| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links). |
| Clinical features |
| Intentional ingestions of tablets or concentrated powders are most dangerous |
Clinical findings: - Vomiting
- Hypokalemia
- Hyperglycemia
- Sinus tachycardia and other tachydysrhythmias (SVT, VT)
- Hypotension
- Seizures
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| Acutely poisoned patients are at high risk for seizures and dysrhythmias if caffeine serum concentrations ≥80 mg/L |
| Diagnostic evaluation |
| All symptomatic patients |
- Serum caffeine concentration (if hospital has an in-house assay with rapid turnaround time, obtain immediately and repeat every 2 hours until peak concentration occurs, otherwise can send as confirmatory forensic test)
- Serum electrolytes, glucose (serum potassium <2.9 mEq/L suggestive of severe toxicity)
- Complete blood count
- Electrocardiogram
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| Treatment |
| Supportive care |
Vomiting: - IV ondansetron 0.15 mg/kg, maximum dose 16 mg; obtain electrocardiogram prior to administration to screen for prolonged QTc
- For vomiting refractory to ondansetron, high-dose IV metoclopramide up to 0.5 to 1 mg/kg, maximum single dose 50 mg over 15 minutes (IV diphenhydramine 25 to 50 mg [pediatric dose 1 mg/kg], maximum single dose 50 mg, may be given to prevent or treat a dystonic reaction)
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Seizures (for dosing, timing, and alternative medications for refractory seizures, refer to UpToDate content on convulsive status epilepticus): - First line: Benzodiazepines (eg, lorazepam, repeat once)
- Refractory seizures: Phenobarbital or propofol; avoid fosphenytoin or phenytoin
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Dysrhythmias: - Treat according to ACLS or PALS guidelines, with addition of esmolol for ventricular dysrhythmias
- Supraventricular tachycardia: Benzodiazepines or beta-1-selective antagonist (eg, esmolol 500 mcg/kg loading dose [optional] over 1 minute; follow with a 50 mcg/kg/minute infusion titrated)
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Hypotension: - First line: IV isotonic saline or lactated Ringer (20 mL/kg, maximum 1 L), up to 60 mL/kg (3 L) and, for SVT or VT, treatment of dysrhythmias
- Second line: Options include one of the following:
- Phenylephrine continuous IV infusion (patient approximately 80 kg) – Initial dose 40 to 160 mcg/minute (adults: 0.5 to 2 mcg/kg/minute; children: 0.1 to 0.5 mcg/kg/minute), titrate to effect
- Norepinephrine continuous IV infusion (patient approximately 80 kg) – Initial dose 5 to 15 mcg/minute (0.05 to 0.15 mcg/kg/minute), titrate to effect
- If hypotension is refractory to phenylephrine or norepinephrine, use a beta-adrenergic antagonist (eg, esmolol 500 mcg/kg loading dose [optional] over 1 minute; follow with a 50 mcg/kg/minute infusion titrated); medical toxicologist consultation advised
- Avoid epinephrine, dobutamine, and isoproterenol
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Tremulousness, anxiety, restlessness: - Benzodiazepines (eg, lorazepam, diazepam) orally or IV
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Hypokalemia: - Replete only if symptomatic (eg, muscle weakness), electrocardiogram changes (abnormal T waves or prolonged QTc), or ventricular dysrhythmia – potassium supplementation 10 mEq/hour IV
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| Gastrointestinal decontamination |
- Administer activated charcoal 1 g/kg up to 50 grams if patient presents within 2 hours of ingestion
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| Elimination enhancement and extracorporeal removal |
- For symptomatic patients with an acute caffeine overdose, perform elimination enhancement with MDAC 0.5 to 1 g/kg every 2 to 4 hours without cathartic (eg, sorbitol)
- Perform high-efficiency hemodialysis (preferred) in patients with high risk for life-threatening toxicity based upon clinical symptoms (eg, seizures, refractory shock, or life-threatening dysrhythmias), caffeine concentration >100 mg/L (555 mmol/L) or rising (if available), or clinical deterioration despite optimal management; for specific indications, refer to UpToDate content on caffeine poisoning
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