ACLS 2020 toxicology

The 2020 ACLS guidelines provide recommendations on the medication-specific management recommendations for toxicology [1]. Although the name of the guidelines emphasize they are ‘Advanced,’ these are still relatively basic toxicology recommendations and largely apply to patients in cardiac arrest or refractory shock. There are also our 2020 ACLS guideline summaries on vasopressor and non-vasopressor medications used during cardiac arrest and arrhythmia management.


  • Flumazenil if NOT recommended in undifferentiated coma (COR3, LOE B-R)


  • Benzodiazepines, alpha blockers, calcium channel blockers, nitroglycerin, and/or morphine can be beneficial for hypertension, tachycardia, agitation, or chest discomfort (COR 2a, LOE B-NR)
  • Pure beta-adrenergic blockers may be reasonable to avoid, although “contradictory evidence exists (COR 2b, LOE C-LD)

Local Anesthetics

  • IV lipid emulsion may be reasonable (COR 2b, LOE C-LD)

Sodium Channel Blockers (e.g. tricyclic antidepressants)

  • Sodium bicarbonate can be beneficial for cardiac arrest or life-threatening conduction delays, such as QRS >120 msec (COR 2a, LOE C-LD)
  • Extracorporeal membrane oxygenation (ECMO) may be considered for cardiac arrest or refractory shock (COR 2b, LOE C-LD)


  • Antidigoxin Fab should be administered in severe toxicity (COR 2b, LOE B-R)

Carbon Monoxide

  • Hyperbaric oxygen may be helpful in severe toxicity (COR 2b, LOE B-R)


  • Hydroxocobalamin can be beneficial, along with oxygen +/- sodium thiosulfate (COR 2a, LOE C-LD)

Atrioventricular Nodal Blockers

InterventionBeta-adrenergic blockerCalcium channel blockerEvidence (COR/LOE)
High-dose insulinReasonableReasonable2a/C-LD
Glucagon IVReasonableMay be considered2a/C-LD and 2b/C-LD
CalciumMay be consideredReasonable2b/C-LD and 2a/C-LD
ECMOMight be consideredMight be considered2b/C-LD

Table: Medications and interventions in the management of beta-adrenergic and calcium channel blocker toxicity (COR: class of recommendation, LOE: level of evidence, ECMO: extracorporeal membrane oxygenation)


Panchal AR, Bartos JA, Cabañas JG, et al; Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. Epub 2020 Oct 21. PMID: 33081529.
Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

Leadership Team, ALiEM
Creator and Lead Editor, Capsules and EM Pharm Pearls Series
Attending Pharmacist, EM and Toxicology, MGH
Associate Professor of EM, Division of Medical Toxicology, Harvard Medical School
Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP


EM Pharmacist & Toxicologist @MassGeneralEM | Asst Prof @HarvardMed/@EMRES_MGHBWH | @ALiEMteam leadership | Capsules creator, ALiEMU | President, ABAT | #FOAMed