What are the recommended ED treatments for ivermectin-induced seizures and respiratory depression?
Executive summary
Emergency treatment of ivermectin toxicity is primarily supportive: secure the airway and breathing (oxygen, intubation and mechanical ventilation as needed), manage seizures with standard anticonvulsant protocols (initial benzodiazepines), treat hypotension with IV fluids and vasopressors, and consider gastrointestinal decontamination (activated charcoal) if ingestion was recent and the airway is protected; poison-control consultation and ICU-level monitoring are essential [1] [2] [3].
1. Airway and respiratory support must be immediate and definitive when depressed
Patients with central nervous system depression from ivermectin commonly present with somnolence up to coma and respiratory failure, and emergency departments should prioritize oxygenation and ventilatory support; endotracheal intubation and mechanical ventilation are indicated for those with impaired airway protective reflexes or inadequate respiratory drive, with ICU-level monitoring for progression to respiratory failure [2] [4] [5].
2. Seizure control follows standard ED algorithms, beginning with benzodiazepines
Seizures associated with ivermectin toxicity should be treated promptly using first-line benzodiazepines (e.g., IV lorazepam), followed by second-line antiepileptics if needed; toxicology guidance explicitly states seizures “should be initially treated” with standard measures, and aggressive control is required to limit hypoxia and hemodynamic instability [1] [4]. An important caveat from public-health advisories: ivermectin can potentiate the depressant effects of other CNS depressants, including benzodiazepines, so clinicians must balance seizure control with respiratory monitoring and be prepared to secure the airway [6] [3].
3. Circulatory support — fluids first, pressors if required
Hypotension is a documented feature of severe ivermectin overdose; emergency management is supportive with isotonic IV fluids and escalation to vasopressors when fluids are insufficient, mirroring standard shock protocols used in poisonings and emphasized in toxicology guidance [1] [2].
4. Gastrointestinal decontamination and toxin-directed measures have narrow windows
If the patient presents within roughly one hour of ingestion and has a protected airway, activated charcoal can be considered to reduce further absorption of oral ivermectin; beyond that early window, care is mainly supportive because no specific, widely accepted antidote for ivermectin exists [1] [2]. Consultation with regional poison-control centers is repeatedly recommended for dosing, decontamination decisions, and disposition [3].
5. Antidotes and adjunctive therapies — experimental and limited evidence only
There is no established human antidote for ivermectin; reports note use of intravenous lipid emulsion (ILE) as an experimental therapy in veterinary cases and limited toxicology literature (not established in humans), and any such use should be guided by toxicology experts and poison-control consultation [2]. Case reports and series document that management is largely supportive and outcomes hinge on early supportive interventions rather than a specific reversal agent [2] [4].
6. Escalation of care, monitoring, and special considerations
Severely poisoned patients often require hospitalization and sometimes intensive care for prolonged neurologic, respiratory, or hemodynamic support; older adults and those who ingested veterinary formulations or very large doses are at higher risk for ICU-level illness and deserve low thresholds for admission [5] [4]. Genetic or disease-related blood–brain barrier impairment has been implicated in rare pronounced neurotoxicity and may explain unexpected severe presentations, underscoring the need to report and investigate atypical cases [7] [8].
7. Practical bottom line for ED clinicians
Treat ivermectin-induced seizures and respiratory depression as you would other toxin-induced CNS depressions: secure airway and breathing (intubate early if needed), give benzodiazepines for seizures while anticipating respiratory compromise, stabilize circulation with fluids/pressors, consider activated charcoal if within the short post‑ingestion window and airway is secure, consult poison control and toxicology early, and admit for ICU-level care when there is altered mental status, ongoing seizures, respiratory failure, or hemodynamic instability — all guidance reflected in CDC, poison-center, and toxicology sources [3] [1] [2].