Antidotes for Toxicological Emergencies

A Practical Review

Jeanna M. Marraffa, Pharm.D., DABAT; Victor Cohen, Pharm.D.; Mary Ann Howland

Disclosures

Am J Health Syst Pharm. 2012;69(3):199-212. 

In This Article

Abstract and Introduction

Abstract

Purpose Appropriate therapies for commonly encountered poisonings, medication overdoses, and other toxicological emergencies are reviewed, with discussion of pharmacists' role in ensuring their ready availability and proper use.
Summary Poisoning is the second leading cause of injury-related morbidity and mortality in the United States, with more than 2.4 million toxic exposures reported each year. Recently published national consensus guidelines recommend that hospitals providing emergency care routinely stock 24 antidotes for a wide range of toxicities, including toxic-alcohol poisoning, exposure to cyanide and other industrial agents, and intentional or unintentional overdoses of prescription medications (e.g., calcium-channel blockers, β-blockers, digoxin, isoniazid). Pharmacists can help reduce morbidity and mortality due to poisonings and overdoses by (1) recognizing the signs and symptoms of various types of toxic exposure, (2) guiding emergency room staff on the appropriate use of antidotes and supportive therapies, (3) helping to ensure appropriate monitoring of patients for antidote response and adverse effects, and (4) managing the procurement and stocking of antidotes to ensure their timely availability.
Conclusion Pharmacists can play a key role in reducing poisoning and overdose injuries and deaths by assisting in the early recognition of toxic exposures and guiding emergency personnel on the proper storage, selection, and use of antidotal therapies.

Introduction

Poisoning is a leading cause of morbidity and mortality in the United States;[1] in fact, it is the second leading cause of injury-related mortality, and its incidence is rising. The American Association of Poison Control Centers' National Poison Data System receives reports of more than 2.4 million human poison exposures and approximately 1300 poisoning-related deaths annually.[2] However, it is likely that the associated mortality is much higher than those statistics would indicate, as it is estimated that only about 5% of U.S. poisoning deaths are reported to poison control centers.[3,4]

Antidotes play a critical role in the care of poisoned or overdosed patients. Recently issued national consensus guidelines include a recommended list and the quantities of antidotes that should be readily available in hospitals that provide emergency care.[5] Some of the anti-dotes should be available for immediate administration on a patient's arrival, which requires stocking in the emergency department (ED) at most hospitals; other antidotes should be available within 60 minutes and can be stocked in the hospital pharmacy provided that prompt delivery to the ED can be assured. A recommended antidote stocking list and sample inventory log can be found in eFigure 1 and eTable 1, available at www.ajhp.org. This list should be adapted by each individual facility based on a needs assessment. Most importantly, this list should be decided on by vested parties (e.g., pharmacists, physicians, and other health care practitioners involved in providing emergency care and critical care).

One of the many roles of the ED pharmacist is participating in the management of toxicological emergencies. The goal of this review is to provide essential information to guide the appropriate use of antidotes. The antidotes discussed (in alphabetical order) are those whose use likely entails the greatest involvement of ED pharmacists. As recommendations may change, clinicians should always consult a regional poison control center (1-800-222-1222) to ascertain the most current recommendations on antidote use and to report exposures and poisonings.

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