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38-10: Antidotes

Craig Smollin

Give an antidote (if available) when there is reasonable certainty of a specific diagnosis (Table 38–3). Be aware that some antidotes themselves may have serious side effects. The indications and dosages for specific antidotes are discussed in the respective sections for specific toxins.

Table 38–3.Some toxic agents for which there are specific antidotes (listed in alphabetical order).1
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Table 38–3. Some toxic agents for which there are specific antidotes (listed in alphabetical order).1
Toxic Agent Specific Antidote

Acetaminophen

N-acetylcysteine

Anticholinergics (eg, atropine)

Physostigmine

Anticholinesterases (eg, organophosphate pesticides)

Atropine and pralidoxime (2-PAM)

Benzodiazepines

Flumazenil (rarely used)2

Carbon monoxide

Oxygen (hyperbaric oxygen of uncertain benefit)

Cyanide

Sodium nitrite, sodium thiosulfate; hydroxocobalamin

Digitalis glycosides

Digoxin-specific Fab antibodies

Heavy metals (eg, lead, mercury, iron) and arsenic

Specific chelating agents

Isoniazid

Pyridoxine (vitamin B6)

Methanol, ethylene glycol

Ethanol (ethyl alcohol) or fomepizole (4-methylpyrazole)

Opioids

Naloxone, nalmefene

Snake venom

Specific antivenin

Sulfonylurea oral hypoglycemic drugs

Glucose, octreotide

1See text for indications and dosages.

2May induce seizures in patients with preexisting seizure disorder, benzodiazepine addiction, or concomitant tricyclic antidepressant or other convulsant overdose. If seizures occur, diazepam and other benzodiazepine anticonvulsants will not be effective. As with naloxone, the duration of action of flumazenil is short (2–3 hours) and resedation may occur, requiring repeated doses.

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Dart  RC  et al. Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Ann Emerg Med. 2018;71:314.
[PubMed: 28669553]  
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Hon  KL  et al. Antidotes for childhood toxidromes. Drugs Context. 2021;10:2020-11-4.
[PubMed: 34122588]

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