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Caffeine Toxicity Treatment & Management

  • Author: David Yew, MD; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Mar 31, 2014
 

Prehospital Care

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.
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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.[17]
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Consultations

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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Contributor Information and Disclosures
Author

David Yew, MD Assistant Clinical Professor, Department of Surgery, University of Hawaii, John A Burns School of Medicine; Medical Director and Flight Physician, Hawaii Life Flight, AirMed International

David Yew, MD is a member of the following medical societies: American College of Emergency Physicians, Air Medical Physician Association

Disclosure: Nothing to disclose.

Coauthor(s)

China N Byrns Department of Cell and Molecular Biology, University of Hawaii at Manoa

China N Byrns is a member of the following medical societies: Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

John G Benitez, MD, MPH Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Undersea and Hyperbaric Medical Society, Wilderness Medical Society, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

James E Keany, MD, FACEP Associate Medical Director, Emergency Services, Mission Hospital Regional Medical Center, Children's Hospital of Orange County at Mission

James E Keany, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, California Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Jeffrey T Laczek, MD Gastroentology Fellow, Walter Reed Army Medical Center

Disclosure: Nothing to disclose.

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Caffeine content of various foods, beverages, medications, and supplements. Caffeine content is approximate for brewed beverages and chocolate).
Chemical structure of caffeine.
Table 1. Reported Caffeine Content of Common Items[3]
ItemAmountCaffeine Content, mg
M & M Milk Chocolate Candies47.9 g (1 bag)7
Coca-Cola Classic12 oz35
Fiorinal/Fioricet1 tablet40
Brewed black tea, generic8 oz45-74
Red Bull Regular8.4 oz80
Brewed coffee, generic8 oz57
Midol1 Gel Cap60
No Doz1 tablet100
Regular 5-Hour Energy2 oz138
Rockstar16 oz160
Monster Energy16 oz160
Espresso, generic1 oz170
Vivarin1 tablet200
NOS16280
Starbucks Tall Americano16330
Table 2. Caffeine-Related Poisonings Reported to the NPDS From 2009-2011
CategorySingle ExposuresDeaths
200920102011200920102011
Energy Drinks      
Caffeine containing-139548-01
Caffeine only-1691062-00
Ethanol and caffeine containing-76131-00
Ethanol and caffeine only-23-00
       
Pheylnolamine and caffeine combinations (diet aid)102211000
       
Caffeine343333282655000
Table 3. Energy Drink Exposure
ItemNo. Exposures (single)Exposures (5)Exposures (6-12)Exposures (12-19)Exposures (20)
Energy Drinks     
Caffeine containing54822760141111
Caffeine only106258291128226
Ethanol and caffeine containing1311557828
Ethanol and caffeine pnly31002
      
Pheylnolamine and caffeine combinations (diet aid)115114
      
Caffeine2655105583428938
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