Resuscitate, identify, decontaminate, give an antidote, enhance elimination
Expansion
Five steps, in order of importance
- Resuscitate: airway, breathing, circulation, glucose, and treat seizures and arrhythmias
- Identify the agent: history, collateral, ambulance crew, empty packets, and the toxidrome on examination
- Decontaminate: activated charcoal 50 g within 1 hour of ingestion, if the airway is protected and the agent binds. Gastric lavage is essentially obsolete
- Antidote, where one exists
- Enhance elimination: urinary alkalinisation (salicylates), haemodialysis (lithium, methanol, ethylene glycol, salicylates, metformin), multiple dose charcoal
“Treat the patient, not the poison.” Supportive care saves far more lives than antidotes.
Charcoal does not bind the PHAILS group: Pesticides, Hydrocarbons, Acids and alkalis, Iron, Lithium, Solvents. Also alcohols.
Toxbase is the UK reference and should be consulted for any agent, with the National Poisons Information Service for advice.
Always check: paracetamol and salicylate levels in any deliberate overdose regardless of the stated agent, a blood glucose, an ECG (QRS and QT), and a blood gas with lactate.
Every deliberate overdose needs a psychosocial assessment, whatever the medical severity, because the medical severity correlates poorly with intent.