The Role of Sodium Bicarbonate in the Management of Some Toxic Ingestions

Abstract

Adverse reactions to commonly prescribed medications and to substances of abuse may result in severe toxicity associated with increased morbidity and mortality. According to the Center for Disease Control, in 2013, at least 2113 human fatalities attributed to poisonings occurred in the United States of America. In this article, we review the data regarding the impact of systemic sodium bicarbonate administration in the management of certain poisonings including sodium channel blocker toxicities, salicylate overdose, and ingestion of some toxic alcohols and in various pharmacological toxicities. Based on the available literature and empiric experience, the administration of sodium bicarbonate appears to be beneficial in the management of a patient with the above-mentioned toxidromes. However, most of the available evidence originates from case reports, case series, and expert consensus recommendations. The potential mechanisms of sodium bicarbonate include high sodium load and the development of metabolic alkalosis with resultant decreased tissue penetration of the toxic substance with subsequent increased urinary excretion. While receiving sodium bicarbonate, patients must be monitored for the development of associated side effects including electrolyte abnormalities, the progression of metabolic alkalosis, volume overload, worsening respiratory status, and/or worsening metabolic acidosis. Patients with oliguric/anuric renal failure and advanced decompensated heart failure should not receive sodium bicarbonate.

Figure 1

An overview of the endogenous bicarbonate metabolism.

Figure 2

(a) Sodium channel toxicity on 12-lead ECG (taken from https://lifeinthefastlane.com). On this 12-lead ECG you can see regular wide QRS tachycardia with no clear P waves, right axis deviation, tall R wave in AVR, and poor R wave progression in precordial leads. (b) Sodium channel toxicity on 12-lead ECG after administration of sodium bicarbonate (taken from https://lifeinthefastlane.com). On this 12-lead ECG after administration of sodium bicarbonate you can see atrioventricular dissociation with normal QRS, normal axis, and resolution of tall R wave in AVR.

Figure 3

An overview of in vivo methanol and ethylene glycol metabolism.