Toxicology

Internal Medicine Sections Toxicology
GlobalRPh Clinical Toxicology, Antidote, Overdose and Poisoning Resources

Clinical Toxicology and Poisoning Resource Center

Clinician-focused resources for stabilization of the poisoned patient, toxidrome recognition, acetaminophen poisoning, opioid toxicity, toxic alcohols, salicylates, cardiovascular poisoning, sodium-channel blockade, methemoglobinemia, cyanide and carbon monoxide exposure, antidotes, gastrointestinal decontamination, extracorporeal toxin removal, therapeutic drug levels, and current toxicology reviews.

Initial stabilization Acetaminophen Cardiovascular poisoning Internal Medicine Sections
Primary audience: physicians, pharmacists, nurses, advanced practice clinicians, emergency clinicians, intensivists, medical toxicologists, and other healthcare professionals involved in poisoning, overdose, medication toxicity, exposure assessment, and antidote management.

Clinical reference index

Toxicology clinical domains

Clinical framework

Poisoning management begins with physiology, exposure reconstruction, and time-sensitive supportive care

Toxicology frequently requires treatment before the exact substance or dose is known. Initial management should prioritize airway, ventilation, oxygenation, circulation, glucose, temperature, seizures, dysrhythmia, shock, and other immediately reversible threats while the exposure history, medication access, timing, formulation, co-ingestants, laboratory findings, ECG, and clinical trajectory are reconstructed.

We organize our Toxicology resources around the clinical syndrome rather than a simple antidote list. Antidotes are important, but supportive care, targeted resuscitation, serial reassessment, toxin-specific laboratory interpretation, gastrointestinal decontamination in selected patients, and extracorporeal treatment when indicated may be equally important.

Stabilize physiology Airway, ventilation, perfusion, dysrhythmia, seizures, temperature, glucose, and severe agitation take priority.
Define the exposure Agent, formulation, amount, route, time, repeated exposure, co-ingestants, and relevant medical history.
Recognize the syndrome Toxidromes, ECG findings, acid-base patterns, osmolar gap, anion gap, and organ injury can narrow the differential.
Reassess dynamically Delayed absorption, extended-release products, redistribution, recurrent opioid toxicity, and evolving organ injury require serial evaluation.
1. Immediate stabilization Correct life-threatening physiologic abnormalities and obtain an ECG early when cardiotoxic exposure is possible.
2. Exposure-specific evaluation Obtain targeted levels and laboratory tests only when they can alter diagnosis, treatment, monitoring, or disposition.
3. Antidote / enhanced elimination Use the correct antidote, decontamination strategy, urinary manipulation, or extracorporeal therapy for the clinical situation.
4. Observation / disposition Account for formulation, duration of toxicity, recurrent effects, psychiatric intent, substance-use treatment, and follow-up needs.
Consultation matters Complex, severe, unusual, or rapidly evolving poisoning often benefits from regional poison-center and medical-toxicology consultation.
Antidotes do not replace resuscitation Airway support, ventilation, circulation, seizure control, glucose correction, temperature management, and targeted cardiovascular therapy remain fundamental.
Measured values need context Drug concentrations, osmolar gap, anion gap, lactate, pH, ECG intervals, and renal function must be interpreted with timing and clinical course.
Current resuscitation framework

2025 AHA Special Circumstances of Resuscitation

Current AHA guidance includes life-threatening poisoning from opioids, beta blockers, calcium-channel blockers, digoxin, sodium-channel blockers, local anesthetics, cyanide, carbon monoxide, methemoglobinemia, organophosphates, sympathomimetics, and other toxicologic emergencies.

Open AHA Toxicologic Resuscitation Guidance

Current acetaminophen framework

2023 US and Canada Acetaminophen Poisoning Consensus

The 2023 consensus statement provides a unified approach to acute ingestion, repeated supratherapeutic ingestion, high-risk exposures, extended-release products, uncertain timing, acetylcysteine management, laboratory evaluation, and stopping criteria. We use this as the current reference point for modernizing our acetaminophen resources.

Open the Acetaminophen Consensus Statement

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Initial stabilization and toxidrome recognition

Airway, breathing, circulation, neurologic status, temperature, glucose, ECG, and exposure pattern

Toxidromes are useful pattern-recognition tools but are often incomplete in mixed ingestions, chronic toxicity, older adults, children, or patients with significant comorbidity. Treatment should remain physiology-driven even when the precise toxin is uncertain.

Immediate threats

  • Respiratory depression or airway compromise
  • Shock or life-threatening dysrhythmia
  • Seizures or severe agitation
  • Hypoglycemia or severe metabolic disturbance
  • Hyperthermia or hypothermia
  • Severe acidemia, hypoxemia, or evolving organ injury

Common toxidrome patterns

  • Opioid / sedative-hypnotic
  • Sympathomimetic
  • Anticholinergic
  • Cholinergic
  • Serotonergic
  • Sodium-channel blockade / cardiotoxic ingestion

Early data that often matter

  • 12-lead ECG and serial rhythm assessment
  • Bedside glucose
  • Electrolytes, renal function, acid-base status, and lactate when indicated
  • Acetaminophen concentration when ingestion is possible or history is unreliable
  • Pregnancy testing when clinically relevant
  • Targeted toxicant concentrations rather than indiscriminate screening

GlobalRPh toxicology calculators and laboratory resources

BAC estimation, toxic alcohol support, therapeutic concentrations, ABG, renal function, and related calculations

Blood alcohol estimate

This calculator uses population assumptions and cannot establish a measured BAC, legal impairment, clinical sobriety, or safe driving capacity.

Legacy ethylene-glycol / ethanol calculator

This is an older IV ethanol dosing calculator, not a contemporary toxic-alcohol management pathway. Current care requires antidote selection, acid-base and osmolar-gap interpretation, renal assessment, and criteria for extracorporeal treatment.

Laboratory / concentration support

Acetaminophen poisoning

Acute ingestion, repeated supratherapeutic ingestion, acetylcysteine, laboratory monitoring, and severe toxicity

Acetaminophen management depends on the type of exposure, timing, formulation, measured concentration, hepatic injury, acid-base status, and whether acetylcysteine has already been started. The Rumack-Matthew framework applies to defined acute ingestion scenarios and should not be extrapolated indiscriminately to repeated supratherapeutic exposure or unknown ingestion time.

Current consensus guidance

GlobalRPh acetylcysteine resources

High-risk / severe poisoning

  • Massive ingestion with early metabolic acidosis or altered mental status
  • Progressive hepatic injury despite acetylcysteine
  • Renal dysfunction, hypoglycemia, coagulopathy, encephalopathy, or severe lactate elevation
  • Consideration of extracorporeal therapy in selected massive exposures
Acetylcysteine should not be delayed when treatment is indicated and the acetaminophen concentration will not be available within an appropriate treatment window. Stopping acetylcysteine should be based on clinical and laboratory criteria, not solely on completion of a fixed-duration protocol.

Opioid poisoning

Ventilation, naloxone, recurrent toxicity, polysubstance exposure, and post-overdose treatment engagement

The immediate objective in opioid poisoning is restoration of adequate ventilation and oxygenation. Naloxone dosing should be titrated to the clinical objective and exposure context. Recurrent respiratory depression can occur when the opioid duration exceeds that of naloxone or when long-acting or high-potency opioids are involved.

Current resuscitation guidance

GlobalRPh naloxone resources

Post-overdose priorities

  • Observation appropriate to opioid duration and recurrence risk
  • Assessment for co-ingestants and aspiration or pulmonary complications
  • Withdrawal management after naloxone when clinically significant
  • Overdose-prevention counseling and naloxone access
  • Assessment and treatment linkage for opioid use disorder
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Toxic alcohols

Methanol, ethylene glycol, alcohol dehydrogenase blockade, acid-base assessment, and extracorporeal treatment

Toxic-alcohol poisoning may evolve from an early osmolar-gap pattern to high-anion-gap metabolic acidosis and organ-specific toxicity as parent alcohol is metabolized. A normal osmolar gap does not exclude a late presentation, and treatment should not be deferred when the exposure and clinical picture are strongly suggestive.

Current EXTRIP resources

GlobalRPh toxic-alcohol support

Clinical red flags

  • Visual symptoms or severe acidosis in suspected methanol exposure
  • Acute kidney injury, hypocalcemia, or calcium-oxalate findings in ethylene glycol exposure
  • Seizure, coma, shock, or severe metabolic derangement
  • Criteria for extracorporeal treatment
Our ethylene-glycol calculator is an older IV ethanol dosing resource and should not be presented as the primary management pathway. We plan to replace it with a contemporary toxic-alcohol decision-support tool centered on diagnosis, fomepizole/ethanol selection, cofactor therapy, serial laboratory interpretation, and EXTRIP criteria.

Salicylate poisoning

Serial concentrations, acid-base physiology, alkalinization, airway risk, and hemodialysis

Salicylate toxicity is a dynamic physiologic syndrome. Clinical severity cannot be determined from a single concentration alone. Serial concentrations, pH, respiratory status, mental status, kidney function, glucose, potassium, and the overall trajectory should guide management.

Current toxicology references

Key management concepts

  • Serial salicylate concentrations until clearly declining in clinical context
  • Potassium correction and serum/urine alkalinization when indicated
  • Glucose considerations, including neuroglycopenia despite normal serum glucose
  • Avoidance of acidemia and careful airway strategy
  • Early hemodialysis assessment in severe toxicity

Dialysis triggers are clinical

EXTRIP recommends extracorporeal treatment for severe salicylate poisoning under defined clinical and concentration-based circumstances, including altered mental status, new hypoxemia, treatment failure, marked concentrations, and severe acidemia.

Cardiovascular poisoning and toxicologic resuscitation

Beta blockers, calcium-channel blockers, digoxin, sodium-channel blockers, local anesthetics, and refractory shock

Toxicologic shock and cardiac arrest may require interventions that differ from routine cardiac-arrest algorithms. Mechanism-specific therapy should be integrated with high-quality resuscitation and expert consultation.

Beta blocker / calcium-channel blocker poisoning

High-dose insulin is an important early therapy in life-threatening beta-blocker and calcium-channel-blocker poisoning, with toxin-specific use of vasopressors, calcium, glucagon, lipid emulsion, pacing, or extracorporeal support.

Digoxin / cardiac glycosides

Intravenous lipid emulsion

The 2026 GlobalRPh lipid-rescue article is useful as a review, but some of its broader non-LAST claims are based largely on case reports and observational evidence. We plan to revise the article so recommendations track current AHA toxicologic-resuscitation guidance and clearly distinguish established from rescue or refractory indications.

CNS and sodium-channel toxicology

Tricyclic antidepressants, sodium-channel blockade, sedative-hypnotics, serotonin toxicity, anticholinergic toxicity, and seizures

Sodium-channel blockers / TCA poisoning

ECG changes, ventricular dysrhythmia, hypotension, seizures, and acidosis require prompt recognition. Sodium bicarbonate remains central to severe sodium-channel-blocker toxicity in appropriate cases.

Sedative-hypnotics / flumazenil

Flumazenil is not a routine reversal agent for undifferentiated coma or mixed overdose. Seizure risk, benzodiazepine dependence, proconvulsant co-ingestion, and indication must be considered carefully.

Serotonergic / anticholinergic / sympathomimetic syndromes

  • Differentiate clonus and hyperreflexia from rigidity, delirium, or isolated agitation
  • Review medication combinations, recreational drugs, and recent dose changes
  • Treat hyperthermia and severe agitation aggressively when present
  • Avoid relying on a toxidrome label when mixed exposure is likely
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Cellular hypoxia and dyshemoglobinemia

Methemoglobinemia, cyanide, carbon monoxide, oxygen delivery, and antidotal therapy

Dyshemoglobinemia and cellular toxins can produce severe tissue hypoxia despite apparently reassuring conventional oxygen measurements. Exposure history, co-oximetry, acid-base status, lactate, neurologic findings, cardiovascular instability, and fire/smoke context can be essential.

Methemoglobinemia

Co-oximetry and clinical symptoms should guide interpretation. G6PD deficiency and serotonergic medication exposure can materially affect methylene-blue risk-benefit assessment.

Cyanide / smoke inhalation

Carbon monoxide

Standard pulse oximetry does not accurately quantify carboxyhemoglobin. Clinical context, co-oximetry, neurologic findings, pregnancy, cardiac ischemia, and exposure severity affect management.

Gastrointestinal and external decontamination

Activated charcoal, dermal/ocular decontamination, aspiration risk, and selective use

Decontamination should be individualized to toxin, route, time, formulation, dose, airway status, and the expected benefit of removing unabsorbed material. Routine use of gastrointestinal decontamination is not appropriate for every ingestion.

Activated charcoal

Consider potential benefit against aspiration risk, toxin adsorption characteristics, time from ingestion, bowel function, and whether the airway is protected.

Dermal / ocular exposure

  • Remove contaminated clothing when appropriate
  • Use copious irrigation for many ocular and dermal exposures
  • Protect healthcare personnel from secondary contamination
  • Identify substances requiring specialized decontamination or hazardous-material support

Legacy cathartic content

Our broad Toxicology drug table includes sorbitol and older gastrointestinal decontamination material. We plan to remove routine-cathartic framing and align decontamination content with contemporary selective-use principles and airway safety.

Extracorporeal treatment in poisoning

Hemodialysis and extracorporeal toxin removal require toxin-specific criteria

Dialyzability depends on molecular size, protein binding, volume of distribution, endogenous clearance, toxicity severity, organ failure, and available extracorporeal modality. EXTRIP provides toxin-specific recommendations for a growing group of clinically important poisonings.

EXTRIP recommendation index

Other important EXTRIP toxins

  • Lithium
  • Valproic acid
  • Theophylline
  • Carbamazepine
  • Metformin
  • Baclofen
  • Isoniazid
  • Selected beta blockers and calcium-channel blockers

Clinical principle

A toxic concentration alone may be insufficient to determine extracorporeal-treatment need. Clinical status, kidney function, acid-base abnormalities, neurologic findings, shock, treatment failure, toxin kinetics, and the specific EXTRIP recommendation should be considered.

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GlobalRPh antidote and toxicology drug library

Established antidote references retained with contemporary safety context

Our Toxicology drug table includes acetylcysteine, activated charcoal, iron chelators, digoxin immune Fab, flumazenil, fomepizole, methylene blue, naloxone, and older gastrointestinal agents. The table remains useful as a centralized starting point but requires a comprehensive current-labeling review.

Core antidote table

High-priority antidote groups

  • Acetylcysteine – acetaminophen
  • Naloxone – opioid respiratory depression
  • Fomepizole / ethanol – toxic alcohol metabolism blockade
  • Digoxin immune Fab – severe cardiac glycoside toxicity
  • Methylene blue – selected clinically significant methemoglobinemia
  • Iron chelation – acute or chronic iron toxicity depending clinical context

Antidotes requiring careful indication

  • Flumazenil – seizure / dependence / mixed-overdose considerations
  • Intravenous lipid emulsion – toxin-specific or refractory-rescue use
  • Sodium bicarbonate – sodium-channel blockade and selected toxin-specific indications
  • High-dose insulin – severe beta-blocker / calcium-channel-blocker poisoning
  • Hydroxocobalamin / cyanide antidotal therapy – exposure-specific use

Alphabetical GlobalRPh drug index

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GlobalRPh toxicology and overdose article library

Current toxicology, medication-toxicity, and overdose-related reviews

The legacy Toxicology portal contains no functional article library. We now surface GlobalRPh content relevant to antidotal therapy, cardiotoxic overdose, opioid overdose, drug toxicity, medication burden, and toxicologic resuscitation.

Intravenous Lipid Rescue in Drug Toxicity LAST | Sodium-channel blockers | CCB | Beta blockers | Refractory cardiovascular toxicity Cefepime Neurotoxicity and Exposure Risk Renal function | Neurotoxicity | Drug exposure | Critical illness Naloxone Access and Opioid Overdose Update – 2026 Naloxone | Recurrent toxicity | Emergency response | Opioids Buprenorphine Induction in the Emergency Department Opioid use disorder | Post-overdose care | Withdrawal | ED treatment Medication Burden and Cumulative CNS / Anticholinergic Exposure Polypharmacy | CNS depression | Anticholinergic effects | Medication safety Opioid Prescribing, Overdose Risk, and Patient Safety Opioids | Fentanyl era | Naloxone | Safe prescribing

GlobalRPh toxicology video development

Priority clinician education topics

The current Toxicology portal has an empty video section. We identify focused topics for a future toxicology video library rather than populating the section with unrelated media.

Priority poisoning videos

  • Initial stabilization and toxidrome recognition
  • Acetaminophen poisoning and the 2023 consensus pathway
  • Opioid overdose, naloxone, and recurrent toxicity
  • Methanol and ethylene glycol poisoning
  • Salicylate poisoning and dialysis indications
  • TCA / sodium-channel-blocker poisoning

Priority antidote / resuscitation videos

  • High-dose insulin for beta-blocker / CCB toxicity
  • Digoxin immune Fab
  • Intravenous lipid emulsion and LAST
  • Methylene blue and methemoglobinemia
  • Flumazenil: when reversal can be dangerous
  • EXTRIP: when poisoning requires hemodialysis
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Clinical content modernization

Priority updates within the GlobalRPh Toxicology library

The current Toxicology portal is largely a historical index. We plan to preserve useful calculators and drug references while rebuilding the section around current poisoning assessment, antidote indications, life-threatening toxicologic resuscitation, enhanced elimination, and current labeling.

Priority resource reviews

  • Toxicology Drug Table: rebuild the page by toxin/antidote pair rather than one long monograph list; verify current formulations, labeling, dosing, contraindications, monitoring, and availability.
  • Acetylcysteine: align acute, repeated supratherapeutic, unknown-time, high-risk, and extended-release acetaminophen pathways with the 2023 consensus statement; update stopping criteria and severe-poisoning considerations.
  • Ethylene Glycol Calculator: replace the legacy IV ethanol-only approach with a toxic-alcohol decision-support tool centered on fomepizole/ethanol blockade, anion/osmolar gaps, cofactors, renal function, and EXTRIP criteria.
  • Blood Alcohol Calculator: retain it as a population estimate while strengthening forensic and clinical limitations and removing any implication that estimated BAC establishes legal impairment or clinical sobriety.
  • Naloxone: update current intranasal and injectable products, fentanyl-era dosing considerations, ventilation-first principles, recurrent toxicity, infusion considerations, precipitated withdrawal, and post-overdose treatment linkage.
  • Flumazenil: revise the page to emphasize narrow indications and seizure risk in benzodiazepine dependence, proconvulsant co-ingestion, mixed overdose, and certain seizure disorders.
  • Activated Charcoal: update selective-use indications, timing, adsorbability, airway protection, aspiration risk, bowel obstruction/ileus, and remove routine decontamination framing.
  • Digoxin Immune Fab: update current product availability, dosing strategies for known and unknown ingestion, chronic toxicity, potassium, renal dysfunction, post-Fab digoxin-level interpretation, and rebound toxicity.
  • Fomepizole: update methanol and ethylene glycol dosing, dialysis adjustments, laboratory monitoring, cofactor therapy, and integration with EXTRIP recommendations.
  • Methylene Blue: update methemoglobinemia indications, co-oximetry interpretation, G6PD considerations, serotonergic interactions, dosing, and alternatives when methylene blue is inappropriate.
  • Iron Chelation: distinguish acute iron poisoning from chronic iron overload; update deferoxamine indications in acute toxicity and place deferasirox/deferiprone within chronic chelation rather than an acute-antidote list.
  • Salicylate Pathway: create a dedicated calculator/decision aid with serial concentrations, pH, potassium, alkalinization, airway warnings, renal function, and EXTRIP dialysis triggers.
  • Cardiovascular Poisoning: build beta-blocker, calcium-channel-blocker, digoxin, sodium-channel-blocker, local-anesthetic, and refractory-shock modules using current AHA special-circumstances guidance.
  • High-Dose Insulin Tool: develop a clinician calculator for severe beta-blocker and calcium-channel-blocker poisoning with insulin, dextrose, potassium, glucose monitoring, hemodynamic reassessment, and escalation safeguards.
  • Intravenous Lipid Emulsion: develop a separate LAST/rescue calculator using current resuscitation guidance and explicitly distinguish established LAST use from less certain rescue indications in other lipophilic poisonings.
  • Methemoglobinemia / Cyanide / CO: add exposure-specific clinical pathways, co-oximetry, antidotal therapy, oxygen strategy, and indications for specialty consultation or hyperbaric referral where appropriate.
  • Therapeutic Drug Levels: separate chronic therapeutic monitoring from acute poisoning interpretation and verify current toxic ranges, sampling times, free-level indications, and concentration-based treatment thresholds.
  • EXTRIP Integration: add toxin-specific dialysis links for lithium, salicylate, methanol, ethylene glycol, valproate, theophylline, carbamazepine, metformin, baclofen, isoniazid, and other reviewed toxins.
  • Pediatric Toxicology: develop weight-based antidote and exposure resources with pediatric resuscitation cross-links, child-resistant medication issues, accidental ingestion, and age-specific toxic dose considerations.
  • Medication-Error Toxicology: add accidental double-dosing, concentrated products, insulin, anticoagulants, sulfonylureas, acetaminophen, opioids, and other high-risk medication-error pathways.
Antidote dosing dashboard Weight-based antidote selection, preparation, repeat dosing, monitoring, and major contraindications.
Toxic alcohol 2.0 Methanol / ethylene glycol diagnosis, fomepizole, cofactors, laboratory trends, and EXTRIP dialysis criteria.
High-dose insulin calculator Severe CCB / beta-blocker poisoning with glucose, potassium, hemodynamic, and escalation monitoring.
Salicylate severity tool Serial level, pH, renal function, neurologic status, oxygenation, alkalinization, and dialysis prompts.
Acetaminophen pathway 2.0 Acute, high-risk, unknown-time, repeated supratherapeutic, extended-release, and severe-poisoning workflows.
Toxidrome / ECG assistant Structured physiologic findings, QRS/QT patterns, pupils, bowel/bladder, temperature, and targeted differential diagnosis.

Current external clinical standards

Authoritative toxicology, resuscitation, and extracorporeal-treatment references

Toxicology guidance often depends on low-frequency, high-acuity evidence and expert consensus. We therefore link directly to current professional resources while modernizing our individual toxicology pages.

2025 AHA Adult and Pediatric Special Circumstances of Resuscitation Current guidance for life-threatening opioid, beta-blocker, calcium-channel-blocker, digoxin, sodium-channel-blocker, local-anesthetic, cyanide, carbon-monoxide, methemoglobin, and other poisoning emergencies. Open AHA Guidance
2023 Acetaminophen Poisoning Consensus Statement US/Canada consensus for acute and repeated acetaminophen poisoning, acetylcysteine treatment, high-risk exposure, extended-release products, and stopping criteria. Open Acetaminophen Consensus
American College of Medical Toxicology Statements Professional toxicology position and practice statements, including management priorities in salicylate toxicity and other clinical topics. Open ACMT Statements
EXTRIP Workgroup Recommendations Toxin-specific extracorporeal-treatment recommendations for methanol, ethylene glycol, salicylates, lithium, valproate, theophylline, carbamazepine, metformin, and other toxins. Open EXTRIP Recommendations
America’s Poison Centers National poison-center network and professional/public poison-exposure resources. Open Poison Center Network
GlobalRPh Critical Care Portal ICU resuscitation, vasoactive therapy, airway support, electrolyte, and acute-care cross-links for severely poisoned patients. Open Critical Care Portal

Supporting GlobalRPh clinical resources

Critical care, pharmacokinetics, psychiatry, nephrology, hepatology, laboratory, and medication-safety support

Acute care / monitoring

Organ injury / elimination

Intentional overdose / substance use

Rationale for retaining established toxicology pages

Several GlobalRPh toxicology pages remain useful as dosing references or historical clinical tools. We retain them for continuity while modernizing antidote availability, current labeling, toxin-specific indications, extracorporeal-treatment criteria, decontamination principles, concentration interpretation, and current resuscitation guidance.

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Clinical use: Our toxicology calculators, antidote tables, therapeutic drug-level references, and clinical articles are intended to support, not replace, immediate stabilization, current toxicology and resuscitation guidance, poison-center or medical-toxicology consultation when appropriate, current product labeling, serial clinical and laboratory reassessment, institution-specific protocols, and independent professional judgment.

Return to Internal Medicine Sections  |  Toxicology Drug Table  |  Critical Care  |  Therapeutic Drug Levels  |  EXTRIP

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Alphabetical Listing of individual drugs

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Common LAB Values  Renal Dosing

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