General supportive care should be provided. Atropine is often effective for bradycardia or AV block. The use of digoxin antibodies (see Chapter 13) has revolutionized the treatment of digoxin toxicity; they should be administered intravenously in the dosage indicated in the package insert. Symptoms usually improve within 30–60 minutes after antibody administration. Digoxin antibodies may also be tried in cases of poisoning by other cardiac glycosides (eg, digitoxin, oleander), although larger doses may be needed due to incomplete cross-reactivity.
Overdosage with ethanol and sedative-hypnotic drugs (eg, benzodiazepines, barbiturates, γ-hydroxybutyrate [GHB], carisoprodol [Soma]; see Chapters 22 and 23) occurs frequently because of their common availability and use.
Patients with ethanol or other sedative-hypnotic overdose may be euphoric and rowdy (“drunk”) or in a state of stupor or coma (“dead drunk”). Comatose patients often have depressed respiratory drive. Depression of protective airway reflexes may result in pulmonary aspiration of gastric contents, leading to pneumonia. Hypothermia may be present because of environmental exposure and depressed shivering. Ethanol blood levels greater than 300 mg/dL usually cause deep coma, but regular users are often tolerant to the effects of ethanol and may be ambulatory despite even higher levels. Patients with GHB overdose are often deeply comatose for 3–4 hours and then awaken fully in a matter of minutes.
General supportive care should be provided. With careful attention to protecting the airway (including endotracheal intubation) and assisting ventilation, most patients recover as the drug effects wear off. Hypotension usually responds to intravenous fluids, body warming if cold, and, if needed, dopamine. Patients with isolated benzodiazepine overdose may awaken after intravenous flumazenil, a benzodiazepine antagonist. However, this drug is not widely used as empiric therapy for drug overdose because it may precipitate seizures in patients who are addicted to benzodiazepines or who have ingested a convulsant drug (eg, a tricyclic antidepressant). There are no antidotes for ethanol, barbiturates, or most other sedative-hypnotics.
Ethylene glycol and methanol are alcohols that are important toxins because of their metabolism to highly toxic organic acids (see Chapter 23). They are capable of causing CNS depression and a drunken state similar to ethanol overdose. In addition, their products of metabolism—formic acid (from methanol) or hippuric, oxalic, and glycolic acids (from ethylene glycol)—cause a severe metabolic acidosis and can lead to coma and blindness (in the case of formic acid) or renal failure (from oxalic acid and glycolic acid). Initially, the patient appears drunk, but after a delay of up to several hours, a severe anion gap metabolic acidosis becomes apparent, accompanied by hyperventilation and altered mental status. Patients with methanol poisoning may have visual disturbances ranging from blurred vision to blindness.
Metabolism of ethylene glycol and methanol to their toxic products can be blocked by inhibiting the enzyme alcohol
CHAPTER 58 Management of the Poisoned Patient 1045 dehydrogenase with a competing drug, such as fomepizole (4-methylpyrazole). Ethanol is also an effective antidote, but it can be difficult to achieve a safe and effective blood level.