- Activated Charcoal
- Atropine
- Flumazenil
- Fomepizole
- Intralipid
- Pralidoxime
- N-Acetylcysteine
- Naloxone
- Thiamine

Activated Charcoal
Rapid Review
- Mechanism of Action: Adsorbent agent. Large surface area of charcoal binds to toxins and prevents systemic absorption.
- Indications: Toxic ingestions/drug overdoses (solids only); should be administered within 1-2 hours of ingestion.
- Contraindications: Risk of aspiration, ingestion of caustic material
- Dosage: 25-100mg PO
- Onset: Begins within 1 minute; achieves equilibrium within 10-25 minutes.
- Duration: Up to 4 hours
- Adverse Reactions: aspiration, bowel obstruction.
- Special Considerations: N/A
Pearls

Atropine
Rapid Review
- Mechanism of Action: Anticholinergic and parasympatholytic; antagonizes acetylcholine receptors and prevents activation of parasympathetic nervous system.
- Indications: organophosphate toxicity; bradycardia. May also be used to reverse effects of paralytics.
- Contraindications: allergy; primary glaucoma
- Dosage: symptomatic bradycardia: 0.5 mg rapid IV push; organophosphate toxicity: 1-3 mg IV/IM/SC. Paralytic reversal: 1.2 mg IV push
- Onset: 2-4 minutes
- Duration: 5 hours
- Adverse Reactions: dry mouth, blurred vision, tachycardia, hyperthermia
Pearls
Deep Dive

Flumazenil
Rapid Review
- Mechanism of Action: Benzodiazepine antagonist; competitively inhibits GABA/benzodiazepine receptor sites
- Indications: Benzodiazepine overdose
- Contraindications: Hypersensitivity, use of benzodiazepine to control seizures
- Dosage: 0.2 mg slow IV push initially. Repeat every 60 seconds prn. Max dose 1 mg.
- Onset: 1-2 minutes
- Duration: 19-50 minutes
- Adverse Reactions: Sedation, seizure, arrhythmias, confusion, nausea/vomiting
Pearls

Fomepizole
Rapid Review
- Mechanism of Action: Antidote; inhibits alcohol dehydrogenase
- Indications: Methanol or ethylene glycol toxicity
- Contraindications: Allergy
- Dosage: 15 mg/kg IV loading dose, then 10 mg/kg q12 hours
- Onset: 1.5 – 2 hours
- Duration: Half life not determined
- Adverse Reactions: Headache, nausea, bradycardia, hypotension
Pearls
Deep Dive

Intralipid
Rapid Review
- Mechanism of Action: Lipid emulsion; unknown mechanism, but thought to create a “lipid sink” in the blood where lipophilic anesthetic agents can dissolve, thus reducing systemic circulation. Available in 10%, 20%, and 30%.
- Indications: Local anesthetic systemic toxicity (LAST)
- Contraindications: Severe egg allergy,
- Dosage:
- Weight > 70kg: 100mL bolus (20%), followed by 200-250mL infusion over 20-30 minutes
- Weight <70kg: 1.5mL/kg bolus (20%), followed by 0.25 mL/kg/minute infusion
- Half-Life: 15 minutes
- Adverse Reactions: Fat embolism, hypersensitivity reactions, pancreatitis, hypertriglyceridemia
Pearls
Deep Dive

Pralidoxime
Rapid Review
- Mechanism of Action: Oxime antidote. Reactivates the acetylcholinesterase enzyme to promote clearance of acetylcholine at muscarinic and nicotinic sites.
- Indications: Organophosphate toxicity
- Contraindications: Allergy to drug/class
- Dosage: 1-2 grams IV over 5-10 minutes or 600 mg IM X 3 doses (15 minutes apart)
- Onset: 5-15 minutes
- Duration: 3-4 hours
- Adverse Reactions: Blurred vision, diplopia, dizziness, tachycardia, hypertension
Pearls
Deep Dive

N-Acetylcysteine
Rapid Review
- Mechanism of Action: Antidote/Mucolytic; helps replete glutathione reserves in the liver, which helps protect the liver from hepatotoxic NAPQI metabolite. Also functions as a mucolytic to help break down thick pulmonary secretions.
- Indications: Acetaminophen toxicity
- Contraindications: Allergy to drug/class
- Dosage: Three separate infusions:
- First dose: 150mg/kg in 100 mL D5W over 60 minutes
- Second dose: 50mg/kg in 250 mL D5W over 4 hours
- Third dose: 100 mg/kg in 500 mL D5W over 16 hours
- Onset: Generally rapid onset
- Duration: Generally short duration
- Adverse Reactions: Nausea/vomiting, anaphylaxis
- Special Considerations: Almost 100% effective if given within 8 hours of ingestion for maximum benefit. May still be beneficial after >24 hours.
Pearls
Deep Dive

Naloxone
Rapid Review
- Mechanism of Action: Opiate antagonist; competitively binds to mu, kappa, and sigma opiate receptor sites in the CNS for reversal of opiate toxicity and improvement of respiratory drive.
- Indications: Opioid toxicity (recreational or iatrogenic)
- Contraindications: Allergy to class/drug
- Dosage: 0.4 – 2.0 mg (IV/IM/SC), repeat q 2-3 minutes prn. Max dose 10 mg
- Onset: 1-2 minutes
- Duration: 20-90 minutes
- Adverse Reactions: Non-cardiogenic pulmonary edema, opioid withdrawal (diaphoresis, tachycardia, agitation)
- Special Considerations: Patients with opiate overdose should be held in the ED until naloxone wears off (usually 1-3 hours). Consider discharging patients with naloxone in-hand.
Pearls

Thiamine
Rapid Review
- Mechanism of Action: Vitamin; combines with ATP in liver, kidneys, and leukocytes to produce thiamine diphosphate, which acts as a coenzyme in carbohydrate metabolism. Used to prevent brain damage (encephalopathy) from thiamine-depleted states.
- Indications: Alcoholism, beriberi anorexia, bulimia, pregnancy, malignancies
- Contraindications: Allergic reactions to vitamin supplements
- Dosage:
- Beriberi: 5-30 mg TID x 1 month
- Wernicke’s Encephalopathy: 500mg IV TID x 2 days
- Onset: Rapid
- Duration: Depends on degree of deficency
- Adverse Reactions: Anaphylaxis, pruritus, injection site pain
- Special Considerations: None
Pearls