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Toxicology - Related Medications
acetylcysteine (Mucomyst ® )
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| Mechanism of Action Exerts mucolytic action through its free sulfhydryl group which opens up the disulfide bonds in the mucoproteins thus lowering mucous viscosity. The exact mechanism of action in acetaminophen toxicity is unknown; thought to act by providing substrate for conjugation with the toxic metabolite. ------------------------------ Dosing: Acetaminophen poisoning: Children and Adults: Oral: 140 mg/kg; followed by 17 doses of 70 mg/kg every 4 hours; repeat dose if emesis occurs within 1 hour of administration; therapy should continue until all doses are administered even though the acetaminophen plasma level has dropped below the toxic range I.V. (Acetadote®): Loading dose: 150 mg/kg over 15 minutes. Maintenance dose: 50 mg/kg infused over 4 hours followed by 100 mg/kg infused over 16 hours. Note: To avoid fluid overload in patients <40 kg and those requiring fluid restriction, decrease volume of D5W proportionally. ------------------------------ Adjuvant therapy in respiratory conditions: Note: Patients should receive an aerosolized bronchodilator 10-15 minutes prior to acetylcysteine. Inhalation, nebulization (face mask, mouth piece, tracheostomy): Acetylcysteine 10% and 20% solution (Mucomyst®) (dilute 20% solution with sodium chloride or sterile water for inhalation); 10% solution may be used undiluted Children and Adults: 3-5 mL of 20% solution or 6-10 mL of 10% solution until nebulized given 3-4 times/day; dosing range: 1-10 mL of 20% solution or 2-20 mL of 10% solution every 2-6 hours Inhalation, nebulization (tent, croupette): Children and Adults: Dose must be individualized; may require up to 300 mL solution/treatment Direct instillation: Adults: Into tracheostomy: 1-2 mL of 10% to 20% solution every 1-4 hours Diagnostic bronchogram: Nebulization or intrathecal: Adults: 1-2 mL of 20% solution or 2-4 mL of 10% solution administered 2-3 times prior to procedure ------------------------------ Mucolytic: nebulize 1-10 ml of 20% solution or 2 to 20 ml of 10% solution every 2-6 hr. Usual dose: 6-10 ml of 10% solution or 3-5 ml of 20% solution. ------------------------------ Decrease risk of contrast-induced nephropathy: (4 doses total): 600 mg (3ml) po BID on the day before the contrast injection, then 600 mg (3ml) in a.m. on the day of the contrast injection (immediately before) and 600 mg (3ml) in the evening. In all cases the patient should be well hydrated. This is particularly important in patients with underlying renal dx or diabetes mellitus. Oral administration: dilute to 5% with soft drinks. ------------------------------- Administration Inhalation: Acetylcysteine is incompatible with tetracyclines, erythromycin, amphotericin B, iodized oil, chymotrypsin, trypsin, and hydrogen peroxide. Administer separately. Intermittent aerosol treatments are commonly given when patient arises, before meals, and just before retiring at bedtime. Oral: For treatment of acetaminophen overdosage, administer orally as a 5% solution. Dilute the 20% solution 1:3 with a cola, orange juice, or other soft drink. Use within 1 hour of preparation. Unpleasant odor becomes less noticeable as treatment progresses. If patient vomits within 1 hour of dose, readminister. ------------------------------- Supplied: Injection, solution (Acetadote®): 20% [200 mg/mL] (30 mL) [contains disodium edetate] Solution, as sodium (Mucomyst®): 10% [100 mg/mL] (4 mL, 10 mL, 30 mL); 20% [200 mg/mL] (4 mL, 10 mL, 30 mL) |
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Charcoal:
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Use Emergency treatment in poisoning by drugs and chemicals; aids the elimination of certain drugs and improves decontamination of excessive ingestions of sustained -release products or in the presence of bezoars; repetitive doses have proven useful to enhance the elimination of certain drugs (eg, theophylline, phenobarbital, and aspirin); repetitive doses for gastric dialysis in uremia to adsorb various waste products; dietary supplement (digestive aid) Mechanism of Action Adsorbs toxic substances or irritants, thus inhibiting GI absorption; adsorbs intestinal gas; the addition of sorbitol results in hyperosmotic laxative action causing catharsis ---------------------------------------- Dosage: Oral: Acute poisoning: Note: ~10 g of activated charcoal for each 1 g of toxin is considered adequate; this may require multiple doses. If sorbitol is also used, sorbitol dose should not exceed 1.5 g/kg. When using multiple doses of charcoal, sorbitol should be given with every other dose (not to exceed 2 doses/day). Children: 1 g/kg as a single dose; if multiple doses are needed, additional doses can be given as 0.25 g/kg every hour or equivalent (ie, 0.5 g/kg every 2 hours) or >1 year-12 years: 25-50 g as a single dose; smaller doses (10-25 g) may be used in children 1-5 years due to smaller gut lumen capacity Children >12 years and Adults: 25-100 g as a single dose; if multiple doses are needed, additional doses may be given as 12.5 g/hour or equivalent (ie, 25 g every 2 hours) Dietary supplement: Adult: 500-520 mg after meals; may repeat in 2 hours if needed (maximum 10 g/day) ---------------------------------------- Administration Flavoring agents (eg, chocolate) and sorbitol can enhance charcoal's palatability. If treatment includes ipecac syrup, induce vomiting prior to administration of charcoal. Often given with a laxative or cathartic; check for presence of bowel sounds before administration. ---------------------------------------- Supplied: Capsule, activated (Char-Caps, Charcocaps®): 260 mg Liquid, activated: Actidose-Aqua®: 15 g (72 mL); 25 g (120 mL); 50 g (240 mL) Kerr Insta-Char®: 25 g (120 mL) [cherry flavor]; 50 g (240 mL) Liquid, activated [with sorbitol]: Actidose® with Sorbitol: 25 g (120 mL); 50 g (240 mL) Kerr Insta-Char®: 25 g (120 mL); 50 g (240 mL) Pellets, activated (EZ-Char™): 25 g Powder for suspension, activated: 30 g, 240 g Tablets, activated (Charcol Plus® DS): 250 mg |
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deferoxamine (Desferal ®)
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Iron-chelating agent. Dosing (Adults): Acute iron intoxication: 1 gram IV/IM initially, then 500 mg every 4 hr for 2 doses, then subsequent doses of 500 mg every 4-12 hr as needed. MAX 6 g/day. Note: IV route is used when severe toxicity is evidenced by systemic symptoms (coma, shock, metabolic acidosis, or severe gastrointestinal bleeding) or potentially severe intoxications (serum iron level >500 mcg/dl). When severe symptoms are not present, the I.M. route may be preferred (per manufacturer). Chronic iron overload: 0.5-1 g/day IM, plus 2 g IV per unit of blood. Max of 1 g/day with no transfusion, 6 g/day if 3 or more units of infused blood or packed red blood cells. Alternative: 1-2 g SC (20-40 mg/kg/day) infused over 8-24 hr . Administration: IM route preferred for all patients with acute iron intoxication not in shock. IV administration only for patients in state of cardiovascular collapse and then only by slow infusion. Maximum IV rate: 15 mg/kg/hr for first 1000 mg. Subsequent IV dosing, if needed - Maximum rate 125 mg/hr. Renal Dosing: crcl <10 ml/min: Administer 50% of dose. Supplied: Injection (powder for reconstitution): 500 mg, 2 g |
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digoxin immune fab (Digibind ®)
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Reconstitution: Dissolve each vial with 4 ml sterile water
(do not shake). May be further diluted with normal saline. Infuse over
30 minutes-- must use 0.22 micron filter. If cardiac arrest is imminent,
may give as a bolus. ----------------------------------- Use Treatment of life-threatening or potentially life-threatening digoxin intoxication, including: acute digoxin ingestion (ie, >10 mg in adults or >4 mg in children). Chronic ingestions leading to steady-state digoxin concentrations > 6 ng/mL in adults or >4 ng/mL in children. Manifestations of digoxin toxicity due to overdose (life-threatening ventricular arrhythmias, progressive bradycardia, second- or third-degree heart block not responsive to atropine, serum potassium >5 mEq/L in adults or >6 mEq in children). ----------------------------------- Mechanism of Action Digoxin immune antigen-binding fragments (Fab) are specific antibodies for the treatment of digitalis intoxication in carefully selected patients; binds with molecules of digoxin or digitoxin and then is excreted by the kidneys and removed from the body ----------------------------------- Dosage Each vial of Digibind® 38 mg or DigiFab™ 40 mg will bind ~0.5 mg of digoxin or digitoxin. Estimation of the dose is based on the body burden of digitalis. This may be calculated if the amount ingested is known or the postdistribution serum drug level is known (round dose to the nearest whole vial). See table. Fab dose based on serum drug level postdistribution: Digoxin Immune Fab
Fab dose based on serum drug level postdistribution: Digoxin: No. of vials = level (ng/mL) x body weight (kg) divided by 100 Digitoxin: No. of vials = digitoxin (ng/mL) x body weight (kg) divided by 1000 If neither amount ingested nor drug level are known, dose empirically as follows: For acute toxicity: 20 vials, administered in 2 divided doses to decrease the possibility of a febrile reaction, and to avoid fluid overload in small children. For chronic toxicity: 6 vials; for infants and small children </=( 20kg), a single vial may be sufficient --------------------------------------- Administration Continuous I.V. infusion over >/= 30 minutes is preferred. May give by bolus injection if cardiac arrest is imminent. Small doses (infants/small children) may be administered using tuberculin syringe. Stopping the infusion and restarting at a slower rate may help if infusion-related reactions occur. --------------------------------------- Monitoring Parameters Serum potassium, serum digoxin concentration prior to first dose of digoxin immune Fab; digoxin levels will greatly increase with digoxin immune Fab use and are not an accurate determination of body stores ; standard digoxin concentration measurements may be misleading until Fab fragments are eliminated from the body. Patients with renal failure should be monitored for a prolonged period for re-intoxication with digoxin following the re-release of bound digoxin into the blood. --------------------------------------- Supplied: Injection, powder for reconstitution: Digibind®: 38 mg DigiFab™: 40 mg |
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flumazenil (Romazicon ®)
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| Use Benzodiazepine antagonist; reverses sedative effects of benzodiazepines used in conscious sedation and general anesthesia; treatment of benzodiazepine overdose Mechanism of Action Competitively inhibits the activity at the benzodiazepine recognition site on the GABA/benzodiazepine receptor complex. Flumazenil does not antagonize the CNS effect of drugs affecting GABA-ergic neurons by means other than the benzodiazepine receptor (ethanol, barbiturates, general anesthetics) and does not reverse the effects of opioids ----------------------------------------------- Dosing: Sedation reversal: 0.2 mg IV over 15 seconds, then 0.2 mg every minute as needed up to 1 mg total (most patients respond to doses of 0.6-1 mg). If re-sedation occurs, repeated doses may be administered at 20-minute intervals as needed. For repeat treatment, no more than 1 mg (given as 0.2 mg/min) should be administered at any one time, and no more than 3 mg should be given in any one hour. Overdose reversal: 0.2 mg IV over 30 seconds. If the desired level of consciousness is not obtained after waiting 30 seconds, a further dose of 0.3 mg IV over another 30 seconds may be given. Additional doses of 0.5 mg IV over 30 seconds at 1 minute intervals may be given up to a cumulative dose of 3 mg. In the event of re-sedation, repeated doses may be given at 20 minute intervals if needed. For repeat treatment, no more than 1 mg (given as 0.5 mg/min) should be given at any one time and no more than 3 mg should be given in any one hour. ----------------------------------------------- Parenteral: For I.V. use only; administer via freely running I.V. infusion into larger vein to decrease chance of pain, phlebitis
Resedation: Repeated doses may be given at 20-minute intervals as needed; repeat treatment doses of 1 mg (at a rate of 0.5 mg/minute) should be given at any time and no more than 3 mg should be given in any hour. After intoxication with high doses of benzodiazepines, the duration of a single dose of flumazenil is not expected to exceed 1 hour; if desired, the period of wakefulness may be prolonged with repeated low intravenous doses of flumazenil, or by an infusion of 0.1-0.4 mg/hour. Most patients with benzodiazepine overdose will respond to a cumulative dose of 1-3 mg and doses >3 mg do not reliably produce additional effects. Rarely, patients with a partial response at 3 mg may require additional titration up to a total dose of 5 mg. If a patient has not responded 5 minutes after receiving a cumulative dose of 5 mg, the major cause of sedation is not likely to be due to benzodiazepines. Supplied: Injection, solution: 0.1 mg/mL (5 mL, 10 mL) |
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fomepizole (Antizol ®)
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| Use: Treatment of methanol or ethylene glycol poisoning alone or in combination with hemodialysis -------------- Mechanism of Action Fomepizole competitively inhibits alcohol dehydrogenase, an enzyme which catalyzes the metabolism of ethanol, ethylene glycol, and methanol to their toxic metabolites. Ethylene glycol is metabolized to glycoaldehyde, then oxidized to glycolate, glyoxylate, and oxalate. Glycolate and oxalate are responsible for metabolic acidosis and renal damage. Methanol is metabolized to formaldehyde, then oxidized to formic acid. Formic acid is responsible for metabolic acidosis and visual disturbances. -------------- Dosing: loading dose: 15 mg/kg, followed by 10 mg/kg every 12 hours x 4 doses, then 15 mg/kg every 12 hours thereafter until ethylene glycol levels <20 mg/dl. Dialysis should be considered in addition to fomepizole in the case of renal failure, significant or worsening metabolic acidosis, or a measured ethylene glycol level >50 mg/dl. Fomepizole is dialyzable and should be given q4h during hemodialysis. MOA: complexes and inactivates alcohol dehydrogenase thus preventing formation of the toxic metabolites of the alcohols. Given by slow IV infusion over 30 minutes. Supplied: Injection, solution [preservative free]: 1 g/mL (1.5 mL) |
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methylene blue:
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Use Antidote for cyanide poisoning and drug-induced methemoglobinemia, indicator dye Unlabeled/Investigational Has been used topically (0.1% solutions) in conjunction with polychromatic light to photoinactivate viruses such as herpes simplex; has been used alone or in combination with vitamin C for the management of chronic urolithiasis ---------------------- Mechanism of Action Weak germicide in low concentrations, hastens the conversion of methemoglobin to hemoglobin; has opposite effect at high concentrations by converting ferrous ion of reduced hemoglobin to ferric ion to form methemoglobin; in cyanide toxicity, it combines with cyanide to form cyanmethemoglobin preventing the interference of cyanide with the cytochrome system ---------------------- Dosing: Children: NADPH-methemoglobin reductase deficiency: Oral: 1-1.5 mg/kg/day (maximum: 300 mg/day) given with 5-8 mg/kg/day of ascorbic acid Children and Adults: Methemoglobinemia: I.V.: 1-2 mg/kg or 25-50 mg/m 2 over several minutes; may be repeated in 1 hour if necessary Adults: Genitourinary antiseptic: Oral: 65-130 mg 3 times/day with a full glass of water (maximum: 390 mg/day) ---------------------- Administration Administer I.V. undiluted by direct I.V. injection over several minutes. ---------------------- Supplied: Injection, solution: 10 mg/mL (1 mL, 10 mL) Tablet (Urolene Blue®): 65 mg |
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naloxone (Narcan ®)
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Use Complete or partial reversal of opioid depression, including respiratory depression, induced by natural and synthetic opioids, including propoxyphene, methadone, and certain mixed agonist-antagonist analgesics: nalbuphine, pentazocine, and butorphanol Diagnosis of suspected opioid tolerance or acute opioid overdose Adjunctive agent to increase blood pressure in the management of septic shock --------------------------------- Mechanism of Action Pure opioid antagonist that competes and displaces narcotics at opioid receptor sites --------------------------------- Dosing: I.M., I.V. (preferred), intratracheal, SubQ: Postanesthesia narcotic reversal: Infants and Children: 0.01 mg/kg; may repeat every 2-3 minutes, as needed based on response Opiate intoxication: Children: Birth (including premature infants) to 5 years or <20 kg: 0.1 mg/kg; repeat every 2-3 minutes if needed; may need to repeat doses every 20-60 minutes >5 years or >/= 20 kg: 2 mg/dose; if no response, repeat every 2-3 minutes; may need to repeat doses every 20-60 minutes --------------------------------- Children and Adults: Continuous infusion: I.V.: If continuous infusion is required, calculate dosage/hour based on effective intermittent dose used and duration of adequate response seen, titrate dose 0.04 to 0.16 mg/kg/hour for 2-5 days in children, adult dose typically 0.25 to 6.25 mg/hour (short-term infusions as high as 2.4 mg/kg/hour have been tolerated in adults during treatment for septic shock); alternatively, continuous infusion utilizes 2 /3 of the initial naloxone bolus on an hourly basis; add 10 times this dose to each liter of D5W and infuse at a rate of 100 mL/hour; 1 /2 of the initial bolus dose should be readministered 15 minutes after initiation of the continuous infusion to prevent a drop in naloxone levels; increase infusion rate as needed to assure adequate ventilation Narcotic overdose: Adults: I.V.: 0.4 to 2 mg every 2-3 minutes as needed; may need to repeat doses every 20-60 minutes, if no response is observed after 10 mg, question the diagnosis. Note: Use 0.1-0.2 mg increments in patients who are opioid dependent and in postoperative patients to avoid large cardiovascular changes. --------------------------------- Administration Intratracheal: Dilute to 1-2 mL with normal saline I.V. push: Administer over 30 seconds as undiluted preparation I.V. continuous infusion: Dilute to 4 mcg/mL in D5W or normal saline IV infusion: ( 2 mg/500 ml per manufacturer) - Usual infusion rate: @ 0.4 mg/hr (100 ml/hr)-titrate to respiratory rate/ level of consciousness. --------------------------------- Monitoring Parameters Respiratory rate, heart rate, blood pressure --------------------------------- Supplied: Injection, solution, as hydrochloride: 0.4 mg/mL (1 mL, 10 mL) Narcan®: 0.4 mg/mL (1 mL) |
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sodium polystyrene sulfonate (Kayexalate ®)
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Dosing (Adults):
Hyperkalemia: 15 to 30 grams (60 ml) orally 1 to 4 times daily or 30-50 g rectally every 6 hours. Alternatively: 15 to 50 grams orally (bid-qid). PK: Onset: within 1 - 2 hours. Duration: 4 - 6 hours. Rectal route: Adults: 30 to 50 grams q6h. The enema should be retained for least 30 to 60 minutes and followed by a cleansing enema. After the initial cleansing enema, a soft, large rubber tube is inserted and secured at about 20 cm into the rectum with the tip well into the sigmoid colon. The resin suspension is introduced by gravity and flushed by an additional 50 to 100 ml fluid. The tube is clamped and left in place for several hours if possible. The colon is then flushed with up to 2 quarts of a non-sodium containing solution to remove the resin and to prevent necrosis. Exchange capacity is 1 mEq/gram in vivo, and in vitro capacity is 3.1 mEq/g, therefore, a wide range of exchange capacity exists such that close monitoring of serum electrolytes (potassium, sodium, calcium, magnesium) is necessary; ECG. Supplied: Suspension: 15 g/60 ml. |
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Sorbitol
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Use Genitourinary irrigant in transurethral prostatic resection or other transurethral resection or other transurethral surgical procedures; diuretic; humectant; sweetening agent; hyperosmotic laxative; facilitate the passage of sodium polystyrene sulfonate through the intestinal tract Mechanism of Action A polyalcoholic sugar with osmotic cathartic actions -------------------------------- Dosing: Hyperosmotic laxative (as single dose, at infrequent intervals): Children 2-11 years: Oral: 2 mL/kg (as 70% solution) Rectal enema: 30-60 mL as 25% to 30% solution -------------------------------- Children >12 years and Adults: Oral: 30-150 mL (as 70% solution) Rectal enema: 120 mL as 25% to 30% solution Adjunct to sodium polystyrene sulfonate: 15 mL as 70% solution orally until diarrhea occurs (10-20 mL/2 hours) or 20-100 mL as an oral vehicle for the sodium polystyrene sulfonate resin -------------------------------- When administered with charcoal: Oral: Children: 4.3 mL/kg of 35% sorbitol with 1 g/kg of activated charcoal Adults: 4.3 mL/kg of 70% sorbitol with 1 g/kg of activated charcoal every 4 hours until first stool containing charcoal is passed Topical: 3% to 3.3% as transurethral surgical procedure irrigation -------------------------------- Monitoring Parameters Monitor for fluid overload and/or electrolyte disturbances following large volumes; changes may be delayed due to slow absorption -------------------------------- Supplied: Solution, genitourinary irrigation: 3% (1500 mL, 3000 mL); 3.3% (2000 mL, 4000 mL) Solution, oral: 70% (480 mL, 3840 mL) |
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Listed dosages are for - Adult patients ONLY. PLEASE READ THE
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any diagnosis or treatment made in reliance thereon. David F. McAuley, Pharm.D., R.Ph. GlobalRPh Inc. |
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