Updates

What's New in Toxicology and Toxinology

December 2024

In line with Therapeutic Guidelines’ living guidelines approach, the Toxicology and Toxinology guidelines have been updated with new advice in specific areas. Updates have been made in response to important new evidence and significant changes in practice since the guidelines were published in 2020. In addition, several new topics have been included in the Toxicology and Toxinology guidelines.

An increase in nonmedical use of nitrous oxide has led to more frequent presentations of significant chronic nitrous oxide poisoning to health care services. New guidance, with a particular focus on the management of chronic nitrous oxide toxicity, has now been included.

Previously covered in the Addiction guidelines, ethanol intoxication has been moved into the Toxicology and Toxinology guideline and has been expanded to provide greater detail. This includes the treatment of hypoglycaemia, in the context of ethanol intoxication, as well as risk assessment, clinical presentation and patient disposition advice.

Isopropyl alcohol is one of the main components commonly found in hand sanitisers. The COVID-19 pandemic has resulted in more hand sanitiser use, and therefore increased accessibility in higher volumes, in the community. This update provides more specific advice for the treatment of isopropyl alcohol poisoning, particularly in children.

Tramadol poisoning and tapentadol poisoning are commonly implicated in poisonings. Previously, guidance on these was provided only in the context of serotonin and noradrenaline reuptake inhibitor (SNRI) or opioid poisoning. Detailed advice on the management of both these poisonings has been provided in dedicated monographs.

Although previously covered as a subsection of the lead poisoning topic, the management of lead object ingestion has been expanded on and clarified.

The similarities and differences in management of poisonings between the selective alpha-2a adrenoreceptors clonidine and guanfacine have been highlighted. Specific advice has been provided for guanfacine, a modified-release preparation, relating to the use of activated charcoal and the duration of observation after poisoning.

Advice for naloxone to treat opioid poisoning and buprenorphine poisoning has been refined. Detail has been added to clarify the total initial bolus dose of naloxone, as well as the indication for starting a naloxone infusion.

Other important changes in the Toxicology and Toxinology guidelines include:
  • a new recommendation for corticosteroid treatment for methanol poisoning to prevent optic neuropathy, which can lead to severe visual impairment or even blindness
  • revised advice on when to start sodium bicarbonate treatment for urinary alkalinisation in patients with aspirin poisoning and chlorophenoxy herbicide poisoning
  • updates to haemodialysis recommendations for baclofen poisoning, beta-blocker poisoning and isoniazid poisoning, prompted by the Extracorporeal Treatments in Poisoning Workgroup (EXTRIP) advice
  • a new nomogram to determine the need for haemodialysis for chronic lithium accumulation
  • revised advice on when to repeat measurement of serum paracetamol concentration as part of assessment of paracetamol poisoning associated with liquid formulations in children younger than 6 years
  • clarification of information on D-dimer testing (including timing and specific test cut-offs) for snake bite, based on newly published evidence
  • clarification of the indication for high-flow oxygen therapy and admission to hospital for carbon monoxide poisoning.