Slides for a talk by Chris Nickson at the Toxicology Workshop at CONCEPTOS 2016 in Chile. See also: http://lifeinthefastlane.com/ccc/conceptos/

1. ANTIDOTES IN THE!
EMERGENCY DEPARTMENT
Chris Nickson FACEM FCICM
Intensivist, The Alfred ICU

2. Financial
Conflicts of InterestNO!
http://litfl.org/CONCEPTOS

3. Objectives
!
The role of antidotes in
emergencies!
!
The problem of antidote stocking!
!
Tips, Tricks and Controversies!

4. THE ROLE OF ANTIDOTES!

5. Antidotes !
correct the effects of
poisoning!

6. Antidote use is based on !
risk-benefit analysis

7. Antidotes should !
generally be!
titrated to effect

8. Consider transporting the
antidote not the patient

9. ANTIDOTE STOCKING!

10. Antidote stocking is a!
difficult problem

11. Dart et al (2009) PMID:19406507!

12. Atropine! Methylene blue!
Calcium! Naloxone!
Cyanide antidotes! Physostigmine!
Digoxin immune Fab! Pyridoxine!
Flumazenil! Sodium bicarbonate!
Glucagon!
Immediately available!

13. N-Acetylcysteine
(NAC)!
Ethanol/!
fomepizole!
Antivenoms! Octreotide!
Deferoxime! Potassium iodide!
Dimercaperol! Pralidoxime!
Available <60 minutes!

14. !
!
Hospitals should perform!
Vulnerability Assessments

15. ANTIDOTAL TIPS & TRICKS!

16. Know the nuances of!
naloxone

17. Glucagon should be!
glucaGONE

18. Flumazenil…!
forget about it

19. Goodbye Cyanide kit…!
Hello hydrocobalamin

20. Refractory seizures…!
Think pyridoxine

21. Physostigmine!
is your friend!

22. Know the key antidotes for
cardiotoxic overdoses

23. Toxic cardiac arrest
(or shock)
Early aggressive resuscitation:
• ABC & ACLS protocols
• Large bore intravenous access
• Crystalloid fluid bolus/catecholamines
• Early ECHO: pump vs vasoplegia
• Consult Poisons Centre/Toxicologist
BB/CCB NCBD (or WCT) Antidoted toxin* LA agent
HIE NaHCO3
Antidote ILE
Consider:
• Other Inotropes
• ECMO
• Haemodialysis
• IABP
• Cardiac pacing
• Vasopressin/4-AP
• ILE for lipophilic
All patients:
• Optimise electrolytes
• ILE for lipophilic
cardiac toxin
•
• Maintain euglycaemia
• Consider prolonged resuscitation
• Maintain communication with
Gunja (2011) PMID:21284810!

24. HIET! 1U/kg insulin + 50mL
D50W!
Digoxin immune Fab! Depends!!
NaHCO3! 1mmol/kg q3-5min!
Intralipid 20%! 1.5 mL/kg IV bolus!
Key cardiotoxic antidotes!

25. Antidotes are rarely used
but can have an important
role

26. Antidote stocking!
is a challenge

27. Know the nuances!
and phone a friend!

28. http://litfl.org/CONCEPTOS