bite may cause local and systemic effects. Local effects
include pain, swelling, bruising, and tender enlargement of
regional lymph nodes. Systemic effects include early
anaphylactic symptoms (transient hypotension with
syncope, angioedema, urticaria, abdominal colic, diarrhoea,
and vomiting), with later persistent or recurrent
hypotension, ECG abnormalities, spontaneous systemic
bleeding, coagulopathy, adult respiratory distress syndrome,
and acute renal failure. Fatal envenoming is rare but the
potential for severe envenoming must not be
Early anaphylactic symptoms should be treated with
adrenaline/epinephrine p. 222. Indications for european
viper snake venom antiserum p. 1371 treatment include
systemic envenoming, especially hypotension, ECG
abnormalities, vomiting, haemostatic abnormalities, and
marked local envenoming such that after bites on the hand
or foot, swelling extends beyond the wrist or ankle within
4 hours of the bite. For those patients who present with
clinical features of severe envenoming (e.g. shock, ECG
abnormalities, or local swelling that has advanced from the
foot to above the knee or from the hand to above the elbow
within 2 hours of the bite), a higher initial dose of the
european viper snake venom antiserum is recommended; if
symptoms of systemic envenoming persist contact the
National Poisons Information Service.
Adrenaline/epinephrine injection must be immediately to
hand for treatment of anaphylactic reactions to the european
European viper snake venom antiserum is available for
bites by certain foreign snakes and spiders, stings by
scorpions and fish. For information on identification,
management, and for supply in an emergency, telephone the
National Poisons Information Service. Whenever possible
the TOXBASE entry should be read, and relevant
information collected, before telephoning the National
Stings from ants, wasps, hornets, and bees cause local pain
and swelling but seldom cause severe direct toxicity unless
many stings are inflicted at the same time. If the sting is in
the mouth or on the tongue local swelling may threaten the
upper airway. The stings from these insects are usually
treated by cleaning the area with a topical antiseptic. Bee
stings should be removed as quickly as possible.
Anaphylactic reactions require immediate treatment with
intramuscular adrenaline/epinephrine; self-administered
intramuscular adrenaline/epinephrine (e.g. EpiPen ®) is the
best first-aid treatment for patients with severe
hypersensitivity. An inhaled bronchodilator should be used
for asthmatic reactions, see also the management of
anaphylaxis. A short course of an oral antihistamine or a
topical corticosteroid may help to reduce inflammation and
relieve itching. A vaccine containing extracts of bee and
wasp venom can be used to reduce the risk of anaphylaxis
and systemic reactions in patients with systemic
hypersensitivity to bee or wasp stings.
The severe pain of weeverfish (Trachinus vipera) and
Portuguese man-o’-war stings can be relieved by immersing
the stung area immediately in uncomfortably hot, but not
scalding, water (not more than 45° C). People stung by
jellyfish and Portuguese man-o’-war around the UK coast
should be removed from the sea as soon as possible.
Adherent tentacles should be lifted off carefully (wearing
gloves or using tweezers) or washed off with seawater.
Alcoholic solutions, including suntan lotions, should not be
applied because they can cause further discharge of stinging
hairs. Ice packs can be used to reduce pain.
Consult either the National Poisons Information Service day
The National Poisons Information Service (Tel: 0344
892 0111) will provide specialist advice on all aspects of
ANTIDOTES AND CHELATORS › INTESTINAL
Reduction of absorption of poisons in the gastro-intestinal
▶ Child 1 month–11 years: 1 g/kg (max. per dose 50 g)
▶ Neonate: 1 g/kg every 4 hours, dose may be reduced and
the frequency increased if not tolerated, reduced dose
▶ Child 1 month–11 years: 1 g/kg every 4 hours (max. per
dose 50 g), dose may be reduced and the frequency
increased if not tolerated, reduced dose may
▶ Child 12–17 years: Initially 50 g, then 50 g every 4 hours,
reduced if not tolerated to 25 g every 2 hours,
alternatively 12.5 g every 1 hour, reduced dose may
▶ Adult: Initially 50 g, then 50 g every 4 hours, reduced if
not tolerated to 25 g every 2 hours, alternatively 12.5 g
every 1 hour, reduced dose may compromise efficacy
Accelerated elimination of teriflunomide
▶ Adult: 50 g every 12 hours for 11 days
Accelerated elimination of leflunomide (washout
▶ Adult: 50 g 4 times a day for 11 days
▶ In adults Activated charcoal doses in BNF may differ from
l CAUTIONS Comatose patient (risk of aspiration—ensure
airway is protected). drowsy patient (risk of aspiration—
ensure airway protected).reduced gastrointestinal
motility (risk of obstruction)
l SIDE-EFFECTS Bezoar. constipation . diarrhoea . gastrointestinal disorders
l DIRECTIONS FOR ADMINISTRATION Suspension or
reconstituted powder may be mixed with soft drinks (e.g.
caffeine-free diet cola) or fruit juices to mask the taste.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Activated charcoal 200 mg per 1 ml Charcodote 200mg/ml oral
suspension sugar-free | 250 ml p £11.88
1366 Active elimination from the gastro-intestinal tract BNF 78
Emergency treatment of poisoning
▶ Carbomix (Kent Pharmaceuticals Ltd)
Activated charcoal 813 mg per 1 gram Carbomix 81.3% granules
Severe poisoning with cyanides
▶ Child: Consult the National Poisons Information
▶ Adult: 300 mg, to be given over 1 minute (or 5 minutes
if condition less serious), dose to be followed
immediately by 50 mL of glucose intravenous infusion
50%; if response inadequate a second dose of both may
be given, but risk of cobalt toxicity
l CAUTIONS Owing to toxicity to be used only for definite
cyanide poisoning when patient tending to lose, or has
l SIDE-EFFECTS Reflex tachycardia . vomiting
l EXCEPTIONS TO LEGAL CATEGORY Prescription only
medicine restriction does not apply where administration
is for saving life in emergency.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Dicobalt edetate (Non-proprietary)
Dicobalt edetate 15 mg per 1 ml Dicobalt edetate 300mg/20ml
solution for injection ampoules | 6 ampoule P £117.20 DT =
Poisoning with cyanides (used in conjunction with sodium
▶ Child: Consult the National Poisons Information
l SIDE-EFFECTS Arrhythmias . dizziness . headache . hypotension . palpitations
l EXCEPTIONS TO LEGAL CATEGORY Prescription only
medicine restriction does not apply where administration
is for saving life in emergency.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Sodium nitrite (Non-proprietary)
Sodium nitrite 30 mg per 1 ml Sodium nitrite 300mg/10ml solution
for injection vials | 1 vial P s
Sodium thiosulfate 16-Mar-2018
▶ Child: Consult the National Poisons Information
▶ Adult: 12.5 g, to be given over 10 minutes, dose may be
repeated in severe cyanide poisoning
DOSE EQUIVALENCE AND CONVERSION
▶ 12.5 g equates to 50 mL of a 25% solution or 25 mL of a
l EXCEPTIONS TO LEGAL CATEGORY Prescription only
medicine restriction does not apply where administration
is for saving life in emergency.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: solution for
▶ Sodium thiosulfate (Non-proprietary)
Sodium thiosulfate 250 mg per 1 ml Sodium thiosulfate 12.5g/50ml
solution for injection vials | 1 vial P s
Other drugs used for Organophosphorus toxicity Atropine
Adjunct to atropine in the treatment of poisoning by
organophosphorus insecticide or nerve agent
▶ Child: Initially 30 mg/kg, to be given over 20 minutes,
followed by 8 mg/kg/hour; maximum 12 g per day
▶ Adult: Initially 30 mg/kg, to be given over 20 minutes,
followed by 8 mg/kg/hour; maximum 12 g per day
l UNLICENSED USE Pralidoxime chloride doses may differ
from those in product literature.
▶ In children Licensed for use in children (age range not
l CONTRA-INDICATIONS Poisoning with carbamates . poisoning with organophosphorus compounds without
l RENAL IMPAIRMENT Use with caution.
l DIRECTIONS FOR ADMINISTRATION The loading dose may
be administered by intravenous injection (diluted to a
concentration of 50 mg/mL with water for injections) over
at least 5 minutes if pulmonary oedema is present or if it is
not practical to administer an intravenous infusion.
▶ In children For intravenous infusion, reconstitute each vial
with 20 mL Water for Injections, then dilute to a
concentration of 10–20 mg/mL with Sodium Chloride
l PRESCRIBING AND DISPENSING INFORMATION Available
from designated centres for organophosphorus insecticide
poisoning or from the National Blood Service (or Welsh
BNF 78 Organophosphorus toxicity 1367
Emergency treatment of poisoning
Ambulance Services for Mid West and South East Wales)—
see TOXBASE for list of designated centres).
l EXCEPTIONS TO LEGAL CATEGORY Prescription only
medicine restriction does not apply where administration
is for saving life in emergency.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for injection
▶ Pralidoxime chloride (Imported (United States))
Pralidoxime chloride 1 gram Protopam Chloride 1g powder for
solution for injection vials | 6 vial P s
Reversal of sedative effects of benzodiazepines in
anaesthesia and clinical procedures
▶ Adult: 200 micrograms, dose to be administered over
15 seconds, then 100 micrograms every 1 minute if
required; usual dose 300–600 micrograms; maximum
Reversal of sedative effects of benzodiazepines in
▶ Adult: 300 micrograms, dose to be administered over
15 seconds, then 100 micrograms every 1 minute if
required; maximum 2 mg per course
Reversal of sedative effects of benzodiazepines in
intensive care (if drowsiness recurs after injection)
▶ INITIALLY BY INTRAVENOUS INFUSION
▶ Adult: 100–400 micrograms/hour, adjusted according
to response, alternatively (by intravenous injection)
300 micrograms, adjusted according to response
Flumazenil should only be administered by, or under the
direct supervision of, personnel experienced in its use.
l CONTRA-INDICATIONS Life-threatening condition (e.g.
raised intracranial pressure, status epilepticus) controlled
symptoms). elderly . ensure neuromuscular blockade
cleared before giving . head injury (rapid reversal of
benzodiazepine sedation may cause convulsions) . history
of panic disorders (risk of recurrence). prolonged
benzodiazepine effects may persist for at least 24 hours)
common in patients with epilepsy)
▶ Frequency not known Withdrawal syndrome
l PREGNANCY Not known to be harmful.
l BREAST FEEDING Avoid breast-feeding for 24 hours.
l HEPATIC IMPAIRMENT Manufacturer advises caution (risk
Dose adjustments Manufacturer advises cautious dose
l DIRECTIONS FOR ADMINISTRATION For continuous
intravenous infusion, dilute with Glucose 5% or Sodium
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Flumazenil (Non-proprietary)
Flumazenil 100 microgram per 1 ml Flumazenil
ANTIDOTES AND CHELATORS › ANTIBODIES
arrhythmias or bradyarrhythmias unresponsive to
atropine and when measures beyond the withdrawal of
digoxin and correction of any electrolyte abnormalities
▶ Child: Serious cases of digoxin toxicity should be
discussed with the National Poisons Information
Service (consult product literature)
▶ Adult: Serious cases of digoxin toxicity should be
discussed with the National Poisons Information
Service (consult product literature)
l DIRECTIONS FOR ADMINISTRATION
▶ In adults For intravenous infusion (DigiFab ®), given
intermittently in Sodium chloride 0.9%. Reconstitute with
water for injections (4 mL/vial), then dilute with infusion
fluid and give over 30 minutes.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
▶ DigiFab (BTG International Ltd)
Digoxin-specific antibody fragments 40 mg DigiFab 40mg powder
for solution for infusion vials | 1 vial P £750.00 (Hospital only)
Overdosage with intravenous injection of unfractionated
▶ Adult: Dose to be administered at a rate not exceeding
5 mg/minute, 1 mg neutralises 80–100 units heparin
when given within 15 minutes; if longer than 15 minute
since heparin, less protamine required (consult product
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