Beruflich Dokumente
Kultur Dokumente
11/12/2012
Epidemiology
2 million calls 52% of poison center calls < 6years Peak age 18 months - 3 years
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Epidemiology
Intentional (adolescent)
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Unable to discriminate safe from unsafe liquid Fail to recognize the suitability of the drink
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Epidemiology
Around Meal time Grand parents home Kerosene or gasoline in a soda bottle Older sibling can pharmaceutically treat younger sibling
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Very toxic!
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ICU Admission
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Toxic Exposures/Death
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Fatal Sip
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Fatal Sip
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Fatal Sip
Benzocaine
2 ml
Methemoglobinemia Seizure
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Malignant Swallow
Chloroquine (20 mg/kg) Theophylline (8.4 mg/kg) Imipramine (15 mg/kg) Chlorpromazine (25 mg/kg)
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Malignant Swallow
Clonidine
0.3 mg tablet
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Highly Toxic
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Acetonitriles
Artificial Nail Tip remover Methemolobinemia Delayed presentation (4-12 hours) Must be hospitalized
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Ammonium Fluoride
Glass etching, de-rusting and wheel cleaning commercial products Armoral Quick Silver Wheel cleaner (17% ammonium fluoride) only 2 ml
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Ammonium Fluoride
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Benzocaine
Teething gels (Orajel), first aid cream hemorrhoidal preparations Methemoglobinemia < 6 months (methemoglobin reductase)
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Camphor
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Pennyroyal Oil
Health food products, herbal preparations Depletes glutathione Toxicity to liver & lung < a teaspoon A tablespoon (fatal)
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Look-Alike, Sound-A-Like
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Look-Alike, Sound-A-Like
Hydralazine Hydrocodone
Hydroxyzine Hydrocortisone
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Plant Toxidromes
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Digitalis Effects
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Nicotinic Effects
Poison hemlock
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Atropinic Effects
Jimsonweed
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Non-Toxic Products
Ball point ink Bubble bath soaps Candles (beeswax or paraffin) Chalk Cigarettes (< 3 butts) Crayons
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Non-Toxic Products
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Evaluation
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History
What? When? How much?
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What ?
Medication Illicit
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What form?
Pill Solid Liquid Gaseous
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What route ?
Ingestion Inhalation Topical Intravenous
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When ?
Elapsed
time
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How much ?
Estimate
amount Concentration
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Vital signs
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Bradycardia
Digoxin Narcotics Organophosphates Carbon
monoxide Beta-blocker
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Tachycardia
Alcohol/amphetamine Atropine/tricyclic Theophylline Salicylates,
Iron Cocaine/PCP
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Slow Respiration
Alcohol Narcotics Clonidine Sedatives
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Tachypnea
Amphetamines Salicylates Carbon
monoxide
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Hypotension
Methemoglobinemia Carbon
Hypertension
OTC
Ventricular Tachycardia
Amphetamines Carbamzepine Chloral hydrate Cocaine Digitalis Theophylline
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Torsades de Pointes
Chloral hydrate Cisapride Organophosphates Terfenadine Phenothiazines
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Hypoglycemia (HOBBIES)
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Hypothermia
Ethanol Narcotics Carbon
monoxide
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Hyperpyrexia
Atropine Salicylates Theophylline Cocaine TCA
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Mental Status
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Coma
Narcotic Anticholinergic Carbon
monoxide
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Delirium/Psychosis
Alcohol PCP/marijuana LSD
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Convulsion
Cocaine/Amphetamine Lead Salicylate Isoniazid Theophylline
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Pupil size
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Miosis (COPS)
Cholinergics,
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Mydriasis (AAAS)
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Caution!
Polydrug overdoses with opposite pupillary actions Nontoxin diagnoses
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Cyanosis
Unresponsive to oxygen
methemoglobinemia
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Cyanosis
Aniline Nitrites Benzocaine Dapsone
dyes
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Dry Skin
Anticholinergic
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Breath Odors
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Toxidromes
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Cholinergic
DUMBBEL SLUDGE
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DUMBBELS
D
DUMBBELS
E
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SLUDGE
S
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SLUDGE
G
GI complaint E Emesis
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Anticholinergic Syndrome
Dry mouth Flushed appearance Dilated pupils Fever Ileus Urinary retention Disorientation
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Anticholinergic
Hot as a hare Blind as a bat Dry as a bone Red as a beet Mad as a hatter
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Anticholinergic
Full as a flask
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Anticholinergic
Anticholinergic
Sympathomimetic
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Narcotic
Pinpoint Coma Respiratory
pupils depression
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Salicylates
Fever Tachypnea & hyperpnea Lethargy Metabolic acidosis
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Theophylline
Protracted Vomiting Tremors Tachycardia Seizures Hypotension
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Isoniazid
Seizures Metabolic acidosis Hyperglycemia
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Phencyclidine (4 Cs)
Combative Catatonia Convulsion Coma Nystagmus
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TCA
Metabolic acidosis Prolonged QRS Seizures Dilated pupils Dysrhythmia
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Cyanide
Feeling of impending doom Sudden coma Metabolic acidosis Hypotension Bitter almond odor
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Carbon monoxide
Headache Lethargy Dizziness Influenza like syndrome Coma
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Ethanol
Hypoglycemia Lethargy Ataxia Seizure Characteristic breath odor
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Methanol
Severe Metabolic acidosis Sluggish pupils Hyperemic retina Blurred vision
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Ethylene Glycol
Lethargy or coma Metabolic acidosis Urinary sediment Crystalluria
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Clonidine
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ABCs
Anticipate Before
Complications
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ABC
Airway
C-spine
immobilization
Breathing Circulation
secure
IV access
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ABC
Disability
consciousness
Drugs Decontamination
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consciousness
A:
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Drugs
Dextrose Oxygen
Naloxone
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Decontamination
Ocular-
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Lab Evaluation
No tox panel that is uniformly helpful
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Urine Screen
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EKG
All suspected ingestion Tricyclics
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Pulse oximetry
Measure of oxygen saturation of normal hemoglobin
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Pulse oximetry
Does not differentiate COHB
from oxyhemoglobin
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Blood gas
Salicylates
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Chest X-ray
Hydrocarbons
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Esophagoscopy
Caustics
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Optimum time
Actaminophen Salicylates Iron Carboxyhemoglobin Methemoglobin
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Optimum time
Ethanol Ethylene glycol Methanol Digoxin
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Serial Levels
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Radiopaque (CHIPS)
Chloral hydrate Heavy metals Iron Phenothiazine Slow release
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GI. Decontamination
Preventing absorption
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Decontamination
Syrup
Syrup of ipecac
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Syrup of Ipecac
Nonprescription CTZ
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Syrup of Ipecac
No evidence of improved outcome Delays AC or antidote for 2 hours No role in hospital setting
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Adverse effect
Protracted Sedation Diarrhea Bradycardia
vomiting
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Contraindications
Altered Seizure Hemetemesis hydrocarbon corrosives
mental status
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Contraindications
Anticipated
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Gastric Lavage
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Gastric Lavage
Life
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Gastric Lavage
Large
bore orogastric tube (36 - 40 French) 0.9% saline 15 ml/kg max 200-400 ml/cycle
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Gastric Lavage
<
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Gastric Lavage
Not a routine With in one hour Life-threatening ingestion Absence of pill fragments does not rule out toxic ingestion
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Gastric Lavage
TCA Calcium-blocker Colchicine
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Complications
Pulmonary
aspiration
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Contraindications
Caustic Hydrocarbon Sharp
co-ingestion
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Activated Charcoal
Universal antidote
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Single dose AC
adsorbing the ingested substance
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Activated Charcoal
Oxidizing process Increases the adsorptive capacity Inert substance Reduce the bioavailability of drug
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Activated Charcoal
Surface area 2/g 950-2000m
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Poorly bound by AC
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CHEMICaL CamP
C H E M I C L
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CHEMICaL CamP
C Camphor P Phosphorus
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Recommended Dose
Up
to 1 year year
gm
1g/kg
1-12
25-50
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Complications
Pulmonary Emesis Constipation
aspiration
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Contraindications
Hydrocarbon Corrosive Ileus
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Home AC?
1,208,860 exposure in < 6 year 16 fatalities 4 might have benefited from early administration of AC American Association of Poison Control Centers Toxic Exposure Surveillance System (1998)
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Benefits of Home AC
Early administration Reduced morbidity & mortality
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Risks of Home AC
Inappropriate administration Inadequate dosing Pulmonary aspiration
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Multiple-Dose AC
Gastrointestinal Dialysis
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Multiple-Dose AC
Continue to adsorb remaining toxin Interfere with enterohepatic circulation Lower the free drug concentration
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Multiple-Dose AC
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Cathartics
Decrease transit time
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Cathartics
Sorbitol
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Complications
Nausea Abdominal Vomiting Transient
cramps
hypotension
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Contraindications
Unprotected Ileus Absent
airway
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WBI
Decontaminate entire gastrointestinal tract
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WBI
Commonly used for agents not bound to activated charcoal
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WBI
polethylene glycol
No fluid abnormality No electrolyte imbalance End point clear rectal effluent Sustained release preparation
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WBI
9
months to 6 years
ml/hr
500
6-12
ml/hr
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WBI
Calcium-channel-blockers Iron Arsenic Lead/zinc Packets
of illicit drugs
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Complications
Nausea
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Urinary Alkalinization
Salicylates Phenobarbital Chlorpropamide
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Urinary Acidification
Never indicated Systemic acidosis Renal impairment in myoglobinuria
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Extracorporeal Clearance
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Hemodialysis
Severe poisoning Renal failure
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Hemodialysis
8-10 fold increased clearance Corrects acid-base imbalance Corrects electrolyte imbalance
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Hemodialysis
Small molecular weight Non-ionized, uncharged molecule Low plasma protein binding Small volume of distribution (<1.0L/kg)
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Hemodialysis
Lithium 4 mEq/L Ethylene glycol 50 mg/dl Methanol 50 mg/dl Salicylates 100 mg/dl
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Hemoperfusion
A charcoal or resin cartridge More effective in selected poisonings Not limited by plasma protein binding Not limited by molecular size
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Hemoperfusion
Not effective for acid-base & electrolyte imbalance correction Ineffective in patients with renal failure
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Hemoperfusion
Phenobarbital Theophylline Paraquat Glutethimide Meprobamate
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Antidotes
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Antidotes
Use only if specific criteria met
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Immediate use
Oxygen
carbon
monoxide
Naloxone
Opioids
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Immediate use
Methylene
severe >
blue 1%
cyanosis
40%
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Immediate use
Sodium
Cyanide
nitrite
Deferoxamine
Iron
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Antidotes
Acetaminophen - N-Acetylcysteine
140 mg/kg PO 70 mg/kg q4h for 17 doses
Anticholinergics - Physostigmine
0.5 mg IV
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Antidotes
Organophosphates
Atropine 0.05-0.1 mg IM or IV Pralidoxime 25-50 mg/kg IV
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Antidotes
Benzodiazepine - Flumazenil
0.01 mg/kg IV
Beta Blockers
- Glucagon
50 ug/kg IV
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Antidotes
Isoniazid
TCA
Warfarin
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New Antidotes
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New Antidotes
Glucagon
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New Antidotes
TCA
Methanol & ethylene glycol Opioid poisoning Benzodiazepine
Fomepizole (Antizol)
Nalmefene
Flumazenil (Romazicon)
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Basic supportive care has saved more lives than all the antidotes put together Small quantities can have significant consequences Most pediatric ingestion are trivial
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Resources
Drug Information (AHFS) Poisindex computer database
212-POISONS
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