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Appendix 1: Advanced Antidote List

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Appendix 1: Advanced Antidote List Appendix 1: Advanced Antidote List Healthcare facilities with emergency departments must maintain a minimum stock of the following antidotes according to their individual average of cases treated for any of the following indications. It is the responsibility of the healthcare facility to ensure that stock levels to be maintained at the facility are not limited to the “Minimum stock required“ as mentioned in this list. The recommended minimum stocking levels (Shall be rounded up to full “pack-sizes” where necessary). Advanced Antidote list Antidote Recommended Minimum Indication Minimum stock stock to treat 1 patient required* (70 kg) for the first 24 hours Atropine sulfate 300 mg total (vials) Alpha-2 agonists (e.g. 900 mg clonidine, guanabenz and guanfacine), Alzheimer drugs (e.g. donepezil, galantamine, rivastigmine, tacrine), antimyesthenic agents (e.g. pyridostigmine), bradyarrhythmia-producing agents (e.g. beta blockers, calcium channel blockers and digitalis glycosides), cholinergic agonists (e.g. bethanechol), muscarine- containing mushrooms (e.g. Clitocybe and Inocybe sp), nerve agents (e.g. sarin, soman, tabun and VX), organophosphate and carbamate insecticides Bromocriptine 30 mg total( 12 X 2.5 Medications causing 30 mg mesylate mg) neuroleptic malignant syndrome (NMS)(haloperidol, levodopa withdrawal Calcium disodium 3 g total (200mg/ml Lead, zinc salts (e.g., zinc 9 g (9 amps) to EDTA 5ml amp) (= 3 amps) chloride) cover 3 days of treatment for Calcium 2.5 % (25 g or 30 g tube) Hydrofluoric acid skin 4 tubes gluconate gel total 4 tubes exposure Calcium 30 g of 100 mg/mL Calcium channel blockers, 30 g gluconate INJ (10%) calcium gluconate fluoride salts (e.g. NaF), hyperkalemia (not digoxin- induced), hypermagnesemia Charcoal 3 bottle of 50 g Reduction of absorption of 250 g poisons in the gastro- intestinal system Hydroxycobolami One kit Acetonitrile, acrylonitrile, Two Kits ne 5g bromates (thiosulfate only), (Cyanokit®)1 chlorates (thiosulfate only), cyanide (e.g. HCN, KCN and NaCN), cyanogen chloride, cyanogenic glycoside natural sources (e.g. apricot pits and peach pits), hydrogen sulfide (nitrites only), laetrile mustard agents (thiosulfate only), nitroprusside (thiosulfate only), smoke inhalation (combustion of synthetic materials) Cyproheptadine 36 mg (9 tablets of 4 Serotonin syndrome 100 mg mg Dantrolene 700mg total (35 x 20mg Malignant hyperthermia 700 mg sodium vial) of DANTRIUM® (MH) and Neuroleptic /REVONTO®) malignant syndrome (NMS) OR ( 3 X 250 vials of RAYNODEX®) Deferoxamine 6 g total (12 x 500 mg Iron overdose 6 g mesylate vial) Benzodiazepines 10mg Solution, Injection Supportive in the 50 mg ( Diazepam or management of seizures , lorazepam) anxiety due to poisoning (Diazepam for Chloroquine and related antimalarial drugs over dose) Digoxin immune 20 vials Cardiac glycoside-containing 20 vials Fab plants (e.g. foxglove and oleander), digitoxin, digoxin Dimercaprol (BAL) 1.8 g total (18 Arsenic, copper, gold, lead, 1.8 g x50mg/ml -2ml lewisite, mercury ampoules) Dimercaptosuccin ORAL Heavy metal poisoning: One bottles of ic acid Succimer 10 mg/kg three times Arsenic, Lead, and Mercury 100 mg caps (DMSA) per day for five days, Maximum dose is 500 mg followed by 10 mg/kg twice per day for two weeks Diphenhydramine 500 mg total (10 X Drug-induced extrapyramidal 2.5 g HCL 50mg/ml vial) symptoms (e.g. acute dystonic reactions) 4-factor Dose is brand specific, Reversal of acquired Quantity will prothrombincomp quantity will vary coagulation factor3 be according lex accordingly deficiency induced by to the brand, concentrate(PCC ) vitamin K antagonists to be enough 2 to treat one adult patient Flumazenil(UK/US 10 mg total (20 x Benzodiazepines, zaleplon, 10 mg ) 0.1mg/ml -5ml vial) zolpidem Folinic acid 200 mg total (2 x10 Methanol, methotrexate4, 200mg (Leucovorin mg/mL -10 mL vial) trimetrexate, pyrimethamine, Calcium) trimethoprim Fomepizole 3 g (2 x 1.5ml (1g/ml) Ethylene glycol, methanol 6 g vials Glucagon 50 mg total ( 50 x 1mg Beta blockers, calcium 100 mg vials ) channel blockers, hypoglycemia, hypoglycemic agents Idrucizumab 5 g total as two separate Reversal of the anticoagulant 5 g (Parxbind®) vials each containing effects of dabigatran in life- 2.5g /50 mL threatening or uncontrolled bleeding Insulin (Reglular 2 vials of 10-ml Beta blockers, Calcium 4 vials Insulin) channel blockers (diltiazem,nifedipine, verapamil) Lipid emulsion (IV) 2x250 mL or 500 mL bag Severe systemic local 500 ml of 20% intravenous lipid anesthetic toxicity emulsion Lipophilic cardio toxic drugs (eg, bupropion, calcium channel blockers, cocaine, beta-blockers, tricyclic antidepressants). Reserved for cardiotoxicity not responding to standard resuscitation guidelines L-Carnitine 12 g total (12 x Valproic acid 12 g 200mg/ml - 5ml vial (hyperammonemia, encephalopathy, liver failure) Methylene blue 500 mg total (5 x Methemoglobin-inducing 500 mg 10mg/ml - 10ml vial) agents (e.g. aniline dyes, dapsone, dinitrophenol, benzocaine, licdocaine, metoclopramide, monomethylhyrdazine- containing, mushrooms (e.g., Gyromitra), naphthalene, nitrates and nitrites, nitrobenzene, phenazopyridine N-Acetylcysteine 20 % solution for Acetaminophen, carbon 42 g (22 vials) (IV) injection, 21 vials (10 ml tetrachloride, other each) hepatotoxins N-Acetylcysteine 50 g oral Acetaminophen, carbon 100 g (Oral) tetrachloride, other hepatotoxins Naloxone 10 mg total (25 x Opioids (e.g. codeine, 20 mg 0.4mg/ml - 1ml dextromethorphan, ampoule) diphenoxylate, fentanyl, heroin, meperidine, morphine, diphenoxylate, buprenorphine, pentazocine, and propoxyphene), possibly useful for: alpha-2 agonists (e.g. clonidine, guanabenz, and guanfacine), imidazoline decongestants (e.g.,oxymetazoline and tetrahydrozoline), loperamide Octreotide 0.2 mg total ( 4 Sulfonylurea hypoglycemic 4 ampoules acetate ampoules) agents (e.g. glipizide, glibenclamide), quinine induced hypoglycemia Phentolamine 10 mg total( Catecholamine extravasation, 10 mg mesylate 1X10mg/ml-1ml intradigital epinephrine ampoule injection Physostigmine 20 mg total(10X1mg/ml- Anticholinergic alkaloid- 20mg salicylate 2 ml vials) containing plants (e.g. deadly nightshade and jimson weed), antihistamines, atropine and other anticholinergics, intrathecal baclofen Phytonadione 20 mg total) Coumarin and Indandione 20 mg One (vitamin K1) (IV) derivatives, long-acting Patient anticoagulant, rodenticides (e.g. brodifacoum and bromadiolone), warfarin Phytonadione 20 mg oral tablets Coumarin and Indandione 40 mg (vitamin K1) oral derivatives, long-acting anticoagulant, rodenticides (e.g. brodifacoum and bromadiolone), warfarin. Pralidoxime 6 g total (6 x 1g vial) Cholinesterase inhibitor 12 g chloride insecticides and nerve agents, carbamates insecticides Protamine sulfate 50 mg total (1 x Heparin, Low-Molecular - 100 mg 10mg/ml - 5ml - Weight heparin (LMWH) (e.g ampoule) Enoxaparin, Dalteparin, tinazaparin) Pyridoxine 20 g total (20 x 100mg/ Isoniazide, 20 g ml 10ml- vial) Hydrazine,Gyromitra mushrooms. Adjunct to therapy for ethylene glycol intoxication. Scorpion IV 5 -10 vials of Grade II (systemic) or higher 1 box Antivenom Polyvalent Scorpion envenomation after stings by containing 10 Antivenom form the black scorpion (androctonus ampoules of 1 Saudi National Antivenom crassicauda) or by yellow ml and Vaccine Production scorpions (leiurus Center quinquestriatus) Snake Antivenom 4-5 vials of the Polyvalent Snake bites: ; 40-50 ml (fixed 5 vials Snake Antivenom Saudi dose) of the antivenom is to National Antivenom and be diluted in5ml normal Vaccine Production saline / kg body weight, and Center to be infused intravenously over a period of 30-60 minutes. This dose can be repeated every 4-6 hours until definite improvement of the signs Sodium 500 mEq total (10 Chlorine gas, Hyperkalemia, 1000 mEq bicarbonate x1mEq/ml (8.4%) - 50ml- Serum Alkalinization:Agents vial) producing a quinidine-like effect as noted by widened QRS complex on EKG (e.g., amantadine,carbamazepine, chloroquine,cocaine, diphenhydramine, flecainide,propafenone, propoxyphene,tricyclic antidepressants, quinidine) Urine Alkalinization:Weakly acidic agents (e.g.,chlorophenoxy herbicides,chlorpropamide, phenobarbital and salicylates) Thiamine 1 g total (5 x 100mg/ml Ethanol, Ethylene glycol 1 g - 2ml ampoule) 1 Only When hydroxycobalamin is not available, Nithiodote® which contains sodium nitrite and sodium thiosulfate can be stocked instead as an alternative. However, the risk of methemoglobinemia should be considered and the product should not be used in smoke inhalation patients with carbon monoxide poisoning. 2 Or 3-factor PCC with Fresh Frozen Plasma (FFP) 3 The antiodote Andexanet alfa , Andexxa® was approved in 2018 under the FDA's accelerated approval pathway and is the only agent to specifically reverse the anticoagulation effects of direct factor Xa inhibitors ; rivaroxaban and apixaban. Andexxa® is not included among the mandatory list of antidote as at this stage we can not guarantee the international large scale production, however we recommend hospital to stock the item once it became obtainable. 4 Glucarpidase is used as treatment of toxic methotrexate plasma concentrations (>1 micromole/L) in patients with delayed clearance due to renal impairment Glucarpidase is intended for use by paediatric and adult oncology and haematology consultants for treating adults and children receiving high-dose methotrexate chemotherapy who develop a significant deterioration in renal function after the start of the high dose methotrexate, have toxic plasma methotrexate levels and are at risk of life-threatening methotrexate-induced toxicities. GlucarpidaseIs not included among the antidote list as it may not be routinely stocked in hospitals because of its high cost and infrequent use, so the drug should be ordered by the hospital once the use is anticipated. .
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