Poisoning, Antidotes

Poisoning, Antidotes is a topic covered in the 5-Minute Emergency Consult.

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Treatment

Other

N-Acetylcysteine (NAC)
  • Indications: Acetaminophen overdose
  • 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

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

Other

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

Other

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)

Other

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

Other

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

Other

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

Other

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.

Other

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

Other

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

Other

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

Other

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

Other

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.

Other

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

Other

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

Other

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

Other

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 μg/dL: 4–5 mg/kg IM q4h until Pb <50 μg/dL, in conjunction with EDTA

Other

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

Other

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

Other

Epinephrine
  • Indications: Angioedema, anaphylaxis, acute asthma, spinal shock, β-blocker overdose
  • Warnings: Dysrhythmias, HTN, tremor, anxiety
  • Dose:
    • Hypotension/shock:
    • Adult: 1–4 μg/min IV infusion
    • Pediatric: Start IV infusion at 0.1 μg/kg/min.
    • Anaphylaxis
      • Adult: 0.3–0.5 mg IM/SC
      • Pediatric: 0.01 mg/kg IM/SC

Other

Ethanol
  • 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/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

Other

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

Other

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

Other

Glucagon
  • 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: 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)

Other

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

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Citation

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TY - ELEC T1 - Poisoning, Antidotes ID - 307050 Y1 - 2016 PB - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307050/all/Poisoning__Antidotes ER -