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 Formulary Chapter 18: Emergency Treatment of Poisoning - Full Chapter
Notes:
In the event of poisoning please phone the National Poisons Information Service (0344 892 0111) rather than Medicines Information.
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18  Expand sub section  Poisoning
Acetylcysteine (Parvolex)
(Paracetamol overdose)
View adult BNF View SPC online View childrens BNF
Formulary
Red
Injection
  • Paracetamol overdose 
  • Link  SFH: Acetylcysteine calculator and auto-prescription
    Link  Link to reviews
    Link  MHRA information page about the changes in Sept 2012
    Link  Treating paracetamol overdose with intravenous acetylcysteine: new guidance
       
    Activated charcoal
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Suspension 50g in 250ml
  • Reduction of absorption of poisons in the gastro-intestinal system or for active elimination techniques
     
  • Link  Link to reviews
       
    Antivenoms for non-indigenous venomous animals
    View adult BNF View childrens BNF
    Formulary
    Red
    Discussion with National Poisons Information Service recommended.
  • Not stocked at NUH or SFH
  • Held supra-regionally for treatment of significant envenomation
  • Held by the pharmacy, Royal Liverpool Hospital and Guy’s & St Thomas’ NHS Foundation Trust
  • see European Viper Venom antiserum entry for Viper Berus bite treatment 
  • Link  Toxbase: National Poisons Information Service
       
    Atropine
    (Antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
  • Antidote for organophosphorus, carbamate insecticides poisoning or nerve agents. Discussion with National Poisons Information Service recommended.
  • Treatment of bradycardia
    See also section 15.1.3
     
  • Link  ED Briefing Note - Management of suspected Novichok poisoning
       
    Benzatropine
    (antidote)
    Formulary
    Red
    Injection (unlicensed)
  • For extrapyramidal symptoms / acute dystonic reactions
  • See section 4.9.2
  • See Toxbase for guidance and dosing information
  • Not routinely stocked at SFH 
  • Link  Toxbase: National Poisons Information Service
       
    Botulism antitoxin (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
  • Not routinely stocked at SFHT
  • Contains specific antitoxic globulins that have the power of neutralising the toxins formed by types A,B & E of Clostridium Botulinum
  • See also section 14.4
  • For post-exposure prophylaxis of botulism and for the treatment of persons thought to be suffering from botulism 
  •    
    Calcium chloride
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Discussion with National Poisons Information Service recommended for serious cases
  • calcium channel blocker antidote
  • 10% injection or infusion 
  •    
    Calcium gluconate
    (Poisoning)
    View adult BNF View childrens BNF
    Formulary
    Red
    Injection
  • Discussion with National Poisons Information Service recommended for all cases of hydrofluoric acid poisoning and serious cases of calcium channel blocker poisoning
  • See also section 9.5.1.1  
  •    
    Calcium gluconate gel
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    2.5% Gel
  • Discussion with National Poisons Information Service recommended in primary care, and for serious cases in secondary care
  • For hydrofluoric acid burns 
  •    
    Cyproheptadine (Periactin®)
    View adult BNF View childrens BNF
    Formulary
    Red
    Tablets
  • Discussion with National Poisons Information Service recommended
  • For the treatment of serotonin syndrome
  • Link to SPC 
  •    
    Dantrolene
    (Poisoning)
    View adult BNF View SPC online View childrens BNF
    Formulary See also section 15.1.8
  • Discussion with National Poisons Information Service recommended if treating drug related malignant hyperpyrexia unless due to anaesthetic
     
  •    
    Desferrioxamine
    (Poisoning)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection
  • Discussion with National Poisons Information Service recommended
  • Iron poisoning
  • Also see section 9.1.3 
  • Link  Link to reviews
       
    Diazepam
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    See section 4.1.2 for further information. 

     
       
    Dicobalt edetate
    (cyanide poisoning)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection
  • Discussion with National Poisons Information Service recommended.
  • SFH stock sodium nitrate and sodium thiosulphate on the poisons unit as alternatives. Contact NPIS for advice if required.
  • NUH stocked in ED
  • Severe poisoning only 
  •    
    Digoxin specific antibody fragments (Digifab®)
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
  • See section 2.1.1 for information 
  •    
    Dimercaprol
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Solution for injection
  • Discussion with National Poisons Information Service recommended.
  • Heavy metal poisoning
  • Held supra-regionally for treatment of heavy metal poisoning 
  • Link  Toxbase: National Poisons Information Service
       
    DMPS (unithiol)
    (antidote)
    View adult BNF View childrens BNF
    Formulary
    Red
    Injection - unlicensed
    Hard capsules - unlicensed
  • Discussion with National Poisons Information Service recommended.
  • Not stocked at NUH or SFH
  • Held supra-regionally for treatment of heavy metal poisoning 
  • Link  Toxbase: National Poisons Information Service
       
    DMSA (succimer)
    (antidote)
    View adult BNF View childrens BNF
    Restricted Drug Restricted
    Red
    Capsules - unlicensed
  • Discussion with National Poisons Information Service recommended.
  • Not stocked at NUH or SFH
  • Held supra-regionally for treatment of heavy metal poisoning 
  • Link  Toxbase: National Poisons Information Service
       
    Ethanol (alcohol) injection
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection (unlicensed)
  • Used in the treatment of antifreeze (ethylene glycol) or methanol poisoning
  • Discussion with National Poisons Information Service recommended.
    At SFH:
  • IV ethanol 90%, 20mL vial, kept in A&E, supplied by pharmacy.
  • Vodka 37.5%, supplied from RDC.
    At NUH:
  • injection 5ml kept in A&E and emergency cupboards both sites.  
  • Link  NUH: Ethylene Glycol poisoning: Clinical Features and Management
    Link  SFH adverse reactions to drug withdrawal information
    Link  SFH guidelines drinking alcohol while taking medication
       
    European Viper Venom Antivenom
    (antiserum / antidote)
    Formulary
    Red
    Vial (for intravenous infusion)
  • Vipera berus (European adder) envenomation
  • Stocked at NUH and KMH A&E (fridge item)
  • The UK Department of Health now supplies (from April 2014) the viper antivenom (antiserum) product ViperaTAb® - for human use only. This product is unlicensed in the UK.  
  •    
    Flumazenil
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection
  • Reversal of benzodiazepine effects
  • Discussion with National Poisons Information Service recommended if using for poisoned patient or in cases of severe persistent hypotension
  • Rarely required in benzodiazepine overdose
  • Not to be used in mixed overdose or as a diagnostic test (see toxbase advice)
  • Also see section 15.1.7
  • NUH: kept in anaphylaxis and oversedation boxes as per memo 
  • Link  NUH: IV Flumazenil for benzodiazepine overdoses
       
    Folinic acid
    (Poisoning)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Methotrexate, methanol or formic acid overdose
  • See also section 8.1
  • Discussion with National Poisons Information Service recommended for methanol poisoning
  • Also known as calcium folinate and calcium leucovorin
     
  •    
    Fomepizole
    View adult BNF View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Injection (unlicensed in UK)
  • See Toxbase and discuss with National Poisons Information Service to ensure appropriate use.
  • Costs around £5,000 per treatment course. 
  • Link  Midlands Rarely Used & Emergency Drugs availability list
    Link  NUH: Ethylene Glycol poisoning: Clinical Features and Management
       
    Glucagon (GlucaGen® Hypokit)
    (Poisoning)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection
  • Discussion with National Poisons Information Service recommended when used as a treatment of poisoning (e.g. beta-blocker poisoning)
    See also section 6.1.4
     
  • Link  NUH ED: administration of IV glucagon in adults
       
    Glucarpidase (Carboxypeptidase)
    (Poisoning)
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Injection 1000 units- NUH only
  • Unlicensed medicine - named patient use only. Not routinely stocked at NUH but it can be ordered out-of-hours between the hours of 5pm and 9am through Clinigen and received within 24 hours (see appendix 2 of oncology guideline for pharmacy procedure).
  • Used for treatment of methotrexate-induced renal
    dysfunction and delayed methotrexate excretion. Consultant request only
  • Imported from USA as Voraxaze® 
  • Link  NUH: Haematology guideline for the use of high dose methotrexate
    Link  NUH: Oncology guideline for the use of high dose methotrexate
    Link  Adverse event reporting form - see above guideline for use
    Link  Patient Access Form - see above guideline for use
       
    Glyceryl Trinitrate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection
    Treatment of hypertension associated with poisoning or overdoses
  • Injection (secondary care only)- Use Polyethylene (PE), giving set for infusion (NOT PVC!).
  • NUH: Isoket stocked on most wards but GTN stocked in A&E
  • Also see section 2.6.1 
  • Link  SFH guide for use in ICCU
    Link  SFH IV GTN guidelines
    Link  SFH: IV drugs which need special giving sets
       
    Hydroxocobalamin (Cyanokit®)
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection (for infusion)
  • Used for the treatment of cyanide poisoning
  • Discussion with National Poisons Information Service recommended
    NUH: Kept in A&E
    SFH: One kit kept on ED (Major - Poisons cupboard), can borrow an extra kit from Chesterfield Hospital in the event of needing 2 kits . See guides below
     
  • Link  SFH: A+E guide to sorting supplies
    Link  SFH: Pharmacy guide to sorting supplies
       
    Lorazepam
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Injection

    • Convulsions or agitation related to overdose / poisoning.
    • See section 4.1.2 for other indications or more details
     
       
    Macrogol '3350' (Klean-Prep®)
    (Poisoning)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Oral powder (polyethylene glycol)
  • Discussion with National Poisons Information Service recommended
  • Used for whole bowel irrigation for agents not bound by activated charcoal e.g. iron, lithium
  • Also used for whole bowel irrigation for bodypackers and for slow release medicines
  • for standard uses see section 1.6.5 
  • Link  Link to reviews
       
    Mesna
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    See also section 8.1
  • Treatment of cyclophosphamide induced haemorrhagic cystitis 
  •    
    Methionine
    (paracetamol overdose)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Tablet
  • No longer available in the UK. Seldom used for the treatment of paracetamol poisoning
  • Discussion with National Poisons Information Service recommended
  • Follow advice on Toxbase if patient has a reaction to acetylcysteine.  
  •    
    Methylthioninium chloride (Proveblue®)
    (for IV use)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    10ml 0.5% (50mg) for IV use. 
    (SFH: Another version also available as 1ml 1% for enteral (not for IV) use. See here.)

    • Also known as "methylene blue"
    • Used for methaemoglobinaemia (licensed) or prior to parathyroid surgery (unlicensed) - speak to Medicines Information for details (SFH: 3163).
    • Approx £50 per vial
     
    Link  MHRA safety update April 2009
       
    Naloxone
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Injection
  • For treatment of opioid overdose / poisoning
  • See also section 15.1.7
     
  • Link  NUH Lite Bite: Adult Naloxone Guidelines Updated (July 18)
    Link  NUH: Guideline for the use of naloxone in adults
    Link  SFH naloxone guidelines for opioid overdose
    Link  UKMI Q&A further reading on naloxone usage
       
    Octreotide
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection
  • Discussion with National Poisons Information Service recommended if severe refractory hypoglycaemia
  • Sulphonylurea induced hypoglycaemia / poisoning (off-label indication), rarely required
  • for standard uses see section 8.3.4.3 
  •    
    Penicillamine (Distamine)
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Tablets
  • Treatment of heavy metal poisoning
  • See section 10.1.3 for information about use in Rheumatological conditions
  • See section 9.8.1 Treatment of Wilson's disease and metabolic disorders
     
  •    
    Phentolamine
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection (unlicensed)
  • Resistant hypertension due to amphetamines and other sympathomimetic drugs of abuse, MAOIs, clonidine etc
  • Digital ischaemia related to injection of epinephrine (adrenaline)
  • Licensed injection discontinued in the UK but imported unlicensed product should be available. At SFH this product is held in Emergency Department resus. 
  •    
    Phytomenadione (Vitamin K1)
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection
  • Vitamin K dependent anticoagulant reversal / poisoning
  • Konakion MM Paediatric formulation can be given orally
  • See section 9.6.6 for more details 
  • Link  NUH: Haemostasis and Thrombosis protocols
    Link  SFH: Anticoagulation guidelines
       
    Potassium ferric hexacyanoferrate (Berlin / Prussian Blue)
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Discussion with National Poisons Information Service recommended.
  • Also known as Berlin blue or Prussian blue
  • Not stocked at NUH or SFH
  • Held supra-regionally for treatment of thallium poisoning 
  • Link  Toxbase: National Poisons Information Service
       
    Pralidoxime chloride (Protopam®)
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection 1g
    Organophosphorus insecticide and nerve agent poisoning (adjunct to atropine)
  • Stocked at NUH pharmacy
  • Discussion with National Poisons Information Service required
  • For other local holding centres see Toxbase or Midlands Medicines rarely used drug list
  • Supplies for deliberate release available from National blood service 24/7 
  • Link  Midlands Medicines rarely used drug list
       
    Procyclidine
    (Poisoning)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection
  • Treatment of extrapyramidal symptoms
  • See also section 4.9.2 
  •    
    Protamine Sulphate
    (Heparin overdose / reversal)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection (secondary care only)
  • Discussion with haematology recommended
  • Remember maximum dose is 50mg.
  • See local guidelines for dosing and administration in secondary care
  • Also see section 2.8.3 
  • Link  NUH: Haemostasis and Thrombosis protocols
    Link  SFH: Anticoagulation guidelines
    Link  SFH: Reversal of bleeding caused by anticoagulant, antiplatelet and fibrinolytic drugs
       
    Pyridoxine
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection 50 mg in 2mL (unlicensed)
  • Convulsions in isoniazid poisoning
  • Discussion with National Poisons Information Service recommended in severe cases 
  •    
    Sodium bicarbonate
    (Poisoning)
    Formulary
    Red
    Injection
  • Tricyclic antidepressant overdose or treatment of class 1a and 1c antiarrhythmic drugs
  • Discussion with National Poisons Information Service recommended for severe cases
    See also section 9.2.2.1
     
  •    
    Sodium calcium edetate
    (antidote)
    Restricted Drug Restricted
    Red
    Injection 5% (unlicensed in UK)
  • Discussion with National Poisons Information Service recommended
  • Heavy metal poisoning especially lead
  • Not stocked at NUH, stocked at SFH A&E
  • Held supra-regionally for treatment of heavy metal poisoning 
  •    
    Sodium nitrite
    (antidote)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Grey
    Injection
  • Discussion with National Poisons Information Service recommended
     
  •    
    Sodium thiosulfate
    (antidote)
    Formulary
    Red
    Injection (25%, 50%)
  • Discussion with National Poisons Information Service recommended
  • Cyanide poisoning (in conjunction with sodium nitrite) if dicobalt edetate is not available
  • Link to SPC.
     
  •    
    18  Expand sub section  Body Temperature
    18  Expand sub section  Pesticides
    18  Expand sub section  Prevention of absorption
    18  Expand sub section  Specific Drugs to top
    18  Expand sub section  Analgesics (non-opioid)
    18  Expand sub section  Analgesics (opioid)
    18  Expand sub section  Antidepressants
    18  Expand sub section  Beta Blockers
    18  Expand sub section  Calcium-channel blockers to top
    18  Expand sub section  Hypnotics and anxiolytics
    18  Expand sub section  Iron Salts
    18  Expand sub section  Phenothiazines and related drugs
    18  Expand sub section  Stimulants
    18  Expand sub section  Other poisons to top
    18  Expand sub section  Cyanides
    18  Expand sub section  Ethylene glycol and methanol
    18  Expand sub section  Heavy Metals
     ....
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to children's BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    Grey

    Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
    Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
    Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
      

    Red

    Medicines which should normally be prescribed by specialists only. eg hospital only.
    For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
      

    Amber 1

    Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
    Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
      

    Amber 2

    Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
    A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
    *Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
      

    Amber 3

    Primary care/ non specialist may initiate as per APC guideline.
    The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
      

    Green

    Medicines suitable for routine use within primary care.
    Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing.   

    OTC

      

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