**Call poison control for all ingestions. They will fax important information to you re: symptoms and treatment.

Consider ingestions in all cases of altered mental status.

Calculate anion and osmolar gap for all suspected ingestions.

Tylenol ingestion

Toxic range: 200 mg/kg or 10 g

  1. Obtain levels and LFTs – do not wait to treat until levels return if concerning amount of drug was ingested.  Continue to monitor frequently.
  2. Plot on Rumack-Matthew nomogram to determine potential for toxicity.
  3. N-acetylcysteine (NAC) therapy administered over 20 hours. Give 150 mg/kg loading dose over 15 minutes, then 50 mg/kg over 4 hours, followed by 100 mg/kg over remaining 16 hours.
  4. Know the stages of toxicity
    • Stage I (12-24 hrs) – N/V or asymptomatic
    • Stage II (> 24 hrs) – Transaminase elevation occurs
    • Stage III (48-72 hrs) – Liver fxn abnormalities peak, N/V/anorexia return
    • Stage IV- Recovery phase 

Salicylate ingestion

Toxic range: >150 mg/kg (Symptoms more important than level)

Sx: Respiratory alkalosis, N/V, tinnitus, lethargy, coma

  1. Obtain and monitor levels.
  2. Alkalinize the urine to enhance elimination. 
  3. Consider dialysis if needed.

Iron ingestion

Toxic range: 60 mg/kg elemental iron

  1. Monitor levels and watch for symptoms. If > 6 hrs Goes by w/o sxs, unlikely to become toxic. Watch for metabolic acidosis.
  2. Consider deferoxamine if level > 500 mcg/dL or if CV collapse, otherwise supportive cares.
  3. Know phases of iron toxicity.
    • Stage I (w/in 30 mins) – N/V/D, hematemesis or hematochezia
    • Stage II- GI sxs resolve, nonspecific malaise. Tachycardia and acidosis may develop.
    • Stage III (>12 hrs) – Hemodynamic instability & shock
    • Stage IV – Liver failure 

Metabolic Acidosis (anion gap >12)

  • Methanol
  • Uremia
  • DKA
  • Paraldehyde
  • Isoniazid / iron
  • Lactic acidosis
  • Ethanol / ethylene glycol
  • Salicylates

Agents not absorbed by charcoal

  • “Charcoal PHAILS”
  • Pesticides
  • Hydrocarbons
  • Acids/ alkalis/ alcohols
  • Iron
  • Lithium
  • Solvents