Acetaminophen | Oral N-acetylcysteine (NAC) | Loading dose: 140mg/kg diluted in juice or soda | Maintenance dose 70mg/kg Q4h × 17 doses | Solution for inhalation/oral: 10%, 20%; 10, 30mL |
Acetaminophen | Intravenous NAC | Loading dose: 150mg/kg in 2mL D5W over 1h | Maintenance dose 50mg/kg in 500 mL D5W over 4h; then 100mg/kg in 1000mL of D5W over 16h; dosing based on ideal body weight; for pediatric poisonings, use smaller volumes of D5W diluent | Solution for injection: 20%; 30mL |
Alcohols (ethylene glycol, methanol) | Fomepizole | Loading: 15mg/kg; Maintenance: 10mg/kg Q12h × 4 doses | Administer as IV infusion over 30min; continue therapy until ethylene glycol or methanol concentrations <20mg/dL & pt asymptomatic | Solution for injection: 1g/mL; 1.5mL |
Benzodiazepine | Flumazenil | 0.1–0.2mg IV over 30s | Repeat as needed to max of 1mg; continuous infusion of 0.1–1mg/h in NS or D5W may be considered, but rarely indicated; may cause withdrawal (seizures, adrenergic stimulation, or autonomic instability) | Solution for injection: 0.1mg/mL; 5, 10mL |
β-antagonist | Glucagon | 5–15mg slow IV push | Continuous infusion 5–15mg/h for prolonged toxicity; monitor for nausea, vomiting, & hyperglycemia | Powder for reconstitution: 1mg |
Calcium channel antagonist | High-dose insulin euglycemic therapy (HIE) | Bolus 1 unit/kg IV followed by 0.5–1unit/kg/h | Requires frequent glucose monitoring to prevent hypoglycemia; monitor serum potassium & replace PRN to avoid hypokalemia | Solution for injection: 100 units/mL; 3, 10mL, 500units/mL; 20mL |
Cardiac glycoside | Digoxin immune Fab | Dosage based on serum digoxin level or estimated ingested dose; 40mg of Fab binds 0.5mg of digoxin Round to the nearest vial | Dose determination based on amount of digoxin ingested; 1 vial binds 0.5mg (mg digoxin/0.5mg/vial = # of vials required); multiply mg of digoxin by 0.8 if tablet ingestion to account for bioavailability. For digoxin toxicity at steady state (serum concentration × wt in kg/100 = # vials required); infuse dose over 30min if patient is stable; may bolus if cardiac arrest imminent | Powder for reconstitution: 40mg |
Cyanide | Hydroxocobalamin (Cyanokit) | 5g IV over 15min | A 2nd 5g dose may be considered in severe poisonings | Powder for reconstitution: 2.5g; solution for injection 1000mcg/mL; 30mL |
Iron toxicity | Deferoxamine | 15mg/kg/h IV, not to exceed 1g/h over a total of 6h | Re-evaluate after 6h; iron toxicity associated with serum iron levels >500mcg/dL; hypotension requiring crystalloid boluses common | Powder for reconstitution: 500mg; 2g |
Isoniazid, hydrazine | Pyridoxine | 5g IV; do not exceed 0.5g/min | Dose gram-per-gram with isoniazid up to 5g; repeat doses as need for continued seizure activity; consider benzodiazepine or barbiturates for seizure | Solution for injection: 100mg/mL; 1mL |
Lipophilic cardiotoxic agents | Intravenous lipid emulsion | Bolus 1.5mL/kg IV followed by 0.25mL/kg/min | Consider repeat bolus if inadequate response after 1h | Solution for injection: 20%; 100, 250, 500, 1000mL |
Methemoglobinemia (drug-induced) | Methylene blue | 1–2mg/kg IV over 5min | Repeat dose if no improvement is observed within 1h; repeat dose every 6h if methemoglobin concentrations are >30% | Solution for injection: 10mg/mL; 1, ... |