常用解毒劑 Antidotes

常用解毒劑Antidotes

 
Amyl nitrite (inhalation), Sodium nitrite (IVD)-- Cyanide, H2S

 Inhalation 30 secs, for 3 minutes.

 3% sodium nitrite (max. 10 ml. IVD 2—5 minutes.) (child: 0.2 ml/kg)

 Sodium thiosulfate (max. 12.5gm, child: 1.65ml./kg) IV. [1]

 

Anti-venom Snake bite – snake bite

 (H)青竹絲 總量1—4 vials. 視病況需要調整用量 (大部份1 vial, 轉診來的3vials,有開刀的 3 vials).

 (H)龜殼花 總量1—4 vials. 視病況需要調整用量

   百步蛇 總量1—4 vials. 視病況需要調整用量

 (N)眼鏡蛇 總量6—12vials 視病況需要調整用量(大部份1vial, 轉診來的4.5vials有開刀的 8.5 vials)

 (N)雨傘節 總量1—4 vials. 視病況需要調整用量

 鎖鏈蛇 總量1—4 vials. 視病況需要調整用量[2].

 

Atropine-- Organophosphate/Carbamate

 2—4mg IV/ 10—15 minutes視病況追加 (child:0.05mg/kg) [3]. 

(ex: Atropine 8 amps + N/S run 125 c.c./hr) 

 

Chelators: DMPS -- As, Hg, Cu, Gold, Cr, Cd.

  劑型 250mg/5 ml/amp. 100mg/tab

  Dose: 5mg/kb IM/IV, 1^st day q6h—q8h; 2^nd day q8h—q12h; 3^rd day: q12h—q24h [4].

 

Calcium- HF: 局部接觸, 可以用calcium gluconate 軟膏局部塗抹. 若為吞服(swallowing), 則需靜脈注射calcium gluconate, 口服calcium carbonate powder, milk. 注意metabolic acidosis [5].

 

Cyanide kit – Cyanide

  Inhalation 30 secs, for 3 minutes.

  3% sodium nitrite (max. 10 ml. IVD 2—5 minutes.) (child: 0.2 ml/kg)

  Sodium thiosulfate (max. 12.5gm, child: 1.65ml./kg) IV.

 

Deferoxamine-- Iron

  Acute iron poisoning

  Adult Dose: 1000 mg, IM or IV stat. (maximum IV rate: 15 mg/kg/hour)

Maintenance dose: 500 mg, IM or IV, q4h , for 2 doses; 追加500 mg doses q4—q12h 依臨床病況需要

  Maximum dose: 6000 mg / day [6].

 

Digibind-- Digoxin

  Indication: arrhythmia with hemodynamic change.

服用 digoxin 總量（mg）X 0.8÷0.5 mg=所需 Digibind 瓶數[7].

  急性中毒可以先給2 vials, IVD; 慢性中毒可以先給1 vial, 1 hr後視病況需要再給[8].

 

EDTA (Ethylenediamine tetraacetic acid)—Lead, Cd

  1-2 g/d (25-50 mg/kg/day) IVD/ IM (divided into 2 doses) *2-5days [9].

 

Ethanol-- Methanol, Ethylene glycol

  For 20% ethanol, loading 4ml/kg, maintain 0.4—0.8ml/kg/hr, to maintain serum ethanol concentration of 100-200 mg/dL [10].

 

Fomepizole-- Methanol, Ethylene glycol  劑型: 1 g/ml，1.5 ml/vial

  10—20 mg/kg/day * 3—5 days [11].

 

Glucagon -- β-blockers, CCB

  0.05—0.15mg/kg IVD > 1 minute, 1—5 mg/ hr IVD [12].

 

Hydroxocobalamin—Cyanide, to form Vitamin B12.

  5 gm or 70 mg/kg IVD 30 minutes [13].

 

Methylene blue--Methemoglobinemia

  1—2 mg/kg IVD [14].

 

N-Acetylcysteine--Acetaminophen

   NAC PO, 140 mg/kg, 70 mg /kg q4h* 17 times.

　 NAC IV, 150 mg /kg for 15 to 60 minutes,

12.5 mg /kg /hr * 4-hours, then    

6.25 mg /kg/hr * 16 hours [15].

 

Naloxone-- Opioids

  1—5 amps stat. repeated doses of waking up dose * 1/2 to 2/3 if necessary [16].

 

Oxygen—CO

  100% oxygen

  HBO when AMS, cardiac ischemia, pH<7.1, HbCO> 25%, and pregnancy with HbCO> 20% [17].

 

Pralidoxime  -- Organophosphate

 1—2 gm stat. in adult. Then 8mg/kg/hr or 2 gm for 30 minutes. 0.5—1 gm/hr 依病況調整[18, 19].

 Child: 20 to 50 mg/kg (maximum 2gm/dose) IVD over 15 to 30 minutes

      Then IV pump with 10 to 20 mg/kg/hour [18, 19].

      (ex: PAM 3--4 amps IVD st. > 30 minutes and 4 amps +N/S run 125 c.c./hr) 

 

Pyridoxine-- Isoniazid (INH) poisoning

1 g of pyridoxine intravenously for 1 gram of isoniazid (known to have been ingested) (至多52gm) 用50 c.c. N/S or dextrose 稀釋 (rate of 1 g/min) IVD > 5 minutes.

4–5 g IV and repeat q 5–20 minutes as needed:若吃的INH量不知道的時候 [20].

 

Sodium. Bicarbonate --Salicylate

  1—2 mEq/kg to keep urine pH 7.5—8 [21].

 

Sodium. Thiosulfate --Cyanide

  Sodium thiosulfate (max. 12.5gm, child: 1.65ml./kg) IV.

 

Succimer (Dimercaptosuccinic acid), DMSA-- 是用於Pb, As, Hg中毒[22].

  Pb: Lead Poisoning: 10 mg/kg PO q8hr * 5 days;

then 10 mg/kg/dose q12hr *14 days;

not to exceed 500 mg/dose. 

  As: Arsenic Poisoning: 300 mg PO q6hr * 3 days

     直到urinary arsenic <50 mcg/L

  Hg: Mercury Intoxication: 15mg/kg [23].

 

Vitamin K1 --Warfarin. Rodenticides

1—10mg, IM/SC better than IV to keep INR less than 5 [24].

 

REFERENCES

1.      急診醫學會. 急性中毒救命術, 第三版p. 295

2.      2019 International Conference for Poison Control and Research Development. Nov 15—17, 2019, Taipei. Taiwan.

3.      急診醫學會. 急性中毒救命術, 第三版p. 69

4.      衛服部 全國解毒劑儲備網http://www.pcc-vghtpe.tw/antidote/page_detail.asp?cid=6&nid=20

5.      Su YJ, Lu LH, Choi WM, Chang KS. Survival after a massive hydrofluoric acid ingestion with ECG changes [published correction appears in Am J Emerg Med. 2009 Jan;27(1):126.]. Am J Emerg Med. 2001;19(5):458–460. doi:10.1053/ajem.2001.24503

6.      https://www.drugs.com/dosage/deferoxamine.html#Usual_Adult_Dose_for_Iron_Poisoning___Acute

7.      http://www.pcc-vghtpe.tw/antidote/file/pdf/%E6%AF%9B%E5%9C%B0%E9%BB%83%E4%B8%AD%E6%AF%92%E8%A7%A3%E6%AF%92%E5%8A%91.pdf

8.      Chan BS, Buckley NA. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol (Phila). 2014;52(8):824–836. doi:10.3109/15563650.2014.943907

9.      http://www.pcc-vghtpe.tw/antidote/page_detail.asp?cid=6&nid=20

10.  https://mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2013/June%202013%20ToxTidbits.pdf

11.  急診醫學會. 急性中毒救命術, 第三版p. 260

12.  急診醫學會. 急性中毒救命術, 第三版p. 354

13.  急診醫學會. 急性中毒救命術, 第三版p. 296

14.  急診醫學會. 急性中毒救命術, 第三版p. 284

15.  Heard KJ. Acetylcysteine for acetaminophen poisoning. N Engl J Med. 2008;359(3):285–292. doi:10.1056/NEJMct0708278

16.  Clarke SF, Dargan PI, Jones AL. Naloxone in opioid poisoning: walking the tightrope. Emerg Med J. 2005;22(9):612–616. doi:10.1136/emj.2003.009613

17.  急診醫學會. 急性中毒救命術, 第三版p. 312—13.

18.  https://www.drugs.com/dosage/pralidoxime.html#Usual_Adult_Dose_for_Organophosphate_Poisoning

19.  急診醫學會. 急性中毒救命術, 第三版p. 60

20.  https://accessmedicine.mhmedical.com/content.aspx?bookid=391&sectionid=42070045

21.  急診醫學會. 急性中毒救命術, 第三版p. 348

22.  https://reference.medscape.com/drug/chemet-succimer-343751

23.  https://www.biolab.co.uk/docs/dmsaprov.pdf

24.  Hirsh J. Reversal of the anticoagulant effects of warfarin by vitamin K1. Chest. 1998;114(6):1505–1508. doi:10.1378/chest.114.6.1505

-- edited 21th December 2019, Yu-Jang Su.