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Poisoning, Antidotes, Emergency Medicine

Treatment

N-Acetylcysteine (NAC)

- Diazepam: - Adult: 2 " 5 mg IV/IM, repeat in 10 " 15 min - Pediatrics: 0.1 mg/kg IV/IM

- Indications: Clinical botulism, prior to onset of paralysis - Warnings: - Binds only free toxins - Not for infant botulism - Equine serum derived: Immediate hypersensitivity, serum sickness 10 " 14 days - Premedicate for anaphylaxis if know equine serum hypersensitivity. - Administer slow IV push.

- Indications: - Hyperkalemia with cardiac toxicity - Hydrofluoric acid burn - Calcium channel blocker overdose - Citrate, oxalate, phosphate poisoning

- Warnings: - Avoid in digoxin toxicity, hypercalcemia - Calcium chloride(CaCl) corrosive to skin, SC tissue - Incompatible with certain IV solutions - Administer slow IV push.

- Indications: - Malignant hyperthermia - Neuroleptic malignant syndrome - Serotonin syndrome - Muscle rigidity

- Indications: Benzodiazepine overdose - Warnings: - Contraindicated in tricyclic antidepressant (TCA) overdose - Lowers seizure threshold - Induces benzodiazepine withdrawal

- Indications: - Organophosphate toxicity - Reversal of nicotinic effects - Reactivates enzyme - Use in conjunction with atropine

  • Indications:Acetaminophenoverdose
  • Warnings:Unpleasant odor, nausea, vomitingMost effective if given in 1st 8 hr postingestion
  • Dose:PO: 140 mg/kg, then 70 mg/kg q4h for 17 dosesIV (consult poison center): 150 mg/kg in 200 mL D5W over 60 min, then 50 mg/kg in 500 mL D5W over 4 hr, then 100 mg/kg in 1,000 mL D5W over 16 hr

This volume of D5W will need to be reduced in dosing pediatric patients to avoid fluid overload/hyponatremia. Discuss with pharmacy.

Atropine

  • Indications:Bradycardia owing to drugsOrganophosphate insecticides
  • Warnings:Myasthenia gravis, narrow-angle glaucoma, HTN, coronary ischemia, and urinary obstruction
  • Dose:Adult: 1 " 2 mg IVPediatric: 0.02 mg/kg (min. 0.1 mg) IVLarge repeated doses needed in organophosphate poisoning

Benztropine (Cogentin)

  • Indications: Acute dystonic reactions
  • Warnings: Carbamates, myasthenia gravis, narrow-angle glaucoma, HTN, coronary ischemia, and urinary obstruction
  • Dose:Adult: 1 " 2 mg IV (for acute reaction) or PO (to prevent reaction)Pediatric: 0.02 mg/kg IV (for acute reaction) or PO (to prevent reaction)

Benzodiazepine

  • Indications: Agitation, stimulant drugs, seizures
  • Warnings: Respiratory/CNS depression
  • Dose:Midazolam:Adult: 1 mg IV/IM every 2 " 3 min PRNPediatric: 0.1 mg/kg IV/IMDiazepam:Adult: 2 " 5 mg IV/IM, repeat in 10 " 15 minPediatrics: 0.1 mg/kg IV/IM

Bicarbonate, Sodium

  • Indications: Cyclic antidepressant poisoning, metabolic acidosis, urinary alkalinization
  • Warnings: May cause CHF, excessive alkalosis, hypokalemia
  • Dose:Serum alkalinization:Urine alkalinization:100 " 150 mEq in 1 L DW at 2 " 3 mL/kg/h IV, goal urine pH 7 " 8

Black Widow Spider Antivenin (Lactrodectus Mactans)

  • Indications: Severe HTN, muscle spasms not alleviated by analgesics and muscle relaxants; consider in extremes of age (<5 or >65 years), pregnant women with threatened abortion
  • Warnings:Equine serum derived: Immediate hypersensitivity, serum sickness 10 " 14 daysPremedicate for anaphylaxis if know equine serum hypersensitivity.
  • Dose: 1 " 2 vials IM or IV slowly over 15 " 30 min; dilute 1 vial in 50 mL saline for IV

Botulin Antitoxin Trivalent A, B, E

  • Indications: Clinical botulism, prior to onset of paralysis
  • Warnings:Binds only free toxinsNot for infant botulismEquine serum derived: Immediate hypersensitivity, serum sickness 10 " 14 daysPremedicate for anaphylaxis if know equine serum hypersensitivity.Administer slow IV push.
  • Dose: 1 " 2 vials IV q4h for 4 or 5 doses; reconstitute 1 vial with 2 mL sterile water. Administer 0.5 mL/kg/h IV. Double rate after 15 min if no ill effects.

Calcium

  • Indications:Hyperkalemia with cardiac toxicityHydrofluoric acid burnCalcium channel blocker overdoseCitrate, oxalate, phosphate poisoning
  • Warnings:Avoid in digoxin toxicity, hypercalcemiaCalcium chloride(CaCl) corrosive to skin, SC tissueIncompatible with certain IV solutionsAdminister slow IV push.
  • Dose:Adult: 5 " 10 mL of 10% CaCl, or 10 " 20 mL of 10% Ca gluconatePediatric: 0.1 " 0.2 mL/kg of 10% CaCl, or 0.2 " 0.3 mL/kg of 10% Ca gluconate

Calcium Edta (Edetate Disodium)

  • Indications: Lead, chromium, nickel, manganese, zinc toxicity
  • Warnings: Nausea, vomiting, chill, nephrotoxicity, hypercalcemia
  • Dose: 1 g/m2/day IV over 8 " 12 hr for 5 days, skip 2 " 4 days, then repeat. Follow lead (Pb) level

Coral Snake Antivenin (Micrurus Fulvius)

  • Indications: Eastern or Texas coral snake
  • Warnings:Equine serum derived: Immediate hypersensitivity, serum sickness 10 " 14 daysPremedicate for anaphylaxis if we know the equine serum hypersensitivity.
  • Dose: 4 " 10 vials slow IV push over 15 " 30 min

Cyanide Antidote Kit

  • Indications: Cyanide poisoning
  • Warnings: Hypotension, methemoglobinemia
  • Dose:Amyl nitrite: 1 " 2 amp crushed, inhaledUse amyl nitrite only until IV access is establishedSodium nitrite:Adult: 300 mg in 10 mL IV over 5 minPediatric: 0.3 mL/kg of 3% solution IVSodium thiosulfate:Adult: 12.5 g IV, may repeat in 1 hrPediatric: 50 mg/kg IV

Cyanokit (Hydroxocobalamin)

  • Indications: Cyanide poisoning
  • Warnings: Erythema, HTN
  • Dose:Adult: 5 g IV over 15 min; may repeat a 2nd 5 g dose depending on severity of poisoning and clinical response. Max. 10 g. Reconstitiute each 2.5 g vial with 100 mL 0.9% NaClPediatric: Safety and efficacy have not been established in children. Suggested initial dose: 70 mg/kg IV.

Dantrolene

  • Indications:Malignant hyperthermiaNeuroleptic malignant syndromeSerotonin syndromeMuscle rigidity
  • Warnings: Muscle weakness, respiratory depression, hepatitis
  • Dose: 1 " 2 mg/kg IV bolus, repeat q10 " 15 min PRN, max. 10 mg/kg

Deferoxamine (Desferal)

  • Indications: Iron toxicity
  • Warnings:Do not treat for >24 hr, risk for delayed adult respiratory distress syndrome (ARDS).Hypotension if >15 mg/kg/h, flushing, urticaria
  • Dose: 10 " 15 mg/kg/h IV, may increase in severe iron (Fe) poisoning

Digoxin Antibody (Digibind)

  • Indications: Digoxin, digitoxin toxicity
  • Warnings:Falsely elevated digoxin levels after useDevelopment of CHF/atrial fibrillation in patients requiring digoxin
  • Dose:1 vial (40 mg) binds 0.6 mg digoxin.Number of vials = digoxin level (ng/mL) weight (kg)/100Dose estimate: Acute overdose 10 " 20 vials, chronic overdose 4 " 6 vials

Dimercaprol (BAL)

  • Indications: Arsenic, gold, mercury, lead-induced encephalopathy
  • Warnings: Renal toxicity, fever, nausea, vomiting, urticaria, cholinergic symptoms
  • Dose:3 mg/kg deep IM q4h for 2 days, then q12h for 7 days; follow metal levelsFor Pb level >100 Όg/dL: 4 " 5 mg/kg IM q4h until Pb <50 Όg/dL, in conjunction with EDTA

Diphenhydramine (Benadryl)

  • Indications: Antihistamine, acute dystonic reaction
  • Warnings: Sedation, excitation in children, anticholinergic symptoms
  • Dose:Adult: 25 " 50 mg IV/IM/PO q4 " 6hPediatric: 0.5 " 1 mg/kg IV/IM/PO q4 " 6h

Dmsa (Succimer, Chemet)

  • Indications: Pediatric lead poisoning
  • Warnings:Caution in renal impairment " urinary eliminationNausea, vomiting diarrhea
  • Dose: 10 mg/kg PO q8h for 5 days, then q12h for 14 days, then reassess blood lead levels

Epinephrine

  • Indications: Angioedema, anaphylaxis, acute asthma, spinal shock, ²-blocker overdose
  • Warnings: Dysrhythmias, HTN, tremor, anxiety
  • Dose:Hypotension/shock:Adult: 1 " 4 Όg/min IV infusionPediatric: Start IV infusion at 0.1 Όg/kg/min.AnaphylaxisAdult: 0.3 " 0.5 mg IM/SCPediatric: 0.01 mg/kg IM/SC

Ethanol

  • Indications: Methanol or ethylene glycol toxicity
  • Warnings:Disulfiramreaction, CNS sedationHypoglycemia in pediatric populationIncrease dose during dialysis, for chronic alcoholics.
  • Dose:IV: 10 mL/kg load as 10% solution over 1 hr, then 1 mL/kg/h maintenancePO: 1.5 mL/kg as 100-proof solution, then 0.3 mL/kg/h maintenanceGoal: Ethanol level of 100 " 150 mg/dL

Flumazenil (Romazicon)

  • Indications: Benzodiazepine overdose
  • Warnings:Contraindicated in tricyclic antidepressant (TCA) overdoseLowers seizure thresholdInduces benzodiazepine withdrawal
  • Dose:Adult: 0.2 mg IV slow, repeat q2 " 3min to 1 mg max.Pediatric: 0.01 " 0.05 mg/kg IV over 30 min " 1 hr

Fomepizole (4-MP, Antizol)

  • Indications: Methanol or ethylene glycol toxicity
  • Warnings: Nausea, dizziness, headache
  • Dose: 15 mg/kg load IV, then 10 mg/kg q12h for 4 doses, then 15 mg/kg q12h

Glucagon

  • Indications: ²-blocker or calcium channel blocker overdose with bradycardia/hypotensionHypoglycemia
  • Warnings:Nausea, vomiting, hyperglycemiaHypotension from diluent (phenol containing)
  • Dose: ²-blocker or calcium channel blocker overdose:Adult: 5 " 10 mg IV over 1 minPediatric: 0.15 mg/kg IV over 1 minHypoglycemia:Adult: 0.5 " 1 mg IM/IV/SCPediatric: 0.025 " 0.1 mg/kg IM/IV/SC (max. 1 mg per dose)

Insulin/Glucose

  • Indications:Calcium channel blocker overdose with severe hypotension/symptomatic bradycardia refractory to other therapiesHyperkalemia
  • Warnings:Experimental therapy: Consult a poison control center/medical toxicologist.Follow serum glucose q15min for 1 hr after the 1st bolus or after any increase in dose, then q1h
  • Dose:Bolus:0.5 " 1 IU/kg regular insulin, followed by 25 g glucose (1 amp D50)Maintenance:Insulin 0.5 IU regular insulin per kg/hr, titrate to 1 IU regular insulin per kg/hrGlucose D10 start at 100 mL/h (10 g/h) and titrate to keep glucose ≥100 mg/dL

Intralipids

  • Indications:Cardiac arrest due to local anesthetic toxicity, most commonly bupivacaine, however may be useful for other lipid-soluble drugs
  • Warnings:Experimental therapy: Consult a poison control center/medical toxicologist.
  • Dose:Intralipid 20% bolus; 1.5 mL/Kg over 1 min followed by infusion 0.25 mL/kg/min.Repeat bolus in 3 " 5 min if circulation not restored.

Methylene Blue

  • Indications: Methemoglobinemia with dyspnea or >25%
  • Warnings: G6-PD deficiency
  • Dose: 1 " 2 mg/kg slow IV as 1% solution, repeat in 1 hr

Narcan

  • Indications:Opiate poisoning, empiric treatment of coma
  • Warnings:Acute opiate withdrawal, severe agitation
  • Dose:Adult: 0.4 " 2 mg IV or IM, repeat to 10 mgPediatric: 0.1 mg/kg IV or IM

Octreotide

  • Indications: Sulfonylurea overdose with hypoglycemia
  • Warnings: Use with caution in diabetic patients.
  • Dose:Adult: 50 Όg SC q6hPediatric: 4 " 5 Όg/kg/d SC div. q6h

Oxygen, Hyperbaric

  • Indications: Carbon monoxide (CO) poisoning
  • Warnings:Tympanic membrane (TM) perforation, seizures owing to oxygen toxicityDifficulty monitoring patient
  • Dose: 100% oxygen at 2 " 3 atm

Penicillamine

  • Indications: Arsenic, copper, lead, mercury with/following BAL or EDTA
  • Warnings: Contraindicated in penicillin allergy, renal insufficiency
  • Dose:Lead:Adult: 250 " 500 mg per dose PO q8 " 12hPediatric: 25 " 40 mg/kg/d PO in 3 div. dosesArsenic: 100 mg/kg/d PO div. in 4 doses for 5 days (max. 1 g/d)Mercury:Adult: 250 mg PO QIDPediatric: 20 " 30 mg/kg/d PO in 4 div. doses

Phentolamine

  • Indications:Hypertensive crisis: Stimulants, sympathomimetics, MAO " tyramine reaction, and extravasated pressorsReversal of cocaine-mediated vasospasm
  • Warnings: HTN, tachycardia, dysrhythmias
  • Dose:HTN (HTN):Adult: 1 " 5 mg IV bolusPediatric: 0.02 " 0.1 mg/kg bolusExtravasation:Adult: 5 mg diluted in 10 " 15 mL saline SCPediatric: 0.1 mg/kg diluted in 10 " 15 mL saline SC

Physostigmine

  • Indications: Severe anticholinergic syndrome
  • Warnings: Contraindicated in TCA overdose
  • Dose:Adult: 0.5 " 1 mg IV, repeat in 10 min PRNPediatric: 0.02 mg/kg IV, repeat in 10 min PRN

Pralidoxime (2-PAM, Protopam)

  • Indications:Organophosphate toxicityReversal of nicotinic effectsReactivates enzymeUse in conjunction with atropine
  • Warnings:Myasthenic crisis if myasthenia gravisNausea, headache, dizziness, laryngospasm, muscle rigidity
  • Dose:Adult: 1 " 2 g IV in 100 mL NaCl over 15 min, repeat in 1 hr PRN, repeat in 6 hr if nicotinic symptoms returnPediatrics: 25 " 50 mg/kg over 15 min, repeat in 1 hr PRN, repeat in 6 hr if nicotinic symptoms return

Protamine

  • Indications: Reversal of heparin anticoagulation
  • Warnings:Hypersensitivity in patients with fish allergyAvoid benzyl alcohol diluent in neonates.
  • Dose: 1 mg for each 100 IU heparin, 1/2 dose if 30 " 60 min; 1/4 dose if 2 hr after heparin bolus;25 " 50 mg slow IV over 15 min. Initial dose should not be >50 mg

Pyridoxine (Vitamin B6)

  • Indications:Isoniazid-induced seizuresGyromitra mushroom
  • Warnings: None, nontoxic
  • Dose:Isonicotinic acid hydrazide (INH) " induced seizures:Unknown ingested amount: 5 g for adult or 1 g for pediatricsDose (mg) = amount INH ingested (mg)Gyromitra: 25 mg/kg IV over 30 min " 1 hr

Rattlesnake Antivenin (Crotaline)

  • Indications: Significant envenomation by Crotaline species: Rattlesnake, cottonmouth, water moccasin, pit viper
  • Warnings:Ovine-derived products: Immediate hypersensitivity, serum sickness 10 " 14 daysPremedicate for anaphylaxis if we know the equine/ovine serum hypersensitivity.
  • Dose:
  • Ovine derived (CroFab):4 " 6 vials slowly; may repeat dose of 4 " 6 vials if control of envenomation not achieved, then 2 vials q6h for 3 dosesReconstitute each vial with 25 mL sterile water. Dilute in 250 mL 0.9% NaCl and infuse over 1 hr.

Vitamin K (Phytonadione, Aqua Mephyton)

  • Indications: Reversal of Coumadin anticoagulation
  • Warnings: Hypersensitivity from IV administration
  • Dose:2 " 10 mg SC/slow IV, may repeat in 8 hr2 " 10 mg PO, may repeat in 12 " 48 hr

Codes

ICD9

977.9 Poisoning by unspecified drug or medicinal substance

ICD10

T65.91XA Toxic effect of unspecified substance, accidental (unintentional), initial encounter

SNOMED

  • 75478009 Poisoning (disorder)
  • 67329000 Administration of antidote (procedure)