Top Things to Know: 2022 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning

Published: September 18, 2023

  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 (VA-ECMO), 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 is 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 beta blocker and calcium channel blocker poisoning.
  4. Sodium bicarbonate is appropriate in addition to standard advanced life support for the treatment of life-threatening dysrhythmias caused by cocaine or other sodium channel blockers.
  5. Cyanide poisoning should be treated immediately with treated immediately with hydroxocobalamin (preferred) or sodium nitrite plus sodium thiosulfate do not wait for confirmatory testing.
  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, prevent rhabdomyolysis and injury, and 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. VA-ECMO can be lifesaving for patients with cardiogenic shock or dysrhythmias that are refractory to other treatment measures. Because VA-ECMO implementation takes time, the process should be started early in patients who are not responding well to other therapies.


Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR; on behalf of the American Heart Association. 2023 American Heart Association focused update on the management of patients with cardiacarrest or life-threatening toxicity due to poisoning: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation andEmergency Cardiovascular Care [published online ahead of print September 18, 2023]. Circulation. doi: 10.1161/CIR.0000000000001161