Emergency Medicine

AHA Tox Resus Guideline Update

Amber Sheeley, PA-C
By Amber Sheeley, PA-C on
July 28, 2025

Few things complicate an already challenging resuscitation effort more than a concomitant poisoning or toxic exposure—and unfortunately, this scenario is becoming more common. 

According to the National Center for Health Statistics at the CDC, over 100,000 people died from poisoning or drug overdose in 2021—a 20% increase from the year prior. In response, the American Heart Association released updated guidelines on managing cardiac arrest and life-threatening toxicity due to poisoning. This guideline update helps to clarify best practices for these situations. 

If you are familiar with AHA guidelines, you know they use a “Class of Recommendation” (COR) system based on evidence strength: 

  • COR 1: Strong evidence; benefit outweighs risk—these treatments should be performed.
  • COR 2a: Moderate evidence; treatments are reasonable to perform.
  • COR 2b: Weaker evidence; treatments may be considered, but the benefit is less certain.
  • COR 3: No benefit demonstrated.
  • COR 4: Harmful; risk outweighs benefit.

 

Toxin-Specific Updates 

Benzodiazepines:

     Naloxone:

  •  ▪️Give first if opioid co-ingestion is suspected.  

     Flumazenil:

  • ▪️Consider only in pure benzodiazepine OD without seizure risk.  

▪️Contraindicated in anyone with a seizure history or chronic benzo/ETOH use. 

  • ▪️No role in cardiac arrest from benzodiazepine poisoning

  • ▪️Flumazenil administration is associated with harm in patients who are at increased risk for seizures or         dysrhythmias. 

 

Beta Blockers:

  • ▪️High-dose insulin and Vasopressors are first-line therapy. 

  • ▪️Give Glucagon for bradycardia/hypotension: 

    •      ▪️Use a bolus of glucagon, followed by a continuous infusion, for bradycardia or hypotension.

  • ▪️VA-ECMO should be used for life-threatening BB poisoning with cardiogenic shock refractory to pharmacological interventions.  

    • ▪️Atropine may be reasonable for BB-induced bradycardia. 

▪️Electrical pacing may be reasonable for BB-induced bradycardia.  Hemodialysis would be used specifically for life-threatening atenolol or sotalol poisoning. 

▪️Hemodialysis would be used specifically for life-threatening atenolol or sotalol poisoning.

  • ▪️Lipid-emulsion therapy is not likely to be beneficial for BB poisoning.

 

Calcium Channel Blockers (CCB)

▪️High-dose insulin + vasopressors: The mainstays for managing hypotension from CCB poisoning. 

▪️Calcium and atropine are reasonable adjuncts for managing hypotension and bradycardia, respectively, from CCB poisoning.

▪️VA-ECMO should be considered for patients experiencing cardiogenic shock due to CCB poisoning that is refractory to pharmacologic interventions.

  • ▪️Electrical pacing may be used for CCB-induced, refractory bradycardia. 

  • ▪️Glucagon bolus and infusion are of uncertain utility for CCB poisoning. 

  • ▪️Methylene blue for refractory vasodilatory shock is of uncertain utility for CCB poisoning.

  • ▪️Lipid therapy is not recommended. 

 

Cocaine

  • ▪️Cool rapidly for hyperthermia. 

  • ▪️Bicarb or lidocaine is administered for wide complex tachycardia or arrest from cocaine poisoning. 

  • ▪️Vasodilators (nitrates, phentolamine, CCBs) for cocaine induced coronary vasospasm or hypertensive emergency. 

* Obtain a thorough medication history to ensure the patient is not already taking a CCB or nitrate. *

 

Cyanide

  • ▪️Hydroxocobalamin is first-line. 

  • ▪️Use sodium nitrite only if hydroxocobalamin is unavailable. 

  • ▪️Add sodium thiosulfate if possible. 

  • ▪️100% O2 is helpful, but don't delay antidotes.

* Remember to consider cyanide poisoning in patients presenting from a house fire, given the numerous household products and plastics that can contain cyanide. *

 

Digoxin/Cardiac Glycosides

  • ▪️Digoxin-specific antibody fragments (immune fab) are the first-line for digoxin, digitoxin, or other cardiac glycoside poisoning. 

  •      ▪️This can be given for Bufo toad or yellow oleander exposure. 

  • ▪️It may be reasonable to administer lidocaine, phenytoin, or bretylium to treat ventricular dysrhythmias caused by digitalis and other cardiac glycoside poisoning until digoxin immune fab can be administered. 

  • ▪️Atropine or pacing may help bradydysrhythmias. 

  • ▪️Electrical pacing may be reasonable for managing bradydysrhythmias. 

  • ▪️No dialysis/hemoperfusion/plasmapheresis—it's ineffective. C

 

Local Anesthetic  

  • ▪️Lipid emulsion is first-line. 

  • ▪️Give Benzos for seizures.  

  • ▪️Bicarb is reasonable to give for wide complex tachycardia.  

  • ▪️Give Atropine for life-threatening bradycardia.  

  • ▪️VA-ECMO may be useful for refractory cardiogenic shock from local anesthetic poisoning.  

 

Methemoglobinemia

  • ▪️Methylene blue is the standard of care. 

  • ▪️Exchange transfusion may be reasonable for cases that do not respond to methylene blue. 

  • ▪️Hyperbaric O2 may be effective for reducing methemoglobin concentrations, but this takes hours, making it impractical for use in life-threatening situations. 

  • ▪️Avoid NAC as it is not effective. 

  • ▪️Ascorbic acid can be used, but its onset is slow and requires multiple doses to achieve the desired effect, rendering it impractical for life-threatening situations. 

Opioids

  • ▪️ABC’s! If no pulse/breathing, start CPR and call EMS! Don’t delay BLS/ALS for an antidote. 

▪️Naloxone

  • ▪️This can be given for Bufo toad or yellow oleander exposure.

  • ▪️Give to patients with a pulse but abnormal breathing.  

  • ▪️A naloxone infusion may be needed for recurrent toxicity.  CR 2aCOR 2a

  • ▪️Observe patients after naloxone until the recurrence risk is low & GCS and vitals have normalized. 

 

Organophosphates/Carbamates

  • ▪️Atropine immediately for bradycardia, bronchorrhea, bronchospasm, and/or seizures. These indicate severe poisoning. Much larger doses than usual are required. (1-2mg IVP, doubled every 5 min, titrate to effect). 

  • ▪️Early intubation for life-threatening organophosphate or carbamate poisoning.

  • ▪️Benzos for seizures. 

  • ▪️PPE + decon are crucial for providers. 

  • ▪️Pralidoxime: is reasonable to give.

  • ▪️Avoid succinylcholine and mivacurium as these confer a prolonged paralysis risk. 

 

Sodium Channel Blockers (e.g., TCAs)

  • ▪️Sodium bicarbonate is the cornerstone for managing cardiotoxicity (wide QRS or arrest) 

  • ▪️VA-ECMO may be used for refractory shock. 

  • ▪️Consider class Ib antidysrhythmics (e.g., lidocaine)to treat cardiotoxicity. 

  • ▪️Lipid emulsion is reasonable to consider only if other therapies fail. 

 

Bottom Line for the ED 

  • ▪️Antidote use is nuanced—match the right one to the right toxidrome.

  • ▪️VA-ECMO is increasingly recommended for refractory cardiogenic shock across poisonings.

  • ▪️High-dose insulin is now firmly first-line for both BB and CCB poisonings.

  • ▪️Lipid therapy is NOT a catch-all, and should be reserved for select cases.

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