Professional Documents
Culture Documents
0.4-2 mg
Naloxone (narcan) Opioids Not in addicts
I.V., repeat
100% mask
Oxygen CO, cyanide, HS Not in paraquat
4-5 L\min
20
mg\kg\day
Copper, lead, Max. daily dose 2 g,
Penicillamine on empty
mercury allergy
stomach in
3 doses
1-2 gm I.V.
Obidoxime
Organophosphates over 10 Not in myasthenia
(toxogonin)
min, repeat
Dose
depends on Slow I.V.
Protamine Heparin
heparin Hypersensitivity
dose
INH, ethylene 1 gm I.V.\1 Dilute in 50 ml D5W
Pyridoxine (vit. B6)
glycol g INH over 5 min.
Metabolic
acidosis, 1 mEq\kg
Measure potassium
NaHCO3 enhanced I.V. bolus,
level
elimination, TCA, repeat
tegretol…etc.
Starch Iodine
Thiamine (vit.B1) Alcoholism, 100 mg Hypersensitivity
ethylene glycol slow I.V. or
I.M.,
repeat\6 h
5-10 mg
Warfarin, S.C., then
Konakion (vit. K1) Hypersensitivity
rodenticides oral 10-25
mg\day
Hydroxycobolamine 50 mg\kg
Cyanide
(vit.B12 ) I.V.
Always call the poison center first
NEW ANTIDOTES
Ken Bizovi MD
New Antidotes:
Fomepizol – a newly approved antidote for Ethylene
Glycol
Insulin And Glucose – for treatment of Calcium channel
blocker overdose
Octreotide – for sulfonylurea overdose refractory to glucose
administration
Not So New Antidotes:
Flumazenil
Digoxin Specific Antibody Fragments
Brief Review of other Antidotes
Frequently used antidotes: N-acetylcysteine, Calcium Salts,
Glucagon, Sodium Bicarbonate, Naloxone
B. Indication
1. Organophosphate or carbamate toxicity with
a. respiratory secretions causing hypoxemia
b. fasciculations and weakness
c. lethargy
d. bradycardia
1. tachycardia is not a contraindication
C. Contraindications
a. none in the setting of OP overdose
b. relative contraindications – angle closure glaucoma,
obstructive uropathy
D. Dosing
1. start with 0.5-1 mg in adults and 0.01 –0.02 mg/kg in
children and titrate up until bronchosecretions are dry
2. double the dose every 2 doses
3. Cases using hundreds of milligrams of atropine have been
reported
E. Side effects
1. Anticholinergic poisoning
a. hot as a hare, dry as a bone, blind as a bat, red as a beet,
mad as a hatter
F. Alternatives - none
G. Costs – 50 cents/mg
Antivenin
B. Indication
1. progression of swelling beyond the area of the bite.
2. Systemic symptoms – fasciculations, weakness, hypotension,
coagulopathy, hemolysis
D. Dosing
1. Moderate envenomation – progression of swelling beyond
the area of the bite. Anxiety, nausea, tingling, may be seen.
a. 5-10 vials mixed 1:10 volume: volume with normal
saline
b. have Benadryl, and epinephrine at the bedside
c. start drip at 25 ml/hour and increase rate every 10 –15
minutes with an infusion rate that equals 2-10 vials per
hour maximum.
d. Total dose for moderate envenomation 5-10 vials
E. Side effects
1. Anaphylactic and anaphylactoid reactions
2. Serum sickness –
a. Usually joint pain and swelling
b. Can develop more severe syndrome of immune complex
vasculitis, myocarditis, neuritis, and glomerulonephritis
F. Alternatives
1. supportive care and administration of antivenin better than
surgical excision
G. Costs - $ 180/vial
Calcium Salts
Calcium Gluconate 10 ml of 10% = 4.5 meq of calcium
Calcium chloride 10 ml of 10% = 13.6 meq of calcium
B. Indications
1. hypocalcemia
2. hydrofluoric acid exposure (calcium gluconate if
subcutaneous injection is needed)
3. Hypotension due to calcium channel blockers or beta
blockers
4. Hyperkalemia
5. Black widow Spider bite may be used
6. Hypermagnesemia
7. Ethylene glycol poisoning with hypocalcemia
C. Contraindications
1. digoxin
D. Dosing
1. CCB OD
1. ampule (10 ml of 10% CaCl) given IV over 10 minutes
2. may repeat up to 3 amps
2. HFl
a. topical – mix calcium gluconate with KY jelly 1:3 and
apply (2.5%)
b. intradermal injection of 5% calcium gluconate 0.5ml/cm2
do not inject CaCl intradermally
E. Side effects
1. Tissue necrosis if CaCl is given subcutaneously or
infiltrates
F. Alternatives
1. HFl – probably should be used with IV magnesium for
anything greater than small area of minor irritation from low
concentration
2. CCB or Beta blocker - multiple other agents used in these
overdoses with no clear agent of choice (glucagon,
catecholamines, amrinone..)
3. Hyperkalemia – insulin and glucose, sodium bicarbonate,
dialysis
4. Black widow – opiate and benzodiazapine with or without
calcium salts are adequate for most cases
A. Mechanism
Amyl nitrite – can cause a small Methemoglobinemia which
provides a place for CN to bind other than cytochrome oxidase
A3
B. Indication
1. Shock and acidosis in known cyanide exposure
2. Shock and acidosis in suspected cyanide exposure
3. In smoke inhalation victims who have shock and acidosis
that is not explained by hypoxemia, or CO consider
administration of sodium thiosulfate for CN
E. Side effects
1. Sodium Thiosulfate – vein irritation, minimal other
side effects
2. Nitrites – may cause hypotension similar to nitrates
F. Alternatives
1. Hyperbaric Oxygen
G. Costs - $ 160/kit
Deferoxamine
A. Mechanism
1. Chelates Iron
a. has high affinity for iron with little effect on other ions
b. 100 mg of deferoxamine binds 9.35 mg of elemental iron
B. Indication
1. Anion Gap acidosis attributable to iron overdose
2. CNS depression
3. Hypotension unresponsive to fluids and shock
4. Serum iron > 500 micrograms/dl
D. Dosing
1. 15 mg/kg/hour
2. total dose
a. stop infusion when clinical symptoms and anion gap
acidosis resolves
b. stop infusion after 24 hours of therapy
1. continuation may be considered if patient remains
profoundly ill
c. avoid giving over 6 grams if symptoms and anion gap
resolved
E. Side effects
1. anaphylaxis
2. flushing and hypotension
a. stop temporarily or slow down drip rate, give fluid bolus
3. ARDS – associated with prolonged infusion, large doses
4. Yersinia enterocolitica – may cause diarrhea syndrome after
treatment
G. Costs
$ 11.60/500 mg
Digibind
A. Mechanism - Fab antibody fragments bind to digoxin making it
inactive
B. Indications
1. Bradydysrhythmia
Severe sinus bradycardia
Second or third degree heart block unresponsive to
atropine
2. Ventricular dysrhythmias – V-tach, V-fib
3. Potassium > 5.0 associated with an acute ingestion (ref)
4. Acute ingestion
a. 4 mg in a child
b. 10 mg in an adult
5. Serum concentrations
a. 15 ng/ml in acute ingestion
6. Consider for bradycardic overdose patient
with unknown ingestion
C. Dosing
1. Dosing is based on estimating the total body
load of digoxin and the binding capacity of
Digibind.
2. Each vial binds 0.5 mg of digoxin
3. Dosing based on ingested dose
a. # mg ingested X 0.8
(bioavailability of 80%) divided by
0.5 vial/mg
b. Example 25 X 0.25 mg Pills ingested
D. Side effects
1. Minimal side effects reported
a. Rash in 2 of 451 (< 1%) patient
in post marketing surveillance
b. Hypokalemia 6 of 150 (4%)
c. Worsening CHF 4 of 150 (3%)
d. At least 1 patient has received multiple doses at
different times without adverse reaction
E. Alternatives
Nothing really compares
B. Indication
1. sedation from benzodiazepines in the absence of
contraindications
a. Pediatric ingestion of benzodiazepine or iatrogenic cause
are most likely to have a risk benefit ratio that favors the
administration of flumazenil.
C. Contraindications
1. Tricyclic Antidepressants
a. by history
b. ECG evidence of TCA – QRS or QT prolongation, R-
wave in aVR and S wave in AVL
2. Chronic benzodiazepine use
3. History of substance capable of causing seizures
4. Abnormal vital signs
D. Dosing
1. 0.1 mg/min until sedation reverses up to 1 mg
2. 0.2 mg IV over 15 seconds, then 0.2 mg q 1 minute up to 1
mg total
3. Flumazenil drip using 0.25-1.0 mg/hour in D5W or normal
saline has been reported but is not FDA approved
4. Onset of action is 1-2 minutes
5. T ½ 53 minutes
6. Durations of action depends on dose and T ½ of
benzodiazepine and dose of flumazenil, as well as hepatic
function
a. Resedation may occur in 20–120 minutes
E. Side effects
1. Seizures
2. Cardiac Dysrhythmias
F. Alternatives
5. Supportive care with focus on airway management and
intubation as needed
B. Indications –
1. History consistent with
significant ingestion of Methanol
or Ethylene Glycol
a. Significant dose >.15 mg/kg
1.5 mg in a 10 kg child (approx. 1.5 ml)
15 mg in a 100 kg adult (approx. 15ml)
2. Ethylene Glycol level greater than 25 mg/dl
3. Anion gap acidosis - suspected EG or Methanol ingestion
C. Side effects
1. Headache 12%
2. Nausea 11%
3. Dizziness 7%
D. Dosing
1. 15mg/kg followed by 10 mg/kg q 12 hours X 4 doses
then
2. 15 mg/kg q 12 hours
3. During dialysis dose q 4 hours see package insert for
details
E. Alternatives
1. Ethanol
Mechanism - Works as a competitive inhibitor of
ADH
Indications –
History consistent
with significant
ingestion
Methanol level greater than 10 mg/dl
Anion gap acidosis - suspected EG or Methanol
ingestion
Ethanol continued
Side effects
CNS depression
Hypoglycemia especially children
Negative metabolic effects (minor)
Dosing
Load
10cc/kg of 10%
ETOH IV over
30 minutes
OR 2.5 ml/kg of 40% po
Maintenance
0.8 – 1.9 ml/kg/hour of 10% ETOH
During Dialysis
2.7-3.8 ml/kg/hour of 10% ETOH
b. Pediatric considerations
Neither Etoh or fomepizole is FDA approved
for pediatrics
More experience with ethanol
Hypoglycemia more likely in pediatric
population
CNS depression likely to be greater in children
c. Costs
Fomepizol – 1 vial containing 1.5 grams is
enough for 1 dose in a 100 kg adult costs $
1150.00
Glucagon
D. Dosing
1. 50 microgram/kg (3.5 in a 70 kg adult) IV bolus infused over
1 minute{dilute with sterile water for injection)
2. Continuous infusion 2-5 mg/hour5 in D5W
3. Onset – within minutes
4. Peak – 5-7 minutes
5. Duration – 10-15 minutes
E. Side effects
1. nausea and vomiting (not maybe, for sure)
2. hyperglycemia
3. hypokalemia (intracellular shift)
4. allergic reactions
C. Dosing
Bolus Regular insulin 10-20 IU IV
With a bolus of glucose (25 grams)
Drip: 0.2-1.0 IU/kg/h
Glucose infusion to
keep serum glu >
100mg/dl
D. Side effects
Hypoglycemia (surprise!!!)
Hypokalemia – replace gently for K+ levels less than 2.5
meq/L Decrease in serum K+ represents an intracellular
shift in K+, not a loss.
F. Costs
Regular insulin 1 vial (1000 units) $ 9.23
Ampule of D50 $ 16.18
1. Kline JA, Leonova E, Raymond RM. Beneficial myocardial
metobolic effects of insulin during verapamil toxicity in the
anesthetized canine. Crit Care Med 23:1251, 1995
2. Kline JA, Leonova E, Willians TC, Schroeder JD, Watts JA.
Myocardial metabolism during graded intraportal verapamil infusion
in awake dogs. J of Cardiovascular Pharm. 27:719-726, 1996
3. Yaun T, Kerns, Tomaszewski C, Ford M, Kline J. Insulin and glucose:
Novel Treatment for Calcium Agonist-Induced Shock. J Tox Clin Tox
1997;35:562 (abstract)
4. Kline J, Tomaszewski C, Schroeder JD, Raymond RM. Insulin is a
Superior Antidote for Cardiovascular Toxicity Induced by Verapamil
in the Anesthetized Canine . J Pharm and Exp Ther 267:744, 1993
5. Yuan TH. Kerns WP 2nd. Tomaszewski CA. Ford MD. Kline JA.
Insulin-glucose as adjunctive therapy for severecalcium channel
antagonist poisoning. Journal of Toxicology - Clinical Toxicology.
37(4):463-74, 1999.
Methylene Blue
A. Mechanism - Methylene is the substrate for the NADPH
methemoglobin reductase, which reduces Fe3+ to FE2+
B. Indication
1. Symptoms due to methemoglobinemia – dyspnea, syncope,
chest pain
2. Methemoglobinemia of 30% or greater
C. Contraindications
1. Known G6PD deficiency is a contraindication but pretesting
is not necessary
D. Dosing
1. 1-2 mg/kg (0.1 ml/kg of 1%{10 mg/ml} solution)
E. Side effects
1. may cause hemolysis in G6PD cases
2. overdose may worsen methemoglobinemia
3. turns all secretions blue (urine, tears …)
4. explain to parents that the blue IV fluid going into there blue
child is really the right thing to do
F. Alternatives
1. ascorbic acid is used for congenital forms of
methemoglobinemia but not effective in treating drug induces
methemoglobinemia.
G. Costs – 7.80 ml = 10 mg
B. Indications
a. Acute overdose - treat for patients whose acetaminophen
level falls above the possible toxicity line.
1. NOTE: Since the time of ingestion effects the
interpretation of the level use the earliest possible time
of ingestion.
2. give first dose prior to 8 hours post-ingestion, it
will not effect the interpretation of the nomogram
b. Chronic overdose
1. history of more than recommended dose and:
a. elevated LFT’s (AST, ALT)
b. persistent vomiting
c. elevated acetaminophen levels
c. Late presenters with history of acute or chronic overdose
with elevated LFTS
C. Dosing
Oral
140 mg/kg po x 1
70 mg/kg q 4 hours x24 doses
Dilute to 5% solution
IV
48 hour protocol: 140 mg/kg load, 70 mg/kg q 4 hours
for 12 additional doses. give doses in dilute solution
over 1 hour
20 hour protocol: 1250 mg/kg over 15 minutes, the 50
mg/kg over 4 hours. then 100mg/kg over 16 hours
D. Side effects
1. Oral - nausea and vomiting
2. IV anaphylactoid reactions (rash, urticaria, bronchospasm,
hypotension, death)
Naloxone (Narcan)
A. Mechanism – antagonist at
1. reverses the respiratory, CNS, and pain effects of opiates
B. Indications
1. primary indication is for respiratory depression in known or
suspected opiate overdose
2. Use for CNS depression in an suspected opiate overdose
may be diagnostic, allow history to be obtained and avoid
unnecessary diagnostic tests
a. Consider necessity of reversing CNS depression without
significant respiratory depression
C. Dosing
1. 0.4 or 2 mg IV push – for rapid reversal of respiratory and
CNS depression
2. may repeat 2 mg q 3-5 minutes up to 10 mg total
a. approved for IV dosing but is absorbed subcutaneously,
IM and endotracheally
b. poor bioavailability if given orally
3. Small doses 0.1 mg at a time to titrate an oversedated pain
patient
4. Drip rate for patients with resedation after initial use = 2/3 of
the dose required for reversal per hour
5. Kinetics
a. Onset 1-2 min if given IV
b. T1/2 of approx. 1 hour with duration of activity of 20-90
min
1. shorter than most opiates so resedation may occur
6. Pediatric consideration
a. 0.1 mg/kg dose, max of 2mg/dose
b. No adverse effect is expected when giving naloxone to a
patient who is not opiate dependent.
D. Side effects
1. Precipitation of opiate withdrawal (hypertension,
tachycardia, vomiting, gastrointestinal cramping, anxiety,
agitation)
a. titration of patients with suspected opiate tolerance may
make ED management much simpler
b. administration of naloxone in EMS setting should be
limited to those with respiratory depression.
2. Reports of hypertension, cardiac arrhythmias and non-
cardiogenic pulmonary edema are exceedingly rare and
probably represent unmasking of underlying condition.
E. Alternatives
1. Supportive care
2. naltrexone – duration of effect 24-72 hours, antagonist at
andcan be given orally
a. this may be useful in pediatric overdose
b. Down sides
1. too long a duration for pain patients
2. opiate abuser may be discharged and could use large
doses to override the antagonist effect and develop
respiratory depression when naltrexone wears off
3. nalmefene – derivative of naltrexone, oral bioavailability
40%
a. Dosing – duration of activity is dependant on dose
1. 0.5 mg IV – 4 hours
2. 2 mg IV – 8 hours
3. 50 mg po – 50 hours
b. T ½ 8-9 hours
c. May be given IV or po
d. Downsides – see naltrexone
Octreotide
A. Mechanism
1. inhibits insulin release form Beta islet cells of the pancreas
B. Indication
1. hypoglycemia from sulfonylurea
2. OD unresponsive to po or IV administration of glucose.
a. I recommend using it for any patient who need more than
D 10 IV or who are having multiple episodes of
hypoglycemia
b. Additionally if a patient is in a setting where frequent
(hourly) capillary blood glucose (CBG) levels are
difficult or impossible to obtain consider octreotide
1. warning – use of octreotide does not guarantee
prevention of hypoglycemia, but evidence supports that it
decreases the chances of hypoglycemia
3. Has been used for hypoglycemia induced by quinine-
induced hypoglycemia
C. Contraindications - allergy
D. Dosing
50 micrograms q 12 hours (I suggest this dosing to start)
30 ng/kg/min (use if pt. Gets hypoglycemic despite single dose
of octreotide) 1
1 microgram/kg maximum of 50 microgm
there is a case report of a 20 kg child tx’d with 25
micrograms octreotide
E. Side effects
1. Bradycardia (seems rare)
2. QT prolongation
F. Alternatives
1. diazoxide – octreotide appears to have considerably less side
effects than diazoxide
1. Boyle PJ, Justice K, Krentz AJ, Nagy RJ, Schade DS. Octreotide
reverses hyperinsulinemia and prevents hypoglycemia induced by
sulfonylureas overdose J Clin Endorine Soc 76:752-756
Physostigmine
B. Indications
1. severe CNS agitation, or seizures due to anticholinergic
poisoning
2. severe tachydysrhythmias due to anticholinergic poisoning
3. diagnostic test to avoid other diagnostic and therapeutic
interventions
C. Contraindications –
1. TCA poisoning
2. can prolong duration of action of succinylcholine
D. Dosing
1. adult – 1-2 mg IV over 5 min
2. pediatric – 0.02 mg/kg maximum of 0.5 mg IV over 5 min
E. Side effects
1. Cholinergic excess – have atropine at bedside
2. SLUG BAM (Salivation, Lacrimation, Urination, GI distress
Bradycardia, Asthma, Miosis)
3. May cause brady-asystole
F. Alternatives
1. Benzodiazepines will lower the seizure threshold, decrease
temp by decreasing agitation, and decrease sympathetic
overdrive.
G. Costs – $ 7.80/mg
Pralidoxime (2-PAM)
A. Mechanism – Binds to the organophosphate molecule and
removes it form the acetylcholinesterase enzyme
1. only effective prior to aging of the OP-acetylcholinesterase
bond
a. aging is the process where an unstable bond is replaced
by a permanent bond
2. acts at all sites of acetylcholine activity
a. nicotinic sites at parasympathetic and sympathetic
ganglion
b. nicotinic sites at neuromuscular junction
c. muscarinic sites of the parasympathetic system and sweat
glands
3. pralidoxime administration may decrease the atropine
requirement
B. Indication
1. Organophosphate toxicity with
a. respiratory secretions causing hypoxemia
b. fasciculations and weakness
c. lethargy
d. bradycardia
1. tachycardia is not a contraindication
e. any case that requires atropine
D. Dosing
1. Adult 500mg/hour over 4 hours give q 6 hours x 48 hours
2. Pediatric – 20-40 mg/kg dripped over 4 hour (maximum 1
gram)
3. Alternatively peds or adult 3.2 mg/kg/hour (max: 1 gram in
child, 2 gram in adult )
4. Package insert dosing is slightly different
a. Adult – 1-2 grams in 100 ml of NS over 15 –30 minutes,
maximum rate 200mg/min
b. Pediatric – 20-40 mg/kg over 15-30 min
c. Pralidoxime has a shorter duration of effect if given as
directed in the package insert
E. Side effects
1. may cause cholinergic symptoms if given too fast
a. reports of respiratory and cardiac arrest with rapid
administration
2. other side effects – dizziness, blurred vision, increase in
diastolic BP,
F. Alternatives – other oximes (obidoxime, H-series) not available
in US
Pyridoxine
A. Mechanism – pyridoxine is a cofactor that is necessary in the
synthesis of gamma amino butyric acid (GABA).
a. INH depletes pyridoxine and its active metabolite
pyridoxine-5’phosphate
D. Dosing
1. dose - A gram of pyridoxine should be given IV for each
gram of INH ingested, up to 5 grams total.(INH 3)
2. If the dose ingested is unknown, then 5 grams should be
given.
3. Pediatric dose - 70 mg/kg up to a maximum of 5 grams
4. Administration - 1 gram IV should be given every 2-3
minutes until the seizure stops. The remainder may be
given more slowly.
5. If IV pyridoxine is not available in sufficient quantities
then NG administration can be considered.
E. Side effects
1. peripheral Neuropathy has occurred with chronic use (INH 6)
and high doses (INH 7)
2. the diluent chlorobutanol has caused fatality (INH 8)
F. Alternatives – no substitute
1. If IV pyridoxine is not available in sufficient quantities then
NG administration can be considered.
Sodium Bicarbonate
B. Indication
1. QRS < 100 msec
2. Hypotension
C. Contraindications – none
1. CHF is a relative contraindication due to sodium load but
increase in contractility in setting of TCA toxicity outweighs
risk
E. Side effects
F. Alternatives
1. Hyperventilation is effective but not as efficacious as sodium
bicarbonate
2. Treatment with hypertonic sodium is described but is not as
well documented as sodium bicarbonate or hyperventilation
and has the theoretic risk of central pontine myelinolysis
J. Indication
2. Organophosphate or carbamate toxicity with
e. respiratory secretions causing hypoxemia
f. fasciculations and weakness
g. lethargy
h. bradycardia
1. tachycardia is not a contraindication
K. Contraindications
c. none in the setting of OP overdose
d. relative contraindications – angle closure glaucoma,
obstructive uropathy
L. Dosing
4. Adults start with 0.5-1 mg IV
a. 1-2 mg IV q 5 minutes and titrate up until
bronchosecretions are dry and hemodynamically
significant bradycardia resolved
b. IM administration can be considered if IV acces is not
available
5. Pediatrics - 0.01 –0.04 mg/kg in children (never use less
than 0.1 mg)
a. 1-2 mg IV q 5 minutes and titrate up until
bronchosecretions are dry and hemodynamically
significant bradycardia resolved
b. IM administration can be considered if IV acces is not
available
6. Cases using hundreds of milligrams of atropine have been
reported
a. 10-15 mg/hour rates may be required titrate to effect
(above)
M. Side effects
1. Anticholinergic poisoning
a. hot as a hare, dry as a bone, blind as a bat, red as a beet,
mad as a hatter
N. Alternatives - none
O. Costs –
1. 1mg/ml x 1ml vial - 50 cents/mg AWP
2. 0.1 mg/ml x 10 ml (AMP) $ 13 AWP
I. Mechanism
Sodium Thiosulfate – provide substrate for the enzyme
Rhodanese which combines CN and thiocyanate to form
thiocyanate. Thiocyanate is subsequently cleared by the
kidneys
J. Indication
1. Shock and acidosis in known cyanide exposure
2. Shock and acidosis in suspected cyanide exposure
3. In smoke inhalation victims who have shock and acidosis
that is not explained by hypoxemia, or CO consider
administration of sodium thiosulfate for CN. There is little
downside to administration of sodium thiosulfate in any
seriously ill smoke inhalation victim.
L. Dosing
1. Adult – 12.5 grams = 50 ml of 25 % solution
2. Pediatric – 0.4125 grams/kg = 1.65 mL/kg of 25% solution
max dose 12.5 grams
M. Side effects
1. Sodium Thiosulfate – vein irritation, minimal other
side effects
N. Alternatives
1. Hyperbaric Oxygen
J. Indication
2. Organophosphate toxicity with
e. respiratory secretions causing hypoxemia
f. fasciculations and weakness
g. lethargy
h. bradycardia - tachycardia is not a contraindication
i. consider for any case that requires atropine
L. Dosing
1. Intermittent dosing
d. Adult – 1-2 grams in 100 ml of NS over 15 –30 minutes,
maximum rate 200mg/min
1. May repeat in 1 hour if weakness is not
resolved then q 6 hours.
e. Pediatric – 20-40 mg/kg over 15-30 min
1. May repeat in 1 hour if weakness is not resolved then
q 6 hours
2. Drip dosing
a. Adult - 1-2 grams in 100 ml of NS over 15 –30 minutes,
then 500mg/hour
b. Pediatric – 20-40 mg/kg over 15-30 min, then 5-10 mg/kg
drip(maximum 500 mg/hour gram)
c. duration varies with the agent (organophosphate or nerve
agent) intermittent evaluation with drip off may be
required
3. Intermittent versus drip - Intermittent uses less pralidoxime
but may lead to periods of sub-therapeutic serum
concentration. If supplies are limited consider intermittent
dosing with increase frequency if indicated by fasciculations
or weakness
M. Side effects
2. may cause cholinergic symptoms if given too fast
b. reports of respiratory and cardiac arrest with rapid
administration
3. other side effects – dizziness, blurred vision, increase in
diastolic BP,
A. Mechanism
Amyl nitrite – can cause a small Methemoglobinemia which
provides a place for CN to bind other than cytochrome oxidase
A3
Sodium Nitrite - can cause a Methemoglobinemia which
provides a place for CN to bind other than cytochrome oxidase
A3
B. Indication
4. Shock and acidosis in known cyanide exposure
5. Shock and acidosis in suspected cyanide exposure
6. In smoke inhalation victims who have shock and acidosis
that is not explained by hypoxemia, or CO consider
administration of sodium thiosulfate for CN
F. Side effects
1. Nitrites – may cause profound hypotension similar to nitrates
G. Alternatives
1. Hyperbaric Oxygen
2. Hydroxocobalamin (when the FDA gets around to approving
it)
Pyridoxine
B. Mechanism – pyridoxine is a cofactor that is necessary in the
synthesis of gamma amino butyric acid (GABA).
b. INH & hydrazines deplete pyridoxine and its active
metabolite pyridoxine-5’phosphate
J. Dosing
6. Hydrazine exposure – 25 mg /kg for adult and pediatric
patients
7. INH OD -
a. A gram of pyridoxine should be given IV for each gram
of INH ingested, up to 5 grams total.(INH 3)
b. If the dose ingested is unknown, then 5 grams should be
given.
c. Pediatric dose - 70 mg/kg up to a maximum of 5 grams
d. Administration - 1 gram IV should be given every 2-3
minutes until the seizure stops. The remainder may be
given more slowly.
e. If IV pyridoxine is not available in sufficient quantities
then NG administration can be considered.
K. Side effects
3. peripheral Neuropathy has occurred with chronic use (INH 6)
and high doses (INH 7)
4. the diluent chlorobutanol has caused fatality (INH 8)
L. Alternatives – no substitute
2. If IV pyridoxine is not available in sufficient quantities then
NG administration can be considered.
Sulfonylurea Agents
and Octreotide
Ethylene glycol (EG) and methanol are small chain alcohols that
are widely used as industrial solvents and as components of automobile
products such as antifreeze and windshield wiper fluid. In 2000, TESS
reported 2,620 exposures to these two alcohols and 30 deaths.2
Although the EG and methanol are themselves non-toxic,
metabolism by hepatic alcohol dehydrogenase (ADH) initiates the
enzymatic conversion of these alcohols to their toxic metabolites which
are glycolic acid and formic acid respectively. Intoxication with both EG
and methanol is classically characterized by an anion gap metabolic
acidosis. Conventional therapy includes administration of ethanol to
competitively block hepatic ADH, correction of metabolic acidosis and
urgent hemodialysis to remove the parent alcohol and toxic metabolites.
Ethanol can be administered orally or intravenously and blood
concentrations of > 100 mg/dl are required for effective competitive
blockade of ADH. Unfortunately, ethanol use produces intoxication in the
patient and therapeutic levels can be difficult to maintain despite frequent
monitoring. Additional side effects include hepatotoxicity and
hypoglycemia especially in children. Of note, the use of ethanol as an
antidote has never been validated and it is not FDA approved for this
purpose.
Fomepizole (4-methylpyrazole) is a competitive inhibitor of ADH
that has been available as an antidote for EG poisoning in France since
1982 and now is also FDA approved for use in the United States. The
treatment regimen (Figure 3) is designed to maintain efficacious blood
levels throughout the course of therapy and no levels need to be
monitored. During the Methylpyrazole for Toxic Alcohols (META) trial,
fomepizole was shown to effectively stop EG and methanol metabolism
and reduce the accumulation of toxic metabolites.11,12 It also reduced the
need for hemodialysis with EG but not methanol.
In summary, fomepizole is the preferred
antidote for EG and methanol poisoning. Its
efficacy and safety have been demonstrated in
prospective human studies and the primary
factor limiting its widespread use at this time is
cost.
Figures
Octreotide
Cost: $10.70/ml
Fomepizole