General treatment of poisoning

The general principles are: stabilize the patient (ABCD), stop further absorption, give a specific antidote if one exists, speed elimination, and give supportive care. Most poisoned patients, conscious or unconscious, recover with supportive care alone.

1. Life-saving measures (ABCD)

Airway: Clear secretions, vomit and foreign bodies. Intubate if the airway can't be protected. Place an unconscious patient in the recovery position (on the side).
Breathing: Give graded oxygen by ventimask or endotracheal tube if blood gases can't be maintained.
Circulation: IV fluids, plus vasopressors or antiarrhythmics as needed.
Depression of CNS: Correct it, for example with naloxone for opioids or flumazenil in selected benzodiazepine cases. Check glucose in every altered patient.

Source: The Essentials of Forensic Medicine and Toxicology, 36th ed., "Treatment of Poisoning", p. 484.

2. Remove unabsorbed poison

The method depends on the route:

Route	Action
Inhaled	Move to fresh air. Give oxygen (6 to 8 L/min). Keep the airway clear. Give a bronchodilator for bronchospasm and a diuretic for pulmonary edema.
Injected (bite or injection)	Apply a tight ligature above the site, loosened for 1 minute every 10 minutes. Excise or suck out the poison if feasible. Immersion in water at 10°C slows absorption.
Skin, eye or mucosal contact	Remove contaminated clothing, contact lenses and jewelry. Wash the skin with water for 30 minutes. Irrigate the eyes with saline for at least 15 minutes.
Ingested	Gastric lavage, emesis, or activated charcoal (details below).

Gastric lavage

The textbook says it is useful within 2 hours of ingestion. For salicylates, phenothiazines, tricyclic antidepressants and antihistamines it can be done up to 12 to 18 hours after, because these slow gastric emptying.
Technique:
- Position the patient on the left side or prone with the head low.
- Pass a lubricated tube to the 50 cm mark. Confirm gastric placement, for example by water-seal bubbling, which indicates a tracheal tube.
- Instil about 250 to 500 mL of warm fluid at a time and siphon it back. Repeat until the return is clear and odorless.
- Keep the first aspirate for chemical analysis.
- Leave activated charcoal or a suitable antidote in the stomach at the end.
Absolute contraindication: Corrosive poisoning (except carbolic acid), because of the risk of perforation.
Caution:
- Convulsant poisons: control the seizures first.
- Comatose patients: protect the airway with a cuffed endotracheal tube first.
- Volatile hydrocarbons, bleeding disorders and recent GI surgery also need caution.

Emesis

Syrup of ipecac was the textbook method (30 mL in adults). It is contraindicated in corrosive or hydrocarbon ingestion, in drowsy or convulsing patients, and after CNS stimulants.
Salt water and mustard are ineffective and dangerous. Salt water can cause fatal hypernatremia.
The book itself notes that some physicians consider ipecac obsolete.

Activated charcoal

Dose: 60 to 100 g in adults and 15 to 30 g in children, mixed with 8 mL of water per gram.
Well adsorbed:
- Barbiturates, benzodiazepines, TCAs and other antidepressants
- Phenothiazines, antiepileptics, antihistamines and theophylline
- Digitalis, quinine, strychnine, beta blockers and aluminium phosphide
Moderately adsorbed: Salicylates, paracetamol, phenol and kerosene.
Not useful for: Corrosives, heavy metals, cyanide, hydrocarbons and alcohols.
Multiple-dose charcoal: 50 g every 4 hours for up to 2 days. It is used for aspirin, phenobarbital, theophylline, phenothiazines, antihistamines, TCAs and carbamazepine. It works as "gut dialysis" by pulling drug from plasma into the bowel.

Other physical antidotes are demulcents (milk, egg white, starch), used for corrosives. Don't use fats or oils for oil-soluble poisons such as kerosene, phosphorus, organophosphates and phenol.

Modern practice is more selective than the older text. Rosen's and Tintinalli's say there is little evidence for routine GI decontamination. They reserve lavage for life-threatening ingestions presenting early, where charcoal is ineffective and no antidote exists, and only where staff can do it safely. Ipecac is no longer used. Charcoal is the preferred option when given early to a patient with an intact airway.

3. Antidotes

The textbook lists these modes of action:

Inert complex formation: chelators for heavy metals, dicobalt edetate for cyanide.
Accelerated detoxification: thiosulfate for cyanide.
Reduced toxic conversion: ethanol or fomepizole for methanol and ethylene glycol.
Receptor blockade: naloxone for opioids, atropine for organophosphates.
Bypass of the toxic effect: 100% oxygen in cyanide poisoning.

Common pairs from standard teaching, not from the pages I read:

Paracetamol: N-acetylcysteine
Organophosphates: atropine plus pralidoxime
Benzodiazepines: flumazenil, used selectively
Iron: deferoxamine
Warfarin: vitamin K
Digoxin: Fab fragments
Snake venom: antivenom

4. Enhance elimination

This section comes from general toxicology teaching, not the pages I retrieved.

Multiple-dose charcoal, as above.
Urinary alkalinization with sodium bicarbonate for salicylates and phenobarbital.
Hemodialysis for toxic alcohols, lithium, salicylates, theophylline and valproate.
Hemoperfusion or chelation for selected agents.

5. Supportive and symptomatic care

Monitor vital signs, ECG, oxygen saturation, urine output and acid-base status.
Treat seizures, arrhythmias, hypotension, hyperthermia and metabolic derangements.
Observe for delayed toxicity, such as paracetamol or sustained-release preparations.
Arrange psychiatric assessment after any deliberate self-poisoning.

6. Other steps

Take a history of the agent, amount, time and route, and bring the container or tablets.
Send blood, urine and gastric contents for toxicology analysis.
Contact a poison information centre.
Medicolegal duties: record findings, preserve samples and inform the police in suspected criminal or suicidal cases.

Recent evidence check

A PubMed search of systematic reviews from the last 2 years on poisoning and activated charcoal found nothing that overturns the above. The results were narrow topics: L-carnitine in drug poisonings (PMID 41692009) and interrupting enterohepatic circulation in amatoxin poisoning (PMID 38411174).

If you want more detail, I can go through a specific poison (organophosphates, paracetamol, opioids, corrosives or others) or the antidote table.

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