This chart serves as a quick reference for managing poisonings and drug overdoses. For more detailed instructions, consult your local poison control center. To find your local center, call the American Association of Poison Control Centers at 1-800-222-1222 or visit http://www.aapcc.org/findyour.htm.
| Poison or drug |
Antidote and dosage |
| acetaminophen |
acetylcysteine (Acetadote, Mucomyst)
Give P.O. as 5% solution by diluting with carbonated diet beverage.
Loading dose: One-time dose of 140 mg/kg. Repeat dose if patient vomits within 1 hour of administration.
I.V. dose: 150 mg/kg over 15 minutes.
Maintenance dose: 50 mg/kg infused over 4 hours, followed by 100 mg/kg infused over 16 hours. |
alpha2-adrenergic
agonists
opiods |
naloxone (Narcan)
Adults: 0.4 to 2 mg I.V., I.M., or subcutaneously; repeat q 2 to 3 minutes, p.r.n. Maximum dosage is 10 mg.
Children > age 5 or > or = to 20 kg: 2 mg/dose I.V.; repeat q 2 to 3 minutes, p.r.n.
Children < age 5 or < 20 kg: 0.1 mg/kg I.V.; repeat q 2 to 3 minutes, p.r.n.
Neonates: Initially, 0.01 mg/kg I.V., repeated q 2 to 3 minutes p.r.n.
Postoperative opioid-induced respiratory depression
Adults: 0.1 to 0.2 mg I.V. q 2 to 3 minutes, p.r.n. If ordered, give initial adult dose of 0.1 mg I.V. to assess patient’s response. Give subsequent doses of 0.4 mg or less (undiluted) by direct injection over 15 seconds, or titrate based on response. As needed, give continuous I.V. infusion, diluting 2 mg of naloxone with 500 ml of normal saline or dextrose 5% in water for a final concentration of 4 mcg/ml; titrate based on patient’s response.
Children: 0.005 to 0.01 mg/kg I.V. q 2 to 3 minutes, p.r.n..
nalmefene (Revex)
Initially, 0.5 mg/70 kg I.V., followed by a second dose of 1 mg/70 kg I.V. 2 minutes later, if necessary. Doses greater than 1.5 mg/70 kg will likely not improve response and may precipitate withdrawal symptoms.
|
anticholinergic agents
antihistamines
atropine |
physostigmine (Antilirium)
Adults: 0.5 to 2 mg slow I.V. injection (not to exceed 1 mg/minute). May repeat q 20 minutes until response or adverse effects occur. If initial dose is effective, additional doses of 1 to 4 mg may be given q 30 to 60 minutes as life-threatening signs (arrythmias, seizures, deep coma) recur.
Children: 0.02 mg/kg I.M. or slow I.V. injection (not to exceed 0.5 mg/minute). May repeat q 5 to 10 minutes until therapeutic response occurs or maximum dosage of 2 mg is given. |
| benzodiazepines |
flumazenil (Romazicon)
Adults: Initially, 0.2 mg I.V. injected over 30 seconds; follow with 0.3 mg if desired level of consciousness isn’t reached. May give further doses of 0.5 mg at 60-second intervals until therapeutic response occurs or cumulative dosage of 3 mg is given. If partial response is achieved at 3 mg, rarely patients may need additional doses up to a total of 5 mg. If sedation recurs, repeat dose at 20-minute intervals. Maximum dosage is 3 mg/hour.
Children: Initially 0.01 mg/kg (maximum dosage 0.2 mg) with repeat doses of 0.01 mg/kg (maximum dosage 0.2 mg) given q minute to maximum cumulative dosage of 1 mg. |
| cyanide |
Antidote kit contains amyl nitrite, sodium nitrite, sodium thiosulfate.
amyl nitrite
Adults and children: Hold amyl nitrite inhalant close to patient’s nose or mouth for 30 seconds each minute until I.V. can be established and sodium nitrite infusion started.
sodium nitrite
Adults: 300 mg (10 ml) I.V. over 5 minutes
Children: 0.15 to 0.33 ml/kg, up to 10 ml I.V., over 5 minutes.
Methylene blue may be given to adults and children who experience methemoglobinemia from excessive sodium nitrite dosage. Methylene blue dosage is 1 to 2 mg/kg or 25 to 50 mg/mm2 I.V. infused very slowly over several minutes. If needed, a second dose may be given after 1 hour. Or, 100 to 300 mg P.O. daily.
sodium thiosulfate
Follow sodium nitrite infusion with sodium thiosulfate.
Adults and adolescents: 12.5 g (50 ml) I.V. at a rate of 2.5 to 5 ml/minute.
Children: 412.5 mg/kg or 7 g/mm2 I.V. at a rate of 2.5 to 5 ml/minute. |
| digoxin |
digoxin immune Fab (Digibind, DigiFab)
Calculate dosage as number of 38-mg vials, using this formula: Digoxin level (in ng) X patient’s weight (in kg) divided by 100. Usual dosage range is four to six vials.
If ingested amount of digoxin is unknown, give 10 to 20 vials (380 to 800 mg) I.V. over 30 minutes through a 0.22-micron filter. May give bolus dose if cardiac arrest is imminent. |
| ethylene glycol |
fomepizole (Antizol)
Loading dose: 15 mg/kg I.V. over 30 minutes, followed by 10 mg/kg I.V. over 30 minutes q 12 hours for four doses
Maintenance dose: 15 mg/kg I.V. over 30 minutes q 12 hours until ethylene glycol level falls below 20 mg/dl |
| heparin |
protamine sulfate
Dosage is based on partial thromboplastin time; usually, 1 mg for each 100 units of heparin. Give I.V. over 10 minutes (maximum rate of 5 mg/minute) in doses not exceeding 50 mg. Patients allergic to fish, vasectomized or infertile men, and patients taking protamine-insulin products are at increased risk for protamine hypersensitivity. |
hypercalcemic
emergency |
edetate disodium (Endrate)
Adults: 50 mg/kg/day by slow I.V. infusion over at least 3 hours, up to a maximum of 3 g/day.
Children: 40 mg/kg/day by slow I.V. infusion over at least 3 hours, up to a maximum of 70 mg/kg/day.
Dilute with normal saline solution or dextrose 5% in water; don’t infuse rapidly. Keep patient in bed for 15 minutes after infusion to avoid orthostatic hypotension. Keep I.V. calcium readily available, because drug may cause profound hypocalcemia, leading to tetany, seizures, arrhythmias, and respiratory arrest. Alternate I.V. sites daily to decrease risk of thrombophlebitis.
Alert: Do not confuse drug with edetate calcium disodium, used as lead poisoning antidote. |
| iron |
deferoxamine (Desferal)
Acute iron intoxication: Initially, 1 g I.M., followed by 500 mg q 4 hours for two doses depending on clinical response, and then 500 mg q 4 to 12 hours, up to 6 g/day. May give I.V. infusion of 10 to 15 mg/kg/hour for first 1 g. Subsequent doses shouldn’t exceed 125 mg/hour. Maximum dosage is 6 g in 24 hours.
Chronic iron intoxication: In adults, 1 to 2 g/day subcutaneously. In children, maximum dosage of 2 g/day subcutaneously. |
| lead |
edetate calcium disodium (Calcium Disodium Versenate)
Acute lead encephalopathy
Adults and children: 1 to 1.5 g/m2/day I.V. or I.M. (preferred) in divided doses at 8- to 12-hour intervals for 5 days. A second course may be given after at least two drug-free days.
Lead poisoning without encephalopathy
Children: 1 g/m2/day I.V. or I.M. in divided doses for 5 days
Dilute I.V. dose with 250 to 500 ml of normal saline solution or dextrose 5% in water. Rapid infusion may be lethal; infuse at rate suggested by manufacturer. Discontinue drug at first sign of renal toxicity. For I.M. injections only, may add procaine hydrochloride to minimize pain at injection site.
Alert: Do not confuse drug with edetate disodium, used to treat hypercalcemia.
succimer (Chemet)
Adults: 10 mg/kg/dose P.O. q 8 hours for 5 days; then 10 mg/kg/dose q 12 hours for 14 days.
Lead poisoning in children with blood lead levels above 45 mcg/dl
Children: 10 mg/kg P.O. or 350 mg/m2 P.O. q 8 hours for 5 days; then decrease to 10 mg/kg P.O. or 350 mg/m2 P.O. q 12 hours for 14 days. Treatment lasts 19 days; repeated courses should follow 2-week rest period. Monitor CBC with white cell differential. Stop drug and contact prescriber if neutrophil count drops below 1,200/mm3. |
opioid overdose
and dependence |
naloxone hydrochloride (Narcan)
Opioid overdose
Adults: 0.4 to 2 mg I.V., I.M., or subcutaneously; repeat q 2 to 3 minutes, p.r.n., up to 10 mg
If ordered, give initial adult dose of 0.1 mg I.V. to assess patient’s response. Give subsequent doses of 0.4 mg or less (undiluted) by direct injection over 15 seconds, or titrate based on response. As needed, give continuous I.V. infusion, diluting 2 mg of naloxone with 500 ml of normal saline solution or dextrose 5% in water for a final concentration of 4 mcg/ml; titrate based on patient’s response.
Children: > age 5 or > or equal to 20 kg: 2 mg/dose; repeat q 2 to 3 minutes.
Children: < age 5 or < 20 kg: 0.1 mg/kg; repeat q 2 to 3 minutes.
Postoperative opioid-induced respiratory depression
Adults: 0.1 to 0.2 mg I.V. q 2 to 3 minutes, p.r.n.
Children: 0.005 to 0.01 mg/kg q 2 to 3 minutes.
Opioid dependence
naltrexone (Depade, ReVia)
Adults: Initially, 25 mg P.O.; give an additional dose of 25 mg if no withdrawal symptoms occur within 1 hour. When patient is receiving 50 mg q 24 hours, a maintenance schedule of 50 to 150 mg/day P.O. may be used. Don’t initiate therapy until patient has been opiate-free for 7 to 10 days; do not begin for opioid dependence until a naloxone challenge test has been given.
Alert: Do not confuse naltrexone with naloxone. |
organophosphate
insecticides |
pralidoxime (Protopam)
Adults: 1 to 2 g I.V. in 100 ml of normal saline solution infused over 15 to 30 minutes. If pulmonary edema occurs, may give as 5% solution I.V. over 5 minutes. May repeat dose in 1 hour if muscle weakness persists; may give additional doses at 10- to 12-hour intervals cautiously if muscle weakness continues.
Children: 20 to 50 mg/kg (up to 1 g) in 250 ml normal saline solution I.V. over 30 minutes |
| warfarin |
phytonadione (Vitamin K)
Adults: 2.5 to 10 mg subcutaneously. based on prothrombin time/ International Normalized Ratio; may repeat in 6 to 8 hours as needed.
In emergency, 2.5 to 25 mg slow I.V. (no faster than 1 mg/minute); may repeat 6 to 8 hours after first dose. |
miscellaneous drug
overdose |
activated charcoal
Adults: 1 to 2 g/kg with at least a 10:1 ratio of activated charcoal to intoxicant (usual dose is 25 to 100 g charcoal in water or sorbitol) and administered P.O. or by nasogastric tube. Do not give doses greater than 100 g.
Children: 1 to 2 g/kg or 25 to 50 g charcoal.
The use of repeated oral charcoal with sorbitol doses is not recommended. |
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