N-Acetylcysteine (NAC)

• 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

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

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)

Benzodiazepine

• 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

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/hr IV, goal urine pH 7-8

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 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

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 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

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

Calcium Edta (Edetate Disodium)

• 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

Coral Snake Antivenin (Micrurus Fulvius)

• 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

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: 250 mg/kg IV

Cyanokit (Hydroxocobalamin)

• 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

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 q10-15min p.r.n, max. 10 mg/kg

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/hr, flushing, urticaria
• Dose: 10-15 mg/kg/hr IV, may increase in severe iron (Fe) poisoning

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

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 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

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

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 d, then q12h for 14 d, then reassess blood lead levels

Epinephrine

• 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

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/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

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

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

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: 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)

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 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

Intralipids

• 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

Methylene Blue

• Indications: Methemoglobinemia with dyspnea or >25%
• Warnings: G6-PD deficiency
• Dose: 1-2 mg/kg slow IV as 1% solution, repeat in 1 hr

Naloxone (Narcan)

• 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

Octreotide

• 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

Oxygen, Hyperbaric

• 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

Penicillamine

• 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

Phentolamine

• 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

Physostigmine

• 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

Pralidoxime (2-PAM, Protopam)

• 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

Protamine

• 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

Pyridoxine (Vitamin B6)

• 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

Rattlesnake Antivenin (Crotaline)

• 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

Vitamin K (Phytonadione, Aqua Mephyton)

• 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

ICD9

977.9 Poisoning by unspecified drug or medicinal substance

ICD10

T65.91XA Toxic effect of unspecified substance, accidental (unintentional), initial encounter

SNOMED

• 75478009 Poisoning (disorder)

• 67329000 Administration of antidote (procedure)