Pharmaceutical poisoning represents a significant and growing challenge in intensive care medicine, accounting for up to 10% of ICU admissions and demanding rapid, structured, and highly specialized management. Although the majority of patients recover with supportive measures, a sizeable proportion require advanced organ support, toxicant-specific interventions, and close multidisciplinary coordination. Psychotropic medications and analgesics remain the most frequently implicated agents, and mixed ingestions occur in nearly half of all cases, adding complexity to diagnosis and treatment. Mortality remains relatively low—generally below 5%—but rises substantially in cases marked by cardiotoxicity, delayed presentation, or ingestion of sustained-release formulations.
A structured approach to early stabilization, typically following the ABCDE framework, is essential. Rapid assessment and protection of the airway, early correction of hypoxemia and hypercapnia, and management of circulatory compromise form the foundation of care. Many life-threatening complications follow recognizable clinical patterns: sodium-channel–blocking agents produce wide-QRS tachyarrhythmias; opioids cause hypoventilation; calcium channel blockers and beta-blockers lead to profound cardiogenic shock; and sedative-hypnotics induce coma with preserved vital signs. Identifying toxidromes remains more clinically actionable than broad toxicology screening, which suffers from false positives, false negatives, and delayed results. Alongside clinical examination, ECG monitoring and point-of-care laboratory testing guide early risk stratification and reveal complications such as metabolic acidosis, rhabdomyolysis, hepatic injury, or methemoglobinemia.
Targeted interventions play a central role in preventing further absorption and enhancing elimination. Although evidence for gastrointestinal decontamination is limited, activated charcoal remains appropriate for selected recent ingestions, and whole-bowel irrigation may be considered for sustained-release formulations or non–charcoal-adsorbable substances. Extracorporeal treatments, particularly intermittent hemodialysis, can rapidly clear dialyzable agents such as lithium, salicylates, or toxic alcohols and simultaneously correct fluid, electrolyte, and acid–base disturbances. Clinical decisions regarding extracorporeal removal increasingly rely on structured recommendations from the EXTRIP workgroup.
Antidote therapy is essential for a relatively small number of pharmaceuticals but often lifesaving. Sodium bicarbonate is the cornerstone of treatment in sodium-channel–blocker toxicity; naloxone remains indispensable for opioid-induced respiratory depression; digoxin immune Fab is indicated for severe digitalis intoxication; and N-acetylcysteine continues to be highly effective in acetaminophen poisoning when administered promptly. High-dose insulin euglycemia therapy has emerged as a key intervention in severe calcium channel blocker and beta-blocker overdose, improving myocardial contractility and reducing reliance on high-dose catecholamines. Rescue strategies, including intravenous lipid emulsion for local anesthetic systemic toxicity and venoarterial ECMO for refractory cardiogenic shock, offer additional life-support options when conventional therapies fail.
Despite the availability of evidence-based pathways, major gaps remain. Poisoning cases often present with overlapping toxidromes, inaccurate histories, and delays in recognition. The lack of universal guidelines and variability in available diagnostics complicate clinical decision-making. Continued research is needed to refine antidote indications, optimize extracorporeal treatment thresholds, and evaluate emerging therapies. Strengthening links between ICUs and poison information centers can improve outcomes through real-time expert consultation, reduction of unnecessary interventions, and individualized management.
Ultimately, the care of patients with pharmaceutical poisoning requires rapid stabilization, a systematic diagnostic strategy, early use of targeted therapies when indicated, and timely escalation to advanced life support. As the spectrum of pharmaceuticals expands and new formulations enter clinical practice, critical care teams must remain vigilant and prepared to navigate complex and evolving toxicological emergencies.
Reference
Hüser C, Bethlehem C, Dünser MW, et al. Critical care management of the patient with pharmaceutical poisoning. Intensive Care Med. 2025.
