Enhanced elimination of poisons
- Michael J Burns, MD
Michael J Burns, MD
- Assistant Professor of Medicine
- Harvard Medical School
- Larissa I Velez, MD
Larissa I Velez, MD
- Professor of Emergency Medicine
- University of Texas Southwestern Medical Center
- Section Editors
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Unintended and intentional poisonings and drug overdoses constitute a significant source of morbidity, mortality, and health care expenditures. An estimated two to five million such events occur annually in the United States, although the true incidence is unknown due to under diagnosis and underreporting [1-3].
Management of the poisoned patient begins with a thorough evaluation, recognition that poisoning has occurred, identification of the agent(s) involved, assessment of severity, and prediction of toxicity. Therapy involves the provision of supportive care, prevention of poison absorption, and, when appropriate, the administration of antidotes and enhancement of elimination of the poison.
Methods to enhance the rate of elimination of poisons following a toxic ingestion are reviewed here. General issues regarding the management of toxic ingestions, and specific issues related to decontamination and gastric emptying are discussed separately. (See "General approach to drug poisoning in adults" and "Gastrointestinal decontamination of the poisoned patient" and "Approach to the child with occult toxic exposure".)
Enhanced elimination techniques can accelerate removal of a toxin, but few studies have investigated whether they actually shorten the duration of clinical toxicity and/or improve clinical outcomes. The main methods of enhancing the elimination of toxins are listed in the table (table 1).
General indications for enhanced elimination techniques include:
- Litovitz TL, Smilkstein M, Felberg L, et al. 1996 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1997; 15:447.
- McCaig LF, Burt CW. Poisoning-related visits to emergency departments in the United States, 1993-1996. J Toxicol Clin Toxicol 1999; 37:817.
- Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2010 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 28th Annual Report. Clin Toxicol (Phila) 2011; 49:910.
- Morgan AG, Polak A. The excretion of salicylate in salicylate poisoning. Clin Sci 1971; 41:475.
- Bloomer HA. A critical evaluation of diuresis in the treatment of barbiturate intoxication. J Lab Clin Med 1966; 67:898.
- Henry JA. Specific problems of drug intoxication. Br J Anaesth 1986; 58:223.
- Proudfoot AT, Krenzelok EP, Vale JA. Position Paper on urine alkalinization. J Toxicol Clin Toxicol 2004; 42:1.
- Garrettson LK, Geller RJ. Acid and alkaline diuresis. When are they of value in the treatment of poisoning? Drug Saf 1990; 5:220.
- Frenia ML, Schauben JL, Wears RL, et al. Multiple-dose activated charcoal compared to urinary alkalinization for the enhancement of phenobarbital elimination. J Toxicol Clin Toxicol 1996; 34:169.
- Prescott LF, Balali-Mood M, Critchley JA, et al. Diuresis or urinary alkalinisation for salicylate poisoning? Br Med J (Clin Res Ed) 1982; 285:1383.
- Patel N, Bayliss GP. Developments in extracorporeal therapy for the poisoned patient. Adv Drug Deliv Rev 2015; 90:3.
- Ghannoum M, Roberts DM, Hoffman RS, et al. A stepwise approach for the management of poisoning with extracorporeal treatments. Semin Dial 2014; 27:362.
- Ouellet G, Bouchard J, Ghannoum M, Decker BS. Available extracorporeal treatments for poisoning: overview and limitations. Semin Dial 2014; 27:342.
- Garella S. Extracorporeal techniques in the treatment of exogenous intoxications. Kidney Int 1988; 33:735.
- Fertel BS, Nelson LS, Goldfarb DS. Extracorporeal removal techniques for the poisoned patient: a review for the intensivist. J Intensive Care Med 2010; 25:139.
- Kim Z, Goldfarb DS. Continuous renal replacement therapy does not have a clear role in the treatment of poisoning. Nephron Clin Pract 2010; 115:c1.
- Pappas SC, Silverman M. Treatment of methanol poisoning with ethanol and hemodialysis. Can Med Assoc J 1982; 126:1391.
- Peterson CD, Collins AJ, Himes JM, et al. Ethylene glycol poisoning: pharmacokinetics during therapy with ethanol and hemodialysis. N Engl J Med 1981; 304:21.
- Gonda A, Gault H, Churchill D, Hollomby D. Hemodialysis for methanol intoxication. Am J Med 1978; 64:749.
- Brent J, McMartin K, Phillips S, et al. Fomepizole for the treatment of methanol poisoning. N Engl J Med 2001; 344:424.
- Brent J, McMartin K, Phillips S, et al. Fomepizole for the treatment of ethylene glycol poisoning. Methylpyrazole for Toxic Alcohols Study Group. N Engl J Med 1999; 340:832.
- Cutler RE, Forland SC, Hammond PG, Evans JR. Extracorporeal removal of drugs and poisons by hemodialysis and hemoperfusion. Annu Rev Pharmacol Toxicol 1987; 27:169.
- Hansen HE, Amdisen A. Lithium intoxication. (Report of 23 cases and review of 100 cases from the literature). Q J Med 1978; 47:123.
- Rosansky SJ. Isopropyl alcohol poisoning treated with hemodialysis: kinetics of isopropyl alcohol and acetone removal. J Toxicol Clin Toxicol 1982; 19:265.
- Winchester JF, Gelfand MC, Helliwell M, et al. Extracorporeal treatment of salicylate or acetaminophen poisoning--is there a role? Arch Intern Med 1981; 141:370.
- Calello DP, Liu KD, Wiegand TJ, et al. Extracorporeal Treatment for Metformin Poisoning: Systematic Review and Recommendations From the Extracorporeal Treatments in Poisoning Workgroup. Crit Care Med 2015; 43:1716.
- Volans GN, Vale JA, Crome P, et al. The role of charcoal hemoperfusion in the management of acute poisoning by drugs. In: Artificial Organs, Kenedi RM, Bourtney JM, Gaylor JDS, Gilchris T (Eds), University Park Press, Baltimore 1976. p.178.
- Hampel G, Wiseman H, Widdop B. Acute poisoning due to hypnotics: the role of haemoperfusion in clinical perspective. Vet Hum Toxicol 1979; 21 Suppl:4.
- Bismuth C, Conso F, Wattel F, et al. Coated activated charcoal hemoperfusion: experience of French anti-poison centers about 60 cases. Vet Hum Toxicol 1979; 21 Suppl:2.
- Shannon MW. Comparative efficacy of hemodialysis and hemoperfusion in severe theophylline intoxication. Acad Emerg Med 1997; 4:674.
- Golper TA, Bennett WM. Drug removal by continuous arteriovenous haemofiltration. A review of the evidence in poisoned patients. Med Toxicol Adverse Drug Exp 1988; 3:341.
- Ghannoum M, Gosselin S. Enhanced poison elimination in critical care. Adv Chronic Kidney Dis 2013; 20:94.
- MULTIPLE-DOSE ACTIVATED CHARCOAL
- URINARY ALKALINIZATION
- Indications and efficacy
- - Adults
- - Children
- HEMODIALYSIS AND HEMOPERFUSION
- EXCHANGE TRANSFUSION
- ADDITIONAL RESOURCES
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS