literature for details) as heparin rapidly excreted;
Overdosage with intravenous infusion of unfractionated
▶ Adult: 25–50 mg, to be administered once heparin
infusion stopped at a rate not exceeding 5 mg/minute
Overdosage with subcutaneous injection of
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Adult: Initially 25–50 mg, to be administered at a rate
not exceeding 5 mg/minute, 1 mg neutralises 100 units
heparin, then (by intravenous infusion), any remaining
dose to be administered over 8–16 hours; maximum
Overdosage with subcutaneous injection of low molecular
▶ BY INTRAVENOUS INJECTION, OR BY CONTINUOUS
▶ Adult: Dose to be administered by intermittent
intravenous injection at a rate not exceeding
5 mg/minute, 1 mg neutralises approx. 100 units low
molecular weight heparin (consult product literature of
low molecular weight heparin for details); maximum
l CAUTIONS Excessive doses can have an anticoagulant
▶ Rare or very rare Hypertension . pulmonary oedema noncardiogenic
l ALLERGY AND CROSS-SENSITIVITY Caution if increased risk
of allergic reaction to protamine (includes previous
treatment with protamine or protamine insulin, allergy to
fish, men who are infertile or who have had a vasectomy
and who may have antibodies to protamine).
l MONITORING REQUIREMENTS Monitor activated partial
thromboplastin time or other appropriate blood clotting
l PRESCRIBING AND DISPENSING INFORMATION The long
half-life of low molecular weight heparins should be taken
into consideration when determining the dose of
protamine sulfate; the effects of low molecular weight
heparins can persist for up to 24 hours after
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Protamine sulfate (Non-proprietary)
Protamine sulfate 10 mg per 1 ml Protamine sulfate 100mg/10ml
solution for injection ampoules | 5 ampoule P s
Protamine sulfate 50mg/5ml solution for injection ampoules | 10 ampoule P £49.55
▶ Child 1 month–11 years: Initially 100 micrograms/kg
(max. per dose 2 mg), if no response, repeat at intervals
of 1 minute to a max. of 2 mg, then review diagnosis;
further doses may be required if respiratory function
deteriorates, doses can be given by subcutaneous or
intramuscular routes but only if intravenous route is
not feasible; intravenous administration has more
▶ Child 12–17 years: Initially 400 micrograms, then
800 micrograms for up to 2 doses at 1 minute intervals
if no response to preceding dose, then increased to
2 mg for 1 dose if still no response (4 mg dose may be
required in seriously poisoned patients), then review
diagnosis; further doses may be required if respiratory
function deteriorates, doses can be given by
subcutaneous or intramuscular routes but only if
intravenous route is not feasible; intravenous
administration has more rapid onset of action
▶ Adult: Initially 400 micrograms, then 800 micrograms
for up to 2 doses at 1 minute intervals if no response to
preceding dose, then increased to 2 mg for 1 dose if still
no response (4 mg dose may be required in seriously
poisoned patients), then review diagnosis; further
doses may be required if respiratory function
deteriorates, doses can be given by subcutaneous or
intramuscular routes but only if intravenous route is
not feasible; intravenous administration has more
▶ BY CONTINUOUS INTRAVENOUS INFUSION
▶ Child: Using an infusion pump, adjust rate according to
response (initially, rate may be set at 60% of the initial
resuscitative intravenous injection dose per hour). The
initial resuscitative intravenous injection dose is that
which maintained satisfactory ventilation for at least
▶ Adult: Using an infusion pump, adjust rate according to
response (initially, rate may be set at 60% of the initial
resuscitative intravenous injection dose per hour). The
initial resuscitative intravenous injection dose is that
which maintained satisfactory ventilation for at least
Overdosage with opioids in a non-medical setting
▶ Adult: 400 micrograms every 2–3 minutes, each dose
given in subsequent resuscitation cycles if patient not
breathing normally, continue until consciousness
regained, breathing normally, medical assistance
available, or contents of syringe used up; to be injected
into deltoid region or anterolateral thigh
Reversal of postoperative respiratory depression
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Child 1 month–11 years: 1 microgram/kg, repeated every
▶ Child 12–17 years: Initially 100–200 micrograms,
alternatively (by intravenous injection) initially
1.5–3 micrograms/kg, if response inadequate, give
subsequent doses, (by intravenous injection)
100 micrograms every 2 minutes, alternatively (by
intramuscular injection) 100 micrograms every
Emergency treatment of poisoning
▶ Adult: Initially 100–200 micrograms, alternatively (by
intravenous injection) initially 1.5–3 micrograms/kg, if
response inadequate, give subsequent doses, (by
intravenous injection) 100 micrograms every
2 minutes, alternatively (by intramuscular injection)
100 micrograms every 1–2 hours
▶ Naloxone has a short duration of action; repeated doses
or infusion may be necessary to reverse effects of
opioids with longer duration of action.
l UNLICENSED USE Naloxone doses in BNF may differ from
Doses used in acute opioid overdosage may not be
appropriate for the management of opioid-induced
respiratory depression and sedation in those receiving
palliative care and in chronic opioid use.
l CAUTIONS Cardiovascular disease or those receiving
cardiotoxic drugs (serious adverse cardiovascular effects
reported). maternal physical dependence on opioids (may
precipitate withdrawal in newborn). pain . physical
dependence on opioids (precipitates withdrawal)
▶ Titration of dose In postoperative use, the dose should be
titrated for each patient in order to obtain sufficient
respiratory response; however, naloxone antagonises
▶ Rare or very rare Anxiety . cardiac arrest. erythema
multiforme . pulmonary oedema . seizure
l PREGNANCY Use only if potential benefit outweighs risk.
l BREAST FEEDING Not orally bioavailable.
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use in children For continuous intravenous
infusion, dilute to a concentration of up to
200 micrograms/mL with Glucose 5% or Sodium Chloride
▶ With intravenous use in adults For intravenous infusion
(Minijet ® Naloxone Hydrochloride), give continuously in
Glucose 5% or Sodium Chloide 0.9%. Dilute to a
concentration of up to 200 micrograms/mL and administer
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Naloxone hydrochloride (Non-proprietary)
Naloxone hydrochloride 20 microgram per 1 ml Naloxone
40micrograms/2ml solution for injection ampoules | 10 ampoule P £55.00
Naloxone hydrochloride dihydrate 400 microgram per
Naloxone hydrochloride 1 mg per 1 ml Naloxone 2mg/2ml solution
for injection pre-filled syringes | 1 pre-filled disposable
▶ Child (body-weight up to 20 kg): Initially 150 mg/kg over
1 hour, dose to be administered in 3 mL/kg glucose 5%,
followed by 50 mg/kg over 4 hours, dose to be
administered in 7 mL/kg glucose 5%, then 100 mg/kg
over 16 hours, dose to be administered in 14 mL/kg
▶ Child (body-weight 20–39 kg): Initially 150 mg/kg over
1 hour, dose to be administered in 100 mL glucose 5%,
followed by 50 mg/kg over 4 hours, dose to be
administered in 250 mL glucose 5%, then 100 mg/kg
over 16 hours, dose to be administered in 500 mL
▶ Child (body-weight 40 kg and above): 150 mg/kg over
1 hour, dose to be administered in 200 mL Glucose
Intravenous Infusion 5%, then 50 mg/kg over 4 hours,
to be started immediately after completion of first
infusion, dose to be administered in 500 mL Glucose
Intravenous Infusion 5%, then 100 mg/kg over
16 hours, to be started immediately after completion of
second infusion, dose to be administered in 1 litre
Glucose Intravenous Infusion 5%
▶ Adult (body-weight 40 kg and above): 150 mg/kg over
1 hour, dose to be administered in 200 mL Glucose
Intravenous Infusion 5%, then 50 mg/kg over 4 hours,
to be started immediately after completion of first
infusion, dose to be administered in 500 mL Glucose
Intravenous Infusion 5%, then 100 mg/kg over
16 hours, to be started immediately after completion of
second infusion, dose to be administered in 1 litre
Glucose Intravenous Infusion 5%
DOSES AT EXTREMES OF BODY-WEIGHT
▶ To avoid excessive dosage in obese patients, a ceiling
weight of 110 kg should be used when calculating the
dose for paracetamol overdosage.
MHRA/CHM ADVICE: INTRAVENOUS ACETYLCYSTEINE FOR
PARACETAMOL OVERDOSE: REMINDER OF AUTHORISED DOSE
REGIMEN; POSSIBLE NEED FOR CONTINUED TREATMENT
The authorised dose regimen for acetylcysteine in
paracetamol overdose is 3 consecutive intravenous
infusions given over a total of 21 hours.
Continued treatment (given at the dose and rate as
used in the third infusion) may be necessary depending
on the clinical evaluation of the individual patient.
l CAUTIONS Asthma (see Side-effects for management of
SIDE-EFFECTS, FURTHER INFORMATION Anaphylactoid
reactions (with intravenous use) can be managed by
suspending treatment and initiating appropriate
Emergency treatment of poisoning
management. Treatment may then be restarted at lower
l DIRECTIONS FOR ADMINISTRATION
▶ In children Glucose 5% is preferred fluid; Sodium Chloride
0.9% is an alternative if Glucose 5% unsuitable.
▶ In adults For intravenous infusion (Parvolex ®), give
continuously in Glucose 5% or Sodium chloride 0.9%.
Glucose Intravenous Infusion 5% is the preferred fluid;
Sodium Chloride Intravenous Infusion 0.9% is an
alternative if Glucose Intravenous Infusion 5% is
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
ELECTROLYTES: May contain Sodium
▶ Acetylcysteine (Non-proprietary)
Acetylcysteine 200 mg per 1 ml Acetylcysteine 2g/10ml solution for
infusion ampoules | 10 ampoule P £21.26–£24.99 DT = £21.26
Acetylcysteine 200 mg per 1 ml Parvolex 2g/10ml concentrate for
solution for infusion ampoules | 10 ampoule P £22.50 DT =
Drug- or chemical-induced methaemoglobinaemia
▶ BY SLOW INTRAVENOUS INJECTION
▶ Child 3 months–17 years: Initially 1–2 mg/kg, then
1–2 mg/kg after 30–60 minutes if required, to be given
over 5 minutes, seek advice from National Poisons
Information Service if further repeat doses are
required; maximum 7 mg/kg per course
▶ Adult: Initially 1–2 mg/kg, then 1–2 mg/kg after
30–60 minutes if required, to be given over 5 minutes,
seek advice from National Poisons Information Service
if further repeat doses are required; maximum 7 mg/kg
Aniline- or dapsone-induced methaemoglobinaemia
▶ BY SLOW INTRAVENOUS INJECTION
▶ Child 3 months–17 years: Initially 1–2 mg/kg, then
1–2 mg/kg after 30–60 minutes if required, to be given
over 5 minutes, seek advice from National Poisons
Information Service if further repeat doses are
required; maximum 4 mg/kg per course
▶ Adult: Initially 1–2 mg/kg, then 1–2 mg/kg after
30–60 minutes if required, to be given over 5 minutes,
seek advice from National Poisons Information Service
if further repeat doses are required; maximum 4 mg/kg
l CAUTIONS Chlorate poisoning (reduces efficacy of
methylthioninium).G6PD deficiency (seek advice from
National Poisons Information Service). methaemoglobinaemia due to treatment of cyanide
poisoning with sodium nitrite (seek advice from National
Poisons Information Service). pulse oximetry may give
false estimation of oxygen saturation
l INTERACTIONS → Appendix 1: methylthioninium chloride
▶ Common or very common Abdominal pain . anxiety . chest
pain . dizziness . headache . hyperhidrosis . nausea . pain in
extremity . paraesthesia . skin reactions .taste altered . urine discolouration . vomiting
l PREGNANCY No information available, but risk to fetus of
untreated methaemoglobinaemia likely to be significantly
higher than risk of treatment.
l BREAST FEEDING Manufacturer advises avoid
breastfeeding for up to 6 days after administration—no
Dose adjustments Use with caution in severe impairment;
dose reduction may be required.
l DIRECTIONS FOR ADMINISTRATION
▶ In children For intravenous injection, may be diluted with
Glucose 5% to minimise injection-site pain; not
compatible with Sodium Chloride 0.9%.
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
▶ Methylthioninium chloride (Non-proprietary)
Methylthioninium chloride 5 mg per 1 ml Methylthioninium
chloride Proveblue 50mg/10ml solution for injection ampoules | 5 ampoule P £196.89
IMMUNE SERA AND IMMUNOGLOBULINS ›
Systemic envenoming from snake bites | Marked local
▶ BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS INFUSION
▶ Child: Initially 10 mL for 1 dose, then 10 mL after
1–2 hours if required, the second dose should only be
given if symptoms of systemic envenoming persist
after the first dose, if symptoms of systemic
envenoming persist contact the National Poisons
▶ Adult: Initially 10 mL for 1 dose, then 10 mL after
1–2 hours if required, the second dose should only be
given if symptoms of systemic envenoming persist
after the first dose, if symptoms of systemic
envenoming persist contact the National Poisons
Severe systemic envenoming from snake bites in patients
presenting with clinical features
▶ BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS INFUSION
▶ Child: Initially 20 mL for 1 dose, if symptoms of
systemic envenoming persist contact the National
▶ Adult: Initially 20 mL for 1 dose, if symptoms of
systemic envenoming persist contact the National
l DIRECTIONS FOR ADMINISTRATION By intravenous injection
given over 10–15 minutes or by intravenous infusion over
30 minutes after diluting in sodium chloride 0.9% (use
l PRESCRIBING AND DISPENSING INFORMATION To order,
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