Emergency Preparedness, Toxicology & Antidotes Naplex

Heavy metals (arsenic, copper, gold, lead, mercury, thallium)

Dimercaprol= arsenic, gold, mercury (or lead in conjunction with calcium disodium edetate) Succimer (Chemet)= dimercaptosuccinic acid (DMSA) lead

Opioids

Naloxone (Narcan, Evzio)

Carbon monoxide (CO)

Oxygen, possibly hyperbaric

Petroleum distillates (gasoline)

Oxygen, supportive care Do NOT induce vomiting

Calcium Channel Blockers

Supportive care, calcium chloride/gluconate, possibly glucagon and/or high dose insulin + glucose

Naphthalene, from mothballs

Supportive care, methylene blue

Amatoxin-containing mushrooms

Supportive care, silibinin (Legalon SIL) +/- atropine

TCA

Supportive care, sodium bicarbonate

Organophosphates (OPs), malathion and gases

Atropine and Pralidoxime (DuoDote) Block Ach, which increases Ach levels. Atropine is an anticholinergic and blocks effects of Ach to reduce SLUDGE S= salivation L= lacrimation U= urination D= diarrhea G= gastrintestinal distress E= emesis Pralidoxime= treats muscle weakness and relieve paralysis

Insulin or other hypoglycemics

Dextrose 2nd Line= glucagon when dextrose is not available

Beta Blockers

Supportive care, possibly glucagon and/or high dose insulin with glucose and/or lipid emulsion therapy

Anthrax

1. Anthrax immune globulin (Anthrasil) 2. Raxibacumab (Abthrax) 3. Obitoxaximab (Anthim)

Black Widow Spider

Antivenin (Latrodectus), supportive care

Scorpion stings

Antivenin immune FAB Centruoides (Anascorp), supportive care

Botulinum Toxin (BTX)

Botulism antitoxin heptavalent (BAT) Immune globulin (BabyBIG) Supportive care Botulinum toxin causes botulism/neuroparalysis

Plant: castor beans, jequirity beans, oleander and foxglove, hemlock

Supportive care, DigiFab if oleander or foxglove

Cyanide

2 IV antidotes: 1. Hydroxocobalamin (Cyanokit) 2. Sodium thiosulfate + sodium nitrite (Nithiodote)

APAP

Antidote= N-acetylcysteine 1. (Cetylev) PO 2. Acetadote IV Restores hepatic glutathione (glutathione substrate) Oral: 140mg/kg x1, followed by 70mg/kg every 4hrs x17 additional doses. Repeat the does if emesis occurs within 1hr of administration

Iron or aluminum

Deferoxamin (Desferal), deferiprone (ferriprox) and deferasirox (Exjade, Jadenu)

Digoxin

Digoxin Immune Fab (DigiFab) 40mg vials bind ~0.5mg of digoxin

Nicotine

Supportive care, atropine Atropine is a nicotinic receptor antagonist

Rocuronium bromide Vecuronium bromide Pancuronium bromide

Neostimine methylsulfate (Bloxiverz) Sugammadex (Bridion) Reversal of neuromuscular blockade induced in adults undergoing surgery

Warfarin (Coumadin) Rat poison (rodenticides)

Phytonadione (Vitamine K) Mephyton

Neostigmine, pyridositgmine

Pralidoxime (Protopam) Counteracts muscle weakness and/or respiratory depression secondary to overdose or anticholinesterase meds used for myasthenia gravis

Heparin, LMWH

Protamine 1mg will reverse ~100 units of heparin

Isoniazid

Pyridoxine (vitamin B6), bensodiazepines and/or barbiturates

Decontamination w/ Activated Charcoal

Most effective when used within 1 hour of ingestion Some activated charcoal contains sorbital, but sorbital should be avoided CI= when airway is unprotected Drugs will bind to activated charcoal and should be separated at least two hours Alcohol, heavy metals (iron, lead, lithium, mercury) and corrosives (alkalis) DO NOT bind to charcoal Dose= 1g/kg

Ethanol (alcoholic drink)

Supportive care, correct hypoglycemia, vitamin B1 with chronic ingestion Chronic alcohol used= administer Thiamine (vitamin B1) to prevent Wernicke encephalopathy

Stimulant overdose from amphetamines

Supportive care, possibly benzodiazepines

Anticholinergics: atropine, diphenhydramine, belladonna

Supportive care, rarely physostigmine Physostigmine= inhibits acetylcholinesterase which breaks down Ach Benzodiazepines/anticonvulsants= seizures Anticholinergic overdose symptoms= Red as a Beet, Dry as a Bone, Blind as a Bat, Mad as a Hatter and Hot as a Hare flushing, dry skin and mucous membranes, mydriasis with blurry vision, altered mental status and fever

Animal bits

Rabies vaccine (RabAvert, Imovax) with Human rabies immune globulin (HyperRAB S/D, Imogam Rabies HT) Vaccine dose= days 0, 3, 7, 14 Immune globulin dose= 20units/kg on day 0 Tetanus shot is required if it has been at least 10 yrs

Salicylates

Sodium bicarbonate Salicylate may cause metabolic acidosis, sodium bicarbonate is an alkalinizing agent and is given to alkalinize the urine. This will decrease drug absorption and increase the excretion

Snake bites

Crotalidae polyvalent immune FAB (CroFab)= copperhead and rattlesnakes Antivenin (Micrurus fulvius)= coral snake bites Crotalidae Immune F(ab's)2 (Anavip) for rattlesnake bites

Benzodiazepines

Flumazenil (Romazicon)

Ethylene glycol (antifreeze), diethylene glycol, methanol

Fomepizole (Antizol) Ethanol (2nd line) Both inhibit alcohol dehydrogenase (ADH)

Dabigatran (Pradaxa)

Idarucizumab (Praxbind)

Methotrexate

Leucovorin (foiling acid), levoleucovorin (fusilev), glucarpidase (Voraxaze)

Valproate or Topriramate induced hyperammonemia

Levocarnitine (Carnitor)

Local anesthetics (bpivacine, mepivacaine, ropivacaine) other lipophilic drugs (bupropion, TCAs, CCB, beta blockers)

Lipid emulsion 20%, supportive care, benzodiazepines if seizures present

Methemogloinemia

Methylene blue (ProvayBlue) Methylene blue is contraindicated in patients with G6PD deficiency

5-fluorouracil (5-FU), capecitabine

Uridine Triacetate (vistogard, Xuriden)