Caffeine Toxicity Treatment & Management
- Author: David Yew, MD; Chief Editor: Asim Tarabar, MD more...
Prehospital care is primarily supportive.
- Address ABCs: Administer oxygen, obtain intravenous access, attach cardiac monitors (if available), and frequently assess vital signs and consciousness (eg, by using the alert, responds to voice, responds to pain, and unresponsive [AVPU] or Glasgow Coma scale).
- Check blood glucose level.
- Patients with anxiety, severe agitation, or seizures may require a short-acting benzodiazepine (eg, lorazepam) given intravenously or intramuscularly.
Emergency Department Care
Although most patients with caffeine toxicity improve with supportive care, life-threatening complications can result from severe overdoses. Fatalities are generally related to cardiac dysrhythmias. Other factors contributing to mortality include seizures, myocardial infarction, hypotension, electrolyte disturbances, rhabdomyolysis, and aspiration (secondary to an inability to protect the airway).
Emergency department management consists of restoring cardiovascular stability and addressing the other factors that may contribute to mortality.
- Address ABCs.
- Endotracheal intubation is indicated in patients who are unable to maintain an airway because of altered mental status, severe cardiovascular depression, or seizures.
- Administer oxygen and obtain intravenous access (if not already obtained) and attach cardiac monitors.
- ECG and initial laboratory studies should be performed at this time.
- Caffeine acts as a bronchodilator and generally does not result in respiratory compromise if the patient can protect his or her airway.
- Hypotension can occur in caffeine toxicity.
- It is related to volume depletion, excessive catecholamine stimulation of beta2-adrenergic receptors, or both.
- Vasopressors (eg, dopamine, phenylephrine) may be required if hypotension is refractory to intravenous fluid boluses. Phenylephrine is a good choice because it is a pure alpha-agonist, although norepinephrine can be used as well.
- The treatment of dysrhythmias depends of the nature of the dysrhythmia and the patient's clinical presentation. Dehydration, hypoxemia, metabolic acidosis, and electrolyte disturbances may contribute to morbidity and should be corrected as the patient's dysrhythmia is addressed.
- Patients with SVT and adequate blood pressure and no ECG evidence of ischemia can be treated with supportive care.
- Patients with persistent SVT, hypotension, or evidence of cardiac ischemia require intervention to control their heart rate or to restore a sinus rhythm. Initial treatment of caffeine-induced SVT should include administration of benzodiazepines in order to reduce CNS stimulation and release of catecholamines. A short-acting cardioselective beta-blocker (eg, esmolol) or a calcium channel blocker (eg, diltiazem) may be used to control the heart rate. Caution should be exercised since these agents may contribute to hypotension.
- Adenosine, often used in the treatment of paroxysmal SVT, is unlikely to be effective in patients with caffeine overdose because caffeine antagonizes adenosine receptors.
- Electrical cardioversion may be used in hemodynamically unstable patients or in patients whose condition is refractory to pharmacologic intervention.
- Because caffeine overdose is a situation of catecholamine excess, the use of beta-blockers raises the theoretical concern that unopposed alpha stimulation could precipitate a hypertensive crisis (similar to beta-blockade in patients with pheochromocytoma). In practice, a hypertensive crisis as a consequence of unopposed alpha stimulation has never been reported in cases of caffeine toxicity, and alpha-agonists (eg, phenylephrine) may be needed to support blood pressure in hypotensive patients. In theory, beta-blockade can be beneficial in patients with refractory hypotension and could be used in consultation with the regional poison control center or board-certified toxicologist.
- In the hemodynamically stable patient, amiodarone or lidocaine may be used to treat ventricular tachycardia (VT). If the patient is hemodynamically unstable, electrical cardioversion is indicated.
- Seizures should be treated with benzodiazepines (eg, lorazepam). Barbiturates are second-line agents. Animal studies demonstrated that phenytoin is not useful in controlling seizures induced by methylxanthines and that they may actually increase mortality.
- Caffeine produces a number of metabolic disturbances. Hypokalemia should be sought and aggressively treated with intravenous potassium replacement. Rhabdomyolysis should be treated with intravenous fluids to prevent renal failure. Other metabolic complications, such as hyperglycemia and metabolic acidosis, generally resolve with supportive care.
- Prolonged vomiting should be treated with antiemetic agents.
- Because caffeine is absorbed rapidly, gastric lavage is unlikely to be useful in patients who present longer than 1 hour after the ingestion.
- Activated charcoal is effective in limiting gut absorption of methylxanthines and is recommended early in treatment.
- In rare cases, hemoperfusion or hemodialysis is used in severe caffeine overdose.
- A recent case report describes the use of lidocaine, phenylephrine, and hemodialysis to stabilize cardiovascular collapse in a patient with massive caffeine ingestion.
See the list below:
- A regional poison control center or medical toxicologist can provide valuable information and instructions in severe overdoses.
- After a suicide attempt or an intentional overdose, consultation with a psychiatrist is advised after the patient is medically stable.
- Admit medically unstable patients for the appropriate level of care depending on patient's clinical presentation.
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|Item||Amount||Caffeine Content, mg|
|M & M Milk Chocolate Candies||47.9 g (1 bag)||7|
|Coca-Cola Classic||12 oz||35|
|Brewed black tea, generic||8 oz||45-74|
|Red Bull Regular||8.4 oz||80|
|Brewed coffee, generic||8 oz||57|
|Midol||1 Gel Cap||60|
|No Doz||1 tablet||100|
|Regular 5-Hour Energy||2 oz||138|
|Monster Energy||16 oz||160|
|Espresso, generic||1 oz||170|
|Starbucks Tall Americano||16||330|
|Ethanol and caffeine containing||-||76||131||-||0||0|
|Ethanol and caffeine only||-||2||3||-||0||0|
|Pheylnolamine and caffeine combinations (diet aid)||10||22||11||0||0||0|
|Item||No. Exposures (single)||Exposures (5)||Exposures (6-12)||Exposures (12-19)||Exposures (20)|
|Ethanol and caffeine containing||131||15||5||78||28|
|Ethanol and caffeine pnly||3||1||0||0||2|
|Pheylnolamine and caffeine combinations (diet aid)||11||5||1||1||4|