Poisoning, Antidotes
Treatment
- Indications: Acetaminophen overdose
- Warnings:
- Unpleasant odor, nausea, vomiting
- Most effective if given in first 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
Pediatric Considerations
This volume of D5W will need to be reduced in dosing pediatric patients to avoid fluid overload/hyponatremia. Discuss with pharmacy
- 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
- 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)
- Indications: Agitation, stimulant drugs, seizures
- Warnings: Respiratory/CNS depression
- Dose:
- Midazolam:
- Adult: 1 mg IV/IM every 2–3 min p.r.n
- 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
- Midazolam:
- 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/hr IV, goal urine pH 7–8
- Serum alkalinization:
- Indications: Severe HTN, muscle spasms not alleviated by analgesics and muscle relaxants; consider in extremes of age (<5 or >65 yr), pregnant women with threatened abortion
- Warnings:
- Equine serum derived: Immediate hypersensitivity, serum sickness 10–14 d
- Premedicate for anaphylaxis if known equine serum hypersensitivity
- Dose: 1–2 vials IM/IV slowly over 15–30 min; dilute 1 vial in 50 mL saline for IV
- 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 d
- Premedicate for anaphylaxis if known 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/hr IV. Double rate after 15 min if no ill effects
- 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
- Indications: Lead, chromium, nickel, manganese, zinc toxicity
- Warnings: Nausea, vomiting, chill, nephrotoxicity, hypercalcemia
- Dose: 1 g/m2/d IV over 8–12 hr for 5 d, skip 2–4 d, then repeat. Follow lead (Pb) level
- Indications: Eastern or Texas coral snake
- Warnings:
- Equine serum derived: Immediate hypersensitivity, serum sickness 10–14 d
- Premedicate for anaphylaxis if known equine serum hypersensitivity
- Dose: 4–10 vials slow IV push over 15–30 min
- 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: 250 mg/kg IV
- Amyl nitrite: 1–2 amp crushed, inhaled
- Indications: Cyanide poisoning
- Warnings: Erythema, HTN
- Dose:
- Adult: 70 mg/kg IV to max. 5 g over 15 min; may repeat a second 5-g dose depending on severity of poisoning and clinical response. Max. 10 g. Reconstitute 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
- Indications:
- Malignant hyperthermia
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Muscle rigidity
- Warnings: Muscle weakness, respiratory depression, hepatitis
- Dose: 1–2 mg/kg IV bolus, repeat q10–15min p.r.n, max. 10 mg/kg
- Indications: Iron toxicity
- Warnings:
- Do not treat for >24 hr, risk for delayed adult respiratory distress syndrome (ARDS)
- Hypotension if >15 mg/kg/hr, flushing, urticaria
- Dose: 10–15 mg/kg/hr IV, may increase in severe iron (Fe) poisoning
- 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
- 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 d, then q12h for 7 d; follow metal levels
- For Pb level >100 mcg/dL: 4–5 mg/kg IM q4h until Pb <50 mcg/dL, in conjunction with EDTA
- 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
- Indications: Pediatric lead poisoning
- Warnings:
- Caution in renal impairment – urinary elimination
- Nausea, vomiting, diarrhea
- Dose: 10 mg/kg PO q8h for 5 d, then q12h for 14 d, then reassess blood lead levels
- Indications: Angioedema, anaphylaxis, acute asthma, spinal shock, β-blocker overdose
- Warnings: Dysrhythmias, HTN, tremor, anxiety
- Dose:
- Hypotension/shock:
- Adult: 1–4 mcg/min IV infusion
- Pediatric: Start IV infusion at 0.1 mcg/kg/min
- Anaphylaxis:
- Adult: 0.3–0.5 mg IM/SC
- Pediatric: 0.01 mg/kg IM/SC
- Hypotension/shock:
- Indications: Methanol or ethylene glycol toxicity
- Warnings:
- Disulfiram reaction, 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/hr maintenance
- PO: 1.5 mL/kg as 100-proof solution, then 0.3 mL/kg/hr maintenance
- Goal: Ethanol level of 100–150 mg/dL
- 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
- 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
- Indications:
- β-Blocker or calcium channel blocker overdose with bradycardia/hypotension
- Hypoglycemia
- Warnings:
- Nausea, vomiting, hyperglycemia
- Hypotension from diluent (phenol containing)
- Dose:
- β-Blocker or calcium channel blocker overdose:
- Adult: 5–10 mg IV over 1 min
- Pediatric: 50 mcg/kg IV up to max. 10 mg 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)
- β-Blocker or calcium channel blocker overdose:
- 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 first bolus or after any increase in dose, then q1h
- Dose:
- Bolus:
- 0.5–1 U/kg regular insulin, followed by 25 g glucose (1 amp D50)
- Maintenance:
- Insulin 0.5 unit regular insulin per kg/hr, titrate to 1 unit regular insulin per kg/hr
- Glucose D10 start at 100 mL/hr (10 g/hr) and titrate to keep glucose ≥100 mg/dL
- Bolus:
- 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
- Indications: Methemoglobinemia with dyspnea or >25%
- Warnings: G6-PD deficiency
- Dose: 1–2 mg/kg slow IV as 1% solution, repeat in 1 hr
- Indications:
- Opiate poisoning, empiric treatment of coma
- Warnings:
- Acute opiate withdrawal, severe agitation
- Dose:
- Adult: 0.4–2 mg IV/IM, repeat to 10 mg
- Pediatric: 0.1 mg/kg IV/IM
- Indications: Sulfonylurea overdose with hypoglycemia
- Warnings: Use with caution in diabetic patients
- Dose:
- Adult: 50 mcg SC q6h
- Pediatric: 4–5 mcg/kg/d SC div q6h
- 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
- 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 d (max. 1 g/d)
- Mercury:
- Adult: 250 mg PO q.i.d
- Pediatric: 20–30 mg/kg/d PO in 4 div doses
- Lead:
- Indications:
- Hypertensive crisis: Stimulants, sympathomimetics, MAO–tyramine reaction, and extravasated pressors
- Reversal of cocaine-mediated vasospasm
- Warnings: HTN, tachycardia, dysrhythmias
- Dose:
- 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
- HTN:
- Indications: Severe anticholinergic syndrome
- Warnings: Contraindicated in TCA overdose
- Dose:
- Adult: 0.5–1 mg IV, repeat in 10 min p.r.n
- Pediatric: 0.02 mg/kg IV, repeat in 10 min p.r.n
- 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 p.r.n, repeat in 6 hr if nicotinic symptoms return
- Pediatrics: 25–50 mg/kg over 15 min, repeat in 1 hr p.r.n, repeat in 6 hr if nicotinic symptoms return
- Indications: Reversal of heparin anticoagulation
- Warnings:
- Hypersensitivity in patients with fish allergy
- Avoid benzyl alcohol diluent in neonates
- Dose:
- 1 mg for each 100-unit 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
- 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
- Isonicotinic acid hydrazide (INH)–induced seizures:
- Indications: Significant envenomation by Crotaline species: Rattlesnake, cottonmouth, water moccasin, pit viper
- Warnings:
- Ovine-derived products: Immediate hypersensitivity, serum sickness 10–14 d
- 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
- Ovine derived (CroFab):
- 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
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Citation
Schaider, Jeffrey J., et al., editors. "Poisoning, Antidotes." 5-Minute Emergency Consult, 6th ed., Lippincott Williams & Wilkins, 2020. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307050/0.22/Poisoning_Antidotes.
Poisoning, Antidotes. In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307050/0.22/Poisoning_Antidotes. Accessed October 12, 2024.
Poisoning, Antidotes. (2020). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (6th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307050/0.22/Poisoning_Antidotes
Poisoning, Antidotes [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. [cited 2024 October 12]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307050/0.22/Poisoning_Antidotes.
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BT - 5-Minute Emergency Consult
UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307050/0.22/Poisoning_Antidotes
PB - Lippincott Williams & Wilkins
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