Links To And Excerpts From “2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning”

Today, I reviewed, link to and excerpt from 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2023 Oct 17;148(16):e149-e184. doi: 10.1161/CIR.0000000000001161. Epub 2023 Sep 18. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF].

All that follows is from the above resource.


In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.


  1. Treatment of cardiac arrest and life-threatening toxicity due to poisoning often requires specialized treatments that most clinicians do not use frequently such as antidotes and venoarterial extracorporeal membrane oxygenation, in addition to effective basic and advanced life support. Timely consultation with a medical toxicologist, clinical toxicologist, or regional poison center facilitates rapid and effective therapy.

  2. Opioid overdose remains the leading cause of cardiac arrest due to poisoning in North America. Naloxone administration may reverse respiratory arrest, preventing progression to cardiac arrest.

  3. High-dose insulin therapy is recommended early in the treatment of patients with life- threatening β-blocker and calcium channel blocker poisoning.

  4. Standard advanced life support with the addition of administration of sodium bicarbonate is appropriate for the treatment of life-threatening dysrhythmias caused by cocaine or other sodium channel blockers.

  5. If cyanide poisoning is suspected, do not wait for confirmatory testing. Treat immediately with hydroxocobalamin (preferred) or sodium nitrite plus sodium thiosulfate.

  6. Administration of digoxin-specific immune antibody fragments can reverse life-threatening dysrhythmias from digoxin poisoning.

  7. Use of 20% intravenous lipid emulsion can be efficacious in the resuscitation of life-threatening local anesthetic toxicity, especially from bupivacaine.

  8. Patients with severe agitation from sympathomimetic poisoning require sedation to manage hyperthermia and acidosis, to prevent rhabdomyolysis and injury, and to allow evaluation for other life-threatening conditions.

  9. Flumazenil reverses central nervous system and respiratory depression from benzodiazepine poisoning, but important risks and contraindications limit its use.

  10. Venoarterial extracorporeal membrane oxygenation can be lifesaving for patients with cardiogenic shock or dysrhythmias that are refractory to other treatment measures. Because venoarterial extracorporeal membrane oxygenation implementation takes time, the process should be started early in patients who are not responding well to other therapies.

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