific antidotes for lithium; general supportive care is recommended, focusing on ABC.
charcoal is not effective for lithium overdoses; whole bowel irrigation may be beneficial.
Administer crystalloid to maintain BP, with a goal SBP greater than 90 mm Hg. Consider vasopressors
if fluid resuscitation is not adequate.
Replace serum electrolytes, especially magnesium and potassium, if QT prolongation is present.
Seizure activity should be managed with benzodiazepines, barbiturates, or propofol.
Lithium overdoses are primarily managed with fluid resuscitation and renal replacement therapy.
Saline infusions may be administered if there are no contraindications to fluid therapy (goal is a
serum sodium concentration of 140–145 mEq/L). Lithium clearance is reduced in hyponatremia.
Intermittent hemodialysis may require several sessions to fully remove lithium concentrations
because of the rebound of lithium concentrations that occurs after dialysis sessions. Consider
continuous renal replacement therapy (CRRT) for hemodynamically unstable patients.