CYANIDE ANTIDOTE: Cyanide Antidote Kit: Na nitrate injection - 300mg/10mL (2 ampules) Na thiosulfate - 12.

5g/50mL (2 vials) amyl nitrate inhalant- 0.3mL (12 ampules) INDICATION: tx of cyanide poisoning in symptomatic pxs DOSE: **ADULT Crush 0.3 mL ampul of amyl nitrite q1min and inhale vapor for 15-30 seconds until IV sodium nitrite infusion available Following infusion of 300 mg or 10 mg/kg IV sodium nitrate, over 2-5 minutes, inject 12.5 g sodium thiosulfate IV over 10 minutes PRN; may repeat both injections at 1/2 original dose **PEDIATRIC Administer amyl nitrite as in adults; crush 0.3 mL ampul of amyl nitrite q1min and inhale vapor for 15-30 seconds until IV sodium nitrite infusion available; Follow amyl nitrite administration with sodium nitrate 10 mg/kg (0.33 mL/kg or 6-8 mL/sq.meter of 3% solution; not to exceed 10 mL); Inject sodium thiosulfate IV 7 g/sq.meter over 10 minutes; not to exceed 12.5 g; may repeat both injections at 1/2 original dose LAB: Whole blood cyanide levels Arterial blood gas (ABG), O2 sats Electrolytes, metHB levels (metaolic indicator) ADVERSE EFFECTS: 1. MetHbnemia, hypotension 2. Dizziness, headache 3. Facial flushing, sweating 4. NV, tachy NOTES: If signs reappear, give Na nitrate and Na thiosulfate at original dose 1. 2. 3.

IRON ANTIDOTE: Deferoxamine (Desferal) INDICATION: tx of acute iron toxicity (signs & sx of iron toxicity or serum level >300-500mcg/dL) chronic iron overload DOSE: 15mg/kg/hr IV infusion (up to 35-45 mg/kg/hr for massive poisoning) Max. daily dose: 6 g (up to 16g/day can be tolerated) Can be in IM but IV is preferred LAB: 1. Serum iron, glucose 2. Abdominal radiographs (KUB kidney, ureter, bladder x-ray) 3. WBCs, CBC, BUN, LFTs 4. Electrolytes, serum creatinine ADVERSE: 1. Hypotension (more common with rapid infusion) 2. Rash, generalized erythema, allergic-type rxn, injection site reaction NOTES: Normal serum iron level: 50-150mcg/dL Ferrioxamine chelate may discolour the urine (pink to red-orange color vin rose) Continue tx until: o s/sx resolve o serum iron level <150mcg/dL o repeat KUB is negative for the presence of iron in GI tract KUB valuable to identify those at risk for continued iron absorption IRON TABLETS not rapidly absorbed, stay longer, clamp up making a larger material called pharmacobezoars

DIGOXIN, DIGITOXIN ANTIDOTE: Digoxin immune fab (ovine origin) (Digibind) INDICATION: tx of potentially threatening digoxin intoxication (ie severe ventricular arrhythmias, progressive brady, or 2nd or 3rd degree block not responsive to atropine) ingestion of >10mg of digoxin (adults), 4mg (children) serum conc. >10mg/mL serum K >5mEq/L DOSE: perform sensitivity testing in high risk pxs prior to admin. (ie those with known allergies or previously treated with Digibind contact local poison control center LAB: 1. serum digoxin levels (obtain before admin) 2. K levels (check frequently), serum Mg, other electrolytes 3. BUN, serum creatinine ADVERSE: 1. Allergic rxns (rare), hypokalemia 2. Low cardiac output, CHF 3. Ventricular response those with atrial fib. NOTES: Total serum digozin may rise following Fab admin. However, this will be entirely bound to Fab fragments and therefore not able to react with receptors in the body

ARSENIC, GOLD, MERCURY, LEAD ANTIDOTE: Dimercaprol (BAL in oil) British anti-lewisite INDICATION: tx of arsenic, gold, and acute mercury poisoning (if started within 1-2 hrs) tx of acute lead poisoning 70mcg/dL when used with Ca EDTA not effective for chronic poisoning DOSE: give as deep IM injection MILD ARSENIC OR GOLD POISONING: o 2.5 mg/kg 4x daily for 2 days. 2x daily on the third day, then once daily for 10 days SEVERE ARSENIC OR GOLD POISONING: o 3mg/kg q4h for 2 days, 4x daily on third day, then 2x daily for 10 days MERCURY POISONING: o 5mg/kg initially, followed by 2. 5 mg/kg 1-2x/day for 10 days ACUTE LEAD ENCEPHALOPATHY: o 4mg/kg alone in the first dose and then 4hr intervals in combo with Ca EDTA administered in a separate site LESS SEVERE LEAD POISONING: o Dose reduced to 3mg/kg after initial dose. Maintain tx for 2-7 days depending on clinical response LAB: 1. renal function test 2. urine pH ADVERSE: 1. pain at injection site 2. BP, tachy 3. NVH, fever, restlessness, salivation 4. Convulsions (rare), nephrotox NOTES: Avoid in pxs allergic to peanut oil Urinary alkalinisation recommended for BAL-metal complex breaks down easily in acid medium. Alkaline urine protects the kidney during therapy Do not use for alkyl organic mercury poisoning it worsens nephrotox Caution in pxs with: G-6PD deficiency for hemolysis occur

ETHYLENE GLYCOL anti-freeze, METHANOL ANTIDOTE: Ethanol INDICATION: Symptomatic px with suspected ingestion of ethylene glycol or methanol Ethylene glycol or methanol levels >20mg/dL History or suspected ingestion of toxic amounts and whom blood levels are not readily available DOSE: THERAPEUTIC BLOOD ALCOHOL LEVEL: o 100mg/dL LOADING DOSE: o 10% ethanol (v/v) IV 8-10mL/kg over 30 min MAINTENANCE: o 10% ethanol IV infusion .8 mL/kg/hr for non-drinkers o 10% ethanol IV infusion 2mL/kg/hr for chronic drinkers o Begin maintenance concurrent with loading dose o Adjust dose if px presents existing blood alcohol level or in those undergoing hemodialysis LABS: 1. Stat blood alcohol level, then repeat q 1-2 hrs. until steady state is reached then q 2-4 hrs. 2. Serum ethylene glycol and or methanol levels, serum glucose and electrolytes, serum osmolality (by freezing point depression) 3. Arterial blood gas (ABG), urinalysis (UA), renal fx, anion gap ADVERSE: 1. Inebriation/intoxication, CNS & respi. depression 2. Hypoglycaemia (esp. in children) NOTES: Continue tx until ethylene glycol or methanol level is <20 mg/dL and the pxs sx have resolved including normal serum pH Fomepizole inhibits elimination of ethanol. Concomitant admin is not recommended as toxic ethanol levels may result Stock doses OF ETHANOL: 10%, 5%

BENZODIAZEPINES ANTIDOTE: Flumazenil (Romazicon) INDICATION: Complete or partial reversal of effect of benzodiazepine DOSE: **ADULTS For BZD overdose: 0.2 mg (2mL) IV over 30 secs. If desired level of consciousness is not obtained after 30 secs., give .3 mg (3mL) over another 30 secs. Further doses of.5 mg (5mL) can be given over 30 secs. at 1 min. intervas up to a cumulative dose of 3mg For resedation: repeated doses q 20 mins. For repeat tx: 1 mg (0.5mg/min) at any one time and nmt 3 mg in any one hour **CHILDREN .01 mg/kg over 1 min. repeat doses of .01 mg/kg may be given at 1 min. interval up to 1 mg total dose LABS: Routine labs ADVERSE: 1. DAADDI: dizziness, agitation, abnormal vision, dry mouth, dyspnea, insomnia 2. CCCHEPT: confusion, convulsions, cutaneous vasodialtion, hyperventilation, emotional lability, palpitations, tremors 3. NVH, pain at injection site, increased sweating NOTES: Caution when using in a mixed drug overdose, toxic effects (seizures, dysrhythmias) of other drugs taken esp. TCA may emerge Reversal of BZD my ppt. withdrawal in those dependent on them Monitor for resedation

ETHYLENE GLYCOL, METHANOL ANTIDOTE: Fomepizole (Antizol) INDICATION: Symptomatic px with suspected ingestion of ethylene glycol or methanol Ethylene glycol or methanol levels >20mg/dL History or suspected ingestion of toxic amounts and whom blood levels are not readily available DOSE: LOADING: 15mg/kg MAINTENANCE: 10mg/kg q12 h for 4 doses, then 15mg/kg q 12 h until level is <20 mg/dL and px is asymptomatic with normal pH ADMINISTRATION: dilute doses in 100 mL NS or 5% dextrose and infuse over 30 min. See package insert for concomitant tx with hemodialysis LAB: Serum ethylene glycol and or methanol levels, electrolytes, serum osmolality (by freezing point depression) Arterial blood gas (ABG), urinalysis (UA), renal fx, anion gap, Calcium ADVERSE: 1. NH, dizziness, drowsiness, diarrhea, drunk feeling 2. Pain at injection site 3. Hypotension, increase or decrease heart rate 4. Anxiety, agitation, facial flush NOTES: Continue tx until ethylene glycol or methanol level is <20 mg/dL and the px is asymptomatic including normal serum pH Fomepizole inhibits elimination of ethanol. Concomitant admin is not recommended as toxic ethanol levels may result. Pre-existing ethanol level does NOT preclude use of fomepizole

BETA-BLOCKERS, CALCIUM CHANNEL BLOCKERS ANTIDOTE: Glucagon recombinant DNA INDICATION: aid in improving arterial pressure and contractility due to an overdose of a beta-blocker DOSE: **ADULTS: 5-10 mg IV over 1 min. followed by 1-5 mg/hr IV infusion **CHILDREN: .15 mg/kg IV over 1 min. followed by a .05 mg-.1 mg/kg/hr IV infusion *may also be given IM or SC but IV route is preferred LAB: 1. Glucose, potassium ADVERSE: 1. NV (esp. with rapid infusion) 2. Hyper or hypoglycaemia, hypokalemia 3. allergic rxn NOTES: for continuous infusion, mix glucagon with normal saline or 5% dextrose seum half-life is only 8-18 mins GI DECONTAMINATION ANTIDOTE: Ipecac Syrup INDICATION: aid GI decontamination of potentially toxic subs. in an alert conscious person with an intact gag reflex consider use only if it can be given within 60 mins of ingestion DO NOT USE: o Hydrocarbons o Corrosive substances o Strychnine o Nontoxic subs. o Calcium channel blockers, betablockers o Clonidine o Digoxin o Any subs. that can produce coma or seizures DOSE: **ADULTS AND ADOLESCENTS: 15-30 mL followed by 240 mL water *CHILDREN (1-12 YRS. OLD) 15 ML preceded or followed by 120-240 mL of water *may repeat dose if emesis does not occur in 20-30 mins LAB: NONE ADVERSE: 1. Diarrhea, drowsiness 2. Prolonged >1 hr vomiting NOTES: Emesis begins within 20 mins, and may last for 20-30 mins Avoid giving with milk or carbonated beverages