1984 1AFnT('AT VOT. TmFT 289 22 SEPTEMBER UIQnTCTIT utILtjTOTTRMAT vJV' _- - . _ 742 D.ll.lilm13 4=.-, TIM MEREDITH JANE CAISLEY ABC ofPoisoning GLYN VOLANS EMERGENCY DRUGS: AGENTS USED IN THE TREATMENT OF POISONING A readily available and practical guide to the drugs used in the treatment of / poisoning is important, since many of the agents concerned are used infrequently; some can be obtained only from selected poisons treatment centres, and others, although listed in textbooks, are not available in the United Kingdom; still others are now considered obsolete and, in some cases, actually dangerous. The article Is basen advice Lists ofrecommended drugs have been published by the Department of appendixah artiendixsHto basedcrcularcircuon HNhen(78) Health and Social Security, most recently as HN(62)13 and HN(78)23. DrHuSS s 23 Ougs of Special Value in the1This article is based on these earlier lists, although, necessarily, many more Treatment of Poisoning in drugs have been included and additional information is given on the Accident and Emergency indications for use, mode ofaction, presentation, and dosage. In future this Departments list will be revised as necessary, and copies will be available from the National Poisons Information Service. Agents used for local cleansing, reliefofpain, fluid replacement, oxygen, and the more general care of the injured patient are not included. The need for collaboration and discussion between doctors and pharmacists in the preparation ofthis list is readily apparent and we would welcome comments which may be taken into account in future revisions. (1) Recommended agents that are readily available The decision to stock individual items will depend on the expected ofthe hospital concerned. It is important, however, to be Do not use drugs in the treatment Dognueuitworkloadprepared for the unusual so far as is reasonable. Before any ofthese drugs of poisoning without considering the are used the evidence for toxicity oft e poison concerned should be possibility that they may further add considered together with the expected efficacy of treatment. For this reason to the toxic effects of the poison, we recommend that the user reads the appropriate article either in this series eg treating drug induced arrhythmTias or in other suitable texts. The need to avoid adding to the toxic effects ofa with antiarrhythmic drugs / poison cannot be overemphasised. Drug Indication Mode ofaction Presentation Dose and supplier Readily available agents used as specific antidotes 5% Acetylcysteine Paracetamol Restores depleted glutathione 10 ml ampoules of 150 mg/kg initial dose in 200 ml of Carbon stores; protects against renal 20% w/v aqueous dextrose IV over 15 min, followed by an IV tetrachloride and hepatic failure solution (each infusion of 50 mg/kg in 500 ml of 5% containing 2 g). dextrose over 4 h, then 100 mg/kg in 1 litre Duncan Flockhart of 5% dextrose over 16 h. Total dose (Parvolex) 300 mg/kg of acetylcysteine in 20 h. Most effective up to 8 h after ingestion. ?Effective after 15 h Ammonium Phencyclidine Forced acid diuresis Ammonium chloride 4 g orally every 2 h preceded by 10 g arginine chloride ?Fenfluramine powder hydrochloride IV over 30 min ?Quinine BP. Macarthys (Vestric) until Atropine Organophosphorus and Competitive inhibition of 1 ml ampoules 1 2-2-4 mg IV repeated every 5-10 min carbamate insecticides muscarinic receptors 600 Ftg/ml. full atropinisation is achieved (dry mouth Choline esters, eg carbachol Evans Medical and pulse rate more than 70/mm). Continue for 2-3 days; large quantities may be necessary BRITISH MEDICAL JOURNAL VOLUME 289 22 SEPTEMBER 1984 743 Drug Indication Mode ofactin Presentation Dose and supplier Benztropine Movement disorders or Competitive inhibition of 1 ml ampoules 1-2 mg by IM or IV injection, repeated as psychotropic effects due to: muscarinic receptors; blocks 1 mg/ml. Merck, necessary butyrophenones, eg dopamine reuptake Sharp, and Dohme haloperidol, (Cogentin) diphenylbutylpiperidines, eg fluspirilene or pimozide, domperidone, metoclopramide, phenothiazines, thioxanthenes, eg clopenthixol Benzylpenicillin Amanita phalloides Displaces toxin from plasma 300 mg and 600 mg 250 mg/kg IV daily in divided doses albumin and enhances urinary phials. Glaxo excretion (Crystapen) Calcium Fluorides Binds or precipitates fluoride 2-5% gel. Industrial Hydrofluoric acid skin bums: apply gel gluconate Hydrofluoric acid ions Pharmaceuticals repeatedly but ifpain does not subside Limited inject 10% solution under burn area 10 ml ampoules 10% (0 5 ml/cm2); 10-20 g in 25 ml water orally Hyperkalaemia Reverses neuromuscular paralysis solution followed by 10 ml of 10% solution by IV Hypermagnesaemia (antacids) due to raised K + and Mg + + (2-25 mmol injection Ca in 10 ml). EvanIs Hyperkalaemia and hypermagnesaemna: Soluble tablets 10 ml of 10% solution by slow IV injection (Sandocal) con- taining 10 mol calcium gluconate. Sandoz Desferrioxamine Iron Chelation of ferrous ions 500 mg phials, 5 g (1) 2 g in 10 ml sterile water by IM injection non-sterile packs (2) Undertake gastric lavage with des- for gastric lavage. ferrioxamine solution (2 g in 1 litre of Ciba (Desferal) warm water) (3) After gastric lavage leave 5 g (in 50 ml water) in stomach (4) 5 mg/kg/h by slow IV infusion (maximum 80 mg/kg in 24 hours) or 2 g by IM * injection 12 hourly Dextrose Insulin Increases blood sugar 50 ml ampoules 50 ml by IV injection, repeated as necessary Oral hypoglycaemic agents 50% solution (25 g Macarthys Dicobalt Cyanide and cyanide Chelates to form non-toxic 20 ml ampoule 600 mg by IV injection over 1 min edetate derivatives, eg acrylonitrile cobalti- and cobalto- 300 mg in 20 ml. followed by further 300 mg injection if cyanides (Kelocyanor). response does not occur within 1 min Mona Cyanide poisoning emergency kit. Cuxson, Gerrard, and Co Dimercaprol Arsenic, copper, gold, lead, Chelation of metal ions 2 ml ampoules 2 5-5 mg/kg by deep IM injection 4 hourly for mercury 50 mg/ml in arachis 2 days then 2-5 mg/kg twice daily on the oil. Boots 3rd day and once daily thereafter Ethanol Ethylene glycol Inhibits metabolism of methanol Dehydrated alcohol (1) 50 g orally or IV followed by infusion of Methyl alcohol to formaldehyde and formic injection (absolute 10-12 g/h to maintain plasma ethanol level (methanol) acid. Inhibits metabolism of alcohol). of 1-2 g/l. For induced liver enzymes, ethylene glycol to glycoaldehyde Macarthys eg alcoholism or chronic epilepsy, give and glycolate ethanol infusion at rate of 12-15 g/h. (2) Ifhaemodialysis is used infusion rate should be increased to 17-22 g/h because ethanol is readily dialysable, or ethanol may be added to peritoneal dialysate fluid at concentration of 1-2 g/l ofdialysate Folinic acid Folic acid antagonists, eg Bypasses blocked folate 30 mg/ml ampoules, (1) Methotrexate: up to 60 mg twice daily by methotrexate, metabolism. Stimulation of 30mg dry IV injection followed by 15 mg six hourly trimethoprim, folate dependent one-carbon powder phials, by mouth for 5-7 days pyrimethamine pool pathway for methanol 15 mg tablets. (2) Trimethoprim: 3-6 mg by IV injection ?Methanol metabolism Lederle followed by 15 mg daily by mouth for 5-7 (Calcium days Leucovorin) (3) Pyrimethamine: 6-15 mg IV (4) Methanol: 30 mg IV 6 hourly for 2 days Fuller's earth Paraquat Adsorption of paraquat within gut 60 g sterile Fuller's 250 ml of 30% suspension 4 hourly for 24-48 Diquat earth. ICI Plant hours. Always given with magnesium Protection Divisioin sulphate Glucagon i Adrenoreceptor blocking Bypasses blockade of Pi and P2 1 mg (1 unit) and 50-150 sg/kg IV over one minute followed by drugs receptors; stimulates cyclic 10 mg (10 unit) infusion of 1-5 mg/h AMP formation with positive phials. Eli Lilly, inotropic effect Novo 744 BRITISH MEDICAL JOURNAL VOLUME 289 22 SEPTEMBER 1984 Drug Indication Mode ofaction Presentation Dose and supplier Heparin Ergotamine (chronic Reverses hypercoaguable 1000U/ml i5 ml 30 000-50 000 units daily by IV infusion poisoning) state 5000U/ml multidose Aminocaproic acid 25 OOOU/ml J phials Tranexamic acid Leo, CP Pharma- ceuticals, Burgess Hydrocortisone ?Prevention of stricture forma- Anti-inflammatory agent Injection of hydro- 200 mg 6 hourly by IV injection initially, tion due to acid ingestion cortisone sodium followed by reducing doses as the clinical succinate state permits equivalent to 100 mg hydrocortisone base. Organon, Hypercalcaemia due to Decreases gut absorption and Glaxo, Upjohn alfacalcidol and vitamin D increases renal excretion of calcium Magnesium Paraquat Osmotic purgative to assist Mixture BP 100 ml of mixture in 250 ml ofwater, sulphate Diquat passage of delayed release (4 g in 10 ml) repeated every 2 h until diarrhoea occurs Delayed release preparations preparations through gastrointestinal tract Methionine Paracetamol Restores depleted glutathione 250 mg tablets. Evans 2-5 g initially then 2-5 g 4 hourly for 3 doses stores; protects against renal (10 g'over 12 hours). Most effective up to and hepatic failure 8 h after ingestion. ?Effective after 15 h Methylene blue Chemicals causing methaemo- Promotes conversion of 10 ml ampoules of 1% 1-2 mg/kg (0- 1 ml of 1% solution per kg) by globinaemia, eg cetrimide, methaemoglobin to haemo- methylene blue in- slow IV infusion. In patients with glucose 6 cresols, dapsone, nitrates, globin jection. Macarthys phosphate dehydrogenase deficiency use paradichlorobenzene, ascorbic acid 1 g IV slowly or 200 mg orally phenols, primaquine three times daily as methylene blue causes haemolysis Naloxone Narcotics Competitive inhibitor at opiate 1 ml ampoules 0-4-2-4 mg initially IV repeated every 2-3 min receptor sites 0-4 mg/ml. Dupont up to 10 mg. May also be given as an (Narcan) infusion Neostigmine Anticholinergic drugs Anticholinesterase which causes 1 ml ampoules 0 25 mg subcutaneously reverses peripheral accumulation of acetylcholine 2 5 mg/ml.