The brand new American Heart Association Guidelines on Life-Threatening Toxicology and Toxicological Cardiac Arrest by Lavonas et al.
Why AHA???
They have erred in the past, but these are great
No Actual Conflicts of Interest
The Guidelines
Benzos
- Give nalaxone first in mixed ODs
- Can give it in pure benzo OD with resp depression/resp arrest without contraindications (procedural sedation or peds into pills)
- No Role in Cardiac Arrest
- Associated with harm in patients at risk for seizures or dysrhythmias
Flumazenil dose 0.2 mg, titrated up to 1mg max
Not a part of the coma cocktail risks>benefits
B-Blockers
- We recommend that high-dose insulin be administered for hypotension due to β-blocker poisoning refractory to or in conjunction with vasopressor therapy
- Give vasopressors if hypotension
- It is reasonable to use a bolus of glucagon, followed by a continuous infusion, for bradycardia or hypotension due to β-blocker poisoning
- It may be reasonable to administer atropine for β-blocker–induced bradycardia (case reports)
- May be reasonable to attempt pacing
- Use HD in atenolol or sotalol (maybe nadolol)
- Do not give lipid therapy (doesn't work and clogs up ECMO oxygenator)
Wish they had put a protocol for HIET in the guidelines
Glucagon 2–10 mg bolus followed by 1-15 mg/h (anticipate vomiting)
VA-ECMO
Calcium Channel Blockers
Dihydropyridines (nifedipine, amlodipine) vs. nondihydropyridines (verpamil, diltiazem)
- Vasopressors (doses up to 100 mcg/min)
- HIET
- Reasonable to administer calcium (target iCal twice normal appeared more effective)
- Reasonable to give atropine
- Reasonable to use VA-ECMO
- It might be reasonable to attempt pacing
- Glucagon is uncertain
- Methylene Blue is uncertain
- Lipids are not recommended
Lead author dichotomized into cardiogenic and vasodilatory shock on another podcast
Cocaine
- Rapid external cooling (immerse!!)
- Reasonable to administer sodium bicarb for wide-complex tachycardia or cardiac arrest
- Reasonable to administer lidocaine (reduces QRS prolongation)
- Reasonable to administer nitrates, phentolamine, CCBs if coronary vasospasm or hypertensive emergencies
No rec on b-blockers, but text indicates conflicting studies
Heavy benzos for agitation and to aid in hyperthermia treatment
Cyanide
from labs, industry, and various substances in structure fires
Cyanide assays will never return in real time. Lactate is a good marker of toxicity. Empiric treatment for cardiac arrest for patients with possible exposure.
- Give hydroxocobalamin (B12)
- If not available, give sodium nitrite
- May be reasonable to follow either of those with sodium thiosulfate
- Reasonable to administer 100% oxygen
Hydroxocobalamin 5 G
Sodium nitrite 300 mg
Sodium Thiosulfate 12.5 G
Digoxin & Cardiac Glycosides
- Give dig-Fab for digoxin or digitoxin
- Reasonable to administer for Budo toad venom or yellow oleander
- Reasonable to administer atropine
- May be reasonable to attempt pacing (2 obs studies in mostly chronic–consider if you can't get FAB or while administering)
- May be reasonable to administer lidocaine, phenytoin, or bretylium to treat ventricular dysrhythmias until dig-Fab is administered
- Do not recommend hemodialysis, filtration, perfusion or plasmapheresis
Dig-FAB for Dig
Acute overdose: 1 vial for every 0.5 mg digoxin ingested
Acute overdose, critically ill, ingested dose unknown: 10–20 vials
Chronic poisoning: Use formula: dose in vials=serum digoxin concentration (ng/mL)×weight (kg)/100
Dig-FAB for Bufo or Oleander
1200 mg (30 vials)
Local Anesthetics
Bupivacaine is the classic bad actor
- Administer lipid emulsion
- Use benzos for seizures
- Reasonable to administer sodium bicarbonate
- Reasonable to administer atropine
- Reasonable to use VA-ECMO
Hypoxia and acidemia worsen toxicity
LAST can also cause methemoglobinemia
Methemoglobinemia
Common sources of oxidant stress that can cause methemoglobinemia include nitrates, nitrites, and many pharmaceuticals (eg, dapsone, benzocaine, phenazopyridine).
Discrepancy between pulse ox and abg
- Administer methylene blue
- Exchange transfusion may be reasonable if unresponsive to meth blue
- Hyperbaric therapy may be reasonable if failing above
- NAC is not recommended
- Ascorbic acid is not recommended
Methylene Blue may not work in G6PD deficiency
Opioids
- In resp arrest, prioritize ventilation, then nalaxone
- If in arrest, nalaxone won't help
- Responders should not wait to see response before calling EMS
- Reasonable to give nalaxone if the pt has a pulse, but resp compromise
Organophosphates and Carbamates
decontamination, atropine, benzodiazepines, and oximes
- We recommend giving atropine immediately for severe poisoning, such as bronchospasm, bronchorrhea, seizures, or significant bradycardia, from organophosphate or carbamate poisoning.
- We recommend early endotracheal intubation for life-threatening organophosphate or carbamate poisoning.
- We recommend administration of benzodiazepines to treat seizures and agitation in the setting of organophosphate or carbamate poisoning.
- We recommend use of appropriate personal protective equipment when caring for patients with organophosphate or carbamate exposure.
- We recommend dermal decontamination for external organophosphate or carbamate exposure.
- The use of pralidoxime is reasonable for organophosphate poisoning (especially with muscle fasciculations, weakness, or paralysis) May consider in carbamates.
- Use of neuromuscular blockers metabolized by pseudocholinesterase (ie, succinylcholine and mivacurium) is not recommended for patients with organophosphate or carbamate poisoning. If you forget the paralysis will last for hours.
Atropine dosing 1-2 mg, doubled every 5 minutes. Infusion 10-20% of the total loading dose per hour up to 2 mg/hr. Titrate to reversal of the lung symptoms
Sodium Channel Blockers
Did not cover chloroquine and hydroxychloroquine
- We recommend using sodium bicarbonate to treat life-threatening cardiotoxicity from tricyclic and/or tetracyclic antidepressant poisoning.
- It is reasonable to use sodium bicarbonate to treat life-threatening cardiotoxicity caused by poisoning from sodium channel blockers other than tricyclic or tetracyclic antidepressants.
- It is reasonable to use extracorporeal life support, such as VA-ECMO, to treat refractory cardiogenic shock from sodium channel blocker poisoning.
- It may be reasonable to use Vaughan-Williams class Ib antidysrhythmics (eg, lidocaine) to treat life-threatening cardiotoxicity from class Ia or Ic sodium channel blockers.
- It may be reasonable to use intravenous lipid emulsion to treat life-threatening sodium channel blocker poisoning refractory to other treatment modalities.
Sodium Bicarbonate 50-150 mEq (1-3 amps), for infusion, prepare isotonic bicarb drip (150 mEq/L and infuse at 1-3 mL/kg/hr). Watch for hypernatremia, alkalemis, hypokalemia, and hypochloremia.
No rec regarding hypertonic saline. Shoot for max sodium 150-155 and pH 7.5-7.55.
Can also use the ventilator to manipulate pH.
Lidocaine competes with class Ia and 1c antidysrhythmics for binding at the sodium channel. Phenytoin may also be used.
Sympathomimetics
- We recommend sedation for severe agitation from sympathomimetic poisoning.
- We recommend rapid external cooling for life-threatening hyperthermia from sympathomimetic poisoning.
- Vasodilators, such as phentolamine and/or nitrates, are reasonable for coronary vasospasm from sympathomimetic poisoning.
- Mechanical circulatory support, such as intraaortic balloon pump or VA-ECMO, is reasonable for cardiogenic shock from sympathomimetic poisoning refractory to other treatment measures.
- Prolonged use of physical restraint without sedation is potentially harmful.
Benzos should control the hypertension, no recs if it remains after sedation.
VA-ECMO Stuff
- It is reasonable to use VA-ECMO for persistent cardiogenic shock or cardiac arrest due to poisoning that is not responsive to maximal treatment measures.
- It is reasonable to use VA-ECMO for persistent dysrhythmias due to poisoning when other treatment measures fail.
- The effectiveness of VA-ECMO for poisoned patients with cardiovascular collapse from causes other than cardiogenic shock has not been established.
from Me
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Nice summary!
Great summary thanks.
Excelent as always. Can you recommend a HIET protocol?
thanks
FYI Pablo there is some bolus and drip guides on the EZResus app Scott previously mentioned and they graciously are giving EMCrit members 2 months free.
As always great episode Scott. The HIET protocol would be great to have as mentioned in the other question
When I was at Bellevue (long before any fancy immersion tank!) we’d get the industrial floor blowers from EVS and “simulate a helicopter’s rotors” per Hoffman and assign an intern to spray them with water. Evaporative seems second best if immersion isn’t handy.