Antidotes and management of other toxic ingestions/overdoses

Question 1

Toxin: acetaminophen

Answer 1

PO activated charcoal, IV N-acetylcysteine (repletes glutathione).
Note: charcoal is used if pt presents within 4 hours of overdose along with NAC.

Question 2

Toxin: acid/alkali ingestion

Answer 2

assess ABGs and remove affected clothing, upper endoscopy 6- 24 hrs later, Do not try to neutralize acid or base and do not induce vomiting.
Notes: perform endoscopy too soon and u may not see the full damage, too late and you may perforate. Neutralization generates copious amounts of heat. Vomiting worsens esophageal injury.
If the eyes are involved, should be irrigated with copious amounts of water for at least 15 mins before visiting ED.

Question 3

Toxin: Anticholinesterases, organophosphates

Answer 3

Atropine, Pralidoxime ( reactivates acetylcholinesterase)

Question 4

Toxin: Antimuscarinic / anticholinergic agents

Answer 4

Physostigmine.

Question 5

Toxin: arsenic, mercury, gold

Answer 5

Succimer, dimercaprol.

Question 6

Toxin: B-blockers

Answer 6

Glucagon.

Question 7

Toxin: Barbiturates (phenobarbital)

Answer 7

Urine alkalinization, dialysis, activated charcoal, supportive care.

Question 8

Toxin: Benzodiazepines

Answer 8

Supportive care ( intubation), Flumazenil.
Note: never use flumazenil in the setting of chronic use, even if acutely intoxicated as it can produce deadly withdrawal seizures.

Question 9

Toxin: Copper, arsenic, lead, gold

Answer 9

Penicillamine.

Question 10

Toxin: Cyanide

Answer 10

Hydroxycobalamin, amyl nitrate, sodium nitrite, sodium thiosulftae.
Note: Nitrites induce methemoglobinemia which binds cyanate.

Question 11

Toxin: Digitalis (digoxin)

Answer 11

Anti digitalis fab in symptomatic pts ( arrythmias, AMS altered mental status, AKI, hyperkalemia).
Note: Do not treat hyperkalemia or hypocalcemia before giving antidote as these usually correct once NA/K pump is working.

Question 12

Toxin: Heparin

Answer 12

Protamine sulfate.

Question 13

Toxin: Iron

Answer 13

Deferoxamine
Note: look for radiopaque tablets on x-ray in a child with hematemesis and metabolic acidosis.

Question 14

Toxin: lead

Answer 14

Succimer( Dimercaptosuccinic acid) used when levels 45-69 ug/dl, EDTA (Ethylenediaminetetraacetic acid) and dimercaprol used for levels = or > 70 ug/dl.

Question 15

Toxin: Methanol, ethylene glycol (antifreeze)

Answer 15

Fomepizole> ethanol, dialysis, calcium gluconate for ethylene glycol.

Question 16

Toxin: opioids

Answer 16

Naloxone
Note: it is common to empirically treat pts found unconscious with naloxone.

Question 17

Toxin: Salicylates

Answer 17

Urine alkalinization, dialysis, activated charcoal.

Question 18

Toxin: TCAs

Answer 18

Sodium bicarbonate, diazepam, lorazepam for seizures/ agitation.
Note: Monitor closely and only give bicarb if QRS >100 ms or ventricular arrythmia.

Question 19

Toxin: tPA (tissue plasminogen activator), streptokinase

Answer 19

Aminocaproic acid

Question 20

Toxin: Warfarin

Answer 20

FFP (immediate reversal in hemorrhaging pt) VIT K ( long term reversal).