EMERGENCY DRUGS:AGENTS IN TREATMENT OF POISONING · with antiarrhythmic drugs / poisoncannotbeoveremphasised. Drug Indication Modeofaction Presentation Dose andsupplier Readilyavailable

UIQnTCTIT 1AFnT('AT TOTTRMAT VOT. TmFT 289 22 SEPTEMBER1984

742 D.ll.lilm13 tjutIL vJV'4=.-, _-- . _

TIM MEREDITH

ABC ofPoisoning JANE CAISLEYGLYN VOLANS

EMERGENCY DRUGS: AGENTS USED INTHE 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 treatmentcentres, and others, although listed in textbooks, are not available in theUnited Kingdom; still others are now considered obsolete and, in some

The article Is basen advice cases, actually dangerous.ah artiendixsHbased oncircu nhe Lists ofrecommended drugs have been published by the Department ofappendix toDrHuSS crcular HN (78)

sHealth and Social Security, most recently as HN(62)13 and HN(78)23.

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 of action, presentation, and dosage. In future this

Departments list will be revised as necessary, and copies will be available from theNational Poisons Information Service. Agents used for local cleansing,reliefof pain, fluid replacement, oxygen, and the more general care of theinjured patient are not included. The need for collaboration and discussionbetween doctors and pharmacists in the preparation of this list is readilyapparent and we would welcome comments which may be taken intoaccount in future revisions.

(1) Recommended agents that are readily availableThe decision to stock individual items will depend on the expected

Do nueuitworkload of the hospital concerned. It is important, however, to beDo not use drugs in the treatment g prepared for the unusual so far as is reasonable. Before any of these drugsof poisoning without considering the are used the evidence for toxicity of t e poison concerned should bepossibility that they may further add considered together with the expected efficacy of treatment. For this reasonto 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 of a

with antiarrhythmic drugs / poison cannot be overemphasised.

Drug Indication Mode of action Presentation Doseand supplier

Readily available agents used as specific antidotes

Acetylcysteine Paracetamol Restores depleted glutathione 10 ml ampoules of 150 mg/kg initial dose in 200 ml of 5%

Carbon stores; protects against renal 20% w/v aqueous dextrose IV over 15 min, followed by an IVtetrachloride 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 litreDuncan 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)

Atropine Organophosphorus and Competitive inhibition of 1 ml ampoules 1 2-2-4 mg IV repeated every 5-10 min until

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 maybe necessary

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BRITISH MEDICAL JOURNAL VOLUME 289 22 SEPTEMBER 1984

Drug Indication Mode ofactin Presentation Doseand supplier

Benztropine Movement disorders orpsychotropic effects due to:butyrophenones, eghaloperidol,diphenylbutylpiperidines,eg fluspirilene or pimozide,domperidone,metoclopramide,phenothiazines,thioxanthenes, egclopenthixol

Benzylpenicillin Amanita phalloides

Calcium Fluoridesgluconate Hydrofluoric acid

Competitive inhibition ofmuscarinic receptors; blocksdopamine reuptake

Displaces toxin from plasmaalbumin and enhances urinaryexcretion

Binds or precipitates fluorideions

Hyperkalaemia Reverses neuromuscular paralysisHypermagnesaemia (antacids) due to raised K + and Mg + +

Desferrioxamine Iron

Dextrose

Dicobaltedetate

Chelation of ferrous ions

InsulinOral hypoglycaemic agents

Cyanide and cyanidederivatives, eg acrylonitrile

Dimercaprol Arsenic, copper, gold, lead,mercury

Ethylene glycolMethyl alcohol

(methanol)

Folinic acid Folic acid antagonists, eg

methotrexate,trimethoprim,pyrimethamine

?Methanol

Fuller's earth ParaquatDiquat

Glucagon i Adrenoreceptor blockingdrugs

Increases blood sugar

Chelates to form non-toxiccobalti- and cobalto-cyanides

Chelation of metal ions

Inhibits metabolism of methanolto formaldehyde and formicacid. Inhibits metabolism ofethylene glycol to glycoaldehydeand glycolate

Bypasses blocked folatemetabolism. Stimulation offolate dependent one-carbonpool pathway for methanolmetabolism

Adsorption of paraquat within gut

Bypasses blockade of Pi and P2receptors; stimulates cyclicAMP formation with positiveinotropic effect

1 ml ampoules1 mg/ml. Merck,Sharp, and Dohme(Cogentin)

300 mg and 600 mgphials. Glaxo(Crystapen)

2-5% gel. IndustrialPharmaceuticalsLimited

10 ml ampoules 10%solution(2-25 mmolCa in 10 ml). Evan

Soluble tablets(Sandocal) con-

taining 10 molcalcium gluconate.Sandoz

500 mg phials, 5 gnon-sterile packsfor gastric lavage.Ciba (Desferal)

50 ml ampoules50% solution (25 gMacarthys

20 ml ampoule300 mg in 20 ml.(Kelocyanor).Mona

Cyanide poisoningemergency kit.Cuxson, Gerrard,and Co

2 ml ampoules50 mg/ml in arachioil. Boots

Dehydrated alcoholinjection (absolutealcohol).Macarthys

30 mg/ml ampoules,30mg drypowder phials,15 mg tablets.Lederle(CalciumLeucovorin)

60 g sterile Fuller'searth. ICI PlantProtection Divisioi

1 mg (1 unit) and10 mg (10 unit)phials. Eli Lilly,Novo

1-2 mg by IM or IV injection, repeated asnecessary

250 mg/kg IV daily in divided doses

Hydrofluoric acid skin bums: apply gelrepeatedly but if pain does not subsideinject 10% solution under burn area(0 5 ml/cm2); 10-20 g in 25 ml water orallyfollowed by 10 ml of 10% solution by IVinjection

Is Hyperkalaemia and hypermagnesaemna:10 ml of 10% solution by slow IV injection

(1) 2 g in 10 ml sterile water by IM injection(2) Undertake gastric lavage with des-

ferrioxamine solution (2 g in 1 litre ofwarm water)

(3) After gastric lavage leave 5 g (in 50 mlwater) in stomach

(4) 5 mg/kg/h by slow IV infusion (maximum80 mg/kg in 24 hours) or 2 g by IM

* injection 12 hourly50 ml by IV injection, repeated as necessary

600 mg by IV injection over 1 minfollowed by further 300 mg injection ifresponse does not occur within 1 min

2 5-5 mg/kg by deep IM injection 4 hourly fors 2 days then 2- 5 mg/kg twice daily on the

3rd day and once daily thereafter(1) 50 g orally or IV followed by infusion of

10-12 g/h to maintain plasma ethanol levelof 1-2 g/l. For induced liver enzymes,eg alcoholism or chronic epilepsy, giveethanol infusion at rate of 12-15 g/h.

(2) Ifhaemodialysis is used infusion rateshould be increased to 17-22 g/h becauseethanol is readily dialysable, or ethanolmay be added to peritoneal dialysate fluidat concentration of 1-2 g/l ofdialysate

(1) Methotrexate: up to 60 mg twice daily byIV injection followed by 15 mg six hourlyby mouth for 5-7 days

(2) Trimethoprim: 3-6 mg by IV injectionfollowed by 15 mg daily by mouth for 5-7days

(3) Pyrimethamine: 6-15 mg IV(4) Methanol: 30 mg IV 6 hourly for 2 days250 ml of 30% suspension 4 hourly for 24-48

hours. Always given with magnesiumn sulphate

50-150 sg/kg IV over one minute followed byinfusion of 1-5 mg/h

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Drug Indication Mode ofaction Presentation Doseand supplier

Heparin

Hydrocortisone

Ergotamine (chronicpoisoning)

Aminocaproic acidTranexamic acid

?Prevention of stricture forma-tion due to acid ingestion

Hypercalcaemia due toalfacalcidol and vitamin D

Magnesium Paraquatsulphate Diquat

Delayed release preparations

Methionine Paracetamol

Methylene blue Chemicals causing methaemo-globinaemia, eg cetrimide,cresols, dapsone, nitrates,paradichlorobenzene,phenols, primaquine

Reverses hypercoaguablestate

Anti-inflammatory agent

Decreases gut absorption andincreases renal excretion ofcalcium

Osmotic purgative to assistpassage of delayed releasepreparations throughgastrointestinal tract

Restores depleted glutathionestores; protects against renaland hepatic failure

Promotes conversion ofmethaemoglobin to haemo-globin

1000U/ml i5 ml 30 000-50 000 units daily by IV infusion5000U/ml multidose

25 OOOU/ml J phialsLeo, CP Pharma-ceuticals, Burgess

Injection of hydro- 200 mg 6 hourly by IV injection initially,cortisone sodium followed by reducing doses as the clinicalsuccinate state permitsequivalent to 100mg hydrocortisonebase. Organon,Glaxo, Upjohn

Mixture BP 100 ml of mixture in 250 ml of water,(4 g in 10 ml) repeated every 2 h until diarrhoea occurs

250 mg tablets. Evans 2-5 g initially then 2-5 g 4 hourly for 3 doses(10 g'over 12 hours). Most effective up to8 h after ingestion. ?Effective after 15 h

10 ml ampoules of 1% 1-2 mg/kg (0- 1 ml of 1% solution per kg) bymethylene blue in- slow IV infusion. In patients with glucose 6jection. Macarthys phosphate dehydrogenase deficiency use

ascorbic acid 1 g IV slowly or 200 mg orallythree times daily as methylene blue causeshaemolysis

Naloxone Narcotics

Neostigmine Anticholinergic drugs

Penicillamine CopperGoldLeadMercuryZinc

Phenoxybenza-mine

Competitive inhibitor at opiatereceptor sites

Anticholinesterase which causesaccumulation of acetylcholineat cholinergic receptor sites


Severe hypertension due to Long acting a adrenoceptorclonidine methylphenindate, antagonist causes peripheralmethysergide, monoamine vasodilatationoxidase inhibitors, oxedrine,and phenylephrine

1 ml ampoules0-4 mg/ml. Dupont(Narcan)

1 ml ampoules2 5 mg/ml. Roche(Prostigmin)

50 mg, 125 mg, and250 mg tablets.Dista, E Merck(Distamine,Pendramine)

2 ml ampoules50 mg/ml.Hospital only.Smith, Kline, and

0-4-2-4 mg initially IV repeated every 2-3 minup to 10 mg. May also be given as aninfusion

0 25 mg subcutaneously reverses peripheralbut not central effects

250 mg-2 g orally daily

1 mg/kg diluted in 250 to 500 ml 5% dextroseand infused IV over 60 min

French (Dibenyline)Phentolamine Severe hypertension due to

clonidine, methylpheni-date, methysergide, mono-amine oxidase inhibitors,oxedrine, andphenylephrine

Prenalterol fl Adrenoceptor blockingagents

Propranolol P2 Adrenoceptor stimulantdrugs, eg salbutamol

EphedrineTheophyllineThyroxine

Sodium Used for alkalinisation inbicarbonate forced alkaline diuresis, to

prevent crystallisation ofsulphonamides in renaltubules, and to correctmetabolic acidosis

Sodium calciumedetate

Lead

Short acting a adrenoceptorantagonist causes peripheralvasodilatation

Cardioselective 1 adrenoceptorpartial agonist

1 ml ampoules10 mg in 1 ml.5 ml ampoules50 mg in 5 ml.Ciba (Rogitine)

5-60 mg IV (over 10-30 min), repeated asnecessary

5 ml ampoules 2-15 mg by slow IV injection. Repeat as1 mg/ml. Ciba, Astra necessary(Varbian, Hyprenan)

Non-selective Pi adrenoceptor 1 ml ampoule,blocking drug. Suppresses 1 mg/ml. 40 mgsympathetic overactivity and tablet. ICIrate related myocardial ischaemia (Inderal)

Reverses hypokalaemia due tof3 adrenoceptor stimulants andtheophylline

Alkalinisation and enhancedexcretion of bicarbonate ions inthe urine

Chelation of lead ions

1-2 mg IV over 1 min initially. Repeat every 2min up to 5- 10 mg or 40 mg orally 6-8hourly

NB: Atropine 0-6-1-2 mg IV should be givenbefore propranolol injection

Variety of sterile Dose according to urinary pH or severity ofsolutions available. metabolic acidosisBoots

5 ml ampoules, 1 g in 50-75 mg/kg by IV infusion over 1 h for 55 ml. Sinclair days (every 2 g ofEDTA should be diluted

with 200 ml normal saline).NB: There is evidence that the addition of

dimercaprol 5 mg/kg by deep IM injection4 hourly for 24 h adds to effectiveness ofEDTA regimen

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Sodium chloride Silver nitrateBromides

Sodium nitrite Cyanide and cyanidederivatives, eg acrylonitrile

Hydrogen sulphide

Sodium Severe hypertension due tonitroprusside ergotamine and

methysergideSodium Cyanide and cyanide

thiosulphate derivatives, eg acrylonitrile

Sulphadimidine

Vitamin C

Vitamin K

Amanita phalloides

Chemicals causingmethaemaglobinaemia; usein patients with G6PDdeficiency instead ofmethylene blue

Coumarin and indanedioneanti-coagulants

Precipitates silver as silverchloride. Specifically enhancesurinary excretion of bromideions

Produces methaemoglobinaemiawhich has special affinity forCN- and HS- ions to form cyan-methaemoglobin and sulph-methaemoglobin

Peripheral vasodilator reversingvasoconstriction and severehypertension

Replenishes depleted thiosulphatestores necessary for the con-version ofCN- to thiocyanate

Readily available assodium chlorideBP. Macarthys

300 mg in 10 ml (3%).Macarthys

50 mg dry powderampoules. Roche(Nipride)

50 ml ampoules of50% sodium thio-sulphate.Macarthys

Displaces toxin from plasma 3 ml ampoulealbumin and enhances urinary 1 g/3 ml. ICIexcretion (Sulpamethazine)

Promotes conversion of 200 mg tablets.methaemoglobin to haemoglobin 5 ml ampoules

500 mg/5 ml. Evans

Bypasses inhibition of Vitamin K Injection 10 mg inepoxide reductase enzyme 1 ml. Roche

(Konakion)

10 g/l orally repeated as necessary to precipi-tate silver ions or to produce sodiumchloride diuresis for bromide toxicity

10 ml of 3% solution IV over 3 min followed,in poisoning from cyanide and derivatives,by 25 ml of 50% sodium thiosulphateover 10 min

50-400 p.g/min by IV infusion. Adjust dosesto patient's response. Do not continue forlonger than 48 h

25 ml of 50% sodium thiosulphate over10 min preceded by 10 ml of 3% sodiumnitrate solution IV over 3 min

3 g initially then 1- 5 g 6 hourly by slow IV ordeep IM injection

1 g slowly by IV injection or 200 mg orallythree times daily

10-20 mg by slow IV injection repeated asnecessary

Readily available agents used in supportive therapy

Activatedcharcoal

Adrenaline

Aminophylline

Chlormethiazole

Chlorpheniramine

Chlorpromazine

Cimetidine

Diazepam

Non-specific adsorbent ofparticular use when a lowdose of poison is associatedwith serious toxicity, egmethylxanthines, paraquat,tricyclic antidepressants

Inotropic agent used to treatanaphylaxis and to reverseasystole

Bronchospasm

Anticonvulsant agent used totreat drug induced con-vulsions when diazepam isineffective or inappropriate

Acute drug induced hyper-sensitivity reactions inoverdose

Adsorption of drug in gastro-intestinal tract and interruptionof enterohepatic cycle

Stimulation of a and 1Badrenoceptors

Phosphodiesteraseinhibitor

Anticonvulsant

Hi receptor antagonist

Neuroleptic agent used to treat Major tranquilliserdrug-induced excitementand mania

Prevention of stress ulceration H2 receptor antagonistduring assisted ventilation

Convulsions Anticonvulsant

Medicoal: 5 g sachets.Lundbeck Limited

Carbomix: 50 g singledose plastic bottleof colloidal suspen-sion. PennPharmaceuticalsLtd

Medicoal: 1-2 sachets initially repeated every20 min up to maximum of 50g.

Carbomix: One bottle

1 ml ampoules 1 in Anaphylaxis: 200-500 ,ug by SC or IM1000 (1 mg/ml), or injection, repeated as necessary.10 ml ampoules Asystole: 1 mg IV or intracardiac, repeated as1 in 10000 necessary(1 mg/10 ml).Antigen, Evans

10 ml ampoule Up to 5 mg/kg by slow IV injection over250 mg/10 ml. 10-15 min (usually 250-350 mg)Antigen

500 ml infusion Use minimum effective dose by IV infusion;bottle 8 mg/ml beware of respiratory depressionchlormethiazoleedisylate. Astra

(Heminevrin)1 ml ampoules, 10 mg 10-20 mg by IV injection (mix with 5-10 ml

in 1 ml. 4 mg tablets. blood before injection), 2-4 mg orally 6Allen and Hanbury hourly as necessary(Piriton)

1 ml and 2ml ampoules 25-75 mg IM, repeated as necessary25 mg/ml. May andBaker (Largactil).Antigen

2 ml ampoules,200 mg in 2 ml.Smith, Kline, andFrench (Tagamet)

200 mg by slow (10 min) IV injection 4-6hourly

2 ml ampoules 10mg 5-10mg IV, repeated, as necessaryin 2 ml. Kabivitrum(Diazemuls),Roche (Valium)

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Drng Indication Mode ofactwn Presentation Doseand supplier

Dobutamine Inotropic agent used to treatsevere hypotensionrefractory to use of plasmaexpanders

Inotropic agent used to treatsevere hypotensionrefractory to use of plasmaexpanders and, in low doses,to increase renal blood flowand glomerular filtration rate

Forced diuresis

Stimulation of a,, PI, and P2adrenoceptors

Stimulation of dopaminergicreceptors and alI, PI, and P2adrenoceptors

Loop diuretic

250 mg dry powderphials. Eli Lilly(Dobutrex)

5 ml ampoules40 mg/ml160 mg/ml.American HospitalSupply (UK)(Intropin)

2 ml ampoules 20 mg.Hoechst. Berk(Lasix, Dryptal)

2-40 jg/kg/min by IV infusion

Inotropic dose: 0 5-20 jig/kg/min by IVinfusion

Renal dose: 2-5 jig/kg/min by IV infusion

Bolus injection of 20 mg IV, repeated asnecessary, to initiate and maintainadequate urine flow

Isoprenaline Inotropic agent used to treatsevere hypotensionrefractory to use of plasmaexpanders, especially whenaccompanied by brady-cardia, eg poisoning due toP adrenoceptor blockingdrugs, disopyramidenifedipine, verapamil

Lignocaine Antiarrhythmic agent used totreat ventricular tachy-arrhythmias

Noradrenaline Inotropic agent used to treatsevere hypotensionresistant to use of plasmaexpanders and dopamineand/or dobutamine, egadrenoceptor blocking drugpoisoning

Paraldehyde Anticonvulsant agent usedwhen IV administration ofdiazepam or chlormethia-zole is not possible

Potassiumchloride

Ranitidine

Salbutamol

Agents associated with hypo-kalaemia, eg theophylline,salbutamol. Potassiumreplacement in forceddiuresis

Prevention of stress ulcerationduring assisted ventilation

Stimulation of PI and P2 receptors

Membrane stabilisation

Stimulation of a and ,adrenoceptors

Anticonvulsant

Provides K+ ions

H2 receptor antagonist

Agents causing bronchospasm, Stimulation of PI and P2 adreno-eg P adrenoceptor blocking ceptors causing bronchodilationdrugs, irritant fumes andgases

2 ml ampoule 0-02-0-8 jg/kg/min by IV infusion1 mg/mI. Pharmax(Saventrine)1 ml ampoules200 ,ig/ml.Winthrop (Isuprel)

5 ml ampoules 2% 100 mg bolus over 1 min followed by 2-4solution (100 mg in mg/min by IV infusion; gradually reduce5 ml). 500 ml rate to 1-2 mg/min; continue as neededinfusion bag 0-2% but monitor for lignocaine toxicityin 5% dextrose(2 mg/ml). 0-4%in 5% dextrose(4 mg/ml). Antigen,Boots, Travenol,Astra

2ml and 4ml ampoules 2-5-10 jig/min by IV infusion2 mg/ml noradrena-line acid tartrate.Winthrop(Levophed)2 ml ampoules200 jig/ednoradrenalineacid tartrate.Winthrop(Levophed Special)

5 ml ampoules. Evans 5-10 ml by deep IM injection repeated as

necessary. Must be given in glass syringe

Strong potassium 20-40 mmol in 100 ml 5% dextrose or salinechloride injection over 1-2 hours by IV infusion or added to20 mmol potassium forced diuresis fluid regimenin 10 mls. Antigen

2 ml ampoules 50 mg 6-8 hourly by slow IV injection50 mg/2 ml. Glaxo(Zantac)

5 mg/ml nebuliser Nebuliser: 1-2 ml diluted to a total volume ofsolution (20 ml), 4 ml with normal saline via nebuliser5 ml ampoules Injection: 4 jig/kg IV slowly, repeated as50 jig/ml necessary1 ml ampoules500 jig/el. Allen andHanbury (Ventolin)

Syrup of Method of choice for emptying Orally active emetic agent acting Ipecacuanha emeticipecacuanha the stomach in children. May both centrally and locally mixture paediatric

also be used in adults. Check BNF, ipecacuanhaspecific indications and syrup USPprecautions

10-15 ml of syrup or draught for children,30 ml for adults, followed by 200 ml ofwater, repeated once if necessary after20-30 mi

Dopamine

Frusemide

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(2) Agents held only at selected centres or not available in the United KingdomFor reasons ofsupply, infrequency ofuse, or cost it is impractical for

these agents to be held at all centres. Where possible, selected holdingcentres have been designated and supplies are available for transport toemergency centres. Information on holding centres and arrangements fortransport is available through drug information services and the NationalPoisons Information Service. Certain other agents are not currentlyavailable in the United Kingdom but may be in use abroad. The National

Poisons Information Service will be pleased to advise on the latest status ofthese agents, both in respect of efficacy and availability.


Arginine

hydrochloride

Berlin blue/Prussian blue(potasiumferric hexa-cyanoferrate)

Phencyclidine? Fenfluramine? Quinine

Thallium

DMSA Lead(Succimer) Mercury

DMPS

Digoxin specificantibodyfragments

ArsenicChromiumLeadMercury

Severe digoxin poisoning

Obidoxime Organophosphoruschloride compounds(Toxigonin)

Pralidoxime Some cholinesterase in-hibitors eg organo-phosphorus insecticides

Pyridoxine Isoniazid

Snake anti-venom

Thioctic acid(Lipoic acid)

Forced acid diuresis

Thallium exchanged for potassiumin the molecular lattice andexcreted in faeces



Forms complexes with digoxinwhich are excreted in urine

Reactivates cholinesterases; no

advantages over pralidoxime inpractice

Reactivates cholinesterases

Reversal of acute pyridoxinedeficiency

(1) British-Vipera berus(adder)

(2) Foreign snakes

Amanita phalloides

Used for snake bites whenenvenomnation has occurred

Coenzyme to pyruvatedehydrogenase andoxoglutarate

50 ml phials 10 g in 50 10 g IV over 30 min followed by ammoniumml. Supply via NPIS chloride 4 g orally every 2 hcentres, may beprepared locally

Lamers and Indemans 10 g twice daily orally or through a stomachBV Parallel Weg tube151A Postbus 2745201 AG's-HertogenbaschGermany. Can beobtained via NPIS

Not marketed yet as NPIS will advise on use

the chemicaldimercapto succinic

acid. Still understudy

100 mg sodium (2,3)- 100mg orally three timedimercaptopropan have been used, but lit(1)-sulphonate. experienceHeyl (E Germany).Contact NPIS

40 mg phials Well- NPIS will advise on use

come Research dispatchedLaboratories(supply via NPISLondon centre)

250 mg/ml injection.From E Germanyvia E Merck

s daily. Higher dosesttle published human

when supply

250 mg IV or IM

5 ml ampoules 1 g/ 30 mg/kg by IV or IM injection, 4 hourly for5 ml supplied from 24 h (do not exceed 500 mg/min).designated holding NPIS will advise on use and availabilitycentres.*

Concentrated in-

jection made byMacarthys. Avail-able through NPIS

(1) Zagreb antivenom(monovalent)should be held inall health regions

(2) Antivenoms(polyvalent) are

stocked inpharmacy atWalton Hospital,Liverpool,051-525 3611, andNPIS (01-6359191)

500 mg injection.Homberg,Germany

5 g IV over 3-4 min repeated as necessary.NPIS will advise on use

Advice on management from: NPIS or

Liverpool School of Tropical Medicine(051-708 9393) or tropical consultant onduty, Royal Liverpool Hospital(051-709 0141)

125 mg in 1 litre 5% dextrose by IV injectionevery 6 h for up to 1 week

* These are listed in: Poisonous Chemicals in Homes and Gardens: Notes for Guidance ofMedical Practitioners (HMSO); Chemist and Druggist Directoiy (BEN Publications, Ltd)

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(3) Agents considered obsoleteDrug Indication Why no longer used

Amyl nitrite

Cysteamine

Dextrose

LevallorphanNalorphineMetaraminol

Cyanide poisoning

Paracetamol poisoning

Achieves inadequate levels ofmethaemoglobin

More toxic than acetylcysteine ormethionine

With dicobalt edetate injection for Not neededcyanide poisoning

Opioid poisoning Naloxone more effective

Hypotension

Physostigmnine Anticholinergic poisoning

ApomorphineCopper sulphateSodium chloride

Emesis

Sodium thiosulphate Bleach ingestionoral solution

Universal antidote Universal (!)

No advantages over dopamine,dobutamine, noradrenaline

Response very varied and unpredict-able. Its cholinergic effects can behazardous, including convulsions.Risks outweigh the benefits

Less or no more effective thanipecacuanha with greater risk oftoxicity

Not needed

Newer agents more effective. Canproduce toxicity from tannic acidcontent

Drugs may become obsolete because they arereplaced by more effective agents, or because theyhave been shown to be ineffective or too toxic tojustify their use. For one or more of these reasonsthese drugs are no longer recommended.

Evaluation of the efficacy oftreatments for poisoning is difficult sincemany forms ofpoisoning occur only infrequently, many patients arepoisoned by more than one agent, and there may be considerable variationin the time between exposure and treatment. Not surprisingly, therelore,some of the treatments listed here are not universally accepted. In somecases further data have been gathered or the original data have beenre-examined and found to be inconclusive-for example, hydrocortisone toprevent oesophageal stricture formation after ingestion ofstrong acids oralkalis, ammonium chloride or arginine hydrochloride to produce an acidurine and enhance excretion of fenfluramine and quinine. In other cases,while there are good theoretical grounds for using agents there is as yet noconclusive evidence on their value in practice-for example, acetylcysteinefor carbon tetrachloride; folinic acid for methanol; and benzylpenicillin,sulphonamides, and thioctic acid forAmanita phalloides.

Local practice will also influence the choice of specific treatments, andthere is considerable variation between centres in the type ofsupportivemeasures used-for example, activated charcoal, anticonvulsants, andbronchodilators. It would be inappropriate to try to resolve these issues inthis article, but we hope that we have stimulated further interests and thatresearch will produce results that will simplify the task ofrevising this list.

Dr Tim Meredith, MRCP, is senior medical registrar, Guy's Hospital, and Jane Caisley, BPHARM, MPS, principal pharmacist, Drug Information Service,Guy's Hospital, and Dr Glyn Volans, MD, FRcp, director, National Poisons Information Service, Guy's Poisons Unit, New Cross Hospital, London.

Current controversies

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Documents

EMERGENCY DRUGS:AGENTS IN TREATMENT OF POISONING · with antiarrhythmic drugs / poisoncannotbeoveremphasised. Drug Indication Modeofaction Presentation Dose andsupplier Readilyavailable