Adult Dosing

Nerve agent poisoning (Protopam auto-injector)

• Start 600 mg IM x 1
• May repeat q15min for 2 doses
• Max: 1.8 g or 3 doses

Note:

• Give as soon as possible after poisoning
• Close supervision is needed for at least 48-72 hrs
• Give atropine first; may repeat pralidoxime after atropine effects apparent
• For very severe cases, ensure removal of secretions, maintenance of a patent airway and artificial ventilation are undertaken. Do not use atropine until cyanosis has been overcome
• The auto-injector should be used by individuals who have received adequate training in the recognition and treatment of nerve agent poisoning

Organophosphate agent poisoning

• 1-2 g IV over 15-30 mins; may be repeated in 1 hr if muscle paralysis is still present
• Additional doses may be given cautiously if muscle weakness persists
• IV route is preferred; if not available, may be given IM or SC

Anticholinesterase overdose

• 1-2 g IV, then 250 mg IV q5 mins until symptoms reverse

• Give as soon as possible after poisoning
• Close supervision is needed for at least 48-72 hrs
• Give atropine first (in a dose of 2-4 mg IV); do not give atropine if significant hypoxia is present
• Severe poisoning (coma, cyanosis, respiratory depression) requires intensive management including removal of secretions, airway management, the correction of acidosis, and hypoxemia

Pediatric Dosing

• Safety and effectiveness in pediatric patients have not been established

• Pralidoxime is indicated for the following:
• Early (first 24-36 hr) treatment of organophosphate anticholinesterase insecticide poisoning
• Management of anticholinesterase (neostigmine, pyridostigmine, ambenonium, or nerve gas) overdosage
• Auto-injector is specifically indicated for IM use as an adjunct to atropine in the treatment of poisoning by nerve agents having anticholinesterase activity

• Hypersensitivity to any of the ingredients of the product

Renal Dose Adjustment

• Renal impairment: Decrease dose; specific dose adjustments not defined

Hepatic Dose Adjustment

• Dose adjustments not defined

• Pralidoxime is not effective in the treatment of poisoning due to phosphorus, inorganic phosphates or organophosphates not having anticholinesterase activity
• Rapid injection may result in adverse events such as tachycardia, laryngospasm, and muscle rigidity
• Use with great caution in treating organophosphate overdosage in myasthenia gravis as it may precipitate a myasthenic crisis
• Elevations in SGOT and/or SGPT enzyme levels may occur
• When atropine and pralidoxime are used together, the signs of atropinization may occur earlier than when atropine is used alone
• Pralidoxime Auto-injector should be used only if the individual has donned his mask subsequent to recognizing the existence of a chemical agent hazard in his area and if there is presence of any of these symptoms
• Unexplained runny nose
• Tightness of chest with difficulty in breathing
• Pinpointed pupils of the eye resulting in blurred vision
• Drooling, excessive sweating
• Nausea, vomiting, and abdominal cramps
• Involuntary urination and defecation
• Jerking, twitching, and staggering
• Headache, drowsiness, coma, convulsions
• Breathing difficulties

Pregnancy Category:C

Breastfeeding: Safety unknown

• Reactivates cholinesterase which is inactivated by phosphorylation due to an organophosphate pesticide or related compound. It slows the process of aging of phosphorylated cholinesterase to a nonreactivatable form, and detoxifies certain organophosphates
• Metabolized by liver
• Renally excreted
• Half-life: 74-77 mins

US Trade Name(s)

• Protopam

US Availability

pralidoxime (generic)

• INJ (prefilled auto-injector): 600 mg/2 mL

Protopam

• INJ: 1 g/vial

Canadian Trade Name(s)

• N/A

Canadian Availability

• N/A

UK Trade Name(s)

• Protopam

UK Availability

Protopam

• INJ: 1 g/vial

Australian Trade Name(s)

• N/A

Australian Availability

• N/A

Emergency/Critical Care

Antidotes

Cholinesterase Reactivator