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Tox study > Tox Antidotes > Flashcards

Tox Antidotes Flashcards

1
Q

What is the principal antidote to Methaemglobinaemia

A

Methylene Blue
10ml vial 1% solution (10mg/ml)
1-2mg/kg over 5 minutes followed by a flush

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2
Q

What is the antidote to local anaesthetic toxicity

A

Intralipid
20% vial 100mls (20mg/ml)
Bolus 1.5ml/kg (Approx 1 vial for 70kg Adult)
Then 15ml/kg/hr to max 12ml/kg

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3
Q

What is the antidote to Carbon Monoxide toxicity

A

Hydroxycobalamin
“Cyanokit” 5gm vials
Administer 5gm over 15mins, repeat up to 2 times every 30-60mins to max dose of 15gms
Children 70mg/kg

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4
Q

What is the antidote to Digoxin toxicity

A

Digibind (Digoxin Immune Fab) 40mg per vial

Intra-arrest dose 5 vials (200mg) Q5-10mins to max 20vials, in discussion with tox may give all 20 at once

Not arrested 2 (80mg) vials Q15mins, repeat doses as per toxicologist

Complications: Anaphylaxis, serum sickness, hypokalaemia, exacerbation of underlying heart failure or AF

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5
Q

What is the antidote to Dabigatran (Pradaxa)

A

Praxabind (Idarucizumab)
5gm as single IV bolus

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6
Q

What is the antidote to Benzodiazepines

A

Flumazenil
500mcg/5mls (100mcg/ml) ampoules
100-200mcg Q5mins to max 2000mcg
Paeds 5mcg/kg to max 1000mcg
Infusion 2-10mcg/kg/hour

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7
Q

What is the antidote to toxic alcohols

A

Fomepizole
- 15mg/kg loading dose
- 10mg/kg maintenance doses every 12hrs for 48hrs
- 1.5gm/1.5ml vial

Ethanol
1.8mls/kg (ie 4x 30ml shots vodka 70kg man) as loading dose
0.4ml/kg (30ml shot)/hr
Aiming BAC 0.1-0.15% or 0.1-0.15g/dl

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8
Q

What is the antidote to Sulphonylurea toxicity

A

Octreotide
Subcut: 50mcg Q8hr or 1-2mcg/kg in paeds
IV: 50mcg/kg bolus then 25mcg/hr infusion
Paeds 1mcg/kg bolus then 1mcg/kg/hr

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9
Q

What is the antidote to Organophosphate toxicity

A

Atropine
1.2mg bolus (0.05mg/kg) Q5mins until adequate atropinisation (Hr >80, SBP >80, chest clear)
IV infusion 10-20% of initial dose/hr

Pralidoxime
- 2gm loading dose
- 500mg/hr thereafter
- Paeds 25-50mg/kg load then 10-20mg/kg/hr

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10
Q

What is Calcium Gluconate used to treat?

A

1gm in 10ml vial (100mg/ml)
10% solution, 2.2mmol per vial
Hyperkalaemia
Hypermagnaesamia
Ca+ blocker toxicity
Hydroflouric acid exposure
Hypocalcaemia (ie ethylene glycol toxicity)

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11
Q

What is the antidote to Hydroflouric acid exposure

A

Calcium gluconate/Chloride
Systemic Flourosis: 6.6mmols IV over 5-10mins
Arrest: 2.2mmols every 5mins until ROSC
Dermal: Calcium gel, subcut calcium gluconate, intra-arterial infusion for limbs, and regional IV infusion

Biers block can be used to isolate an affected limb to prevent systemic flourosis and allow concentrated arterial/venous calcium infusions

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12
Q

What is the antidote to Valproate toxicity

A

L-Carnitine

  • Carnitine involved in valproate metabolism
  • depletion leads to conversion of Valproate to hepatotoxic form > hyperammonaemia and encephalopathy

Dose 100mg/kg bolus IV then 15mg/kg IV Q4hr-

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13
Q

What is the antidote in acute iron toxicity

A

Desferrioxamine (DFO)
5mg/kg/hr initial infusion, then increase by 2.5mg/kg/hr every 15mins to max 15mg/kg/hr
Max 80mg/kg in 24hrs

Indications
- Significant systemic toxicity
or
- Peak iron contentration >90umol/L (500ug/dl) at 4-6hr mark
- Peak concentration occurs 4-6hrs post IR OD and 7-9hrs post SR OD

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14
Q

What are the indications for DMPS in poisoning

A

Dimercaptopropane Sulfonate
Chelating agent for lead, arsenic and mercury
5mg/kg IV 4-6hrly
Indicated if symptoms consistent and serum levels of heavy metals high

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15
Q

What are the indications for Succimer in poisoning

A

AKA DMSA, AKA 2,3-dimercaptosuccinic acid
Chelating agent lead, arsenic and mercury
10mg/kg TDS for 5 days, then BD for 14 days

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16
Q

Should Antivenom have pre-treatment

A

Maybe
CSL recommends pretreating with adrenaline (0.25mls of 1:1000 S/C), but this is not backed up by Austin Tox

17
Q

Which Australin non-snake envenomations have antivenom

A

Redback
Funnel web
Box Jellyfish
Stone fish

18
Q

What are the indications for Digibind (Digoxin immune FAB)?

A

Acute (give 5 ampules)
- Cardiac arrest
- Unstable dysrhythmias
- Runs of VE’s
- Digoxin concentration >15 (12)
- K+ >6 in context of toxicity

Chronic (give 2 ampoules)
- Unstable dysrhytmias (fast or slow)
- Cardiac arrest
- Digoxin concentration >2 (1.6) + end organ damage, hyperK or VE’s

Other
- Other cardiac glycoside overdoses

19
Q

What is the dosing of NAC and what are its indications?

A

Indications
- Paracetamol overdose
- Paraquat, Amanita phylloides

Adults
- 200mg/kg over 4hrs, then 100mg/kg over 16hrs

Children
- 200mg/kg (in 7mls/kg) over 4 hrs then 100mg/kg (in 14mls/kg) 16hrs

If in an acute ingestion paracetamol level is more than double the nomogram, > 30gm or >500mg/kg then double the 2nd bag to 200mg/kg

20
Q

How does NAC work?

A

Antagonises the NAPQI toxic metabolite of paracetamol in 4 ways

  • Increases glutathione production
  • Direct binding of NAPQI
  • Provision of inorganic sulfates (ie thiol) that bind NAPQI
  • Can reduce NAPQI back to paracetamol
21
Q

What are the complications and contraindications to NAC? When is it ok to cease NAC?

A

Relative contraindication is previous severe anaphylactoid reaction
- Anaphylactioid reactions occur 10-40% of cases, if it occurs then cease infusion, treat the reaction then slowly restart the infusion
- Pregnancy is not a contraindication

NAC can be ceased at 20hrs if
- Conc <10mg/L or 66umol/L
- ALT <50
- INR <2.0
- Patient clinically stable

22
Q

What are the indications for Naloxone? How does it work?

A

Used prinicipally for opiates, can also be used for clonidine and Imidazoline overdoses with variable effect

Only indicated if the patient is unstable from an A/B/C point of view (ie would be intubated otherwise)

Competitive opioid receptor antagonist (mu, kappa, delta)

23
Q

What is the onset and duration of Naloxone? What are the adverse effects?

A

IV 1-2mins
IM 5-6mins
IN 3-4 mins

Lasts 20-90mins

Nil adverse effects normally
In opioid dependence can precipitate acute withdrawal with GI upset (vomiting/aspiration) and catecholamine surge (APO, AMI, stroke, agitation, arrhythmias)

Paeds dose 10mg/kg

24
Q

What is the therapeutic endpoint with naloxone? When and how should infusions be used?

A

End point- Awake and maintaining sats but not withdrawing

Patient may re-sedate with long acting opioids, if this occurs give 2nd bolus and start infusion 2/3rds the bolus dose per hour

If needing re-bolus then observe for 2hrs post
If needing infusion then observe for 4-6hrs post ceasing

25
Q

What are the indications for Vitamin K (Phytomenadione)?

A

Warfarin overdose with active haemorrhage = IV 5-10mg

Warfarin overdose with no bleeding and not needing anticoagulation
= 10-20mg vitamin K if INR >2

Warfarin overdose with no bleeding but anticoagulation indicated
= titrate vitamin K (IV 1-2mg) to INR, re-measure at 12hrly intervals

Rodenticide overdose
- 10-20mg IV for active haemorrhage
- If INR >1.4 10-20mg PO followed by titration
- May require TDS 10-20mg for months with superwarfarins
- Dont give prophylactically as may mask suprawarfarin toxicity in 1st 48hrs

26
Q

What are the contraindications and adverse effects of Vitamin K?

A

Known allergy

Anaphylaxis (more common IV)
Localised phlebitis
Strange taste in mouth
flushing, sweating

Paediatric dosing 0.25mg/kg

27
Q

What are the indications for charcoal in Paracetamol overdose?

A
  • Within 2hrs and >200mg/kg/10gm
    Or
  • Within 4hrs if >30gm
28
Q

What is the antidote to Neuroleptic malignant syndrome?

A

Bromocriptine 5mg up to every 4hrs

Can also give Dantrolene if severe muscle rigidity develops

29
Q

What is the antidote to Isoniazid?

A

Pyridoxine

30
Q

What is the antidote for Arsenic and other heavy metals?

A

2, 3 Dimercapnol

31
Q

When is Dicobalt Edetate used as an antidote?

A

In severe confirmed cyanide poisonings usually with refractory treatment to Hydroxycobalamin and sodium thiosulphate

The agent works effectively but in itself can cause significant neurological and cardiac compromise

32
Q

What are the antidotes for cyanide?

A

Hydroxocobalamin
- 5gm IV
- 70mg/kg in paediatrics
OR
Sodium Thiosufate
- 12.5gm IV Q60mins
- 400mg/kg in paediatrics

If severe poisoning or cardiac arrest give both of the above and consider with toxicology using Dicobalt Edetate

33
Q

What are the antidotes to lead poisoning ?

A

EDTA and 2, 3 Dimercapnol

34
Q

What are the indications for decontamination, alkalinzation and RRT in salicylate toxicity?

A

Alkalinsation
- symptomatic patient with pH <7.5
- Need to aggressively replete potassium (K+/H+ exchanger) to be effective
- Causes low K+/Ca+, high Na+
- 1-2ml/kg bicarb then infusion 150mls in 850mls 5% dextrose at 166ml/hr

Charcoal
- Any acute ingestion >150mg/kg, can do repeat doses (MDAC)

RRT
- Salicylate level >1000mg/L
- Salicylate >900mg/L + renal failure
- Any severe toxocity

Tox study (7 decks)

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