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Home , Antidote, Calcium gluconate, Idarucizumab, Muscarinic toxin 7, Sodium nitrite, Sugammadex

California Control System CHART (For medical centers choosing to stock , the suggested Stocking Level is based on the dose needed to treat a single 100 kg patient for 8 hours and for 24 hours.* Medical centers that might expect to receive large numbers of patients in a single incident should stock larger amounts of antidotes or have an effective and efficient sharing/transfer procedure in place to rapidly obtain additional antidotal supplies.) Generic / Suggested Access Indications Notes Name Brand Stocking Level Priority

Atropine / May require large amounts 8 Hours: 100 mg or 13 Immediate insecticide in severe vials (0.4 mg/mL, 20 mL emergency poisoning and other inhibitor poisoning. Also each) department cholinesterase inhibitors stocked in the Strategic (eg, warfare agents); National Stockpile: for 24 hours: 200 mg or 26 induced by a mass casualties, the SNS vials (0.4 mg/mL, 20 mL variety of may provide supplies for each) first 48 hours (coordinated Use -free by state department of product health and emergency response system).

Antivenom, Rattlesnake envenomation 8 hours: 18 vials Within 1 hour Crotalidae Polyvalent Immune- 24 hours: 36 vials FAB(ovine)/ Cro- Fab® , Black Black Widow Equine base risk of 8 hours: 1 vial Special Access: Widow / Spider allergic hypersensitivity contact 24 hours: 1 vial Antivenom envenomation manufacturer (Mer ( Mactans)® ck, 800-672-6372); Merck Order Management Center, 1-800-637- 2579, will drop ship up to 2 vials. BAL()/ BAL Heavy metal poisoning IM administration only 8 hours: 800 mg or 3 amps Within 1 hour in oil 10% (100 mg/mL, 3 mL each) 24 hours: 2400 mg or 8 amps (100 mg/mL, 3 mL each)

Bicarbonate , Sodium channel IV bolus dosing for 8 hours: 63 g (750 mEq) or Immediate blocker (“membrane reversal of sodium 750 mL of 8.4% solution emergency stabilizer”) toxicity & channel blocker toxicity; department 24 hours: 84 g (1000 mEq) urinary alkalinization monitor alkalemia or 1 L of 8.4% solution

Botulinum antitoxin/H- Only available through Special Access; BAT- heptavalent the state health CDC -1-770-488- department (CA) or CDC 7100; California call: 1-916-328- 3605; LA call: 213- 240-7941

Calcium Chloride injection channel blocker Can cause tissue necrosis 8 hours: 10 gms or 10 vials Immediate poisoning; if extravasation occurs – (10%, 10 mL) emergency induced by various use large vein for infusion department agents OR use 24 hours: 10gms or 10 (see below) vials (10%, 10 mL)

Calcium Gluconate Powder For manufacture of topical 8 hours: 1 x 100 g powder Within 1 hour gel bottle 24 hours: 1 x 100 g powder bottle

Calcium Gluconate Hydrofluoric acid skin 8 hours: 30 g or 30 vials Immediate injection exposure or poisoning; (10%, 10 mL) emergency hypocalcemia induced department by various agents 24 hours: 30 g or 30 vials (10%, 10 mL)

Calcium Gluconate Hydrofluoric acid For topical 8 hours: 6 x 25 gm tubes Within 1 hour gel/ Calgonate 2.5% dermal burns 24 hours: 10 x 25 gm tubes gel®

Carnitine (L- Hyperammonemia 8 hours: 10g or 10 x 1 g Within 1 hour Carnitine)/ Carnitor® from valproic acid vials toxicity 24 hours: 20 g or 20 x 1 g vials

Cyanide Antidote ;sodium Conventional cyanide 2 kits for small hospitals, 6 kits Immediate Kit (Nithiodote by nitroprusside antidote: contains 1-10mL for major medical centers or emergency Hope toxicity (300mg) vial of sodium stock separate supplies of department Pharmaceuticals) , 1-50 mL (12.5G) vial sodium and sodium of ( vials OR stock the nitrite inhalant ampules not Cyanokit® () included) antidote kit (see below)

• Cyanide Risk of 2 x 10 mL (3%) vials; 6 vials for Immediate major medical centers emergency with use. department (Less expensive than the Cyanokit™ antidote kit)

• Sodium Thiosulfate Cyanide; sodium If used alone for cyanide 2 x 50 mL (25%) vials; 6 Immediate nitroprusside toxicity, may have a slow vials for major medical emergency toxicity onset of action. Thiosulfate centers department is synergistic with sodium nitrite, and the two (Less expensive than the should be used together to Cyanokit™ antidote kit) treat whenever possible. Cyanokit®/ Cyanide poisoning Newer, safer and easier to 8 hours: 10 g or 2 kits Immediate Hydroxocobalami use (but more expensive) emergency 24 hours:10 g or 2 kits n than the conventional department cyanide antidote kit.

Cyproheptadine/ Mild to moderate side effects 8 hours: 20mg, 5 tablets (4 Periactin®, others and only PO administration mg each) 24 hours: 36mg, 9 tablets (4mg each)

Dantrolene 8 hours: 1000 mg or 50 x Immediate 20 mg vials emergency department 24 hours: 2000 mg or 56 vials

Deferiprone/ Ferriprox® overload Oral Chelator 8 hours: 3.3 g or 7 x 500 mg Specialty/optional tablets 24 hours: 9.9 g or 20 x 500 mg tablets

Deferoxamine/ Desferal IV use only 8 hours: 12 g or 6 x 2 g Within 1 hour vials 24 hours: 36 g or 18 x 2 g vials

Digoxin Immune poisoning; Consult with poison 8-24 hours: 15 vials Immediate FAB (ovine)/ other cardiac center regarding dosing, emergency DigiFab® glycosides (eg, especially for cardiac department oleander, foxglove) glycosides than digoxin

DMSA (Succimer)/ Chemet Heavy metal poisoning 8 hours: 1 g or 10 x 100 mg capsules 24 hours: 3 g or 30 x 100 mg capsules

DTPA-Calcium Dirty bomb agents: Only available through 8 hours: 1 x 1 g amp Special access - (Diethylenetriamine radioactive government sources. Strategic National 24 hours: 1 x 1 g amp pentaacetate)/ plutonium, Stocked in the Strategic Stockpile. The Pentetate Calcium americium and National Stockpile: Radiation Trisodium injection) curium supplies for first 48 hours Emergency coordinated by state Assistance department of health and Center/Training emergency response Site (REAC/TS) system. can be contacted for information on use of antidote. business hours: 1-865-576-3131; after hours: 1-865- 576-1005. For product acquisition contact Manufacturer: Geritrex Pharmaceuticals : 1-914-668-4003 Ext 113 DTPA- Dirty bomb agents: Only available through 8 hours: 1 x 1 g amp Special access - (Diethylenetriamine radioactive government sources. Strategic National 24 hours: 1 x 1 g amp pentaacetate)/ plutonium, Stocked in the Strategic Stockpile. The Pentetate Zinc americium and National Stockpile: Radiation Trisodium injection) curium supplies for first 48 hours Emergency coordinated by state Assistance department of health and Center/Training emergency response Site (REAC/TS) system. can be contacted for information on use of antidote. business hours: 1-865-576-3131; afterhours: 1-865- 576-1005. For product acquisition contact Manufacturer: Geritrex Pharmaceuticals: 1-914-668-4003 Ext 113

EDTA-Calcium/ Versenate Heavy metal poisoning Note: Do not confuse 8 hours: 1 g or 1 1000 mg/5mL with “Sodium” EDTA amp 24 hours: 3 g or 3 1000 mg/5mL amps

Ethanol IV 10% with Ethylene glycol or Note: IV 10% 8 hours: 22 x (5-mL) vials or Within 1 hour 5% Dextrose poisoning product no longer ampules of 98% solution for manufactured; injection easier to dose and monitor 24 hours: 44 x (5-mL) vials or than ethanol ampules

(10% solution can be prepared using 98% ethanol product)

Ethanol (oral) Ethylene glycol or Fomepizole easier to dose 8 hours: one pint Within 1 hour methanol poisoning and monitor than ethanol. 24 hours: 750mL Oral ethanol-containing beverage (eg, whiskey, vodka) can be used in an emergency situation.

Flumazenil/ Romazicon poisoning Use small initial dose to 8 hours: 6 mg or 6 x Immediate avoid abrupt awakening/ 1mg/10 mL vials emergency delirium; use with caution in department 24 hours: 12 mg or 12 x 1 patients on chronic benzodiazepine therapy as mg/10 mL vials withdrawal seizures may occur; use with caution in mixed drug overdoses. Fomepizole (4- Preferred antidote for Manufacturer of Antizol™ 8 hours: 1.5 g or 1 x 1.5mL Within 1 MP)/ Antizol/ ethylene glycol or will replace expired stocks (1g/mL) vials hour generics methanol poisoning 24 hours: 6.0 g or 4 x 1.5 mL (1g/mL) vials

Glucagon /calcium Anticipate 8 hours: 90 mg or 90 x 1 mg Immediate channel blocker and kits emergency poisoning department 24 hours: 250 mg or 250 x 1 mg kits

Glucarpidase/ Voraxaze® toxic levels Use in patient with toxic 5 vials(1000U/vial) Specialty/optional levels and impaired renal product accessed function; glucarpidase may by 1-855-786-7292 also metabolize leucovorin so stagger doses at least 2 hours. 8-24 hours: 5 g or 2 x (2.5g/50  Monoclonal that Specific only for Immediate / Praxbind mL) vials binds to and its dabigatran; not effective emergency acylglucuronide for other oral department metabolites and neutralizes their effects Hyperinsulinemia - Accompany with 8 hours: 1000 U or one vial Immediate euglycemia (HIE) therapy dextrose if (100 U/mL, 10mL each) emergency for calcium antagonist and glucose < 200 mg/dL department 24 hours: 3000 U or three beta- blocker poisoning vials (100 U/mL, 10mL each)

Intravenous Fat Lipophilic cardiotoxic drugs Immediately after 8-24 hours: 2500 mL of Immediate Emulsion/ Intralipid administration several 20% or 3 bags (100mL emergency laboratory tests of each) plus 4 bags (500 mL department patient serum/blood each) may be uninterpretable

Leucovorin calcium Folic acid 8 hours: 300 mg (3 x Within 1 hour antagonists/methan 100 mg vials) ol 24 hours: 1000mg (10 x 100mg vials)

Methylene Blue Methemoglobinemia 8 hours: 400 mg or 4 x 10 mL Immediate (10 mg/mL) amps emergency department 24 hours: 600 mg or 6 x 10 mL (10 mg/mL) amps

N- Acetaminophen Use orally. Dilute at least 8 hours: 28 g or 5 x 30mL Immediate (NAC) Mucomyst or poisoning (oral by a 3:1 ratio. (20%) vials emergency generic preparation) department 24 hours: 56 g or 10 x 30 mL (20%) vials

N-Acetylcysteine Acetaminophen Note: 3 different dilutions 8 hours: 24 g or 4 x 30 mL Within 1 (NAC) Acetadote® poisoning (IV are used for 1, 4 and 16 (20%) vials hour preparation) hour infusions. Loading 24 hours: 30 g or 5 x 30 dose should be infused slowly over 45-60 minutes. mL (20%) vials Generic N- acetylcysteine can be used if Acetadote® is not available (consult with poison center and administer via a micropore filter).

Naloxone/ Narcan Use small initial dose to 8 hours: 20 mg or 50 x 0.4 Immediate avoid abrupt mg/2mL amps or 2 x 10 emergency awakening/withdrawal mg/10mL vials department 24 hours: 40 mg or 4 x 10 mg/mL vials

Octreotide Oral sulfonylurea Avoid long-acting 8 hours: 200 mcg or 2 x Within 1 hour acetate/ poisoning and meglitinide depot products 1mL (0.1mg/mL) amps Sandostatin poisoning 24 hours: 1000 mcg or 1 x 5mL (0.2mg/mL) multidose vial

Physostigmine/ Antilirium® Anticholinergic Administer at low dose 8 hours: 4 mg or 2 x 2mL Immediate poisoning, especially (0.5 mg) and slowly, over (1mg/mL) amps emergency antimuscarinic delirium 2-5 minutes to avoid department 24 hours: 10 mg or 10 x 1 mL severe adverse reactions including bradycardia, (1 mg/mL) amps asystole and seizures (Contraindicated in TCA or similar poisoning with widened QRS intervals) Iodide Thyroid radioiodine Highest risk groups for 8-24 hours: 130 mg Within 1 protection radioiodine-induced hour cancer are infants, children and pregnant and nursing females. Shoule only be used when directed by public health officials.

Pralidoxime(2- Cholinesterase Inhibitor Also stocked in the 8 hours: 7 g or 7 x 1 gm Within 1 hour PAM)/ Protopam poisoning Strategic National (20 mL) vials (organophosphate or Stockpile: for mass 24 hours: 18 g or 18 x 1 gm “nerve gas”) casualties, local cache may provide supplies for (20 mL) vials first 48 hours coordinated by state department of health and emergency response system. reversal May also partially 8 hours: 500 mg or 2 vials Immediate neutralize low-molecular (10mg/mL, 25 mL each) emergency weight department 24 hours: 1250 mg or 5 vials (10mg/mL, 25 mL each)

Prothrombin Complex Reversal of bleeding from Specific reversal agents 8-24 hours: 5,000 IU Immediate Concentrate (PCC): 3 factor anticoagulants ( K may be available emergency and 4 factor antagonists, direct thrombin (idarucizumab, andexanet department inhibitors, factor Xa alpha) and . inhibitors) Otherwise, 4 factor PCC is preferred over 3 factor. Activated prothrombin complex concentrate (APCC or FEIBA) does not contain heparin and preferred for direct thrombin inhibitors. Prussian Dirty bomb agents: Only available through Minimum order is 25 bottles (30 Special access - Blue/ radioactive cesium and government sources. capsules each) Strategic National Radiogardas thallium and non- Stocked in the Strategic Stockpile. The e® radioactive thallium National Stockpile: will Radiation provide supplies for first 48 Emergency hours coordinated by state Assistance department of health and Center/Training emergency response Site (REAC/TS) system. can be contacted for information on use of antidote. business hours: 1-865-576-3131; afterhours: 1-865- 576-1005. For product acquisition contact Manufacturer: McGuff Pharmacy: 1-877-444-1133 (INH) poisoning Large amounts needed for 8 hours: 9 g or 3 vials (100 Immediate (Vitamin B6) poisoning: 5 grams is the mg/mL, 30 mL each) or the emergency minimum antidotal dose equivalent department used in an ingestion of an unknown amount. Note: 24 hours: 24 g or 8 vials the 30 mL vials may only (100 mg/mL, 30 mL each) or be available from the equivalent pharmacies. (If possible: Use preservative The 100 mg in 1 mL vials free product or powder for may contain the reconstitution.) preservative chlorobutanol.

Sugammadex (BridionR) Reversal of rocuronium This agent is used in Available in two vial Immediate- stock and vecuronium (and lieu of carbamate sizes: in areas where possibly pancuronium) () reversal accidental neuromuscular blockade. agents such as 200 mg/2 mL (100 mg/mL) in a administration of . single-dose vial for bolus paralytics may Emergent reversal dosing injection (comes in a box of 10 occur (Emergency depends on the depth of More information here: vials) Department of the paralysis and can http://reference.medscape.c Operating Room) range from 2 mg/kg up to Or 16 mg/kg. om 500 mg/5 mL (100 mg/mL), in a /drug/bridion- single-dose vial for bolus - sodium- injection (comes in a box of 10 999851#0 vials)

Uridine 8 hours: 20 g or 2 x 10 g 5-FU, Recommended for use Wellstat triacetate/ capecitabine within 96 hours of last dose packets Medical : 1- Vistogard poisoning where toxicity is evident or 24 hours: 40 g or 4 x 10 g 800-914-0071 expected; doses of up to 10 grams every 6 hours for packets a total of 20 doses have been well-tolerated.

Vitamin , warfarin-based If patient is actively 8 hours: 50 mg or 10 x 5 mg Immediate K1(Phytonadione)/ anticoagulants and bleeding use fresh tabs or 5 x 10 mg/mL amps emergency  super- warfarin based frozen plasma or Factor department Mephyton or 24 hours: 100 mg or 40 x 5 mg  rodenticide poisoning VII concentrate or AquaMephyton tabs or 20 x 10 mg/mL amps prothrombin complex concentrates.

Expert advice regarding use of antidotes and treatment of poisoning and overdose is available 24 hours a day, 7 days a week from the California Poison Control System. Health Professionals: call 1-800-411-8080 Members of the public: call 1-800-222-1222

Stay Connected! California Poison Control @poisoninfo Text “TIPS” to 69866 to subscribe to our weekly poison prevention tips. Order free health education materials on our website at www.calpoison.org.

*Adapted from Dart RC et al. Annals of Emergency Medicine. 2018; 71(3):314-325.

Updated: July 2020