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1.

Activated charcoal







alcohol



enterohepatic recirculation
digitoxin

phenobarbital theophylline

1.

ipecac syrup
2.


1.

2.


hypernatremia

1.
Nacetylcysteine
2.



1. 1 g/kg
10

2.Repeated dose 15-20 g 4-8

2-3

2. Atropine




parasympathetic competitive inhibitor

acetylcholine
acetylcholine muscarinic
receptor



1. organophosphates
carbamates muscarinic receptor
2.

digitalis
beta blockers
3.
cholinergic

1.
atropine

2.

3.
urinary
sphincter
4. myasthenia gravis

1.

angina pectoris
2. atropine 0.5 mg

1. atropine


pralidoxime
(2-PAM) organophosphates
2.
muscarinic histamine

1.
organophosphates carbamates 1-5 mg
0.05

mg/kg
5

10 atropine

atropine
2.
0.5-1 mg
0.01-0.05 mg/kg 0.5 mg

3 mg

organophosphates

Atropine sulphate 0.6 mg/ml (1 ml/ampule)


3. BAL (Dimercaprol)



chelating agent

(arsenic) (mercury)
(gold)

sulfhydryl group


dimercaprol

sulfhydryl
group

1. arsenic
2.

2



3.
acute
lead encephalopathy
4.

1. (iron) cadmium

BAL cadmium

2.
G6PD

3.

arsenic
4.
5.

1.

2.


15-30

3.
BAL

4.





1. iron, cadmium, selenium



2.

rheumatiod arthritis
3. iodine

1. arsenic, gold mercury BAL 3


mg/kg 4
2 3 mg/kg
12

7-10

2.

.
acute encephalopathy

100 mcg/dl BAL 4-5 mg/kg


4
5
.

acute encephalopathy
70 mcg/dl
BAL 3

mg/kg 4
5

3
50 mcg/dl

BAL 50 mg/ml (2 ml/amp)

oil

4. Bromocriptine


ergot alkaloid dopamine agonist

hypothalamic dopaminergic receptors


prolactin anterior pituitary
growth hormone

1.prolactinoma hyperprolactinaemia

prolactin
2. acromegaly growth hormone
3.parkinsonism direct action dopaminergic
receptors substantia nigra

4.Neuroleptic Malignant Syndrome


dopamine
agonist

1.
ergot alkaloid ergotamine
2.
, toxemia of pregnancy,
peptic ulcer,

1.




2.

orthostatic hypotension,
3.


chest pain

(shortness breath)

Neuroleptic Malignant Syndrome

bromocriptine 2.5 mg 2


dose
rigidity

60 mg

Bromocriptine mesylate (parlodel) 2.5 mg

5. Benztropine


antimuscarinic receptor atropine
parkinsonism
phenothiazine

(extrapyramidal
symptoms)

1.
2.
3.Myasthenia gravis
4.Tardive dyskinsia

1.
muscarinic

2.

1.

1-2 mg ( 3

0.02 mg/kg 1 mg)


2.

1-2 mg 12
3

0.02 mg/kg 1 mg

1.Benztropine mesylate (Cogentin) 0.5, 1, 2 mg

2.Benztropine mesylate (Cogentin) 2 mg/2 ml

6. Calcium disodium adetate (CaEDTA)


Calcium EDTA


, zinc, cadmium, manganese,
copper

1.

(encephalopathy)

BAL (Dimercaprol)

2. manganese, zinc, chromium,


nickel

1. (anuria)
CaEDTA

2.

1.



2 2

CaEDTA
hemodialysis

2.

lead encephalopathy
CSF

3.

histamine
4.

0.5%
5. zinc zinc
6. calcium

1.
( )
a.
100 mcg/dl
lead encephalopathy CaEDTA 1,500 mg/m2/day (
30

mg/kg) 6 4

2-4 mg/dl

(diluted in

D-5-W or 0.9% NSS and infused over 1

hour) 5
encephalopathy
BAL

b.

encephalopathy
50-100 mcg/dl
CaEDTA 1000

mg/m2/day ( 20 mg/kg)

4
5
c.

CaEDTA
2.CaEDTA chelating test Lead mobilization test



500 mg/m2

( 20 mg/kg) 1 drip
1

24

(mcg) EDTA (mg)


0.7

Calcium disodium versenate R 200 mg/ml (5


ml/ampule)
:
3
260-8577

:
245-7796, 6446362

7.

Dantrolene

calcium
sarcoplasmic reticulum


1.Malignant hyperthermia
2. hyperthermia rhabdomyolysis

1.



2.
3.

1 vial 20 mg

60 ml

1. 1-2 mg/kg IV
5-10
10 mg/kg
2-5 mg/kg

2.
hyperthemia
1-2
mg/kg 100 mg 4 2-3

1.Dantrolene sodium (Dantrium) 20 mg/vial



2.Dantrolene sodium 25, 50, 100 mg capsule

8. Deferoxamine


(iron chelating agent) free iron


heme cytochrome

deferoxamine


(acute iron
intoxication) 450-500 ug/dl

1. deferoxamine
2.

1.



15 mg/kg/hr
2.

3.
deferoxamine
hemodialysis

1. 15
mg/kg/hr 40-50
mg/kg/hr 1 6 g


350 ug/dl
2.

Deferoxamine mesylate (Desferal) 500 mg/vial


1 vial
sterile water 2 ml
250 mg/ml IV fluid
drip

9. Digoxin - specific antibodies (Fab fragment)


Fab fragment antibody
digoxin
digoxin



digoxin, digitoxin cardiac glycosides
Fab
fragment digoxin

cardiac glycosides

half-life
16-20
digoxin


Fab 30-60

3


potassium
cardiac glycosides

1. serum

Fab fragment
2.

1. serum sickness
2. potassium
potassium
1-5

3.

Fab fragment digoxin
digoxin
4.
digoxin
atrial
fibrillation

1. cardiac glycosides


Fab fragment 2-3

2. Fab fragment antibody


immunoassay digoxin

1. 1 vial (40 mg) Fab digoxin 0.6 mg


2. dose Fab
digitalis


for i.v. infused

diluted

in 0.9% NSS

,infused over 30-60 minutes

Digibind 40 mg/vial

10. DMSA (Succimer)


DMSA (2,3 dimercaptosuccinic acid) chelating
agent
arsenic ,

mercury silver DMSA


half-life 2


, mercury arsenic

1.

2.
zinc copper

10 mg/kg 8
5

12
14

Chemet 100 mg

11. Ethanol (ethyl alcohol)


Ethanol
methanol
formaldehyde formic acid
alcohol

dehydrogenase enzyme ethanol

alcohol
ethanol 100 mg/dl
enzyme alcohol dehydrogenase
ethanol


ethanol

methanol

1.
disulfiram 2
hemodialysis
2.

1.

2.

3.


(Nasogastric tube) loading dose 750 mg/kg maintenance dose
100

mg/kg/hr 150mg/kg/hr

ethanol

hemodialysis ethanol


ethanol
75%

ethanol 100 mg/dl


methanol formic acid
ethanol
whisky

37 degree 37% vol/vol

specific

gravity ethanol 0.79


37 degree 1 ml ethanol 0.3



ethanol

ethanol
100%
ethanol methanol
20 mg/dl 3

1 (ethanol)
methanol

Loading

128 ml

128 ml
Maintenance

17 ml/ht

17 ml/hr
Maintenance
peritoneal dialysis

ml/hr

32ml/hr
hemodialysis

30 ml/hr

43ml/hr

22

12. Flumazenil


1.
benzodiazepines
receptor
benzodiapines

flumazenil receptor


2. flumazenil


benzodiazepines 1-2

2-5

flumazenil half-life 1

1. coma benzodiazepines
flumazenil 1-2

coma
benzodiazepines
2. benzodiazepines

1.
2. alcohol benzodiazepines withdrawall
3. benzodiazepines benzodiazepines

4. Tricyclic antidepressant (TCA) overdose
benzodiazepines


1.



2. benzodiazepines
benzodiazepines withdrawal

()

1. benzodiazepines 0.2-3 mg
(
0.01-0.05 mg/kg)


consciousness
5-6

2. benzodiazepines
0.2-1 mg

Flumazenil (Anexate) 0.5 mg/5 ml

13. Ipecac syrup


alkaloid

90 20-30

30-50%

1. (coma)
2.



(corrosive
substances)
3. petroleum hydrocarbon
4.
tricyclic
antidepressant, strychnine, nicotine, cocaine
amphetamine


1.


2.
3.
4. ipecac

alkaloid

1.

2.

1. 6-12 5-10 ml
2. 1-12 15 ml


30 ipecac

1 dose

3. 30 ml

Ipecac syrup 30 ml
aqueous form syrup

14. Leucovorin calcium


Leucovorin calcium (Folinic acid, citrovorum factor)


Leucovorin folic acid

DNA RNA

folic acid
enzyme dihydrofolate reductase methotrexate
enzyme dihydrofolate reductase folic
acid folic acid

methotrexate

folic acid

1. methotrexate
methotrexate 48

2. methotrexate 75 mg
12
( 10 mg/m2/ ) 12 mg 6

15. Methylene blue


thiazide dye
methemoglobin
hemoglobin methemoglobin reductase
enzyme

G6PD methylene blue

methemoglobinemia

(hypoxemia) methemoglobin
25-30%

1. G6PD methlene blue

2.
3. methylene blue
4. hereditary methemoglobin reductase deficiency

1.GI upset
2. methylene blue
7 mg/kg
methemoglobin methylene blue oxidized
hemoglobin

15 mg/kg

3.
4.

1-2 mg/kg (0.1-0.2 ml/kg 1% )


5-10 ml ( )

30-60

methylene blue 1%, 10 ml/amp

16. N-acetylcysteine (NAC)


paracetamol (acetaminophen)
toxic metabolites
glutathione

sulfhydryl group

reducing toxic metabolites
NAC

sulfhydryl group
glutathione

toxic metabolites
NAC
24
paracetamol

NAC


paracetamol

paracetamol 7.5 g

paracetamol 140 mcg/ml


1.


2.
(flushing)
anaphylactoid

reaction

NAC (activated charcoal)


(
30%)

1. 150 mg/kg D5W 200 ml


15 50 mg/kg D5W 500 ml
4

100 mg/kg D5W 1000

ml 16

2.Oral loading dose 140 mg/kg oral
maintenance dose 70 mg/kg 4
17

NAC

30 %


1.N-acetylcysteine (Fluimucil) 100 mg 5 g
granules

2.N-acetylcysteine (Fluimucil) 300 mg/3 ml

17. Naloxone



opioids
competitive inhibitor opiate receptor
naloxone receptor

naloxone

1-2

1-4
half-life 60

1.
opiates
2.
coma
opiates

naloxone


1.
opiates
2.
(pulmonary edema)
(ventricular fibrillation)
3.

opiate

catecholamines


opioid

coma opioid
i. 0.4-2 mg

2-3 10 mg
opioid
ii. opioid
half-life methadone,
propoxyphene

1-4

Infusion
0.4-0.8
mg/hr 5% dextrose


Naloxone HCI (Narcan) 0.02 mg/ml (2 ml/amp)
0.4 mg/ml (1 ml/amp)
18. Nitrite, sodium and

amyl


Sodium nitrite amyl
nitrite oxidized ferrous ion
hemoglobin ferric ion methemoglobinemia
cyanide nitrite

cyanide

1.
2. methemoglobinemia
3. carbon monoxide

1.



cyanide

poisoning

2.

3. methemoglobin
hypoxia

methemoglobinemia cyanide
nitrite
Dose sodium nitrite
hemoglobin
Hemoglobin

(g/dl)

Initial dose (mg/Kg)

Initial dose of 3% Sodium Nitrite (ml/kg)


7

5.8

6.6

7.5

0.19
0.22
0.25
10

8.3

11

9.1

0.27
0.30
12
0.33

10.0

13

10.8

0.36

1. alcohol


2. methylene blue

methemoglobinemia cyanide

3. cyanide methemoglobin
methemoglobin

1. amyl nitrite 1-2 amp


2.Sodium nitrite
300 mg. iv. (10 ml 3%
) 3-5
0.33 ml/kg. iv. 10 ml
hemoglobin
()
oxidation
hemoglobin
methemoglobin 30

sodium nitrite iv.



dose

19. Penicillamine


derivative penicillin


,
mercury copper EDTA
BAL penicillamine



penicillamine
EDTA BAL

1. penicillin
2.
penicillamine

1.
hematuria
proteinuria
2.
agranulocytosis
3.

4.



phenylbutazone

arsenic 100 mg/kg/day

25-40 mg/kg/day 1 g/





4 1

Penicillamine (Cuprime) 250 mg

20.Physostigmine



acetylcholinesterase enzyme acetylcholine
muscarinic nicotinic receptor

physostigmine

3-8
30-60 half-life 15-40

anticholinergic
atropine
anticholinergic


1. cyclic antidepressant

2. succinylcholine, decamethonium
neuromuscular blocker

1.

2.
3.

4.
5.Fasciculations,

1.
neuromuscular blocking agent
succinylcholine, decamethonium
2.
cyclic antidepressant

0.5-2 mg
0.02 mg/kg IV

20-30
physostigmine atropine

Physostigmine salicylate 1 mg/ml, 2 ml/ampule

21. Pralidoxime (2-PAM)



organophosphates cholinesterase enzyme

organophosphates

acetylcholine muscarinic


nicotinic

anticholinesterases
organophosphates 24


carbamates

1. myasthenia gravis
2.

1.

(hyperventilation))
2. 2-PAM

transient
neuromuscular blockade

atropine
2-PAM


1.1-2 g IV ( 25-50 mg/kg 1g )
5-10 (rate 200 mg/min
4

mg/kg/min ) 100 ml saline (1-2

ml/kg) drip 15-30


1

2. organophosphates

fenthion initial dose
4-12

nicotinic

Parenteral: Pralidoxime chloride (2-PAM) 1 g/vial

22. Pyridoxine (Vitamin B6)


cofactor

enzyme isoniazid
vitamin B6

vitamin B6

isoniazid

1.
2. pyridoxine


pyridoxine

1 g pyridoxine 1 g isoniazid
isoniazid

4-5 g

Parenteral: Pyridoxine hydrochloride 100 mg/ml


( 10%)


1. Goodman&Gilmans
th

therapeutics

the pharmacological basis of

9 Ed. : USA ,1996.

2. Thomas A.Gossel ,J.douglas Bricker .Principle of ClinicalToxicology


3.

nd

Ed.:USA, 1990.

http://www.i-spectrum.com/poisonra

Antidotes
1. Activated
2. Atropine

Charcoal
inj.

3. BAL (Dimercaprol)
4. Bromocriptine
5. Benztropine
6. Calcium disodium adetate (Ca EDTA)
7. Dantrolene
8. Deferoxamine

9. Digoxin specefic antibodies (Fab fragment)


10. DMSA (Succimer)
11. Ethanol (Ethyl Alcohol)
12. Flumazenil
13. Ipecac Syrup
14. Leucovorin calcium
15. Methylene blue

inj.

16. N-Acetylcysteine(NAC)
17. Naloxone (Narcan)
18. Nitrite,sodium and amyl
19. Penicillamine
20. Physostigmine
21. Pralidoxime (2-PAM)
22. Pyridoxine (Vitamin B6)
Presented by Pharmacy Department,
Trang Hospital ,
March,2001.