antidote.docx

Substance

Antidote

Acetaminophen

N-acetylcysteine

Anticholinergic agents (eg, atropine)

Physostigmine

Benzodiazepines

Flumazenil

β-Adrenergic antagonists

Glucagon

Insulin and dextrose

Amrinone

Carbon monoxide

Calcium-channel blockers

Dose



IV: 150 mg/kg over 15 min, then 50 mg/kg over 4 hr, then 100 mg/kg over 16 hr

Comments



AE: vomiting (PO); anaphylactoid reaction (IV).



IV protocol requires large volumes of free water, which may cause hyponatremia and seizures in children.



PO: 140 mg/kg load, then 70 mg/kg/dose every 4 hr for 17 doses



P: 0.5 mg IV slowly



May repeat dose after 15 min.



A: 2 mg IV slowly



AE: cholinergic symptoms occur with excessive dosing.



P: 0.01 mg/kg IV slowly every min (max 1 mg)





A: 0.1–0.2 mg IV slowly every min (max 1 mg)

Titrate to effect or maximal dose. May not reverse respiratory depression. If positive response is of short duration, may be administered as a continuous infusion.



AE: withdrawal symptoms in dependent or chronic use; seizures or dysrhythmias in cyclic antidepressant overdose.



If positive response is of short duration, may be administered as a continuous infusion.



AE: vomiting, hyperglycemia, hypocalcemia.



P: 0.1 mg/kg IV slowly



A: 3–5 mg IV slowly



Insulin 0.5 U/kg/hr IV, with



Dextrose 1 g/kg/hr

750 mcg/kg over 3–5 min slowly (max 3 mg/kg)

AE: hypo- or hyperglycemia, hypokalemia.



May use other phosphodiesterase inhibitors with equal efficacy (eg, milrinone).



AE: hypotension.

Oxygen (100%)

100% oxygen by nonrebreather

Treat until normal CO level or until hyperbaric oxygen initiated.

Oxygen (hyperbaric)

100% oxygen at 23 atmosphere for 20 min

AE: pneumothorax, perforated tympanic membrane.

Calcium chloride (10%)



P: 20 mg/kg (0.2 mL/kg)



May use glucagon, insulin, and dextrose as adjunctive

IV slowly, via central line



Calcium gluconate (10%)

Cyanide

Amyl nitrate

Sodium nitrite (3%)

Sodium thiosulfate (25%)

Digoxin

Ethylene glycol and methanol

Digoxin-specific antibody fragments (Digibind)

Ethanol (10%)

A: 1–2 g (10–20 mL) IV slowly



P: 60 mg/kg (0.6 mL/kg)



A: 3–6 g (30–60 mL) IV

One ampule by inhalation for 30 seconds every 3 min until IV access



P: 0.33 mL (10 mg) IV (for Hb at 12)



A: 10 mL IV over 10 min



P: 1.6 mL/kg IV (for Hb at 12)



A: 50 mL IV over 3 min



For known ingested dose: number of vials = mg ingested × 1.5



For known serum digoxin concentration (SDC, ng/mL): number of vials = SDC × weight (kg)/100



For unknown SDC or dose acute overdose: 10–20 vials



For chronic overdose: P: 2 vials; A: 5 vials

800 mg/kg (8 mL/kg) IV over 20-60 min, then 80-130 mg/kg/hr (0.8-1.3 mL/kg/hr) IV

treatment in CCB as in BB toxicity.



AE: hypercalcemia, phlebitis, nausea, vomiting, flushing, confusion, angina.

AE: methemoglobinemia (see caution for sodium nitrite below).



Dose varies according to weight and Hb level. See package insert.



AE: methemoglobinemia.



Use with caution in unconfirmed or unlikely cyanide poisoning (eg, in the setting of smoke inhalation), because induced methemoglobinemia may exacerbate hypoxemia from other causes.



Dose varies according to weight and Hb count. See package insert.



AE: hypotension, CNS toxicity.



Each 40-mg vial binds 0.6 mg digoxin.



AE: hypokalemia, worsening CHF.

Titrate to serum ethanol 100 mg/dL. Increase dose during dialysis and in chronic alcoholics. Oral dosing may be used in select cases.

Fomepizole (4methylpyrazole)

15 mg/kg over 30 min IV, then 10 mg/kg/dose every 12 hr × 4 doses, then 15 mg/kg/dose every 12 hr

Heparin

Protamine sulfate

Use 1 mg protamine for every 100 units of heparin to be neutralized.

Iron

Deferoxamine

5–15 mg/kg/hr IV (max 6 g/24 hr)



Continue therapy until serum methanol or ethylene glycol level < 20 mg/dL. Increase dose during dialysis.



AE: headache, nausea, dizziness bradycardia, eosinophilia, transient increase of liver enzyme levels

AE: hypotension, bradycardia, hemorrhage. Use with caution with known fish allergy.





Isoniazid

Lead

Pyridoxine (vitamin B6)

Succimer (DMSA)

Dimercaprol (BAL)



Known INH dose: 1g per g of INH ingested IV slowly



Unknown INH dose: 5 g IV over 10 min

10 mg/kg/dose PO every 8 hr × 5 days, then 10 mg/kg/dose twice daily × 14 days

 

CaNa2 EDTA

Methanol

See Ethylene glycol

75 mg/m2/dose IM every 4 hr Max: 450 mg/m2/dose/24 hr

1–1.5 g/m2/day continuous IV infusion × 5 days

Titrate dose slowly to avoid hypotension. Continue therapy until vin rose urine color clears, symptoms clinically resolve, or maximal dose attained. Deferoxamine challenge no longer suggested.



AE: flushing, hypotension, acute respiratory distress syndrome.



Administer 1 g every 23 min.



AE: CNS toxicity—headache, seizure, peripheral neurotoxicity.

AE: rash, neutropenia, increased LFTs, GI upset.



Pretreatment with diphenhydramine suggested. Contraindicated with peanut allergy, hepatic insufficiency.



AE: G6PD hemolytic crisis, nausea, vomiting, histamine release.



In cases of encephalopathy, administer after dimercaprol to prevent increased CNS lead levels.



AE: phlebitis.

Methemoglobinemia Methylene blue (1%)

Opioids

Cholinergic agents (eg, malathion)

Naloxone

Atropine

Pralidoxime

Oral antidiabetic agents

Octreotide

Dextrose

1–2 mg/kg IV over 5 min

0.5–2 mg IV/IM/SC/ET (max 10 mg)



P: 0.02 mg/kg IV initial dose (minimum 0.1 mg)



A: 0.5–1 mg IV initial dose



P: 25–50 mg/kg over 30– 60 min, then 20 mg/kg/hr



A: 1–2 g IV over 15–30 min, then 0.5 g/hr



P: 1–2 mcg/kg SC/IV every 6–12 hr



A: 50–100 mcg SC/IV, then 50 mcg every 12 hr



Neonate: 0.2 g/kg IV (use D10W, 2 mL/kg)



P: 0.5–1 g/kg IV (use D25W, 2–4 mL/kg)



A: 25–50 g IV (use D50W)



Repeat doses as needed.



AE: dyspnea, chest pain, and hemolysis.



Higher dose may be required for certain agents. Can repeat dose every 2–3 min until response or max dose. If no response to total 10-mg dose, unlikely opioid intoxication. If positive response is of short duration, may be administered as a continuous infusion. In setting of possible opioid dependence, consider initial dose of 0.05 mg to avoid withdrawal.



AE: opioid withdrawal (piloerection, agitation, vomiting).



Double dose every 3–5 min. Titrate to reduced bronchorrhea or improved oxygen saturation. May require total doses 5 or 10 times the initial dose or higher.



AE: anticholinergic toxicity.

Pralidoxime should be administered in addition to atropine. Continue therapy for 24–72 hr.



Continue therapy until euglycemic. May require several days of therapy.



AE: bradycardia, dysrhythmias, GI upset, hyperglycemia.

AE: hyperglycemia, extravasation may cause local tissue reaction.

Tricyclic antidepressants

Sodium bicarbonate

Warfarin

Vitamin K

1–2 mEq/kg IV bolus, then titrate to pH ~7.5 with additional doses or with continuous infusion



P: 1–5 mg SC/IM/IV/PO, every 6–8 hr PRN



A: 10 mg SC/IM/IV/PO, every 6–8 hr PRN

AE: volume overload, hypernatremia, metabolic alkalosis.

Much larger doses may be required. Continue therapy until INR within normal limits.

Abbreviations: AE, adverse effects; BB, β-adrenergic blocker; CCB, calcium-channel blocker; CHF, congestive heart failure; CNS, central nervous system; CO, carbon monoxide; D10W, 10% dextrose and water; ET, endotracheally; G6PD, glucose-6-phosphate dehydrogenase; GI, gastrointestinal; Hb, hemoglobin; INH, isoniaizid; IM, intramuscular; INR, international normalized ratio of prothrombin time; IV, intravenous; LFT, liver function tests; max, maximum; PO, oral; PRN, as needed; SC, subcutaneous; SDC, serum digoxin concentration. *Pediatric (P) and adult (A) doses are the same unless specifically noted.