Antidotes


Antidotes at MUH, at CUH

National poisons information Antidotes Booklet.



Antidotes held at regional centres


These are the National Poisons Information Service recommended antidotes - May 2009

Link here for theh 2008 National Poisons Information Service (NPIS) Antidote booklet or www.poisons.ie

Agent / drug

Indications

Presentation

Comments

Activated Charcoal

Reduction absorption toxic substances by GI tract that are adsorbed by charcoal

50g pack

Atropine

Organophosphates, Carbamate insecticides

Injection 600mcg/ml

Use in cardiac arrest iwith ALS guidelines

Calcium gluconate

  1. Prevent transdermal adsorption of hydrofluoric acid (HF)
  2. Ca++ channel blocker XS
  3. Oxalates

A. Calcium gluconate gel 2.5%

B.& C. Calcium gluconate 10% 10ml vial

Cholestyramine

↓t½ and ↑clearance of oral anticoagulants (e.g warfarin) & long acting anticoagulants used as pesticides 4g sachet  

Cyproheptadine

Serotonin syndrome 4mg tabs  

Dantrolene

Drug-induced hyperthermia incl.  neuroleptic malignant syndrome

Tablets 25mg; injection 20mg

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Desferrioxamin

Toxicity with iron

Injection 500mg

Diazepam

Mx convulsions, anxiety, agitation and hypertonia 2° to toxins, toxicity with organophosphates

Tablets 2mg, 5mg, 10mg; injection (Diazemuls) 10mg/2ml; rectal solution 2.5mg, 5mg, 10mg tubes

Dicobalt edetate

Cyanide toxicity

300mg/20ml

Confirm toxicity by measuring the serum cyanide concentration

Digoxin antibodies

Digoxin toxicity   More on digoxin toxicity page or Digifab page

Dimercaprol

Toxicity with arsenic; can be used in conjunction with EDTA in cases of severe toxicity with lead, particularly lead encephalopathy

100mg/2ml

Must be administered intramuscularly. Contains peanut oil as a solvent

Agent / drug

Indications

Presentation

Comments

Ethanol

Toxicity with methanol and ethylene glycol

Dehydrated alcohol (100% ethanol) 5ml injection

Flumazanil

WITH CAUTION in cases of ISOLATED toxicity with benzodiazepines resulting in severe respiratory and central nervous system depression; then only if supportive measures have failed

Injection 500mcg/5ml

Contraindicated in :
1) Toxicity with TCADs [seizures]
2) Toxicity with unknown agents
3) Toxicity with cardiotoxic agents [arrhythmias] (Cocaine, amphetamines, tricyclic antidepressants, calcium channel blocking drugs, β-blockers and chloral hydrate)
4) Toxicity with agents that lower the seizure threshold (cocaine, amphetamines, tricyclic antidepressants, phenothiazines, theophylline)
5) Past history of epilepsy
6) History of long term therapy with benzodiazepines

Agent / drug

Indications

Presentation

Comments

Folinic acid

Toxicity with folinic acid antagonists*;
Toxicity with methanol

Injection 15mg

Used for * e.g. XS Methotrexate or Trimethoprim

Glucagon

Toxicity with β-blockers

1mg

Consider in toxicity with Ca++ channel blockers and other agents that cause myocardial depression. Seek advice from NPIS

Isoprenaline

Toxicity with β- blockers

Injection 0.2 mg/ml

Kept in fridge in CUH resusc. room

Lorazepam

First line therapy in status epilepticus

Injection 4mg/ml; tablets 1mg

Long half life compared with diazepam

Mensa

↓ urothelial toxicity in antineoplastic therapy 100mg/ml in 4ml amps  
   

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Methionine

Toxicity with paracetamol

Tablets 500mg

Useful in anaphylactoid reactions to n-acetylcystene but adsorbed by activated charcoal

Agent / drug

Indications

Presentation

Comments

Methylene blue

Iatrogenic methaemaglobinaemia

100mg/10ml

N-Acetylcysteine

Toxicity with paracetamol

2g/10ml

Please see paracetamol toxicity page

Naloxone

Opioid poisoning with respiratory and CNS depression unresponsive to supportive therapy

Injection 400mcg/ml; neonatal formulation 40mcg/2ml

Neostigmine

Curare type neuromuscular blockade

Tablets 15mg, injection 2.5mg/ml

Octreotide

Refractory hypoglycaemia induced by Sulphonylureas & quinnine    

Paraldehyde

Status epilepticus

Paraldehyde & olive oil enema

Stocked in Ladybird ward CUH

Penicillamine

Toxicity with copper, lead, copper and arsenic poisoning

Tablets 125mg, 250mg

Penicillamine use should be restricted to cases where other chelating agents are unavailable.

Phentolamine

A) Toxicity with alpha-adrenergic agents

B) Cocaine toxicity

10mg/ml

Kept in CUH resusc. fridge

Agent / drug

Indications

Presentation

Comments

Phenytoin

Status epilepticus

250mg/5ml

Patients should have blood pressure and ECG monitored continuously during therapy

Polyethylene glycol
(PEG)

Solution for whole bowel irrigation for drug mules (packers)

Sachets

Pralidoxime

Toxicic exposure to organophosphate insecticides 20% injection

Procyclidine

Dystonic reactions 5mg/ml

Propanolol

Toxicity with beta-adrenergic agonists, theophylline

Tablets 10mg, 80mg, 160mg

Protamine sulphate

Toxicity with heparin

Injection 10mg/ml

Sodium calcium edetate (EDTA)

Toxicity with lead

5% injection (0.5g in 10ml)

Sodium nitrite

Toxicity with cyanide

Injection sodium nitrite 3% (30mg/ml)

Sodium thiosulphate

Toxicity with cyanide

20ml injection sodium thiosulphate 50% (500mg/ml)

 

Starch powder

Iodine poisoning 500g powder  

Vitamin K

(phytomenadione)

Toxicity with coumarin derivatives, including warfarin

Injection 2mg/0.2ml, 10mg/ml; tablets 10mg

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* group 1 = specific antidotes; group 2 = agents to prevent absorption and enhance elimination; group 3 = other useful agents
**Availability; A = available immediately; B<1 hour; C= Supraregionally
Evidence; 1 = well documented; 2 = widely used, lack of evidence; 3 = questionable usefulness


Antidotes held in regional holding centres*

Agent / drug

Indications

Presentation

Comments

DMPS
(Dimercaptopropanesulfonic acid)

Toxicity with mercury

Data regarding efficacy in toxicity with arsenic and lead is less convincing. Seek advice form NPIS

DMSA
(Dimercaptosuccinic acid)

Toxicity with mercury, arsenic, lead

Stored in Beaumont NPIS

Agent / drug

Indications

Presentation

Comments

Fomepizole
(4-Mthylpyrazole)

Toxicity with ethylene glycol, may be considered in cases of toxicity with ethanol

Injection 1.5g/1.5ml

Fomepizole (HSE vs €)is a second line agent after ethanol and haemodialysis for toxicity with ethylene glycol. Fomepizole is stocked in the antidotes cupboard in the ED at MUH.

Hydrocobalamin

Toxicity with cyanide

Not first line therapy in cases of toxicity with cyanide. May be considered in the empirical management of toxicity with cyanide due to smoke inhalation.

Prussian blue

Toxicity with thallium

 

Kept in DDA press in CUH

Silibinin

Amanita phalloides (death cap mushrooms) poisoning

  Kept in Baeumont hospital

Pyridoxine

Toxicity with isoniazid & ethylene glycol

100mg/2ml injection

* group 1 = specific antidotes; group 2 = agents to prevent absorption and enhance elimination; group 3 = other useful agents
**Availability; A = available immediately; B<1 hour; C= Supraregionally
Evidence; 1 = well documented; 2 = widely used, lack of evidence; 3 = questionable usefulness


Content by Dr Íomhar O' Sullivan 19/09/2002. Reviewed by Dr ÍOS 08/07/04. 13/05/2007, 22/03/2008, 28/05/2009. NPIS booklet published with permission 22/03/2008, 28/05/2009. Last review Fiona Ahern5/09/17->, Dr. C. Luke5/09/17->.