2025 PACUPrep BCCCP Preparatory Course Antidotes and Gastrointestinal Decontamination Supportive Care, Complication Prevention, and Multidisciplinary Decision-Making
Supportive Care and Complication Prevention in Toxicology

Supportive Care, Complication Prevention, and Multidisciplinary Decision-Making

Objectives Icon A checkmark inside a circle, symbolizing achieved goals.

Learning Objective

Implement supportive care strategies and multidisciplinary protocols to prevent and manage complications associated with toxicological emergencies and their treatments.

1. Airway Protection and Mechanical Ventilation

Securing the airway and optimizing ventilator settings are critical to prevent aspiration and barotrauma during decontamination procedures.

Indications for Intubation

  • Glasgow Coma Scale (GCS) ≤ 8 or inability to protect the airway
  • Persistent vomiting or emesis during activated charcoal or lavage
  • Ongoing seizures or significant risk of airway compromise
  • Ingestion of caustics or hydrocarbons with a high risk of aspiration

Rapid Sequence Induction (RSI)

  • Preoxygenation: Administer 100% O₂ for 3–5 minutes to denitrogenate the lungs.
  • Induction Agents: Etomidate 0.2–0.3 mg/kg or ketamine 1–2 mg/kg are common choices.
  • Paralysis: Succinylcholine 1–1.5 mg/kg or rocuronium 1 mg/kg to facilitate intubation.

Ventilator Settings

  • Tidal Volume: Use a lung-protective strategy of 4–8 mL/kg of predicted body weight.
  • Plateau Pressure: Maintain < 30 cm H₂O to minimize barotrauma.
  • PEEP: Start at 5–10 cm H₂O to maintain alveolar recruitment without causing gastric insufflation.
  • FiO₂: Titrate to maintain SpO₂ between 92–96%.

Aspiration Prophylaxis

  • Maintain endotracheal tube cuff pressure at 20–30 cm H₂O.
  • Utilize closed suction systems and subglottic secretion drainage if available.
  • Elevate the head-of-bed to 30–45° and perform chlorhexidine oral care every 12 hours.
Pearl Icon A shield with an exclamation mark, indicating a clinical pearl. Clinical Pearl

Preemptive intubation in obtunded patients or those with a high risk of clinical deterioration is a cornerstone of safe management. It significantly reduces the risk of aspiration pneumonia and streamlines the process of performing GI decontamination safely and effectively.

2. Preventing ICU-Related Complications During Decontamination

Vigilant monitoring and prophylactic measures are essential to minimize pulmonary, electrolyte, hemodynamic, and renal complications that can arise during aggressive decontamination.

Aspiration Pneumonia Prevention

  • Maintain head-of-bed elevation at 30–45° at all times.
  • Perform oral hygiene with chlorhexidine swabs every 12 hours.
  • Use subglottic suctioning to remove pooled secretions above the endotracheal tube cuff.

Electrolyte Monitoring during Whole-Bowel Irrigation (WBI)

Large-volume irrigation can cause significant electrolyte shifts. Proactive monitoring and replacement are key.

Electrolyte Management During Whole-Bowel Irrigation
Electrolyte Monitoring Frequency Intervention Guide
Sodium (Na) Every 4–6 hours Correct hypernatremia with isotonic saline or free water as guided by serum levels.
Potassium (K) Every 4–6 hours Aggressively replace potassium chloride (KCl) to prevent life-threatening hypokalemia.
Magnesium (Mg) Every 4–6 hours Administer magnesium sulfate (MgSO₄) boluses for hypomagnesemia.

Hemodynamic and Renal Surveillance

  • Monitor blood pressure, heart rate, central venous pressure, and urine output hourly during large-volume GI lavage.
  • Use guided fluid boluses and dynamic indices (e.g., pulse pressure variation) to avoid hypotension.

Stress Ulcer and VAP Prophylaxis Bundles

  • Stress Ulcer Prophylaxis: Use a proton pump inhibitor (PPI) or H₂-receptor antagonist (H₂RA) in high-risk patients.
  • VAP Bundle: Adhere to the full bundle, including daily sedation vacations, DVT prophylaxis, peptic ulcer prophylaxis, and oral care.
Pearl Icon A shield with an exclamation mark, indicating a clinical pearl. Clinical Pearl

Integrate GI decontamination workflows directly into standard ICU prevention bundles. Treating decontamination as a high-risk procedure that requires the same level of vigilance as any other critical care intervention helps to systematically reduce downstream complications.

3. Management of Iatrogenic Antidote-Related Complications

While life-saving, antidotes are potent medications with their own risk profiles. Prompt recognition and stepwise treatment of adverse events are crucial to mitigate iatrogenic harm.

N-Acetylcysteine (NAC) Anaphylactoid Reactions Accordion IconAn arrow pointing down, which rotates on open.
  • Presentation: Non-IgE mediated histamine release causing rash, pruritus, hypotension, or bronchospasm, typically within the first hour of infusion.
  • Management:
    1. Immediately stop or halve the infusion rate.
    2. Administer diphenhydramine 25–50 mg IV and consider corticosteroids.
    3. For true anaphylaxis with severe hypotension, administer epinephrine IM 0.3–0.5 mg (1:1000).
    4. Once the patient is stable, the NAC infusion can often be safely restarted at a 50% slower rate.
Flumazenil-Induced Seizures Accordion IconAn arrow pointing down, which rotates on open.
  • Risk Factors: Chronic benzodiazepine use, co-ingestion of proconvulsant drugs (e.g., tricyclic antidepressants), or a prior history of seizures.
  • Dosing: Administer cautiously at 0.2 mg IV over 15 seconds. Repeat with 0.1 mg every minute to a maximum of 3 mg.
  • Management: If a seizure occurs, treat with a benzodiazepine (e.g., lorazepam 0.05–0.1 mg/kg IV), secure the airway, and consider continuous EEG monitoring.
Naloxone-Induced Withdrawal Accordion IconAn arrow pointing down, which rotates on open.
  • Prevention: Titrate small IV boluses of 0.04 mg increments to restore adequate respiration without precipitating severe withdrawal. The goal is adequate ventilation, not a normal level of consciousness.
  • Management: For long-acting opioids, an infusion may be necessary. Provide supportive care with clonidine or benzodiazepines for severe adrenergic symptoms (tachycardia, hypertension).
Hydroxocobalamin Side Effects Accordion IconAn arrow pointing down, which rotates on open.
  • Common Effects: Transient, often significant, hypertension; chromaturia (red discoloration of urine); and erythema (red discoloration of skin).
  • Lab Interference: Can interfere with colorimetric laboratory assays (e.g., creatinine, bilirubin, lactate). Verify any critical values with alternate laboratory methods or point-of-care testing if available.
Digoxin-Specific Fab Fragments Accordion IconAn arrow pointing down, which rotates on open.
  • Hypokalemia: As digoxin is unbound from the Na-K-ATPase pump, potassium shifts back into cells. Monitor serum potassium frequently (e.g., every 1-2 hours) after administration to avoid rapid, severe hypokalemia.
  • Hypersensitivity: Watch for infusion-related hypersensitivity reactions; treat with antihistamines and epinephrine if needed.
Pearl Icon A shield with an exclamation mark, indicating a clinical pearl. Clinical Pearl

Tailor antidote administration with vigilant vital sign, neurologic, and laboratory monitoring. Anticipating common complications allows the clinical team to catch and manage them early, preventing iatrogenic harm from life-saving treatments.

4. Multidisciplinary Goals-of-Care and Ethical Considerations

Structured, collaborative discussions are essential to align intensive, and often invasive, interventions with patient values and realistic clinical outcomes.

Prognostic Frameworks

  • Utilize objective severity scores (e.g., SOFA, APACHE) and toxin-specific predictors to frame discussions about prognosis.
  • Carefully weigh the potential benefits of highly invasive therapies (like extracorporeal removal) against the procedural risks and potential for non-beneficial outcomes.

Patient and Family Engagement

  • Review advance directives and confirm code status upon admission.
  • Proactively elicit patient values and what constitutes an acceptable quality-of-life threshold from the patient or their surrogate decision-maker.

Structured Communication Strategies

Using standardized communication tools ensures that critical information is conveyed clearly and consistently among all team members and with the family.

SBAR Communication Framework A diagram showing the four components of the SBAR communication tool: Situation, Background, Assessment, and Recommendation, arranged horizontally. S Situation B Background A Assessment R Recommendation
Figure 1: SBAR Framework. A structured communication tool for interdisciplinary handoffs to ensure clarity and patient safety.

Documentation and Handoff

  • Record all goals-of-care discussions prominently and clearly in the electronic medical record (EMR).
  • Use standardized checklists for handoffs to ensure continuity of the care plan across shifts and care transitions.
Pearl Icon A shield with an exclamation mark, indicating a clinical pearl. Clinical Pearl

Early, transparent, and recurrent goals-of-care conversations are a critical intervention. They prevent the continuation of non-beneficial, high-burden treatments, reduce moral distress for clinicians, and support ethical, patient-centered practice.

5. Complication Prevention Checklists and Protocols

Standardized bundles, checklists, and clinical triggers guide the safe application, escalation, and timely de-escalation of decontamination and antidote therapies.

Decontamination Safety Workflow A flowchart showing the process of care. It starts with two parallel safety checklists (Decontamination and Antidote). Arrows from both point to a central monitoring phase. From monitoring, arrows point to either Escalation Triggers or De-escalation Criteria. Decontamination Safety Bundle • Airway secure, ETT confirmed • Line integrity, labels verified • Monitors calibrated, alarms set Antidote Safety Checklist • Dose, dilution double-checked • Emergency meds at bedside • Roles assigned for response Continuous Monitoring Escalation Triggers De-escalation Criteria
Figure 2: Safety Workflow. Checklists ensure readiness, while predefined triggers for escalation (e.g., hemodynamic instability) and criteria for de-escalation (e.g., clinical stability) guide therapy transitions.

Escalation Triggers

  • Hemodynamic: Mean Arterial Pressure (MAP) < 65 mmHg despite adequate fluid resuscitation.
  • Respiratory: SpO₂ < 92% on an FiO₂ ≥ 0.6, or rising ventilatory pressures.
  • Neurologic: New-onset seizures or a drop in GCS of ≥ 2 points.

De-escalation Criteria

  • Sustained stability of vital signs for > 12 hours without escalating support.
  • Clear resolution of decontamination- or antidote-related adverse events.
  • Improving laboratory parameters and end-organ function.
Pearl Icon A shield with an exclamation mark, indicating a clinical pearl. Clinical Pearl

Employ checklists not as a replacement for clinical judgment, but as a cognitive aid to reduce human error during high-stress, low-frequency procedures. They standardize care, empower all team members to speak up, and streamline complex processes like decontamination and antidote administration.

References

  1. Pickard-Gabriel CJ, Copeland C, Gonzalez M, et al. Mechanical Ventilation during Critical Care Air Transport. Joint Trauma System; 2025.
  2. Fan E, Brodie D, Slutsky AS. Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253–1263.
  3. de Smet AMG, Klompas M, Nys S, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med. 2009;360(1):20–31.
  4. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Position Statement: Gastric Lavage. Clin Toxicol (Phila). 1997;35(7):711–719.
  5. Epperson LC, Shadnia S, Ryan P. A Case Report of a Severe, Unusually Delayed Anaphylactoid Reaction to N-Acetylcysteine. J Med Toxicol. 2021;17(1):62–67.
  6. Whyte AF, Simons FER, Lieberman P. Emergency Treatment of Anaphylaxis: Concise Clinical Guidelines. Thorax. 2022;77(3):276–283.
  7. Shannon MW, Haddad LM. Clinical Management of Poisoning and Drug Overdose. 3rd ed. W.B. Saunders; 1998.
  8. Keyes DC, Dart RC. Medical Toxicology. 3rd ed. Lippincott Williams & Wilkins; 2004.
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