Antidotes

Atropine

Organophosphate/ carbamate insecticide poisoning and other cholinesterase inhibitors (eg, warfare agents); bradycardia induced by a variety of toxins

May require large amounts in severe cholinesterase inhibitor poisoning. Also stocked in the Strategic National Stockpile: for mass casualties, the SNS may provide supplies for first 48 hours (coordinated by state department of health and emergency response system).

8 Hours: 100 mg or 13 vials (0.4 mg/mL, 20 mL each)

24 hours: 200 mg or 26 vials (0.4 mg/mL, 20 mL each)

Use preservative-free product

Immediate emergency department

Antivenom, Crotalidae Polyvalent Immune- FAB(ovine)/ Cro-Fab®

Rattlesnake envenomation

Either antivenom product equally efficacious

8 hours: 18 vials

24 hours: 36 vials

Within 1 hour

Antivenom, Crotalidae Immune- FAB₂(equine)/ Anavip®

Rattlesnake envenomation

Either antivenom product equally efficacious

8 hours: 30 vials

24 hours: 60 vials

Within 1 hour

Antivenom, Black Widow Spider/ Antivenom (Latrodectus Mactans)®

Black Widow Spider envenomation

Equine base risk of allergic hypersensitivity

8 and 24 hours: 1 vial

Special Access: (Merck, 1-800-672- 6372); Merck Order Management Center, 1-800-637-2579, will drop ship up to 2 vials.

BAL(Dimercaprol)/ BAL in oil 10%®

Heavy metal poisoning (Arsenic, mercury, lead and gold)

IM administration only

8 hours: 800 mg or 3 amps (100 mg/mL, 3 mL each)

24 hours: 2400 mg or 8 amps (100 mg/mL, 3 mL each)

Within 1 hour

Bicarbonate, Sodium

Sodium channel blocker toxicity & urinary alkalinization

IV bolus dosing for reversal of sodium channel blocker toxicity; monitor alkalemia

8 hours: 63 g (750 mEq) or 750 mL of 8.4% solution

24 hours: 84 g (1000 mEq) or 1 L of 8.4% solution

Immediate emergency department

Botulinum antitoxin / H- BAT- heptavalent

Botulism

Contact local or state health department for reporting and to facilitate access to the antitoxin.

Only available through the state health department (CA) or CDC

Special Access; CDC 1-770-488- 7100; California call: 1-916-328-3605; LA call: 1-213-240-7941

Calcium Chloride injection

Calcium channel blocker poisoning; hypocalcemia induced by various agents

Can cause tissue necrosis if extravasation occurs – use large vein for infusion OR use calcium gluconate injection (see below)

8 and 24 hours: 10 g or 10 vials (10%, 10 mL)

Immediate emergency department

Calcium Gluconate Powder

Hydrofluoric acid dermal burns

For compounding a topical gel

8 and 24 hours: 1 x 100 g powder bottle

Within 1 hour

• Calcium Gluconate injection

Hydrofluoric acid skin exposure or poisoning; hypocalcemia induced by various agents

8 and 24 hours: 30 g or 30 vials (10%, 10 mL)

Immediate emergency department

Calcium Gluconate gel/ Calgonate 2.5% gel®

Hydrofluoric acid dermal burns

For topical burns

8 hours: 6 x 25 g tubes

24 hours: 10 x 25 g tubes

Within 1 hour

Carnitine (L- Carnitine)/ Carnitor®

Hyperammonemia &/or hepatotoxicity from valproic acid toxicity

8 hours: 10 g or 10 x 1 g vials

24 hours: 20 g or 20 x 1 g vials

Within 1 hour

Cyanide Antidote Kit (Nithiodote by Hope Pharmaceuticals)

Cyanide & sodium nitroprusside toxicity

Conventional cyanide antidote: contains 1-10 mL (300 mg) vial of sodium nitrite, 1-50 mL (12.5 g) vial of sodium thiosulfate (amyl nitrite inhalant ampules not included)

2 kits for small hospitals, 6 kits for major medical centers or stock separate supplies of sodium thiosulfate and sodium nitrite vials OR stock the Cyanokit® (hydroxocobalamin) antidote kit (see below)

Immediate emergency department

• Sodium Nitrite

Cyanide

Risk of methemoglobinemia and hypotension with use.

2 x 10 mL (3%) vials; 6 vials for major medical centers

Immediate emergency department

• Sodium Thiosulfate

Cyanide; sodium nitroprusside toxicity

If used alone for cyanide toxicity, may have a slow onset of action. Thiosulfate is synergistic with sodium nitrite, and the two drugs should be used together to treat cyanide poisoning whenever possible.

2 x 50 mL (25%) vials; 6 vials for major medical centers

Immediate emergency department

Cyanokit®/ Hydroxocobalamin

Cyanide poisoning

Preferred antidote for cyanide poisoning due to better safety and easier use.

8 and 24 hours: 10 g or 2 kits

Immediate emergency department

Cyproheptadine

Mild to moderate serotonin syndrome

Anticholinergic side effects and only PO administration

8 hours: 20 mg or 5 tablets (4 mg each)

24 hours: 36 mg or 9 tablets (4 mg each)

Dantrolene

Malignant hyperthermia

8 hours: 1000 mg or 50 x 20 mg vials

24 hours: 2000 mg or 56 vials

Immediate emergency department

Deferiprone/ Ferriprox®

Iron overload

Oral Chelator

8 hours: 3.3 g or 7 x 500 mg tablets

24 hours: 9.9 g or 20 x 500 mg tablets

Specialty/optional

Deferoxamine/ Desferal®

Iron poisoning

IV use only

8 hours: 12 g or 6 x 2 g vials

24 hours: 36 g or 18 x 2 g vials

Within 1 hour

Digoxin Immune FAB (ovine)/ DigiFab®

Digoxin poisoning; other cardiac glycosides (eg, oleander, foxglove)

Consult with poison center regarding dosing, especially for cardiac glycosides other than digoxin

8 and 24 hours: 15 vials

Immediate emergency department

DMSA (Succimer)/ Chemet®

Heavy metal poisoning (lead, mercury, arsenic)

8 hours: 1 g or 10 x 100 mg capsules

24 hours: 3 g or 30 x 100 mg capsules

DTPA-Calcium (Diethylenetriamine pentaacetate)/ (Pentetate Calcium Trisodium injection)

Dirty bomb agents: radioactive plutonium, americium and curium

Only available through government sources. Stocked in the Strategic National Stockpile: supplies for first 48 hours coordinated by state department of health and emergency response system.

8 and 24 hours: 1 x 1 g amp

Special access - Strategic National Stockpile. The Radiation Emergency Assistance Center/Training Site (REAC/TS) can be contacted for information on use of antidote. Business hours: 1-865-576-3131; After hours: 1-865-576-1005.

DTPA-Zinc (Diethylenetriamine pentaacetate)/ (Pentetate Zinc Trisodium injection)

Dirty bomb agents: radioactive plutonium, americium and curium

Only available through government sources. Stocked in the Strategic National Stockpile: supplies for first 48 hours coordinated by state department of health and emergency response system.

8 and 24 hours: 1 x 1 g amp

Special access - Strategic National Stockpile. The Radiation Emergency Assistance Center/Training Site (REAC/TS) can be contacted for information on use of antidote. Business hours: 1-865-576-3131; After hours: 1-865- 576-1005.

EDTA-Calcium/ Versenate®

Lead poisoning; also zinc, manganese, and certain radioisotopes

Note: Do not confuse with “Sodium” EDTA

8 hours: 1 g or 1 1000 mg/5 mL amp

24 hours: 3 g or 3 1000 mg/5 mL amps

Ethanol IV 10% with 5% Dextrose

Ethylene glycol or methanol poisoning

Note: fomepizole is the preferred antidote due to easier dosing, monitoring and safety.

8 hours: 22 x (5 mL) vials or ampules of 98% solution for injection

24 hours: 44 x (5-mL) vials or ampules

(10% solution can be prepared using 98% ethanol product)

Within 1 hour

Ethanol (oral)

Ethylene glycol or methanol poisoning

Note: fomepizole is the preferred antidote due to easier dosing, monitoring and safety.

Oral ethanol-containing beverage (eg, whiskey, vodka) can be used in an emergency situation.

8 hours: 850 mL of 80 proof (40%) liquor

24 hours: 2450 mL of 80 proof (40%) liquor

Within 1 hour

Flumazenil

Benzodiazepine poisoning

Use small initial dose to avoid abrupt awakening/ delirium; use with caution in patients on chronic benzodiazepine therapy as withdrawal seizures may occur; use with caution in mixed drug overdoses.

8 hours: 6 mg or 6 x 1 mg/10 mL vials

24 hours: 12 mg or 12 x 1 mg/10 mL vials

Immediate emergency department

Fomepizole (4-MP)/ Antizol®

Preferred antidote for ethylene glycol or methanol poisoning

Manufacturer of Antizol® will replace expired stocks

8 hours: 1.5 g or 1 x 1.5 mL (1 g/mL) vials

24 hours: 4.5 g or 3 x 1.5 mL (1 g/mL) vials

Within 1 hour

Glucagon

Beta blocker/calcium channel blocker poisoning

Anticipate nausea and vomiting

8 hours: 90 mg or 90 x 1 mg vials

24 hours: 250 mg or 250 x 1 mg vials

Immediate emergency department

Glucarpidase/ Voraxaze®

Methotrexate toxic levels

Use in patient with toxic levels and impaired renal function; glucarpidase may also metabolize leucovorin so stagger doses at least 2 hours.

8 and 24 hours: 5 vials (1000 U/vial)

Specialty/optional product: 1-855-786-7292

Idarucizumab/ Praxbind®

Monoclonal antibody that binds to dabigatran and its acylglucuronide metabolites and neutralizes their anticoagulant effects

Specific only for dabigatran; not effective for other oral anticoagulants

8 and 24 hours: 5 g or 2 x (2.5 g/50 mL) vials

Immediate emergency department

Insulin

Hyperinsulinemia - euglycemia (HIE) therapy for calcium antagonist and beta-blocker poisoning

Accompany with dextrose if blood glucose < 200 mg/dL

8 hours: 1000 U or one vial (100 U/mL, 10 mL each)

24 hours: 3000 U or three vials (100 U/mL, 10 mL each)

Immediate emergency department

Intravenous Fat Emulsion/ Intralipid®

Lipophilic cardiotoxic drugs

Immediately after administration several laboratory tests of patient serum/blood may be uninterpretable

8 and 24 hours: 1500 mL of 20% or 3 bags (500 mL each) bags (500 mL each)

Immediate emergency department

Leucovorin calcium

Folic acid antagonists / methanol

8 hours: 300 mg (3 x 100 mg vials)

24 hours: 1000 mg (10 x 100 mg vials)

Within 1 hour

Methylene Blue

Methemoglobinemia

8 hours: 400 mg or 4 x 10 mL (10 mg/mL) amps

24 hours: 600 mg or 6 x 10 mL (10 mg/mL) amps

Immediate emergency department

N-Acetylcysteine (NAC) Mucomyst® or generic

Acetaminophen poisoning (oral preparation)

Use orally. Dilute at least by a 3:1 ratio.

8 hours: 28 g or 5 x 30 mL (20%) vials

24 hours: 56 g or 10 x 30 mL (20%) vials

Immediate emergency department

N-Acetylcysteine (NAC) Acetadote®

Acetaminophen poisoning (IV preparation)

Note: 3 different dilutions are used for 1, 4 and 16 hour infusions. Loading dose should be infused slowly over 60 minutes.

8 hours: 24 g or 4 x 30 mL (20%) vials

24 hours: 30 g or 5 x 30 mL (20%) vials

Within 1 hour

Naloxone/ Narcan®

Opioid overdose

Use small initial dose to avoid abrupt awakening/withdrawal

8 hours: 20 mg or 50 x 0.4 mg/2 mL amps or 2 x 10 mg/10 mL vials

24 hours: 40 mg or 4 x 10 mg/mL vials

Immediate emergency department

Octreotide acetate/ Sandostatin®

Oral sulfonylurea poisoning and meglitinide poisoning

Avoid long-acting depot products

8 hours: 200 mcg or 2 x 1 mL (0.1 mg/mL) amps

24 hours: 1000 mcg or 1 x 5 mL (0.2 mg/mL) multidose vial

Within 1 hour

Physostigmine/ Antilirium®

Anticholinergic poisoning, especially antimuscarinic delirium

Administer at low dose (0.5 mg) and slowly, over 2-5 minutes to avoid severe adverse reactions including bradycardia, asystole and seizures (Contraindicated in TCA or similar poisoning with widened QRS intervals)

8 and 24 hours: 4 mg or 2 x 2 mL (1 mg/mL) amps

Immediate emergency department

Potassium Iodide

Thyroid radioiodine protection

Highest risk groups for radioiodine-induced cancer are infants, children and pregnant and nursing females. Should only be used when directed by public health officials.

8 and 24 hours: 130 mg

Within 1 hour

Pralidoxime(2- PAM)/ Protopam®

Cholinesterase Inhibitor poisoning (organophosphate or “nerve gas”)

Also stocked in the Strategic National Stockpile: for mass casualties, local cache may provide supplies for first 48 hours coordinated by state department of health and emergency response system.

8 hours: 7 g or 7 x 1 gm (20 mL) vials

24 hours: 18 g or 18 x 1 gm (20 mL) vials

Within 1 hour

Protamine

Heparin reversal

May also partially neutralize low-molecular weight heparins

8 hours: 500 mg or 2 vials (10 mg/mL, 25 mL each)

24 hours: 1250 mg or 5 vials (10 mg/mL, 25 mL each)

Immediate emergency department

Prothrombin Complex Concentrate (PCC): 3 factor and 4 factor

Reversal of bleeding from anticoagulants (vitamin K antagonists, direct thrombin inhibitors, factor Xa inhibitors)

Specific reversal agents may be available (idarucizumab, andexanet alpha) and Vitamin K. Otherwise, 4 factor PCC is preferred over 3 factor. Activated prothrombin complex concentrate (APCC or FEIBA) does not contain heparin and preferred for direct thrombin inhibitors.

8 and 24 hours: 5,000 IU

Immediate emergency department

Prussian Blue/ Radiogardase®

Dirty bomb agents: radioactive cesium and thallium and non- radioactive thallium

Only available through government sources. Stocked in the Strategic National Stockpile: will provide supplies for first 48 hours coordinated by state department of health and emergency response system.

8 hours: 12.5 g

24 hours: 25 g

Special access - Strategic National Stockpile. The Radiation Emergency Assistance Center/Training Site (REAC/TS) can be contacted for information on use of antidote. Business hours: 1-865-576-3131; After hours: 1-865- 576-1005. For product acquisition contact McGuff Pharmacy: 1-877- 444-1133

Pyridoxine (Vitamin B6)

Isoniazid (INH) poisoning

Large amounts needed for poisoning: 5 grams is the minimum antidotal dose used in an ingestion of an unknown amount. Note: the 30 mL vials may only be available from compounding pharmacies. The 100 mg in 1 mL vials may contain the preservative chlorobutanol.

8 hours: 9 g or 3 vials (100 mg/mL, 30 mL each) or the equivalent

24 hours: 24 g or 8 vials (100 mg/mL, 30 mL each) or the equivalent

(If possible: Use preservative free product or powder for reconstitution.)

Immediate emergency department

Sugammadex/ Bridion®

Reversal of rocuronium and vecuronium (and possibly pancuronium) neuromuscular blockade. Emergent reversal dosing depends on the depth of the paralysis and can range from 2 mg/kg up to 16 mg/kg.

This agent is used in lieu of carbamate (cholinergic) reversal agents such as neostigmine. More information here: https://reference.medscape.com/drug/bridion-sugammadex-sodium-999851

Available in two vial sizes: 200 mg/2 mL (100 mg/mL) in a single-dose vial for bolus injection (comes in a box of 10 vials)

or

500 mg/5 mL (100 mg/mL), in a single-dose vial for bolus injection (comes in a box of 10 vials).

Immediate-stock in areas where accidental administration of paralytics may occur (Emergency Department of Operating Room)

Uridine triacetate/ Vistogard®

5-FU, capecitabine poisoning

Recommended for use within 96 hours of last dose where toxicity is evident or expected; doses of up to 10 grams every 6 hours for a total of 20 doses have been well-tolerated.

8 hours: 20 g or 2 x 10 g packets

24 hours: 40 g or 4 x 10 g packets

Wellstat Medical: 1- 800-914-0071 or Cardinal Health Specialty: 1- 866-677-4844

Vitamin K1(Phytonadione)/ Mephyton® or AquaMephyton®

Warfarin, warfarin-based anticoagulants and super-warfarin based rodenticide poisoning

If patient is actively bleeding use fresh frozen plasma or Factor VII concentrate or prothrombin complex concentrates.

8 hours: 50 mg or 10 x 5 mg tabs or 5 x 10 mg/mL amps

24 hours: 100 mg or 40 x 5 mg tabs or 20 x 10 mg/mL amps

Immediate emergency department