Clinical Toxicology

ISSN: 0009-9309 (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ictx18

Guide to Management of Drug Overdose

To cite this article: (1975) Guide to Management of Drug Overdose, Clinical Toxicology, 8:4,
475-482, DOI: 10.3109/15563657508990079

To link to this article: https://doi.org/10.3109/15563657508990079

Published online: 25 Sep 2008.

Submit your article to this journal

Article views: 1834

View related articles

Citing articles: 1 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=ictx20
CLINICAL TOXICOLOGY 8(4), pp. 475-482 (1975)

LETTER TO THE EDITOR

Guide to Management of Drug Overdose

T O Consulting Faculty of the Institute of Clinical Toxicology

FROM: E r i c G. Comstock, M.D.

Institute of Clinical Toxicology

P.O. Box 2565
Houston, Texas 77001

Discussion on General Treatment for Drug Overdose

Enclosed is a copy of a proposed manuscript to be included in the

inside back cover of the 1975 Physician's Desk Reference. Minor
alteration can still be made. Your suggestions on the discussion
will help to stengthen the text and help avoid inaccuracies. Its
publication in 600,000 copies of the PDR is, I believe, a major achieve-
ment for Clinical Toxicology.

GUIDE T O MANAGEMENT O F DRUG OVERDOSE

Physician's Desk Reference 29th Edition 1975. Published by:

Medical Economics. Prepared by Institute of Clinical Toxicology
E r i c G. Comstock, M.D., Director.

475
476 LETTER TO THE EDITOR

INTRODUCTION

The following discussion is designed for use in adult patients. In

the pediatric age group, the general principles apply, but volumes of
fluid o r suggested medication must be adjusted to be appropriate
for body size. Symptomatic and supportive care is the approach to
drug overdose upon which primary reliance should be placed. All
other approaches to treatment are secondary to the support of vital
function. Procedures directed toward the offending substance, such
as the performance of gastric lavage or the administration of spe-
cific pharmacologic antagonist, should be undertaken only after ade-
quate vital function has been assured. Procedures to facilitate
excretion of toxic substances, such as peritoneal o r extracorporeal
lavage and forced diuresis are required infrequently, and never should
be relied upon as the primary approach to treatment. For sedative,
hypnotic, and tranquilizer drugs, alone or in combination, supportive
care is sufficient as outlined in the following discussion.

I N I T I A L ASSESSMENT

The initial assessment of a drug overdosed patient should deter-

mine whether the patient is asymptomatic or symptomatic. If the
patient is symptomatic, determine the adequacy of respiration and
cardiac function and note reflex activity, such as pupilary, corneal,
gag and deep tendon. If vital function is compromised, or conscious-
ness is impaired, proceed immediately to supportive measures.

T H E ASYMPTOMATIC P A T I E N T

The drug overdosed patient may be asymptomatic because he has

not ingested a sufficient dose of the drugs, o r because a sufficient
quantity of the drugs has not been absorbed to produce symptoms.
After the ingestion of a life threatening quantity of drugs, symptoms
may be delayed as long as six hours, although ordinarily symptoms
are manifested within thirty (30)minutes to two (2) hours. Ingestion
of alcohol simultaneously with drugs may result in symptoms as
early as ten to fifteen minutes with compromise of vital function
within thirty minutes. Vomiting should be induced only during the
asymptomatic interval. If significant central nervous system depres-
sion intervenes between the administration of emetic and the occur-
LETTER TO THE EDITOR 477

rence of vomiting, then the airway should be protected by insertion

of a cuffed endotracheal tube. The delay between the administration
of an emetic and the occurrence of emesis can be avoided by the use
of apomorphine. Fluids must be forced orally to obtain satisfactory
results from any effort to induce vomiting. An alternate approach
to the asymptomatic patient alleged to have ingested drugs, is the
administration by mouth of a slurry of activated charcoal containing
no less than 100 grams of activated charcoal powder (USP) in water.
Gastric lavage with a large caliber tube (34 French) may be performed
in the asymptomatic patient o r in the patient whose consciousness is
impaired but whose reflexes are intact. Any patient whose conscious-
ness is impaired to the point where a cuffed endotracheal tube will
be tolerated should be intubated prior to the performance of gastric
lavage.

THE SYMPTOMATIC PATIENT

If the patient is symptomatic all treatment procedures directed

toward the toxic substance are secondary to appraisal and support
of the vital function. If the patient is in deep coma, attention to
respiratory support and cardiac function should proceed immedi-
ately and simultaneously.

RESPIRATORY SUPPORT

Examine the mouth. Remove all foreign material including

dentures. Position the head so that respiration is not sonorous
and so that regurgitated stomach contents are not readily aspi-
rated. If respiration is not present, provide mechanical ventilation
by mouth-to-mouth, ambu bag, o r positive pressure respirator
until the patient is adequately oxygenated. Insert an oropharyngeal
airway and suction excess excretions while preparing to insert
an endotracheal tube. A cuffed endotracheal tube should be inserted
and the cuff inflated. Bronchial suction should be administered to
clear mucus and foreign material from the major bronchi. Deter-
mine that the chest is being inflated symmetrically and that breath
sounds are audible bilaterally. After the acute emergency, deter-
mine placement of the endotracheal tube by x-ray. Monitor adequacy
of ventilation using arterial blood gases.
478 LETTER TO THE EDlTOR

IV A C C E S S AND C A R D I A C F U N C T I O N

While one member of the treatment team is assuring adequate

ventilation, a second member of the team should be assuring adequate
IV access by insertion of an 18 guage venous catheter and initiation
of IV fluid administration, such as Ringers Lactate, a t a maintenance
rate in adults of 150 ml. per hour. Since hypotension from sedative
drug intoxication results from relative hypovolemia complicated
frequently by dehydration, the rate of intravenous infusion should be
increased to 10-20 cc per minute if the systolic pressure is under
80 mm of mercury. When the systolic pressure returns to 80 mm,
the rate of infusion should be reduced to 2-3 cc per minute. A
central venous pressure catheter and monitoring of central venous
pressure is required if the continuous high rate infusion reaches
one (1)liter o r if the positive fluid balance exceeds two ( 2 ) liters
during the first two hours. Intermittent monitoring of central venous
pressure should continue throughout the period of intensive supportive
care. A baseline electrocardiogram should be obtained as soon as
procedures for support of vital function have been implemented. A n
abnormal electrocardiogram should result in reduction in the rate
of IV infusion to baseline of 2 ml per minute until the cardiac abnor-
mality has been evaluated. The appearance of conduction defects
should lead to suspicion of drugs with direct cardiac affects, such as
the tricyclic antidepressents. In uncomplicated sedative drug over-
dose, the central venous pressure will be under ten centimeters of
water and will not change appreciably with high volume fluid infusion.
If the central venous pressure increases abruptly in excess of five
centimeters of water, o r if the C V P exceeds 16 centimeters of water,
high rate fluid infusion should be stopped pending evaluation of
cardiac status. Adequate tissue perfusion is obtained with a systolic
pressure in the range of 80 to 100 milliliters of mercury. A systolic
pressure higher than this is required only in the patient with pre-
existing hypertension. The formation of urine is an indication that
tissue perfusion is adequate.

URINARY C A T H E T E R I Z A T I O N

An in-dwelling urinary catheter should be inserted early in the

course of treatment of any unconscious drug overdose patient. Upon
insertion of the catheter, the volume of residual urine should be
measured and the specimen should be saved separately for urinaly-
sis including specific gravity, labeled for drug analysis, and sent
LETTER TO THE EDITOR 479

to the laboratory to be retained for 24 hours. The specific gravity

of the initial urine will help identify patients who are severely dehy-
drated at the time of admission and influence the amount of positive
fluid balance which should be tolerated during the initial few hours of
treatment. Recording of urine output hourly is necessary to maintain
fluid balance records. Continuing urine formation is a guide to the
adequacy of tissue perfusion. Abrupt cessation of urine output most
frequently is due to an obstructed catheter, but deserves immediate
appraisal. Anuria for a period in excess of one hour should lead to
reduction of high rate intravascular volume infusion until cardiac and
renal status has been reappraised. Failure to achieve adequate
urinary output after initial emptying of the bladder may reflect uncom-
pensated dehydration and relative hypovolemia, each of which must
be corrected before balanced fluid intake and output plus insensible
loss can be achieved. The immediate or automatic use of diuretics
a t this stage only aggravates the basic defect and may result in intrac-
table hypotension. Addition of vasopresser drugs a t this stage may
precipitate renal failure. Relatively mobile electrolite solutions as
transient volume expanders a r e preferred to whole blood or plasma
to avoid congestive failure when normal vascular tone is re- established.
A positive fluid balance of 2 to 4 liters may be required before fluid
intake and output are in equilibrium. A s vascular tone returns, urine
output may increase abruptly, exceeding one liter per hour. Profound
diuresis may preceed recurrence of deep tendon reflexes and heralds
reduction in CNS depression.

GASTRIC LAVAGE

Gastric lavage should be performed only after vital function has

been determined to be adequate o r procedures for support of vital
function have been implemented. Gastric lavage should be under-
taken only after a cuffed endotracheal tube is protecting the airway.
If corrosive substances are thought to have been ingested, lavage
should not be performed until examination demonstrates there is no
destruction of the mucous membranes of the mouth o r of the esoph-
agus as determined by esophagoscopy. Gastric lavage should be
performed if the ingestion of drugs is estimated to have been within
the preceding six hours. If there are no audible bowel sounds, gastric
lavage should be performed regardless of the time lapse between
ingestion and treatment. A 34 French lavage tube should be used.
Smaller tubes do not permit sufficiently rapid fluid flow to remove
particulate material. Gastric contents should be aspirated prior to
480 LETTER TO THE EDITOR

lavage and saved in the event subsequent laboratory analysis is

required. In an adult, lavage should be performed in cycles of 300
to 500 milliliters of fluid instilled over one to two minutes, left in
place for about one minute, and drained by gravity over a period of
approximately three to four minutes. If these time intervals cannot
be accomplished, then the lavage system is defective. The total fluid
volume to be used in lavage should be three liters beyond that volume
required to obtain a clear return. Lavage may be performed with
tap water or a normal saline solution. Other lavage fluids such as
dilute potassium permanganate, copper sulfate, bicarbonate, tannic
acid, and castor oil are occasionally recommended, but accidental
aspiration of these substances may result in pneumonic processes of
greater hazard than the primary substance. Powdered activated
charcoal is an effective substitute and is less hazardous with aspira-
tion than plain gastric secretions.

A C T I V A T E D CHARCOAL

Powdered activated charcoal effectively adsorbs sedative and

tranquilizer drugs and a vast majority of other drugs, thereby limit-
ing their bio-availability. Upon the completion of lavage, 100 grams
of dry powdered activated charcoal (USP) suspended in six ounces of
water to form a slurry easily passed through the lavage tube should
be instilled and left in place in the stomach. The activated charcoal
forms an effective barrier between any remaining particulate mate-
rial and the gastrointestinal mucosa. Drugs adsorbed on activated
charcoal a r e not desorbed to any practical extent in the lower intes-
tinal tract. When an enteroenteric circulation of the active drug
exists, excess activated charcoal in the intestine effectively prevents
reabsorption thereby facilitating excretion. This appears effective
with the tricyclic antidepressants and the cardiac glycosides. Acti-
vated charcoal is not effective with cyanide or small electrolytes
such as sodium, potassium, chloride, o r mineral acids or bases.

S P E C I F I C ANTIDOTES

Specific antidotal substances effective in the treatment of drug

overdose a r e few. They should be used only with specific indications
and never should be used prophylacticly or in quantities sufficient
to return the comatose patient to consciousness. They should be
used only to improve adequacy of vital function and never be relied
LETTER TO THE EDlTOR 481

upon at the exclusion of supportive care. When specific antidotes are

used, special attention must be given to duration of action of the anti-
dote as compared with the duration of action of the primary drug.
Release of a patient after administration of a relatively short-acting
antidote may result in serious compromise of clinical status after
the patient has been released from medical care.

AVOID UNNECESSARY DRUGS

Whenever possible, support of vital function should be by mechanical

rather than by chemical means. Inadequate respiration should be cor-
rected by using a positive pressure respirator rather than by use of
respiratory stimulant drugs. Central nervous system depression and
coma should be treated by the supportive means described above and
should not be treated by central nervous system stimulant drugs.
Shortening of coma with CNS stimulant drugs may result in hyperpy-
rexia and convulsions which otherwise might be avoided. Hypotension
resulting from sedative or tranquilizer drug overdose is due to rela-
tive hypovolemia properly corrected by increasing the intravascular
volume. Vasopressor drugs a r e not helpful and should be avoided.
Body temperature outside of the normal range should be controlled
by heat exchangers which warm o r cool the body mechanically. Anti-
pyretic drugs should be avoided. Antipyretic drugs in overdose cause
hyperpyrexia. Forced diuresis is not conservative supportive care.
Forced diuresis with alkalinization of the urine is an effective treat-
ment for increasing the excretion of salicylates. Alkaline diuresis
also is effective in removing phenobarbital and barbitol, but only
rarely is it an essential part of treatment of overdose due to these
drugs. The risk benefit ratio of forced diuresis in the treatment of
other drugs does not favor its use. Diuretic drugs should not be a
routine measure in the treatment of drug overdose. Diuretics should
be reserved for use in substances clearly excreted in the urine in
active form or for treatment of overhydration and cerebral edema.

CONTINUING CARE

Coma from sedative drug intoxication may persist for many days.
Total apnea for five days and an isoelectric electoencephalogram for
intervals up to 36 hours have been recorded with drug overdose pa-
tients who have survived without apparent neurologic sequelae. Con-
tinuing care should be provided in a medical intensive care unit with
482 LETTER TO THE EDITOR

monitoring of temperature, blood pressure, pulse, respiratory rate,

tidal volume, electrocardiogram, central venous pressure, fluid
balance, electrolytes, and arterial blood gases with appropriate
compensatory treatment for abnormalities. Intensive respiratory
care should include frequent tracheal suction, frequent repositioning,
and daily chest x-rays. Endotracheal tubes should be changed under
supervision of an anesthesiologist. Tracheostomy should be per-
formed only for surgical indications. Carefully attentive continuous
nursing care is essential.

COMPLICATIONS

Aspiration pneumonia and subsequent infection is the most com-

monly occurring complication of coma secondary to drug overdose.
Treatment consists of vigorous tracheal aspiration, periodic hyper
inflation of lung, and antibiotic coverage. Rarely occurring are
tension pneumothorax and renal failure of the crush syndrome type.
Interstitial edema, including scleredema, is common in profound
coma and usually represents increased capillary permeability
rather than over hydration. Parenteral steroids may be helpful
in this situation. Occasionally, interstitial edema is so severe as
to compromise venous return and to require fasciotomies to pro-
vide venous drainage. Always be mindful that the patient may have
sustained traumatic injury especially to the head, so be watchful
for lateralizing neurologic signs.

T O X I C O L O G I C ANALYSIS

Any ingested material, initial gastric aspirate, and the first

catheterized urine specimen all should be saved and labeled for
laboratory examination with instructions to hold at least twenty-
four (24) hours prior to discarding. Analysis of these fluids for
drugs occasionally will change fundamental approach to treatment.
Qualitative analysis provides confirmation of the clinical deter-
mination of etiology. Frequently multiple drugs are involved.
Interpretation of quantitative findings is extremely difficult and
usually is helpful only to follow the clearance of substances from
the body. Previous drug use results in tolerance which prevents
meaningful interpretation of absolute concentrations. Instructions
for management of specific drugs identified should be consulted
once symptomatic and supportive care is underway.