Poisoning, Antidotes, Emergency Medicine

Treatment

N-Acetylcysteine (NAC)

Indications:Acetaminophenoverdose
Warnings:
- Unpleasant odor, nausea, vomiting
- Most effective if given in 1st 8 hr postingestion
Dose:
- PO: 140 mg/kg, then 70 mg/kg q4h for 17 doses
- IV (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 drugs
- Organophosphate insecticides
Warnings:
- Myasthenia gravis, narrow-angle glaucoma, HTN, coronary ischemia, and urinary obstruction
Dose:
- Adult: 1 " 2 mg IV
- Pediatric: 0.02 mg/kg (min. 0.1 mg) IV
- Large 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 PRN
  - Pediatric: 0.1 mg/kg IV/IM
- Diazepam:
  - Adult: 2 " 5 mg IV/IM, repeat in 10 " 15 min
  - Pediatrics: 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:
  - 1 mEq/kg IVP
- 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 days
- Premedicate 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 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.
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 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.
Dose:
- Adult: 5 " 10 mL of 10% CaCl, or 10 " 20 mL of 10% Ca gluconate
- Pediatric: 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 days
- Premedicate 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, inhaled
  - Use amyl nitrite only until IV access is established
- Sodium nitrite:
  - Adult: 300 mg in 10 mL IV over 5 min
  - Pediatric: 0.3 mL/kg of 3% solution IV
- Sodium thiosulfate:
  - Adult: 12.5 g IV, may repeat in 1 hr
  - Pediatric: 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% NaCl
- Pediatric: Safety and efficacy have not been established in children. Suggested initial dose: 70 mg/kg IV.

Dantrolene

Indications:
- Malignant hyperthermia
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Muscle 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 use
- Development 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)/100
- Dose 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 levels
- For 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 " 6h
- Pediatric: 0.5 " 1 mg/kg IV/IM/PO q4 " 6h

Dmsa (Succimer, Chemet)

Indications: Pediatric lead poisoning
Warnings:
- Caution in renal impairment " urinary elimination
- Nausea, 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 infusion
- Pediatric: Start IV infusion at 0.1 Όg/kg/min.
- Anaphylaxis
  - Adult: 0.3 " 0.5 mg IM/SC
  - Pediatric: 0.01 mg/kg IM/SC

Ethanol

Indications: Methanol or ethylene glycol toxicity
Warnings:
- Disulfiramreaction, CNS sedation
- Hypoglycemia in pediatric population
- Increase dose during dialysis, for chronic alcoholics.
Dose:
- IV: 10 mL/kg load as 10% solution over 1 hr, then 1 mL/kg/h maintenance
- PO: 1.5 mL/kg as 100-proof solution, then 0.3 mL/kg/h maintenance
- Goal: Ethanol level of 100 " 150 mg/dL

Flumazenil (Romazicon)

Indications: Benzodiazepine overdose
Warnings:
- Contraindicated in tricyclic antidepressant (TCA) overdose
- Lowers seizure threshold
- Induces 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/hypotension
- Hypoglycemia
Warnings:
- Nausea, vomiting, hyperglycemia
- Hypotension from diluent (phenol containing)
Dose:
- ²-blocker or calcium channel blocker overdose:
  - Adult: 5 " 10 mg IV over 1 min
  - Pediatric: 0.15 mg/kg IV over 1 min
- Hypoglycemia:
  - Adult: 0.5 " 1 mg IM/IV/SC
  - Pediatric: 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 therapies
- Hyperkalemia
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/hr
  - Glucose 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 mg
- Pediatric: 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 q6h
- Pediatric: 4 " 5 Όg/kg/d SC div. q6h

Oxygen, Hyperbaric

Indications: Carbon monoxide (CO) poisoning
Warnings:
- Tympanic membrane (TM) perforation, seizures owing to oxygen toxicity
- Difficulty 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 " 12h
  - Pediatric: 25 " 40 mg/kg/d PO in 3 div. doses
- Arsenic: 100 mg/kg/d PO div. in 4 doses for 5 days (max. 1 g/d)
- Mercury:
  - Adult: 250 mg PO QID
  - Pediatric: 20 " 30 mg/kg/d PO in 4 div. doses

Phentolamine

Indications:
- Hypertensive crisis: Stimulants, sympathomimetics, MAO " tyramine reaction, and extravasated pressors
- Reversal of cocaine-mediated vasospasm
Warnings: HTN, tachycardia, dysrhythmias
Dose:
- HTN (HTN):
  - Adult: 1 " 5 mg IV bolus
  - Pediatric: 0.02 " 0.1 mg/kg bolus
- Extravasation:
  - Adult: 5 mg diluted in 10 " 15 mL saline SC
  - Pediatric: 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 PRN
- Pediatric: 0.02 mg/kg IV, repeat in 10 min PRN

Pralidoxime (2-PAM, Protopam)

Indications:
- Organophosphate toxicity
- Reversal of nicotinic effects
- Reactivates enzyme
- Use in conjunction with atropine
Warnings:
- Myasthenic crisis if myasthenia gravis
- Nausea, 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 return
- Pediatrics: 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 allergy
- Avoid 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 seizures
- Gyromitra mushroom
Warnings: None, nontoxic
Dose:
- Isonicotinic acid hydrazide (INH) " induced seizures:
  - Unknown ingested amount: 5 g for adult or 1 g for pediatrics
  - Dose (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 days
- Premedicate 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 doses
- Reconstitute 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 hr
- 2 " 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)

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