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Antidotes (Printable Chart)

Last updated: March 2017

For medical centers choosing to stock antidotes, the suggested stocking level is based on the dose needed to treat a single 100 kg patient for 8 hours and for 24 hours [Adapted from Dart RC, et al., Annals of Emergency Medicine, 2009; 54(3):386-394]. Medical centers that might expect to receive large numbers of patients in a single incident should stock larger amounts of antidotes or have an effective and efficient drug sharing/transfer procedure in place to rapidly obtain additional antidotal supplies.

Generic/ Name Brand

Indications

Notes

Suggested Stocking Level

Access Priority

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

 

8 Hours: 18 vials

24 Hours: 36 vials

Within 1 hour

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

Black Widow Spider envenomation

Equine base risk of allergic hypersensitivity

8 Hours: 1 vial

24 Hours: 1 vial

Special Access: contact manufacturer(Mer ck, 800-672-6372)

BAL(Dimercaprol)/ BAL in oil 10%®

Heavy metal poisoning

IM administration only

8 Hours: 600 mg or 2 amps (100 mg/mL, 3 mL each)

24 Hours: 1800 mg or 6 amps (100 mg/mL, 3 mL each)

Within 1 hour

Bicarbonate , Sodium

Sodium channel blocker (“membrane stabilizer”) 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

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

 

Special Access; CDC -1-770-488-7100; California call: 1-510-231-7600

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 (see below)

8 Hours: 10 gms or 10 vials (10%, 10 mL)

24 Hours: 10gms or 10 vials (10%, 10 mL)

Immediate emergency department

Calcium Gluconate Powder

Hydrofluoric acid

For manufacture of topical gel

8 Hours: 1 x 100 g powder bottle

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 Hours: 30 g or 30 vials (10%, 10 mL)

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 gm tubes

24 Hours: 10 x 25 gm tubes

Within 1 hour

Carnitine (L-Carnitine)/ Carnitor®

Hyperammonemia from valproic acid toxicity

 

8 Hours: 10g 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 1-10mL (300mg) vial of sodium nitrite, 1-50 mL (12.5G) 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 with use.

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

(Less expensivethan the Cyanokit™ antidote kit)

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

(Less expensivethan the Cyanokit™ antidote kit)

Immediate emergency department

Cyanokit®/ Hydroxocobalamin

Cyanide poisoning

Newer, safer and easier to use (but more expensive) than the conventional cyanide antidote kit.

8 Hours: 10 g or 2 kits

24 hours: 10 g or 2 kits

Immediate emergency department

Cyproheptadine/ Periactin®, others

Mild to moderate serotonin syndrome

Anticholinergic side effects and only PO administration

8-24 Hours: 32 mg or 8 tablets (4 mg each)

Within 1 hour

Dantrolene

Malignant hyperthermia

 

8 Hours: 1000 mg or 50 x 20 mg vials

24 Hours: 1300 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 than digoxin

8 Hours: 15 vials of either product

24 Hours: 20 vials of either product

Immediate emergency department

DMSA (Succimer)/ Chemet®

Heavy metal poisoning

 

8 Hours: 1 g or 10 x 100 mg capsules

24 Hours: 3 g or 30 x 100 mg capsules

Within 1 hour

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 Hours: 1 x 1 g amp

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 Hours: 1 x 1 g amp

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; afterhours: 1-865-576-1005.

EDTA-Calcium/ Versenate®

Heavy metal poisoning

Note: Do not confuse with “Sodium” EDTA

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

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

Within 1 hour

Ethanol IV 10% with 5% Dextrose

Ethylene glycol or methanol poisoning

Note: IV 10% ethanol product no longer manufactured; fomepizole easier to dose and monitor than ethanol

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

Fomepizole easier to dose and monitor than ethanol. Oral ethanol-containing beverage (eg, whiskey, vodka) can be used in an emergency situation.

8 Hours: one pint

24 Hours: 750mL

Within 1 hour

Flumazenil/ Romazicon®

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 1mg/10 mL vials

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

Immediate emergency department

Fomepizole (4-MP)/ Antizol®/ generics

Preferred antidote for ethylene glycol or methanol poisoning

Manufacturer of Antizol™ will replace expired stocks

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

24 Hours: 6.0 g or 4 x 1.5 mL (1g/mL) vials

Immediate emergency department

Glucagon

Beta blocker/calcium channel blocker poisoning

Anticipate nausea and vomiting

8 Hours: 90 mg or 90 x 1 mg kits

24 Hours: 250 mg or 250 x 1 mg kits

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.

5 vials(1000U/vial)

Specialty/optional product accessed by 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 Hours: 10 g or 4 x (2.5g/50 mL) vials

24 Hours: 20 g or 8 x (2.5g/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, 10mL each)

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

Immediate emergency department

Intravenous Fat Emulsion/ Intralipid®

Lipophilic cardiotoxic drugs

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

8-24 Hours: 3300 mL of 20% or 3 bags (100mL each) plus 6 bags (500 mL each)

Immediate emergency department

Leucovorin calcium

Folic acid antagonists/methanol

 

8-24 Hours: 300 mg or 3 (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 45-60 minutes. Generic N- acetylcysteine can be used if Acetadote® is not available (consult with poison center and administer via a micropore filter).

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

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

Immediate emergency department

Naloxone/ Narcan®

Opioid overdose

Use small initial dose to avoid abrupt awakening/withdrawal

8 Hours: 20 mg or 50 x 0.4 mg/2mL amps or 2 x 10 mg/10mL 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 1mL (0.1mg/mL) amps

24 Hours: 1000 mcg or 1 x 5mL (0.2mg/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 Hours: 4 mg or 2 x 2mL (1mg/mL) amps

24 Hours: 20 mg or 10 x 2 mL (1 mg/mL) amps

Immediate emergency department

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

8-24 Hours: 500 mg or 2 vials (10mg/mL, 25 mL each)

Within 1 hour

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.

Minimum order is 25 bottles (30 capsules each)

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; afterhours: 1-865-576-1005.

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. A 5 gram dose requires 50 of these vials and may deliver a toxic dose of the preservative.

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

(Use preservative free product.)

Immediate emergency department

Sugammadex (BridionR)

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 info at sugammadex sodium.

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

BTG Specialty Solutions Center: 1-844-293-0007.

Vistogard® is distributed exclusively through Cardinal Health (“SPD”), available 24/7

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

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

24 Hours: 200 mg or 40 x 5 mg tabs or 20 x 10 mg/mL amps

Within 1 hour

Note: List is not all-inclusive but reflects agents used more exclusively as antidotes or antidotal agents used infrequently.