IPC's Antidote Stocking Chart

14 Pages·2017·0.06 MB·English

Updated: January2018
Illinois Poison Center Antidote Stocking Chart
UsesandSuggestedMinimumStockQuantitiesforPoisonAntidotesforIllinoisHospitalswithEmergencyDepartments
PoisonCenter24-hourHotline:1-800-222-1222
NOTE: Thefollowingsuggestedantidotestockinglevelsweredevelopedfromapublishedconsensusguidelinepanelandconsultationwiththeclinicalstaffofthe
IllinoisPoisonCenter.TheyweredesignedforguidanceforIllinoisHospitalswithEmergencyDepartments.Requirementsandspecialcircumstancesinother
areasoftheU.S.mayjustifydifferentstockingquantities(e.g.antivenomsforsnakes,scorpions,spiders,etc).
Poison Antidotes
Antidote Poison/Drug/Toxin SuggestedMinimumStockQuantity Rationale/Comments
N-Acetylcysteine Acetaminophen IV:450mL(90g)Acetadote Acetaminophenisthedrugmostcommonlyinvolvedin
(Mucomyst,Acetadote,Cetylev) intentionalandunintentionalpoisonings.IV
Carbontetrachloride Availableas30mLvial,200mg/mL administrationispreferredoverPOinpatientsthatare
uncooperative,vomiting,orpresentwithaltered
Otherhepatotoxins PO:500mL(100g)of20%NACorequivalentmentalstatus,unprotectedairway,pregnancyor
doseofeffervescenttablets hepaticfailure.500mL(100g)oftheoralproduct
providesenoughtotreattwo100kgadultsfor24h.
SeveralvialsmaybestockedintheEDtoprovidea
loadingdoseandtheremainingvialsinthepharmacy.
450mL(90g)ofIVproductwilltreatthree100kgadult
patientsfortheentire21hIVprotocol.
Antivenin,CrotalidaePolyvalentImmune Pitviperenvenomation(eg, 12-18vials AdvisedingeographicareasinIllinoiswithendemic
Fab–Ovine rattlesnakes,cottonmouths,and populationsofcopperhead,watermoccasin,eastern
(CroFab) copperheads) massasauga,ortimberrattlesnake.Inlow-riskareas,
knownearestalternatesourceofantivenin.12vials
willprovide8hoftreatment;18vialswillprovide24hof
treatment.Stockinpharmacy.Storeinrefrigerator.
Antivenin,Latrodectusmactans Blackwidowspiderenvenomation 0-1vial SeriousLatrodectusenvenomationsarerareinIllinois.
(Blackwidowspider) Thisproductisonlyusedforsevereenvenomations.
Availableas2.5mLvial Antiveninmustbegiveninacriticalcaresettingsince
itisanequine-derivedproductthatmaycause
anaphylaxis.Productmustberefrigeratedatalltimes.
Knowthenearestsourceofantidote.
Updated: January2018
Poison Antidotes
Antidote Poison/Drug/Toxin SuggestedMinimumStockQuantity Rationale/Comments
Atropinesulfate Alpha agonists(eg,clonidineand 175mgorgreater Theproductshouldbeimmediatelyavailableinthe
guanfa2cine) ED.Somealsomaybestoredinthepharmacyor
Availableinvariousformulations: otherhospitalsites,butshouldbeeasilymobilizedifa
Alzheimersdrugs(eg,donepezil, 0.4mg/mL(1mL,0.4mgvial) severelypoisonedpatientneedstreatment.
galantamine,rivastigmine,tacrine) 0.4mg/mL(20mL,8mgvial)
0.1mg/mL(10mL,1mgsyringe) Note:Productisnecessarytobeadequatelyprepared
Antimyasthenicagents(eg, 1.0mg/mL(1mL;1mgvial) forWMDincidents;thesuggestedamountmaynotbe
pyridostigmine) sufficientformasscasualtyevents.Auto-injectorsare
Atropinesulfatemilitary-styleauto-injectors: availablefromBoundTreeMedical(800-533-0523).
Bradyarrhythmia-producingagents(eg, (Atropen):2mg/0.7mL;1mg/0.7mL; Drugstockedinchempackcontainersisintendedonly
betablockers,calciumchannel 0.5mg/0.7mL;0.25mg/0.3mL foruseinmasscasualtyevents.
blockers,anddigitalisglycosides)
Atropinesulfate2.1mg/0.7mLwith
Cholinergicagonists(eg,bethanechol) pralidoximechloride600mg/2mL(DuoDote)
Muscarine-containingmushrooms(eg,
ClitocybeandInocybe)
Nerveagents(eg,sarin,soman,tabun
andVX)
Organophosphateandcarbamate
insecticides
Botulinumantitoxin Food-bornebotulism None. Antitoxinmustbegiveninacriticalcaresettingsinceit
isanequine-derivedproduct.
Botulinumantitoxinsavailable: Woundbotulism Productisstoredat9CDCregionalcenters
(includingtheChicagoQuarantine).ToobtainNote:Productmustberefrigeratedatalltimes.
HBAT(heptavalenttypesA-G) Botulismasabiologicalweapon antitoxin,hospitalsmustcalltheirlocalor HeptavalentantitoxinisstoredintheCDCSNS.
stateDepartmentofPublicHealth,whichwill
BabyBotulismImmuneGlobulin(BIG) Note:Heptavalentantitoxinnot contacttheCDCinAtlanta.TheCDC BabyBIGisavailableforinfantbotulismtypesAandB,
currentlyrecommendedforinfant emergencyoperationcentercanbereached throughtheInfantBotulismTreatmentandPrevention
botulism at770-488-7100. Program,sponsoredbytheCaliforniaDepartmentof
PublicHealth,telephone:[phone],
www.infantbotulism.org/physician/obtain.php.
CalciumdisodiumEDTA Lead 2x5mLvials(200mg/mL) Onevialprovides1dayoftherapyforachild.2-4gper
(Versenate) 24hmaybenecessaryinadultpatients.Stockin
Zincsalts(eg,zincchloride) pharmacy.
Note:Edetatedisodium(Endrate)isnotthesameas
calciumdisodiumEDTA,andisusedprimarilyasan
IVchelatorforemergenttreatmentofhypercalcemia.
Updated: January2018
Poison Antidotes
Antidote Poison/Drug/Toxin SuggestedMinimumStockQuantity Rationale/Comments
CalciumchlorideandCalciumgluconate Fluoridesalts(eg,NaF) 10%calciumchloride:10x10mLvials Manyvialsofcalciumchloridemaybenecessaryin
life-threateningHFpoisoning.StockinED.Moremay
Hydrofluoricacid(HF) 10%calciumgluconate:30x10mLvials bestockedinpharmacy.
Hyperkalemia(notdigoxin-induced) Thechloridesaltprovides3xmorecalciumthanthe
gluconatesalt.Calciumchlorideisveryirritatingand
Hypermagnesemia administrationthroughacentrallineispreferable.
Topicalcalciumgluconateorcarbonategelsmaybe
extemporaneouslypreparedbythepharmacy.
Calgonate(calciumgluconate2.5%gel)isnotFDA
approvedbutismanufacturedinanFDA-GMP
approvedfacilityandisdistributedbyCalgonateCorp
inPortSt.Lucie,Florida.
CentruroidesImmuneF(ab) –Equine Scorpionenvenomation None Toxic scorpionenvenomationsarerareinIllinois.This
2
(Anascorp) productismanufacturedbyRareDisease
Therapeutics,Inc.inNashville,Tennessee.Itwas
approvedbytheFDAin2011andcanbestoredat
roomtemperature.Usualdose:1-3vials.
Updated: January2018
Poison Antidotes
Antidote Poison/Drug/Toxin SuggestedMinimumStockQuantity Rationale/Comments
CyanideAntidote: Acetonitrile 2-4kits Stock2kitsintheED.Consideralsostocking2kitsin
thepharmacy.
Sodiumnitriteandsodiumthiosulfate Acrylonitrile Eachkitcontains:
(Nithiodote) 1vial(10mL)sodiumnitrite(300mg) Note:Thiskithasashortshelflifeof24months.
Bromates(thiosulfateonly) 1vial(50mL)sodiumthiosulfate(12.5g)
Significantadversereactionsinclude
Chlorates(thiosulfateonly) Stockingthiskitmaybeunnecessaryifan methemoglobinemiaandhypotension.Forsmoke
adequatesupplyofhydroxocobalaminHClis inhalationvictims,thiosulfatewithouttheuseofnitrites
Cyanide(eg,HCN,KCN,andNaCN) available. maybeconsidered.
Cyanogenchloride In2012,thecyanidekitcontaining12amylnitrite
pearls,two10mLsodiumnitritevials,andtwo50mL
Cyanogenicglycosidenaturalsources sodiumthiosulfatevialswasdiscontinuedbythe
(eg,apricotpitsandpeachpits) manufacturerandisnolongeravailableintheUS.
Hydrogensulfide(nitritesonly)
Laetrile
Mustardagents(thiosulfateonly)
Nitroprusside(thiosulfateonly)
Smokeinhalation(combustionof
syntheticmaterials;thiosulfateonly)
Deferoxaminemesylate Iron 12-36g Quantityrecommendedsupplies8-24hoftherapyfora
(Desferal) 100kgadult.Perpackageinsert,themaximumdaily
Deferoxaminehasalsobeenusedfor Availablein500mgand2gvials doseis6g(12vials).However,thisdosemaybe
chronicaluminumtoxicityinchronic exceededinseriousacuteironpoisonings.Stockin
kidneydiseasepatients pharmacy.
DigoxinimmuneFab Cardiacglycoside-containingplants 15vials Aninitialdoseof2-3vialsforchronicpoisoningor10
(Digibind,Digifab) (eg,foxgloveandoleander) vialsforacutepoisoningmaybegiventoadigoxin-
Eachvial(40mg)neutralizes0.5mgofdigoxinpoisonedpatientinwhomthedigoxinlevelis
Digitoxin unknown.Moremaybenecessaryinsevere
intoxications.15vialswouldeffectivelyneutralizea
Digoxin steady-statedigoxinlevelof15ng/mLina100kg
patient.Knownearestsourceofadditionalsupply.
StockinEDorpharmacy.
Updated: January2018
Poison Antidotes
Antidote Poison/Drug/Toxin SuggestedMinimumStockQuantity Rationale/Comments
Dimercaprol Arsenic 4x3mLvials(100mg/mL) Thisamountprovides3dosesof3-5mg/kg/dosegiven
(BALinoil) every4htotreat1seriouslypoisonedadult(upto
Copper 100kg)orprovidesenoughtotreata15kgchildfor
morethan24h.2400mgwillprovideenoughtotreata
Gold 100kgadultfor24hours.Stockinpharmacy.Know
nearestsourceofadditionalsupply.
Lead
Lewisite
Mercury
Ethanol Ethyleneglycol Ethanolisunnecessaryifadequateamounts 180gprovidesloadingandmaintenancedosesfora
offomepizolearestocked. 100kgadultfor8-24h.Morealcoholorfomepizolewill
Methanol beneededduringdialysisorprolongedtreatment.
Considerstocking180-360gintheformof 95%or40%alcoholdilutedinjuicemaybegiven
95%ethanolorequivalents(10%ethanolcanorallyifIValcoholisunavailable.Stockinpharmacy.
bepreparedfromdehydratedalcoholand
DWforIVuse). Note:Seealsofomepizoleinthischart.Ethanolmay
5
causehypotensionormetabolicabnormalities(eg,
hypoglycemia)especiallyinpediatricpatients.Since
ethanoltreatmentfortoxicalcoholpoisoningisnot
FDAapprovedandfomepizoleoffersgreaterefficacy
andsafety,fomepizoleisthepreferredalcohol
dehydrogenaseinhibitor.
Fatemulsion Localanestheticsandpotentiallyother 1,200mL Fatemulsionisusedtoreversecardiactoxicity
(Intralipid,LiposynII,LiposynIII) cardiactoxins(eg,bupropion,calcium inducedbylocalanestheticsandothercardiactoxins.
channelblockers,cocaine,beta Availablein100mLof20%emulsion Theevidencefortheefficacyoffatemulsiontherapyis
blockers,tricyclicantidepressants) basedonanimalstudiesandhumancasereports.
Consultationwitharegionalpoisoncentertoxicologist
isadvised.Initialdose:1.5mL/kgIVover1min.Follow
withinfusionof0.25mL/kg/minover30min.Loading
dosemayberepeatedonce.Ratemaybeincreased
to0.5mL/kg/minfor60minifbloodpressuredrops.
Maximumtotaldoseis8mL/kg.Considerstoragein
pharmacy,ED,andpossiblysurgicalunits.
Flumazenil Benzodiazepines Total6-12mg Duetoriskofseizures,usewithextremecautionin
(Romazicon) poisonedpatients.Moremaybestockedinthe
Availablein5and10mLvials(0.1mg/mL) pharmacyforuseinreversalofconscioussedation.
StockinED,pharmacy,andanyunitwhereprocedural
sedationisperformed.
Updated: January2018
Poison Antidotes
Antidote Poison/Drug/Toxin SuggestedMinimumStockQuantity Rationale/Comments
FolicacidandFolinicacid Formaldehyde/Formicacid Folicacid:3x50mgvials Foradjunctivetreatmentofmethanol-poisoned
(Leucovorin) patientswithanacidosis,give50mgfolinicacid
Methanol Folinicacid:1x50mgvial initially,then50mgoffolicacidevery4hfor6doses.
Formethotrexate-poisonedpatients,administerfolinic
Methotrexate,trimetrexate acidonly.Stockinpharmacy.
Pyrimethamine
Trimethoprim
Fomepizole Ethyleneglycol 1-2x1.5gvials One1.5gvialprovidesaninitialdoseof15mg/kg/12h
(Antizol) toanadultweighingupto100kg.Morefrequent
Methanol Hospitalswithcriticalcareandhemodialysis dosing(ie,every4h)isrequiredduringhemodialysis.
4-methylpyrazole capabilitiesshouldconsiderstocking4vials
(4-MP) ormore. Ethanolisunnecessaryifadequatesupplyof
fomepizoleisstocked.Fomepizoleispreferredto
Note:Availableinakitof4x1.5gvials ethanolbecauseofeaseofuse,feweradverse
effects,simplicityofdosing,andlessneedforclose
monitoring.Stockinpharmacy.Knowwherenearest
alternatesupplyislocated.
GlucagonHCl Betablockers 50-90x1mgvials Thisquantityprovides4-8hofmaximumdosing(ie,a
10mgIVbolusdosefollowedby10mg/h).Moremay
benecessary.Knowwherenearestalternatesupplyis
located.Stock30mginEDandremainderin
pharmacy.
Glucarpidase Methotrexate Quantitydeterminedbyinstitution. Donotadministerdosewithin2hoursofleucovorin.
Knownearestsourceofsupply.Storeinrefrigerator.
Updated: January2018
Poison Antidotes
Antidote Poison/Drug/Toxin SuggestedMinimumStockQuantity Rationale/Comments
HydroxocobalaminHCl Acetonitrile 2-4kits Seriouslypoisonedcyanidepatientsmayrequire5-
(Cyanokit) 10g(1-2kits).Stock2kitsinED.Consideralso
Acrylonitrile Eachkitcontainsone5gvial. stocking2kitsinthepharmacy.Theproducthasa
shelflifeof30monthspost-manufacture.
Cyanide(eg,HCN,KCN,andNaCN) Note:Diluentisnotincludedinthekit.
Cyanogenchloride
Cyanogenicglycosidenaturalsources
(eg,apricotpitsandpeachpits)
Laetrile
Nitroprusside
Smokeinhalation(combustionof
syntheticmaterials)
Idaracizumab(Praxbind) Dabigatran 5g Storeinrefrigerator.Unopenedvialmaybekeptat
roomtemperatureforupto48hoursifstoredin
Suppliedas22.5g/50mLvials. originalpackageinordertoprotectfromlight,orupto
6hourswhenexposedtolight.
Stockinpharmacy.
Insulinanddextrose Calciumchannelblockers(diltiazem, Quantitydeterminedbyinstitution. High-doseinsulinanddextrosetherapycanreverse
nifedipine,verapamil) cardiovasculartoxicityassociatedwithcalcium
HumulinRisavailableas100units/mLina channelblockeroverdose.
1.5mLcartridgeand10mLbottle.
IVBolus:Recommendedstartingdoseof1unit/kg
Dextrose50%inwaterisavailablein50mL regularinsulin(with1ampD );Thelowest
ampulesandsyringes.Dextrose25%is maintenancedoseis0.5-1un50its/kg/hr.Higherdoses
availablein10mLvialsandsyringesfor maybeconsideredunderconsultationwithmedical
pediatricuse. toxicologist.StockinEDandpharmacy.
Updated: January2018
Poison Antidotes
Antidote Poison/Drug/Toxin SuggestedMinimumStockQuantity Rationale/Comments
Methyleneblue Methemoglobin-inducingagents 600mg Theusualdoseis1-2mg/kgIV(0.1-0.2mL/kgof1%
including: solutionor0.2-0.4mL/kgof5%solution).Asecond
Availableas1%solution(1mLand10mL dosemaybegivenin1h.Moremaybenecessary.
Anilinedyes vials)and0.5%solution(10mLampules). 600mgprovides3dosesof2mg/kgfora100kgadult.
Stockinpharmacy.Methyleneblueisconsideredan
Dapsone experimentaltherapyforshockassociatedwithdrug
overdose.
Dinitrophenol
Localanesthetics(eg,benzocaine)
Metoclopramide
Monomethylhydrazine-containing
mushrooms(eg,Gyromitra)
Naphthalene
Nitratesandnitrites
Nitrobenzene
Phenazopyridine
Naloxone Alpha agonists(eg,clonidineand Total40mg Stock20mgEDand20mgelsewhereintheinstitution.
(Narcan) guanfa2cine)
Availableas0.4mg/mLvial(1mLand10mL)
Unknownpoisoningwithmentalstatus and1mg/mL(2mL)syringe.
depression
Opioids(eg,codeine,diphenoxylate,
fentanyl,heroin,meperidine,morphine,
andpropoxyphene)
Octreotideacetate Sulfonylureahypoglycemicagents(eg, 225mcg Octreotideacetateblocksthereleaseofinsulinfrom
(Sandostatin) glipizide,glyburide) pancreaticbetacellsthat,alongwithIVdextrose,can
Availablein1mLvials(0.05mg/mL, reversesulfonylurea-inducedhypoglycemia.Theusual
0.1mg/mL,and0.5mg/mL)and5mL adultdoseis50-100mcgIVorSCevery6-12h.The
multidosevials(0.2mg/mLand1mg/mL). usualpediatricdoseis1-1.5mcg/kgIVorSCevery6-
12h.225mcgprovides4x75mcgadultdoses.Stock
inpharmacy.
Updated: January2018
Poison Antidotes
Antidote Poison/Drug/Toxin SuggestedMinimumStockQuantity Rationale/Comments
Physostigminesalicylate Anticholinergicalkaloid-containing 2x2mLvials(1mg/mL) Usualadultdoseis1-2mgslowIVpush.
(Antilirium) plants(eg,deadlynightshadeand
jimsonweed) Note:Durationofeffectis30-60min.StockinEDor
pharmacy.
Antihistamines
Atropineandotheranticholinergic
agents
Phytonadione Indandionederivatives 100mginjectable;100mgoral Patientswhoarepoisonedbylong-acting
(VitaminK)(Aquamephyton,Mephyton) anticoagulantrodenticidesmayrequire50-100mg/day
1 Long-actinganticoagulantrodenticides Availableas:0.5mLvials(2mg/mL)and1mL ormoreforweekstomonthstomaintainnormalINRs.
(eg,brodifacoumandbromadiolone) vials(10mg/mL) Anoralsuspensionforpediatricpatientsmaybe
extemporaneouslypreparedbythepharmacy.Stock
Warfarin 5mgtablets inpharmacy.
Pralidoximechloride OrganophosphateInsecticides(OPIs) 7-18g 7gwillprovideenoughtotreata100kgadultwitha
(2-PAM)(Protopam) loadingdoseof2gfollowedbyamaximuminfusionof
Nerveagents(eg,sarin,soman,tabun, Alsoavailableas: 650mg/hrfor8h,18gwillprovideenoughfor24h.
andVX) Pralidoximechloridemilitary-styleauto- Healthcarefacilitieslocatedinagriculturalareaswhere
injectors:600mg/2mL OPIsareusedshouldmaintainadequatesupplies.
Andpossibly: Productisnecessarytobeadequatelypreparedfor
Antimyasthenicagents(eg, Atropinesulfate2.1mg/0.7mLwith WMDincidents;thesuggestedamountmaynotbe
pyridostigmine) Pralidoximechloride600mg/2mL sufficientformasscasualtyevents.Auto-injectorsare
(DuoDote) availablefromBoundTreeMedical(800-533-0523).
Thedrugsstockedinchempackcontainersare
intendedforuseinmasscasualtyeventsonly.Stock
inEDorpharmacy.
Protaminesulfate Heparin 400-1200mg;considerrecommendationof Theusualdoseis1-1.5mgforeach100unitsof
hospitalpharmacy&therapeuticscommittee heparin.400mgwillprovideenoughtotreatapatient
Lowmolecularweightheparins(eg, for8h,1200mgwillprovideenoughtotreatfor24h.
enoxaparin,dalteparin,tinzaparin) Availableas5mLand25mLvials(10mg/mL)Stockinpharmacyinrefrigerator.Preservative-free
formulationdoesnotrequirerefrigeration.
ProthrombinComplexConcentrate Inandionederivatives 5,000IU VitaminK10mgIVshouldbeadministered
concurrentlytomaintainclottingfactorlevelsafter
3-Factor(Bebulin,Prfilnine)OR Long-actinganticoagulantrodenticides prothrombincomplexconcentratelevelshave
4-Factor(Beriplex,KCentra) (egbrodifacoumandbromadiolone) diminished.5,000IUprovidesadequatesupplyfor
patientsactivelybleedingassociatedwith
Warfarin anticoagulationtoxicity.Storeinrefrigerator.
Updated: January2018
Poison Antidotes
Antidote Poison/Drug/Toxin SuggestedMinimumStockQuantity Rationale/Comments
Pyridoxinehydrochloride Acrylamide 10g(100vials) Usualdoseis1gpyridoxineHClforeachgramofINH
(VitaminB) ingested.Ifamountingestedisunknown,give5gof
6 Ethyleneglycol Availableas1mLvials(100mg/mL) pyridoxine.Repeat5gdoseifseizuresare
uncontrolled.Moremaybenecessary.Knownearest
Hydrazine sourceofadditionalsupply.Forethyleneglycol,a
doseof100mg/daymayenhancetheclearanceof
HydrazineMAOIs(isocarboxazid, toxicmetabolite.StockinEDorpharmacy.
phenelzine)
Isoniazid(INH)
Monomethylhydrazine-containing
mushrooms(eg,Gyromitra)
Silibinin Cyclopeptide-containingmushrooms None. Silibininisawater-solublepreparationofsilymarin,a
(Legalon-SIL) (eg,Amanitaphalloides,Amanita flavolignoneextractedfromthemilkthistleplant.It
verna,Amanitavirosa,Galerina 350mg/vial inhibitsuptakeofcyclopeptidesinhepatocytes.These
autumnalis,Lepiotajosserandi,and hepatotoxinsareresponsibleforhighmorbidityand
others) mortalityfollowingingestionofthesemushrooms.
SilibininismanufacturedbyMadaus,Inc.inGermany,
andhasbeenwidelyusedinEuropesince1984.The
initialadultloadingdoseconsistsofa1hinfusionof
5mg/kgfollowedbytherecommendeddailydosageof
20mg/kgviacontinuousIVinfusion.Productisnow
availableintheUSunderanopen-treatment
investigationalnewdrugapplication.Physicianscan
obtaintheproductfree-of-chargebycontactingthe
primaryinvestigatorat866-520-4412.
Sodiumbicarbonate Chlorinegas 15-20x50mLvialsofeither8.4%(50 Stock15vialsinEDandremainderinpharmacy.
mEq/50mL)or7.5%(44mEq/50mL) Nebulized2.5-5%sodiumbicarbonatehasbeen
Hyperkalemia demonstratedinanecdotalcasereportstoprovide
Considerstocking4.2%(5mEq/10mL)for symptomaticreliefforchlorinegasinhalation.
SerumAlkalinization: pediatricpatients.
Agentsproducingaquinidine-likeeffect
asnotedbywidenedQRScomplexon
EKG(eg,amantadine,carbamazepine,
chloroquine,cocaine,diphenhydramine,
flecainide,propafenone,propoxyphene,
tricyclicantidepressants,quinidine,and
relatedagents)
UrineAlkalinization:
Weaklyacidicagents(eg,
chlorophenoxyherbicides,
chlorpropamide,methotrexate,
phenobarbitalandsalicylates)