Poison	Treatment in adults	Treatment in children
Acetaminophen20–22	Antidote:N-acetylcysteine therapy is based on serum acetaminophen levels at ≥ 4 hours following a known ingestion time as plotted on the acetaminophen nomogram: https://ebmcalc.com/AcetaminophenTox.htm 72-hour (oral) protocol: loading dose of 140 mg per kg followed by 70 mg per kg every 4 hours for 17 additional doses 21-hour (IV) protocol: 150 mg per kg infused over 1 hour followed by 50 mg per kg infused over 4 hours, then 100 mg per kg infused over 16 hours The nomogram is used for single, acute ingestions only; oral or IV routes are acceptable but IV route is preferred in patients with vomiting, refusal of oral administration, or liver failure If the time of ingestion is unknown or if ingestion spans more than 24 hours, the decision to treat with N-acetylcysteine should be made in consultation with poison control including screening laboratory tests: serum concentration of acetaminophen in the blood, hepatic function, renal function, coagulation, blood gas, patient risk factors, clinical examination	Gastrointestinal decontamination: activated charcoal (oral), 1 g per kg (maximum dose: 50 g) for patients who present within 1 hour of a known or suspected acetaminophen ingestion of > 150 mg per kg, unless contraindications Antidote:N-acetylcysteine (oral): loading dose of 140 mg per kg followed by 70 mg per kg every 4 hours for 17 additional doses N-acetylcysteine (IV) in children < 40 kg (88 lb): 150 mg per kg infused over 1 hour followed by 50 mg per kg infused over 4 hours, then 100 mg per kg infused over 16 hours N-acetylcysteine (IV) in children ≥ 40 kg: as dosed in adults
Benzodiazepines5,22,23	Supportive care is the recommended treatment; use of flumazenil, a nonspecific competitive benzodiazepine antagonist, is controversial, especially in patients chronically taking benzodiazepines because it may precipitate seizures Antidote: flumazenil, 0.2 mg (IV) over 2 minutes; if adequate reversal is not obtained after 30 seconds, 0.3 mg can be administered over 3 minutes, with an additional 0.5 mg over 5 minutes repeated at 0.1-mg increments over 1-minute intervals to a maximum of 1 mg; if repeat dosing is needed, no more than 3 mg should be administered in any 1 hour	Flumazenil administration in young healthy children without a history of chronic benzodiazepine use is considered safer than in adults Antidote: flumazenil, 0.01 mg per kg administered by a slow IV push over 1 to 2 minutes (maximum dose: 0.2 mg); repeat at 1-minute intervals up to 4 doses of 0.005 to 0.01 mg per kg to a total of 1 or 0.05 mg per kg
Beta blockers and calcium channel blockers22,24,25	For patients with hypotension: initiate judicious IV fluid resuscitation Atropine, 1 mg IV bolus, may repeat every 5 minutes up to 3 mg Glucagon, 3 to 10 mg IV bolus, may repeat bolus and, if clinically improving, start infusion of 3 to 5 mg per hour titrated to hemodynamic response; consider premedication with antiemetic because glucagon may induce vomiting Calcium (chloride formulation preferred if administered via a central venous catheter, gluconate formulation may be administered via peripheral IV catheter); functions as positive inotrope Calcium chloride, 1 g of a 10% solution as a slow push, may repeat up to 4 times as needed or, alternatively, calcium gluconate, 2 to 3 g of a 10% solution as initial bolus, may repeat up to 4 times as needed	Glucagon, 0.05 mg per kg (IV) loading dose, may repeat, then start continuous infusion at 0.05 to 0.1 mg per kg per hour titrate Atropine (for children < 40 kg), 0.02 mg per kg IV bolus (minimum dose: 0.1 mg), may repeat once Calcium chloride, 20 mg per kg (maximum dose: 1 g) up to 60 mg per kg Calcium gluconate, 60 mg per kg per dose (maximum dose: 3 g)
	Refractory shock: infusion of standard doses of norepinephrine or epinephrine (IV); or phenylephrine titrated to the mean arterial pressure goal High-dose insulin: regular insulin, 1 unit per kg IV bolus followed by 0.5 to 1 unit per kg per hour; titrate insulin infusion as needed to the mean arterial pressure goal with a poison center or toxicology consult service; administer with 10% dextrose; monitor serum glucose and potassium levels every 30 minutes High-dose insulin functions as a positive inotrope; onset of action is 30 to 60 minutes, therefore bridging with vasopressors is needed; therapy may cause hypoglycemia and hypokalemia; prolonged therapy may result in fluid overload; consider use of a concentrated formulation of regular insulin	Refractory shock: infusion of standard doses of norepinephrine or epinephrine (IV); or phenylephrine titrated to the mean arterial pressure goal High-dose insulin: same as adult dosing; children < 40 kg: if initial glucose level < 150 mg per dL (8.32 mmol per L), then premedicate with 10% dextrose IV bolus, 25 g
Clonidine22,26	Respiratory or central nervous system depression: trial of naloxone (IV), 0.1 mg per kg (maximum single dose: 2 mg), repeat every 1 to 2 minutes up to 10 mg total, or 0.2 mg per kg (maximum total dose: 10 mg) May require redosing because of naloxone's short half-life Severe bradycardia: atropine (IV), 0.5 to 1 mg, repeat after 3 to 5 minutes to a maximum total dose of 3 mg Epinephrine bolus and continuous infusion Hypotension: IV fluid resuscitation with isotonic fluids Infusion of standard doses of norepinephrine or epinephrine (IV) titrated to the mean arterial pressure goal	Respiratory or central nervous system depression: trial of naloxone same dosing as in adults Severe bradycardia: atropine (IV), 0.02 mg per kg per dose (maximum dose: 0.5 mg per kg) Epinephrine bolus and continuous infusion Hypotension: IV fluid resuscitation with isotonic fluids Infusion of standard doses of norepinephrine or epinephrine (IV) titrated to the mean arterial pressure goal
Digoxin22,27	Acute poisoning, known dose: check serum digoxin level at baseline and again 6 hours after ingestion (if time of ingestion is known) Activated charcoal when appropriate (within 1 hour of ingestion) Administer digoxin immune fab by slow IV push; number of vials is estimated as mg of digoxin ingested × 1.6 Acute poisoning, unknown dose: acute toxicity, administer 5 vials of digoxin immune fab (if hemodynamically stable) or 10 to 20 vials (if unstable), reevaluate clinically in 30 minutes Empiric therapy should be used in life-threatening cases instead of waiting for a serum level Suspected chronic poisoning (most common): check a single serum digoxin level at least 6 hours after the most recent ingestion Digoxin immune fab number of vials is estimated as (digoxin level in ng per mL) × (body weight in kg) ÷ 100; lower doses may be considered initially for patients with chronic digoxin toxicity who are clinically stable (e.g., initiate therapy with 3 vials and follow clinically to determine if additional treatment is warranted) Empiric therapy for chronic poisoning: 3 to 6 vials Monitor and treat hypokalemia If digoxin immune fab fragments are not immediately available, symptomatic bradycardia or bradydysrhythmia can be treated with atropine (adults: IV, 0.5 mg) and hypotension with IV boluses of isotonic crystalloid; in patients with a history of decompensated heart failure, judicious use of fluids may be required; life-threatening ventricular dysrhythmias are treated according to the algorithms of advanced cardiac life support	Acute poisoning, unknown levels: digoxin immune fab, administer 5 vials (if hemodynamically stable) or 10 vials (if unstable), administered by slow IV push; reevaluate clinically in 30 minutes; monitor for volume overload Symptomatic bradycardia or bradydysrhythmia can be treated with atropine (IV; 0.02 mg per kg, minimum dose: 0.1 mg) and hypotension is treated with IV boluses of isotonic crystalloid
Iron22,28,29	Whole bowel irrigation should not be performed routinely but can be considered for patients who have ingested substantial amounts of iron Contraindications include hemodynamic instability, unprotected airway, bowel obstruction, perforation, or ileus; should be performed through nasogastric tube using a polyethylene glycol electrolyte solution approved for gastrointestinal cleansing at a rate of 1,500 to 2,000 mL per hour Antidote: deferoxamine (Desferal) is indicated in systemic toxicity (typically > 500 mcg per dL [89.50 mmol per L]); continuous IV infusion at 15 mg per kg per hour, then increase by 5 to 10 mg per kg per hour every 2 to 4 hours, depending on the clinical course, up to a maximum dosage of 6 g per day	Whole bowel irrigation: children 9 months to 6 years of age: 500 mL per hour; children 6 to 12 years of age: 1,000 mL per hour; children 13 years or older: 1,500 to 2,000 mL per hour Antidote: deferoxamine as a continuous IV infusion at 15 mg per kg per hour and reduce rate as clinically indicated; maximum daily dosage is 80 mg per kg per day, not to exceed 6 g per day
Opioids22,30	Antidotes: IV naloxone is preferred due to faster onset of action and ease of titration, but consider any route (intramuscular, subcutaneous, intranasal, intraosseous, endotracheal) Cardiopulmonary arrest due to opioid overdose: naloxone, 2 mg (IV), while providing cardiopulmonary resuscitation, ventilatory support, and supplemental oxygen Apnea: naloxone 0.2 to 1 mg (IV); lower initial doses for patients with opioid use disorder who are maintaining their airway, 0.1 to 0.4 mg with titration Nalmefene: limited clinical data; use is controversial due to naloxone being more extensively studied and because nalmefene may lead to a prolonged withdrawal; IV route preferred to intranasal, intramuscular, and subcutaneous Nonopioid-dependent patients: nalmefene, initial dose 0.5 mg (IV); if needed, a second dose of 1 mg may be administered 2 to 5 minutes later; if there is no clinical response following a total dose of 1.5 mg, it is unlikely that continued administration of nalmefene will be beneficial; do not administer additional nalmefene once adequate initial reversal has been established Opioid-dependent patients: nalmefene, initial dose of 0.1 mg (IV); if no evidence of withdrawal, administer 0.5 mg; if needed, a repeat dose of 1 mg may be administered 2 to 5 minutes later; if no clinical response following a total dose of 1.6 mg, it is unlikely that continued administration of nalmefene will be beneficial; do not administer additional nalmefene once adequate initial reversal has been established	Antidote: IV naloxone is preferred due to faster onset of action and ease of titration but consider any route (intramuscular, subcutaneous, intranasal, intraosseous, endotracheal) Infants and children < 5 years or ≤ 20 kg (44 lb): naloxone, 0.1 mg per kg per dose (IV), repeat every 2 to 3 minutes if needed; may need repeat doses if duration of action of opioid is longer than naloxone Children ≥ 5 years or > 20 kg and adolescents: naloxone, 2 mg per dose (IV), repeat every 2 to 3 minutes if needed; may need repeat doses if duration of action of opioid is longer than naloxone
Salicylates22,31	Alkalization with sodium bicarbonate: continuous IV infusion of hypertonic sodium bicarbonate (8.4%), 150 mEq in 1 L of 5% dextrose in water at a rate of 150 mL per hour and titrate accordingly to achieve urinary pH of 7.5 to 8.5; monitor serum pH and do not exceed 7.45 to 7.55; supplement potassium to a serum level goal of 5.5 mEq per L (5.5 mmol per L) because hypokalemia prevents urine alkalinization Give dextrose (e.g., 5% dextrose in water) to all salicylate poisoning patients with altered mental status, regardless of serum glucose level; salicylate toxicity can cause neuroglycopenia despite the patient having a normal peripheral glucose concentration	Alkalinization with sodium bicarbonate: IV bolus of 1 to 2 mEq per kg (1 to 2 mL per kg [1 mEq per mL]) of 8.4% sodium bicarbonate, followed by a continuous infusion at 1.5 to 2 times maintenance of sodium bicarbonate, 150 mEq, diluted in 1 L of 5% dextrose
Sodium channel blocker toxicity (e.g., antidysrhythmics, antihistamines, class IA/IC tricyclic antidepressants)22,32	Benzodiazepines for seizures (avoid barbiturates and phenytoin): lorazepam, 2 to 4 mg; hypertonic sodium bicarbonate boluses for seizure; hypertonic sodium bicarbonate boluses for prolonged QRS interval (> 100 ms in patient with normal baseline QRS), repeat as needed to decrease the QRS interval to < 100 ms; may also start an isotonic sodium bicarbonate maintenance fluid infusion after stabilization with hypertonic sodium bicarbonate with a goal serum pH of 7.5 to 7.55; monitor serum electrolytes; may cause hypernatremia, hypokalemia, and hypocalcemia Norepinephrine: 8 to 12 mcg per minute (adjust to maintain a low normal blood pressure), avoid physostigmine and class IA and IC antidysrhythmics	Benzodiazepines for seizures (avoid barbiturates and phenytoin): lorazepam, 0.05 to 0.1 mg per kg Hypertonic sodium bicarbonate bolus and subsequent isotonic sodium bicarbonate infusion Norepinephrine: 0.1 mcg per kg per minute (adjust to maintain a low normal blood pressure); maximum of 6 mcg per minute Avoid physostigmine and class IA and IC antidysrhythmics
Sulfonylureas22,33	50% dextrose IV bolus 25 g up to 1 g per kg Octreotide: 50 mcg per dose subcutaneously every 6 hours; monitor patient for 12 to 24 hours after most recent dose of octreotide to ensure no recurrence of hypoglycemia Dextrose monotherapy promotes insulin release and can result in prolonged hypoglycemia Glucagon: 1 mg per dose intramuscularly or subcutaneously, may repeat every 20 minutes as needed (glucagon should be considered only as a temporary emergent treatment, such as when IV access is not obtained)	1 month to 2 years of age: 25% dextrose IV bolus of 2 to 4 mL per kg > 2 years: 50% dextrose bolus of 1 to 2 mL per kg Octreotide: 4 to 5 mcg per kg per day subcutaneously, divided every 6 hours for maximum of 50 mcg per dose (based on case reports) Glucagon: 0.5 mg for children and 0.025 mg per kg per dose for neonates and infants intramuscularly or subcutaneously, may repeat every 20 minutes as needed (temporary emergent treatment only); consider continuous glucose infusion