Antidotes Flashcards
Acetylcysteine (Mucomyst, Acetadote)
Type: Acetaminophen antidote
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MOA:
MOA for Acetaminophen Overdose:
Restores glutathione concentrations within the liver; Glutathione, an antioxidant, has many actions in the body, including detoxifying substances
MOA for Facilitation of expectoration:
Exerts mucolytic activity through sulfhydryl group, which opens up disulfide bonds in mucoproteins and lowers mucous viscosity of pulmonary secretions
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Indications: Acetaminophen overdose
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Contraindications: Known hypersensitivity | Acute asthma
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Adverse Reactions: Urticaria | Flushing | Rash | Itching | Angioedema | N/V | Bronchospasm | Wheezing | Respiratory distress | Tachycardia | Hypotension
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Drug Interactions: Nitroglycerin
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Dosages:
Adult. Acetaminophen OD: (Within 8-10 hours post ingestion)
Loading dose 150 mg/kg IV, mix in 200 mL of D5W and infuse over 1 hour; Dose 2 is 50 mg/kg IV in 500 mL of D5W and infuse over 4 hours; Dose 3 is 100 mg/kg IV in 1000 mL D5W over 16 hr | If IV access is not available, give 140 mg/kg orally
Adult. Pulmonary Disease.
Facilitation of expectoration: 3-5 mL of 20% solution or 6-10 mL of 10% solution; administer 1 to 10 mL of 20% solution every 6-8 hours or 2 to 20 mL of 10% every 2 to 6 hours
(Solution (10 and 20%) may be used undiluted)
Paediatrics. Pulmonary Disease.
Facilitation of expectoration: (1-11 months) 1-2 mL of 20% solution or 2-4 mL of 10% solution by nebulization q6-8hr PRN | (>11 years; Solution (10 and 20%) may be used undiluted) 3-5 mL of 20% solution or 6-10 mL of 10% solution; administer 1 to 10 mL of 20% solution every 3 to 4 times/day or 2 to 20 mL of 10% every 2 to 6 hours
Paediatrics. Acetaminophen OD:
Medscape link provided; advisable medical command consult do to dilutient varies with pt’s weight
https://reference.medscape.com/drug/acetadote-legubeti-antidote-acetylcysteine-antidote-343740
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Duration: Onset: 1 minute | Peak effect: 5 to 15 minutes | Duration: 100 minutes
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Special Conditions: Pregnancy safety: Category B ; Use cautiously in pregnant and breastfeeding women and only if clearly indicated | When given IV, anaphylactoid-type reactions usually follow the first dose ; Can be minimized by ensuring that the medication is infused over 1 hour | Acetylcysteine smells like rotten eggs because of it’s sulfur content
Activated charcoal
Type: Adsorbent, Antidote
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MOA:
Adsorbs ingested toxic substances from the GI tract
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Indications: Most oral poisonings and medication overdoses in the alert patient | Can be used after evacuation of poisons
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Contraindications: Known hypersensitivity | Unprotected airway | Absence of a gag reflex | Ileus | Intestinal obstruction | Do not use after ingestion of petroleum distillates, hydrocarbons, heavy metals, acids or alkalis (corrosives), alcohols, iron, lithium, solvents | Use caution in patients experiencing abdominal pain of unknown origin
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Adverse Reactions: Emesis (if apsirated from emesis or misplaced NG tube, can induce a fatal form of pneumonitis) | Constipation | Black stools | Diarrhea | Bowel obstruction
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Drug Interactions: Bonds with and inactivates whatever it is mixed with | Moderate interactions with acetylcysteine, citalopram, digoxin, dyphylline, methotrexate, and theophylline
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Dosages:
Adult and Paediatric older than 1 year.
25 to 100g
Paediatric younger than 1 year.
1g/kg
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Duration: Onset: Immediate | Peak effect: Depends on GI function | Duration: Will act until excreted
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Special Conditions: Pregnancy safety: Category C | Shake vigorously before use | Contact medical direction before administering in cases of acetaminophen overdose
Atropine sulfate
Type: Anticholinergic agent
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MOA:
Inhibits acetylcholine at postganglionic parasympathetic neuroeffector sites | Increases heart rate in symptomatic bradydysrhythmias | Reverses muscarinic effects of cholinergic poisoning
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Indications: Hemodynamically unstable bradycardia | Acetylcholinesterase inhibitor poisoning (carbamates, nerve agents, organophosphates) | RSI in pediatrics | Beta blocker or calcium channel blocker overdose
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Contraindications: Known hypersensitivity | Narrow-angle glaucoma | GI obstruction | Severe ulcerative colitis | Toxic megacolon | Bladder outlet obstruction | Myasthenia gravis | Hemorrhage with cardiovascular instability | Thyrotoxicosis
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Adverse Reactions: Drowsiness | Confusion | Headache | Palpitations | Dysrhythmias | N/V | Pupil dilation | Dry mouth/nose/skin | Blurred vision | Urinary retention | Constipation | Flushed, hot, dry skin
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Drug Interactions: Potential adverse effects when administered with digitalis, cholinergics, physostigmine | Effects enhanced by antihistamines, procainamide, quinidine, antipsychotics, benzodiazepines, and antidepressants
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Dosages:
Adult.
Symptomatic bradycardia: 0.5 to 1 mg IV/IO every 3 to 5 minutes as needed (maximum of 3 mg)
Acetylcholinesterase inhibitor poisoning: Extremely large doses (2 to 4mg or higher) may be needed
Paediatric.
Symptomatic bradycardia: 0.02 mg/kg IV/IO; max single dose 0.5mg; total max dosing of 1 mg (child) and 3 mg (adolescent) ; ET dose. 0.04 to 0.06 mg/kg
RSI. IV/IO: 0.01 to 0.02 mg/kg (max dose of 0.5 mg) ; IM. 0.02 mg/kg
Child Younger Than 12.
Acetylcholinesterase inhibitor poisoning: 0.05 mg/kg initially, then repeat and double the dose every 5 minutes until muscarinic sxs reverse
Child Older Than 12.
Acetylcholinesterase inhibitor poisoning: 1mg initially, then repeat and double the dose every 5 minutes until muscarinic sxs reverse
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Duration: Onset: Immediate | Peak effect: 2 to 4 minutes | Duration: 2 to 4 hours
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Special Conditions: Pregnancy safety: Category C | Paradoxical bradycardia can occur w/ doses lower than 0.1mg | Ineffective in hypothermic bradycardia; May be ineffective in patients who have undergone heart transplantation or in infranodal AV blocks | Use with caution in the presence of myocardial ischemia because atropine increases myocardial oxygen demand
Calcium chloride
Type: Electrolyte
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MOA:
Mineral component of bones and teeth; Cofactor in enzymatic reactions and affects the secretory activity of endocrine and exocrine glands; Essential for neurotransmission, blood clotting, and contraction of cardiac, smooth, and skeletal muscles
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Indications: Hypocalcemia | Hyperkalemia | Beta blocker and calcium channel blocker toxicity | Antidote for magnesium sulfate overdose
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Contraindications: Known hypersensitivity | Digoxin toxicity | Hypercalcemia | Suspected severe hypokalemia
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Adverse Reactions: Syncope | Bradycardia | Asystole | Hypotension | N/V | Metallic taste with rapid injection | Tissue necrosis at injection site | Coronary and cerebral artery spasm
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Drug Interactions: May increase ventricular irritability and precipitate digitalis toxicity when taken with digoxin | Potentiated by thiazide diuretics | May antagonize the effects of calcium channel blockers | Incompatible with most all medications, so Flush the IV/IO line before and after its administration
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Dosages:
Adult. Arrhythmias (Emergent) Associated with Hypocalcemia, Hyperkalemia, or Hypermagnesemia: 500 to 1,000 mg slow IV/IO push over 5 minutes; repeat if needed
Adult. Calcium Channel Blocker Overdose:
1-2 g IV infused over 10-20 min; may repeat every 20 minutes prn up to 5 doses
Adult. Beta-blocker Overdose, Refractory to Glucagon & High Dose Vasopressor: (CENTRAL LINE ONLY)
1000 mg IV bolus via central line
Paediatric. Calcium channel blocker OD, Hypocalcemia, and Hyperkalemia:
20 mg/kg slow IV/IO push; Maximum dose: 1 g (10 mL); May repeat the dose if documented or suspected clinical indication persists (Medscape indicates this is the dose for Cardiac Arrest and that its NOT recommended)
Paediatric. Hypocalcemia, Emergency Treatment: (for Infants)
less than 75 mg (20 mg elemental Ca) IV; may repeat as necessary
Paediatric. Hypocalcemia, Emergency Treatment (for Children)
75-519 mg (20-140 mg elemental Ca) IV, may repeat as necessary
Paediatric. Hypocalcemic Tetany: (for Neonates)
171 mg/kg/day IV in divided doses
Paediatric. Hypocalcemic Tetany: (For Infants and Children)
10 mg/kg IV over 5-10 min TID/QID; alternatively, may administer 35-50 mg/kg IV TID/QID
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Duration: Onset: 1 to 3 minutes | Peak effect: Variable | Duration: 20 to 30 minutes but may persist for 4 hours (dose-dependent)
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Special Conditions: Pregnancy safety: Category C | Contains three times more elemental calcium than calcium gluconate, which is preferred in children | Essential for constant ECG and vital sign monitoring | Do NOT administer by either the IM or SubQ
Calcium gluconate
Type: Electrolyte
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MOA:
Mineral component of bones and teeth; Cofactor in enzymatic reactions and affects the secretory activity of endocrine and exocrine glands; Essential for neurotransmission, blood clotting, and contraction of cardiac, smooth, and skeletal muscles
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Indications: Topical use in hydrofluoric acid burn management | Hypocalcemia | Hyperkalemia | Beta blocker and calcium channel blocker toxicity
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Contraindications: Known hypersensitivity | Digoxin toxicity | Hypercalcemia | Suspected severe hypokalemia
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Adverse Reactions: Syncope | Cardiac arrest | Dysrhythmias | Hypotension | Asystole | Peripheral vasodilation | Hypotension | N/V | Metallic taste | Tissue necrosis at injection site | Coronary and cerebral artery spasm
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Drug Interactions: May cause severe bradycardia in pts taking digitalis | May antagonize the effects of calcium channel blockers | Incompatible with most medications, so Flush the IV/IO line before and after its administration
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Dosages:
Adult. Hypermagnesemia and Hyperkalemia:
1.5 to 3g slow IV/IO infused over 2-5 minutes; dose the same for cardiac arrest though NOT recommended to be used
Adult. Hypocalcemia (SEVERE or ionized Ca2+ < 1mmol/L):
(Without seizure or tetany) 0.5 mg/kg/hr IV; may be increased to 2 mg/kg/hr; not to exceed 3-4 g IV over 4 hours
(Hypocalcemic tetany) 100-300 mg elemental calcium (~3 g calcium gluconate) IV over 5-10 minutes, followed by continuous IV infusion at 0.5 mg/kg/hr (may be increased to 2 mg/kg/hr)
Paediatric. Calcium channel blocker OD, Hypocalcemia, and Hyperkalemia: (from textbook)
60 mg/kg slow IV/IO push over 10 minutes; May repeat the dose if documented or suspected clinical indication persists
Paediatric. Hypocalcemic tetany:
100-200 mg/kg IV over 10 minutes; may be repeated after 6 hours, or initiate continuous infusion not to exceed 500 mg/kg/day
Paediatric. Hypocalcemic:
Medscape link provided; Advisable to consult Medical Command
https://reference.medscape.com/drug/calcium-gluconate-344434#0
Adults and Paediatrics. Hydrofluoric Acid Burn Management: (textbook)
Apply generous amounts of topical gel to the exposed burned skin area, and leav in place for at least 20 minutes; reasses after
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Duration: Onset: 1 to 3 minutes | Peak effect: Immediate | Duration: 30 minutes to 2 hours
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Special Conditions: Pregnancy safety: Category C | Constant ECG and vital sign monitoring is essential | Central venous administration is the preferred route in pediatrics | Do NOT administer by either the IM or SubQ
Diazepam (Valium, Diastate, AcuDial)
Type: Benzodiazepine, Anticonvulsant, Anxiolytic, Sedative, Skeletal muscle relaxant ; Schedule IV drug
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MOA:
Appears to act on part of the limbic system, as well as on the thalamus and hypothalamus, to induce a calming effect; Inhibits GABA receptors in the CNS, reducing neuron excitability; Raises the seizure threshold; and Induces amnesia and sedation
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Indications: Uncontrolled shivering associated w/ hyperthermia/heat-exposure, active seizures, chemical restraint, axetylcholinesterase inhibitor poisoning (carbamate, nerve agents, organophosphate)
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Contraindications: Documented hypersensitivity | Neurologic or respiratory depression | Narrow-angle glaucoma | Myasthenia gravis | Head injury
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Adverse Reactions: Dizziness | Drowsiness | Confusion | Headache | Respiratory depression | Hiccups | Hypotension | Reflex tachycardia | N/V | Muscle weakness | Ataxia | Thrombosis | Phlebitis
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Drug Interactions: Incompatible with more drugs and fluids | Concomitant use with other CNS depressants may cause respiratory depression, hypotension, profound sedation, and death | when given orally, milk thistle may decrease diazepam effectiveness and grapefruit juice can significantly increase serum concentrations | motherwort can potentiate the sedative effects and may result in coma
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Dosages:
Adult.
shivering associated w/ hyperthermia/heat-exposure: 2 mg IV/IO; may repeat once in 5 minutes
Chemical restrain: 5 mg IV or 10 mg IM
Paediatric.
Seizure activity: 0.1 mg/kg slow IV or IO (4 mg maximum)
shivering associated w/ hyperthermia/heat-exposure: 0.1 mg/kg IV/IO (2.5 mg maximum single dose) - may repeate once for total max dose of 5mg IV/IO or 0.5mg/kg PR (max single dose of 10mg) - other repeats noted for PR only
Chemical restrain: 0.05 to 0.1 mg/kg IV (5 mg maximum) or 0.1 to 0.2 mg/kg IM (10 mg maximum)
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Duration: Onset: 2 to 5 minutes IV; 15 to 30 minutes IM | Peak effect: 15 minutes IV; 30 to 45 minutes IM | Duration: 15 to 60 minutes IV and IM
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Special Conditions: Pregnancy safety: Category D | Consider decreasing dose by 50% in patients older than 60 years | Convulsive Antidote Nerve Agent (CANA) is a commercially available auto-injector | In cases of an axetylcholinesterase inhibitor agent exposure, administration of diazepam or midazolam id preferred over lorazepam because of their more rapid onset of action
Glucagon (GlucaGen)
Type: Hyperglycemic agent, Pancreatic hormone, Insulin antagonist
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MOA:
Increases blood glucose level by stimulating the breakdown of stored glycogen to glucose (glycogenolysis) and inhibiting thesynthesis of glycogen from glucose (glycogenesis) | Unknown mechanism of stabilizing cardiac rhythm in beta blocker overdose | Minimal positive inotropic and chronotropic responses | Decreases GI motility and secretions
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Indications: Altered mental status when hypoglycemia is suspected | Antidote for symptomatic bradycardia caused by beta blocker or calcium channel blocker overdoses
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Contraindications: Known hypersensitivity, pheochromocytoma, hyperglycemia, insulinoma
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Adverse Reactions: Dizziness/headache | Hypotension | Tachycardia | N/V | Rebound hypoglycemia
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Drug Interactions: Incompatible in solution with most other substances | No significant drug interactions with other emergency medications
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Dosages:
Adult.
Hypoglycemia: 1 mg IM/IN; repeat dose until symptoms have resolved
Calcium channel blocker or beta blocker overdose: 5 mg slowly via IV push - repeat in 5 to 10 minutes for total dose of 10mg
Paediatric.
Hypoglycemia: 1 mg IM/IN (≥ 20 kg or 5 years) otherwise 0.5 mg
Calcium channel blocker or beta blocker overdose: 1 mg (25 to 40 kg) or 0.5 mg (less than 25 kg) slowly via IV push every 5 minutes
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Duration: Onset: 1 minute | Peak effect: 5 to 20 minutes | Duration: 60 to 90 minutes
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Special Conditions: Pregnancy safety: Category B ; use in pregnancy only if clearly indicated | Ineffective if glycogen stores are depleted | Document reassessment of vital signs and mental status after administration
Hydroxocobalamin (Cyanokit)
Type: Antidote, Cyanide poisoning adjunct
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MOA:
A synthetic, injectable form of vitamin B12 (cobalamin) that binds with cyanide to form nontoxic cyanocobalamin; Excreted renally
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Indications: Known or suspected cyanide poisoning
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Contraindications: Documented hypersensitivity
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Adverse Reactions: Hypertension | Allergic reactions | GI bleeding | Nausea/vomiting | Dyspepsia | Dyspnea | Dizziness/headache | Injection site reactions
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Drug Interactions: Do not administer in the same IV line with diazepam, DOBUTamine, DOPamine, fentanyl, NTG, propofol, sodium nitrate, or sodium thiosulfate
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Dosages:
(Each 5 g vial must be reconstituted with 200 mL of lactated Ringer solution, NS, or D5W)
Adult.
5 g administered over 15 minutes at a rate of 10 to 15 mL/min ; Maximum single dose: 5 g
Paediatric.
70 mg/kg IV at a rate of 10 to 15 mL/min ; Maximum single dose: 5 g
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Duration: Onset: Rapid | Peak effect: 8 to 10 minutes | Duration: Varies
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Special Conditions: Pregnancy safety: Category C ; fetal harm risk and breastfeeding should stop | Preferred agent in known or suspected cyanide poisoning | Reassess the patient’s airway, oxygenation, and hydration during administration | Administration causes discoloration of the skin and urine, rendering pulse oximetry values inaccurate | It is best to perform prehospital phlebotomy before administering this medication | Replaces cyanide antidote kit
Naloxone Hydrochloride (Narcan, EVZIO)
Type: Opioid antagonist, Opioid reversal agent, Antidote
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MOA:
Competitive inhibition at opioid receptor sites; reverses respiratory depression and sedation secondary to opioids
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Indications: Complete or partial reversal of CNS and respiratory depression induced by opioids or synthetic opioids
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Contraindications: Known hypersensitivity or allergy | Use with caution in opioid-dependent patients | Use with caution in neonates of opioid-addicted mothers
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Adverse Reactions: Restlessness | Seizures | Dyspnea | Pulmonary edema | Hypertension/hypotension with rapid administration | Dysrhythmias | Diaphoresis | N/V | Withdrawal symptoms in opioid-addicted patients
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Drug Interactions: Incompatible with bisulfite and alkaline solutions
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Dosages:
Adult.
Initial dose 0.4 to 2 mg IV/IO/IM/ET tube or up to a dose of 4 mg IN
Paediatric.
Initial dose 0.1 mg/kg IV/IO/IM/IN/ET tube ; Maximum dose: 2 mg IV/IM/ET tube or 4 mg IN
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Duration: Onset: Less than 2 minutes, IV ; 2 to 10 minutes IM/IN | Peak effect: Less than 2 minutes, IV ; 2 to 10 minutes IM/IN | Duration: 20 to 120 minutes, IV/IM/IN
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Special Conditions: Pregnancy safety: Category C | Repeat dosing may be required | It is generally NOT beneficial in patients with cardiac arrest | Provide ongoing airway support as needed until the patient has adequate respiratory effort | Administration can be titrated until adequate respiratory effort is achieved if given with a syringe IV, IM, IN, or ET tube; When administered IN, divide doses equally to give a maximum of 1 mL per nostril | Administration can result in onset opioid withdrawal | Very high doses may be required when managing novel opioid overdoses | If administered to the patient before EMS arrival, obtain information on the dose and route through which it was administered and bring the devices with the patient
Potassium Iodide (Pima Syrup, SSKI, ThyroSafe, ThyroShield)
Type: Antidote
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MOA:
Potassium iodide (KI) can help block radioactive iodine from being absorbed by the thyroid gland, thereby protecting this gland from radiation injury and reducing the risk of thyroid cancer | Does not keep radioactive iodine from entering the body and cannot reverse health effects caused by radioactive iodine once the thyroid is damaged | the protection against radoiactive iodine provided by KI depends on the time after contamination, the rate of KI absorption, and the dose of radioactive iodine
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Indications: Environmental radiation emergency to block uptake of radioactive iodine isotopes in the thyroid and reduce thyroid cancer risk
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Contraindications: Known iodine hypersensitivity | Hyperthyroidism | Respiratory failure
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Adverse Reactions: Skin rash | Salivary gland swelling | Iodism
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Drug Interactions: Use with caution in patients taking drugs that may increase serum potassium levels, such as ACE inhibitors | NSAIDs may cause potassium retention
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Dosages:
Consult medical direction
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Duration: Onset: Data unavailable | Peak effect: Data unavailable | Duration: About 24 hours
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Special Conditions: Pregnancy safety: Category D | EMS providers may be asked to assist public health agencies in distribution and administration in a mass-casualty incident involving radiation release or exposure | Adults older than 40 years should not take KI without public health or emergency management official acknowledgment | Adults older than 40 years have the lowest chance of developing thyroid cancer or injury after contamination with radioactive iodine and are more likely to have allergic reactions or adverse effects
Pralidoxime (2-PAM, Protopam)
Type: Cholinesterase reactivator, Antidote
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MOA:
Binds to organophosphates and breaks their alkyl phosphate-cholinesterase bonds to restores the activity of acetylcholinesterase
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Indications: Antidote in treating poisoning by organophosphate pesticides and related nerve gases
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Contraindications: Known hypersensitivity | Reduce the dose in: Patients with impaired renal function; Older adults with hypertension; Patients with myasthenia gravis
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Adverse Reactions: Dizziness, drowsiness, headache, neuromuscular blockage, seizure, laryngospasm, hyperventilation, apnea, tachycardia, cardiac arrest, nausea, muscle rigidity/weakness, rash, pain at injection site | Especially in geriatric patients, excessive doses may cause severe systolic and diastolic hypertension, neuromuscular weakness, headache, tachycardia, and visual impairment | An overdose may cause profound neuromuscular weakness and subsequent respiratory depression in children
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Drug Interactions: Avoid using concurrently with succinylcholine, morphine, aminophylline, theophylline, and other respiratory depressants
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Dosages:
(Textbook)
* Consult with medical direction
* Dosage recommendations vary depending on the degree of exposure and patient age and weight
* May be provided in a single-dose vial, prefilled syringes, or auto-injectors; Commercially available auto-injectors contain 600 mg
(Medscape)
Adult. Organophosphate Poisoning:
* 1-2 g IV infusion (10-20 mg/mL) over 15-30 min, repeat in 1 hr if necessary and repeat q12hr thereafter PRN; if not practical or if pulmonary edema present or fluid restriction necessary administer as 50 mg/mL over 5 min; a second bolus of 1-2 g may be indicated after about 1 hr if muscle weakness has not been relieved; may repeat q10-12hr prn
* Alternatively, administer 30 mg/kg IV (IM, SC if no IV access) over 20 min; follow by 4-8 mg/kg/hr maintenance IV infusion
* Use with atropine, which affects muscarinic receptors; pralidoxime’s actions most striking at nicotonic sites (increase muscle strength 10-40 min)
* IM: 600 mg IM x3 doses; administer each dose 15 minutes apart for mild symptoms, or in rapid succession for severe symptoms; not to exceed 1800 mg total dose initially; if symptoms persist may repeat series of three injections 1 hr after last injection
Adult. Acetylcholinesterase Inhibitor Toxicity: (Neostigmine, Pyridostigmine)
1-2 g IV followed by 250 mg increments q5min PRN
Paediatric. Organophosphate Poisoning: (<16 years)
20-50 mg/kg/dose (not to exceed 2 g/dose) IV; follow by 10-20 mg/kg/hr IV continuous infusion for maintenance; alternatively may repeat bolus of 20-50 mg/kg/dose over 1 hr and repeat q10-12hr if muscle weakness has not bee relieved
Paediatric. Organophosphate Poisoning: (>16 years)
1-2 g IV infusion (10-20 mg/mL) over 15-30 min, repeat in 1 hr if necessary and repeat q12hr thereafter PRN; if not practical or if pulmonary edema present or fluid restriction necessary administer as 50 mg/mL over 5 min; a second bolus of 1-2 g may be indicated after about 1 hr if muscle weakness has not been relieved; may repeat q10-12hr prn; Consult Medical Command for IM use
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Duration: Onset: Minutes | Peak effect: 10 to 20 minutes IM ; 5 to 15 minutes IV | Duration: Variable
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Special Conditions: Pregnancy safety: Category C | Slow IV infusion prevents tachycardia, laryngospasm, and muscle rigidity | Consider drawing a blood sample before administration for the hospital to run pretreatment levels | A dose should be administered shortly after the nerve agent or organophosphate poisoning exposure | Cardiac monitoring should be considered in all cases of severe organophosphate poisoning
Sodium bicarbonate
Type: Systemic hydrogen ion buffer, Alkalizing agent
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MOA:
Reacts with hydrogen ions to form water and carbon dioxide, correcting metabolic acidosis | Increases blood and urinary pH by releasing a bicarbonate ion, which in turn neutralizes hydrogen ion concentrations
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Indications: Management of cardiac arrest in which either hyperkalemia or TCA overdose is suspected | QRS prolongation in known or suspected TCA overdose | Crush syndrome
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Contraindications: Documented hypersensitivity | Known metabolic or respiratory alkalosis | Hypokalemia | Hypernatremia | Hypocalcemia | Use with caution in patients with heart failure and renal disease due to high sodium concentration it produces
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Adverse Reactions: Electrolyte imbalance, heart failure, and pulmonary edema | Tremors, twitching, and seizures caused by alkalosis
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Drug Interactions: Increases the effects of amphetamines | Decreases the effects of benzodiazepines and TCAs | May deactivate sympathomimetics
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Dosages:
Adult.
1 mEq/kg slow IV/IO push
Paediatric.
1 mEq/kg slow IV/IO push (4.2% concentration recommended for infants younger than 1 month) ; Consult medical direction for repeat dosing orders
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Duration: Onset: Seconds | Peak effect: Less than 15 minutes | Duration: 1 to 2 hours
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Special Conditions: Pregnancy safety: Category C | Monitor the patient closely for signs and symptoms of fluid overload | Ensure the patient has adequate airway and ventilatory support | May precipitate or inactivate other medications | Flush the IV line well before and after injecting sodium bicarbonate | Extravasation may lead to tissue sloughing, cellulitis, and necrosis at the injection site
Sodium thiosulfate (Nithiodote)
Type: Cyanide antidote
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MOA:
Converts cyanide to the less toxic thiocyanate, which is then excreted in the urine
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Indications: Known or suspected cyanide poisoning
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Contraindications: Documented hypersensitivity
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Adverse Reactions: Diarrhea
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Drug Interactions: N/A
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Dosages:
Adult.
12.5 g (50 mL of 25% solution) IV/IO slow push over 10 minutes
Paediatric.
0.5 g/kg slow IV/IO (2 mL/kg of 25% solution)
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Duration: Onset: 2 to 10 minutes | Peak effect: Varies | Duration: 30 minutes to 2 hours
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Special Conditions: Pregnancy safety: Category C | Hydroxocobalamin is the only agent that is considered safe for treating cyanide poisoning in the pregnant patient
Ondansetron Hydrochloride (Zofran, Zuplenz)
Type: Selective serotonin receptor (5-HT3) antagonist, Antiemetic
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MOA:
Blocks the action of serotonin, a natural substance that causes N/V | Does not affect dopamine receptors, so it does NOT cause extrapyramidal sxs
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Indications: Prevention and control or nausea or vomiting
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Contraindications: Known hypersensitivity to ondansetron or other 5-HT3 receptor antagonists | Known or suspected long QT syndrome | Coadministration with apomorphin (the combination is reported to cause profound hypotension and loss of conciousness)
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Adverse Reactions: Headache | Malaise | Syncope | Wheezing | Bronchospasm | Dysrhythmias | EKG changed | Palpitations | Constipation | Diarrhea | Hives/skin rash | Serotonin syndrome
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Drug Interactions: Avoid administration with other drugs that prolong the QT interval | Serotonin syndrome can occur with simultaneous use of several drugs (ex: fentanyl and morphine)
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Dosages:
Adult.
Antiemetic: 4 mg IV/SL or orally or 4 mg SL of the orally disintegrating tablet formulation
Vomiting associated with AMS: 4 mg IV, SL, or orally every 6 hours
Stimulant poisoning/overdose: 8 mg slow IV over 2 to 5 minutes or 4 to 8 mg IM or 8 mg orally disintegrating tablet
Paediatric.
Antiemetic for ages 6 months to 14 years: 0.15 mg/kg IV or orally ; Maximum dose: 4 mg
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Duration: Onset: 30 minutes | Peak effect: 1.3 hours (oral) ; 10 minutes (IV) | Duration: 3 to 6 hours
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Special Conditions: Pregnancy safety: Category B ; while this med has NOT been adequately studied in pregnancy to determine its safety in this population, it remains a tx option for hyperemesis gravidarum in pregnant pts | ECG monitoring is recommended for patients who have electrolyte abnormalities, heart failure, or bradydysrhythmias, or who are also receiving other medications that cause QT prolongation | It can be sedating in very young children
