Overdose or poisoning

at the bedside

airway, breathing, circulation; full vitals with temperature, cardiac monitor, IV access, capillary glucose, 12-lead ECG
what and how → drug chart (regular, PRN, infusions), tablets found, patient, family, nurses, a visitor’s medication; route: ingestion, inhalation, injection, skin; immediate vs modified release
how much → record the maximum possible exposure for the risk assessment, separate from the confirmed dose
co-ingestants → alcohol, the prescribed chart, over-the-counter and herbal; one drug found is not a reason to stop looking
timeline → time of exposure or last charted dose, onset of symptoms, treatment already given
self-harm suspected → self-harm precautions and observation level per local policy, remove anything else they could take, tell the treating team

escalate now if

unstable, whatever the toxin → ICU and the treating team now
- → shock → hypotension
- → respiratory failure, slow or shallow breathing → bag-mask first → respiratory rate
- → seizure → seizures
- → severe hyperthermia, rigidity, falling consciousness
toxidrome or ECG clue → targeted treatment while ICU is called
- → respiratory depression with sedation → opioid: naloxone; pupils support, they do not decide
- → broad QRS → TCA or sodium-channel blocker: bicarbonate
- → long QTc → stop QT-prolonging drugs, magnesium → ECG on call
- → bradycardia with shock → beta-blocker, calcium-channel blocker or digoxin
- → salicylate with acidosis, confusion or a rising level → ICU and toxicology now; intubation without matching the high minute ventilation can precipitate collapse

paracetamol → silent for a day; on the ward usually a staggered chart total → N-acetylcysteine
salicylate → tinnitus, vomiting, fast breathing, mixed acid-base → venous blood gas
opioid → sedation with a low respiratory rate; patches, PCA, methadone and modified release act late and long
sedatives, alcohol → airway and breathing first; look for the second drug
sulfonylurea or insulin → recurrent hypoglycemia for 24–48 h → hypoglycemia
TCA and other sodium-channel blockers → drowsy, dry, tachycardic, broad QRS, seizures
beta-blocker, calcium-channel blocker → bradycardia and hypotension, hyperglycemia with CCB → bradycardia
lithium → tremor, ataxia, confusion, often after AKI, a new diuretic or NSAID; level and RFT, KPCC
toxic alcohols → methanol, ethylene glycol: high anion gap acidosis, visual symptoms, AKI → venous blood gas, KPCC now
anticoagulant → bleeding or high INR → coagulation profile

exam → respiratory rate and depth, pupils, temperature, sweating or dry skin, tone and clonus, bowel sounds, pressure areas after a long lie
ECG → QRS, QTc, rate and rhythm; repeat for any drug with cardiac effect → ECG on call
chart review → cumulative paracetamol across regular and PRN orders, renal dosing of lithium, digoxin and opioids, new interacting drugs, pump settings

core → ECG, bedside glucose, paracetamol level for every deliberate or uncertain ingestion whatever the patient says, RFT and electrolytes
targeted → salicylate level when the exposure or picture suggests it; CK after a long lie; LFT and INR; blood gas with lactate; osmolar gap; specific levels when they change treatment: digoxin, lithium, iron, theophylline, valproate, ethanol; pregnancy test
note → a normal osmolar gap does not exclude a toxic alcohol, especially late
note → urine drug screens rarely change acute management and must not delay treatment

first hour: support before antidotes

airway and ventilation → bag-mask if breathing is inadequate, oxygen alone does not treat hypoventilation; ICU and anesthesia if not protecting the airway
hypoglycemia → glucose 10% 150–200 mL IV or glucose 20% 75–100 mL IV over 10–15 min → hypoglycemia
seizures → lorazepam 0.1 mg/kg IV, max 4 mg per dose → seizures
hyperthermia → active cooling, stop the serotonergic or anticholinergic drug, ICU if rigid or agitated
electrolytes and acid-base → correct potassium and magnesium, repeat the gas → potassium, venous blood gas
shock → crystalloid bolus and reassess, vasopressors early with ICU → hypotension

call KPCC

Kuwait Poison Control Center for every overdose, 2477 1779: drug, formulation, maximum possible exposure, time, what has been given; they advise and follow the patient with the treating team

antidotes by toxin

opioid → naloxone 0.1 mg IV, repeat every 2–3 min to adequate breathing, not full arousal; 0.4 mg IV/IM if peri-arrest; apnea → 0.4–2 mg IV with ventilation; it wears off before the opioid does → respiratory rate
paracetamol → the nomogram applies only to a single acute ingestion with a known time and a level at 4–24 h; staggered or chart-total, modified release, unknown time, or late with liver injury → start N-acetylcysteine, do not wait for the level → 3-bag protocol; KPCC decides threshold and stopping
salicylate → urinary alkalinization is a sodium bicarbonate infusion titrated to urine pH, potassium checked and replaced (hypokalemia blocks it), directed by toxicology or ICU → bicarbonate; not plain IV fluids
TCA, sodium-channel blocker → bicarbonate dosed to QRS narrowing → bicarbonate
beta-blocker, calcium-channel blocker, digoxin → bradycardia: special cases, toxicology and ICU
sulfonylurea → glucose infusion, octreotide with toxicology → hypoglycemia

decontamination

activated charcoal → rarely relevant on the ward: the time is usually known and more than 1 h has passed; where indicated, usual adult single dose 50 g PO within 1 h of a toxic amount of a drug it binds, airway assessed and protected, with toxicology advice

enhanced elimination

a toxicology and ICU decision, not a ward order: hemodialysis for lithium, severe salicylate, toxic alcohols and valproate; KPCC and nephrology early

observe and hand over

level of care → ward with monitoring, HDU or ICU by the toxin, the ECG and the course; airway, breathing or hemodynamic concern → ICU
how long → by substance, formulation, dose, course, ECG and toxicology advice; an asymptomatic patient can still deteriorate: modified release, patches, delayed absorption; repeat ECG, glucose, gas and levels as KPCC advises
deliberate self-poisoning → precautions continue; psychiatry liaison assessment and a documented safety plan before the patient leaves the ward

hand over → drug, formulation, maximum possible exposure vs confirmed dose, time, levels due, antidote running, KPCC advice, observation level and escalation trigger

source	type
AACT / EAPCCT · Single-dose activated charcoal position statement ↗︎	international position statement
Dart et al. 2023 · Management of acetaminophen poisoning in the US and Canada, consensus statement (JAMA Netw Open)	consensus statement
ISCCM 2024 · Position statement on the management of acute poisoning	specialty-society position statement
2025 AHA ECC guidelines · Opioid-associated emergencies	international guideline
Kuwait Poison Control Center (KPCC) advice	local protocol, case by case

Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.

go deeper the full MOC+ Acute Medicine set covers the on-call essentials.

free the on-call checklist covers the whole shift on one printable page.

studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.

updated Oct 2026file complaint/overdose-poisoning