Nottinghamshire Area Prescribing Committee
Joint Formulary
 
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18 Emergency Treatment of Poisoning
In the event of poisoning please phone the National Poisons Information Service (0344 892 0111) rather than Medicines Information.
18 Poisoning

Acetylcysteine Parvolex
Formulary

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
 

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Activated charcoal
Formulary
Suspension 50g in 250ml
  • Reduction of absorption of poisons in the gastro-intestinal system or for active elimination techniques
  • Link  Link to reviews
     

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    Antivenoms for non-indigenous venomous animals
    Formulary
    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
     

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    Atropine
    Formulary
  • 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
     

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    Benzatropine
    Formulary
    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
     

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    Botulism antitoxin antidote
    Formulary
  • 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

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    Calcium chloride
    Formulary
    Discussion with National Poisons Information Service recommended for serious cases
  • calcium channel blocker antidote
  • 10% injection or infusion

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    Calcium gluconate
    Formulary
    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

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    Calcium gluconate gel
    Formulary
    2.5% Gel
  • Discussion with National Poisons Information Service recommended in primary care, and for serious cases in secondary care
  • For hydrofluoric acid burns

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    Cyproheptadine Periactin®
    Formulary
    Tablets
  • Discussion with National Poisons Information Service recommended
  • For the treatment of serotonin syndrome
  • Link to SPC

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    Dantrolene
    Formulary
    See also section 15.1.8
  • Discussion with National Poisons Information Service recommended if treating drug related malignant hyperpyrexia unless due to anaesthetic

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    Desferrioxamine
    Formulary
    Injection
  • Discussion with National Poisons Information Service recommended
  • Iron poisoning
  • Also see section 9.1.3
  • Link  Link to reviews
     

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    Diazepam
    Formulary

    See section 4.1.2 for further information. 


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    Dicobalt edetate
    Formulary

    Injection

    • Discontinued Sept 2019
    • 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

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    Digoxin specific antibody fragments Digifab®
    Restricted

    Restricted Drug Red View adult BNF  View SPC online  View childrens BNF  HCD
    Dimercaprol
    Formulary
    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
     

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    DMPS (unithiol)
    Formulary
    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
     

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    DMSA (succimer)
    Restricted
    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
     

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    Ethanol (alcohol) injection
    Formulary

    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 NHS Supplies.
      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
     

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    European Viper Venom Antivenom
    Formulary
    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.

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    Flumazenil
    Formulary
    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
     

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    Folinic acid
    Formulary
    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

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    Fomepizole
    Restricted
    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
     

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    Glucagon GlucaGen® Hypokit
    Formulary
    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
     

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    Glucarpidase Carboxypeptidase
    Restricted

    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).
    • From the 1st July 2020 Voraxaze can be ordered from WEP Clinical. 
      If the order is required urgently in an emergency situation, the order must be placed by contacting their emergency supply line
    • 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
     

    Restricted Drug Red  HCD
    Glyceryl Trinitrate
    Formulary
    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
     

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    Hydroxocobalamin Cyanokit®
    Formulary
    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
     

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    Lorazepam
    Formulary

    Injection

    • Convulsions or agitation related to overdose / poisoning.
    • Supply problem with injection Nov 2020: SFH see alternative options compilation table.
    • See section 4.1.2 for other indications or more details

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    Macrogol '3350' Klean-Prep®
    Restricted
    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
     

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    Mesna
    Formulary
    See also section 8.1
  • Treatment of cyclophosphamide induced haemorrhagic cystitis

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    Methionine
    Formulary
    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.

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    Methylthioninium chloride Proveblue®
    Formulary

    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) - contact Medicines Information for details (SFH: 3163).
    • Approx £50 per vial
    Link  MHRA safety update April 2009
     

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    Naloxone
    Formulary
    Injection
  • For treatment of opioid overdose / poisoning
  • See also section 15.1.7
  • Link  NUH Lite Bite: Adult Naloxone Guidelines Reminder (August 20)
    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
     

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    Octreotide
    Restricted
    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

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    Penicillamine Distamine
    Restricted
    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

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    Phentolamine
    Restricted
    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.

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    Phytomenadione Vitamin K1
    Formulary

    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
    Link  Vitamin K (Phytomenadione) pharmacy information
     

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    Potassium ferric hexacyanoferrate Berlin / Prussian Blue
    Formulary
    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
     

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    Pralidoxime chloride Protopam®
    Restricted
    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
     

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    Procyclidine
    Formulary
    Injection
  • Treatment of extrapyramidal symptoms
  • See also section 4.9.2

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    Protamine Sulphate
    Formulary
    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
     

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    Pyridoxine
    Restricted
    Injection 50 mg in 2mL (unlicensed)
  • Convulsions in isoniazid poisoning
  • Discussion with National Poisons Information Service recommended in severe cases

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    Sodium bicarbonate
    Formulary
    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

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    Sodium calcium edetate
    Restricted
    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

  • Restricted Drug Red
    Sodium nitrite
    Formulary
    Injection
  • Discussion with National Poisons Information Service recommended

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    Sodium thiosulfate
    Formulary
    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.

  • Red