What are the specific drugs and dosages used to treat different types of poisoning?

Specific Drugs and Dosages for Poisoning Management

The management of poisoning requires specific antidotes and dosages tailored to the toxin, with early consultation with a poison center being essential for optimal outcomes. 1

Opioid Poisoning

• Naloxone:
  • Adult: 0.2-2 mg IV/IO/IM; intranasal 2-4 mg
  • Pediatric: 0.1 mg/kg
  • Maintenance: Two-thirds of the waking dose per hour
  • Notes: Titrate to reversal of respiratory depression; repeat every 2-3 minutes as needed; duration often shorter than opioids, requiring continuous monitoring 1, 2

Benzodiazepine Poisoning

• Flumazenil:
  • Adult: 0.2 mg, titrated up to 1 mg
  • Pediatric: 0.01 mg/kg
  • Notes: Many contraindications - avoid in patients with seizure history, chronic benzodiazepine use, or co-ingestion of tricyclic antidepressants 1
  • If combined opioid and benzodiazepine poisoning is suspected, administer naloxone first 1

Organophosphate/Carbamate Poisoning

• Atropine:

  • Adult: 1-2 mg, doubled every 5 minutes
  • Pediatric: 0.02 mg/kg, doubled every 5 minutes
  • Maintenance: 10-20% of loading dose per hour up to 2 mg/h
  • Notes: Titrate to reversal of bronchorrhea, bronchospasm, bradycardia, and hypotension 1, 3

• Pralidoxime:

  • Adult: 1-2 g IV
  • Pediatric: 20-50 mg/kg
  • Maintenance: 400-600 mg/h (adult); 10-20 mg/kg/h (pediatric)
  • Notes: Most effective if initiated immediately after poisoning 1, 4

β-Blocker Poisoning

• Glucagon:

  • Adult: 2-10 mg
  • Pediatric: 0.05-0.15 mg/kg
  • Maintenance: 1-15 mg/h (adult)
  • Notes: Anticipate vomiting 1

• Insulin (High-dose):

  • Adult/Pediatric: 1 U/kg
  • Maintenance: 1-10 U/kg/h
  • Notes: Regular human insulin; monitor for hypoglycemia, hypokalemia, volume overload 1

Calcium Channel Blocker Poisoning

• Calcium Chloride:

  • Adult: 2000 mg (20 mL of 10% solution)
  • Pediatric: 20 mg/kg
  • Maintenance: 20-40 mg/kg/h
  • Notes: Titrate to blood pressure; administer through central line 1

• Calcium Gluconate:

  • Adult: 6000 mg (60 mL of 10% solution)
  • Pediatric: 60 mg/kg
  • Maintenance: 60-120 mg/kg/h
  • Notes: Titrate to blood pressure 1

• Insulin (High-dose): Same as for β-blocker poisoning 1

Digoxin/Cardiac Glycoside Poisoning

• Digoxin Immune Fab:
  • Acute overdose: 1 vial for every 0.5 mg digoxin ingested
  • Chronic poisoning: Dose (vials) = serum digoxin (ng/mL) × weight (kg)/100
  • Critically ill with unknown ingestion: 10-20 vials
  • Yellow oleander/Bufo toad venom: 1200 mg (30 vials)
  • Notes: 1 vial contains 40 mg Fab 1

Cyanide Poisoning

• Hydroxocobalamin:

  • Adult: 5 g
  • Pediatric: 70 mg/kg
  • Notes: Preferred antidote; treat immediately without waiting for confirmatory testing 1, 2

• Sodium Nitrite:

  • Adult: 300 mg
  • Pediatric: 6 mg/kg
  • Notes: Watch for hypotension 1

• Sodium Thiosulfate:

  • Adult: 12.5 g
  • Pediatric: 250 mg/kg 1

Local Anesthetic Toxicity

• Intravenous Lipid Emulsion (20%):
  • Adult/Pediatric: 1.5 mL/kg up to 100 mL
  • Maintenance: 0.25 mL/kg/min for up to 30 minutes 1

Sodium Channel Blocker Poisoning (including TCAs, cocaine)

• Sodium Bicarbonate:
  • Adult: 50-150 mEq
  • Pediatric: 1-3 mEq/kg
  • Maintenance: 150 mEq/L solution, infuse at 1-3 mL/kg/h
  • Notes: Watch for hypernatremia, alkalemia, hypokalemia, hypochloremia 1

Methemoglobinemia

• Methylene Blue:
  • Adult/Pediatric: 1-2 mg/kg, repeated every hour if needed
  • Maximum: 5-7 mg/kg 1

Critical Considerations in Poisoning Management

General Approach

1. Secure airway, breathing, circulation:

   • Early endotracheal intubation for life-threatening poisoning
   • Position unconscious patients in left lateral head-down position
   • Administer glucose if patient is unconscious 2

2. Decontamination:

   • Activated charcoal for drugs that can be adsorbed (within 1-2 hours of ingestion)
   • Dermal decontamination for external exposure 1, 2

3. Enhanced elimination:

   • Multiple-dose activated charcoal for drugs that undergo enterohepatic circulation
   • Hemodialysis for water-soluble, low-protein-bound toxins 2

4. Venoarterial extracorporeal membrane oxygenation (VA-ECMO):

   • Consider early for cardiogenic shock or dysrhythmias refractory to other treatments 1, 2

Common Pitfalls to Avoid

• Delaying antidote administration while waiting for confirmatory testing
• Inappropriate use of flumazenil in patients with risk factors for seizures
• Using neuromuscular blockers metabolized by cholinesterase (succinylcholine, mivacurium) in organophosphate/carbamate poisoning
• Delaying consideration of VA-ECMO in severe cases 1, 2

Monitoring

• Continuous cardiac monitoring
• Serial assessment of vital signs and mental status
• Monitoring of myocardial enzymes, renal and hepatic function
• Patients with potentially severe poisoning require hospital monitoring 2, 5

Remember that early consultation with a regional poison center (1-800-222-1222 in the United States) is essential for optimal management of poisoning cases 1, 2.