| Formulary Chapter 18: Emergency Treatment of Poisoning - Full Chapter
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| Notes: |
| In the event of poisoning please phone the National Poisons Information Service (0344 892 0111) rather than Medicines Information. |
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| Chapter Links... |
 Antidote Availability guide for Emergency Departments - Jan 2017 |
| Antidotes list - where to obtain supplies at SFH |
| NUH Pharmacy: Antidotes for Poisoning list |
| NUH: Acute Kidney Injury |
| The Yellow Card Scheme: guidance for healthcare professionals |
| Toxbase: National Poisons Information Service |
| UKMI Q&A: How do I complete a Yellow Card? |
| Yellow card website |
| Details... |
| 18 |
Poisoning |
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Acetylcysteine (Parvolex)
(Paracetamol overdose)
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Formulary
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Injection
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 SFH: Acetylcysteine calculator and auto-prescription
 Link to reviews
MHRA information page about the changes in Sept 2012
Treating paracetamol overdose with intravenous acetylcysteine: new guidance
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Activated charcoal
(antidote)
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Formulary
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Suspension 50g in 250ml
Reduction of absorption of poisons in the gastro-intestinal system or for active elimination techniques
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Link to reviews
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Antivenoms for non-indigenous venomous animals
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Formulary
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Discussion with National Poisons Information Service recommended.
Not stocked at NUH or SFHHeld supra-regionally for treatment of significant envenomationHeld by the pharmacy, Royal Liverpool Hospital and Guy’s & St Thomas’ NHS Foundation Trustsee European Viper Venom antiserum entry for Viper Berus bite treatment
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Toxbase: National Poisons Information Service
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Atropine
(Antidote)
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Formulary
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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
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ED Briefing Note - Management of suspected Novichok poisoning
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Benzatropine
(antidote)
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Formulary
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Injection (unlicensed)
For extrapyramidal symptoms / acute dystonic reactions
See section 4.9.2
See Toxbase for guidance and dosing informationNot routinely stocked at SFH
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Toxbase: National Poisons Information Service
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Botulism antitoxin (antidote)
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Formulary
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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
(antidote)
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Formulary
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Discussion with National Poisons Information Service recommended for serious cases
calcium channel blocker antidote
10% injection or infusion
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Calcium gluconate
(Poisoning)
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Formulary
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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
(antidote)
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Formulary
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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®)
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Formulary
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Tablets
Discussion with National Poisons Information Service recommended
For the treatment of serotonin syndrome
Link to SPC
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Dantrolene
(Poisoning)
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Formulary
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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
(Poisoning)
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Formulary
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Injection
Discussion with National Poisons Information Service recommended
Iron poisoning
Also see section 9.1.3
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Link to reviews
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Diazepam
(antidote)
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Formulary
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See section 4.1.2 for further information.
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Dicobalt edetate
(cyanide poisoning)
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Formulary
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Injection
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®)
(antidote)
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 Restricted
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See section 2.1.1 for information
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Dimercaprol
(antidote)
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Formulary
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Solution for injection
Discussion with National Poisons Information Service recommended.
Heavy metal poisoning
Held supra-regionally for treatment of heavy metal poisoning
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Toxbase: National Poisons Information Service
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DMPS (unithiol)
(antidote)
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Formulary
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Injection - unlicensed
Hard capsules - unlicensed
Discussion with National Poisons Information Service recommended.Not stocked at NUH or SFHHeld supra-regionally for treatment of heavy metal poisoning
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Toxbase: National Poisons Information Service
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DMSA (succimer)
(antidote)
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Restricted
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Capsules - unlicensed
Discussion with National Poisons Information Service recommended.Not stocked at NUH or SFHHeld supra-regionally for treatment of heavy metal poisoning
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Toxbase: National Poisons Information Service
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Ethanol (alcohol) injection
(antidote)
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Formulary
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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.
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 NUH: Ethylene Glycol poisoning: Clinical Features and Management
SFH adverse reactions to drug withdrawal information
SFH guidelines drinking alcohol while taking medication
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European Viper Venom Antivenom
(antiserum / antidote)
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Formulary
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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
(antidote)
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Formulary
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Injection
Reversal of benzodiazepine effectsDiscussion 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
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NUH: IV Flumazenil for benzodiazepine overdoses
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Folinic acid
(Poisoning)
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Formulary
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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
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Restricted
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Injection (unlicensed in UK)
See Toxbase and discuss with National Poisons Information Service to ensure appropriate use.
Costs around £5,000 per treatment course.
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Midlands Rarely Used & Emergency Drugs availability list
NUH: Ethylene Glycol poisoning: Clinical Features and Management
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Glucagon (GlucaGen® Hypokit)
(Poisoning)
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Formulary
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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
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NUH ED: administration of IV glucagon in adults
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Glucarpidase (Carboxypeptidase)
(Poisoning)
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Restricted
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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®
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NUH: Haematology guideline for the use of high dose methotrexate
NUH: Oncology guideline for the use of high dose methotrexate
Adverse event reporting form - see above guideline for use
Patient Access Form - see above guideline for use
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Glyceryl Trinitrate
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Formulary
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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
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SFH guide for use in ICCU
SFH IV GTN guidelines
SFH: IV drugs which need special giving sets
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Hydroxocobalamin (Cyanokit®)
(antidote)
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Formulary
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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
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SFH: A+E guide to sorting supplies
SFH: Pharmacy guide to sorting supplies
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Lorazepam
(antidote)
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Formulary
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Injection
- Convulsions or agitation related to overdose / poisoning.
- See section 4.1.2 for other indications or more details
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Macrogol '3350' (Klean-Prep®)
(Poisoning)
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Restricted
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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
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Link to reviews
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Mesna
(antidote)
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Formulary
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See also section 8.1
Treatment of cyclophosphamide induced haemorrhagic cystitis
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Methionine
(paracetamol overdose)
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Formulary
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Tablet
No longer available in the UK. Seldom used for the treatment of paracetamol poisoningDiscussion with National Poisons Information Service recommendedFollow advice on Toxbase if patient has a reaction to acetylcysteine.
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Methylthioninium chloride (Proveblue®)
(for IV use)
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Formulary
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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) - speak to Medicines Information for details (SFH: 3163).
- Approx £50 per vial
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MHRA safety update April 2009
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Naloxone
(antidote)
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Formulary
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Injection
For treatment of opioid overdose / poisoning
See also section 15.1.7
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NUH Lite Bite: Adult Naloxone Guidelines Updated (July 18)
NUH: Guideline for the use of naloxone in adults
SFH naloxone guidelines for opioid overdose
UKMI Q&A further reading on naloxone usage
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Octreotide
(antidote)
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Restricted
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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)
(antidote)
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Restricted
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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
(antidote)
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Restricted
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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)
(antidote)
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Formulary
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Injection
- Vitamin K dependent anticoagulant reversal / poisoning
- Konakion MM Paediatric formulation can be given orally
- See section 9.6.6 for more details
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NUH: Haemostasis and Thrombosis protocols
SFH: Anticoagulation guidelines
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Potassium ferric hexacyanoferrate (Berlin / Prussian Blue)
(antidote)
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Formulary
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Discussion with National Poisons Information Service recommended.Also known as Berlin blue or Prussian blueNot stocked at NUH or SFHHeld supra-regionally for treatment of thallium poisoning
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Toxbase: National Poisons Information Service
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Pralidoxime chloride (Protopam®)
(antidote)
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Restricted
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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 listSupplies for deliberate release available from National blood service 24/7
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Midlands Medicines rarely used drug list
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Procyclidine
(Poisoning)
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Formulary
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Injection
Treatment of extrapyramidal symptoms
See also section 4.9.2
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Protamine Sulphate
(Heparin overdose / reversal)
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Formulary
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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
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NUH: Haemostasis and Thrombosis protocols
SFH: Anticoagulation guidelines
SFH: Reversal of bleeding caused by anticoagulant, antiplatelet and fibrinolytic drugs
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Pyridoxine
(antidote)
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Restricted
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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
(Poisoning)
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Formulary
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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
(antidote)
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Restricted
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Injection 5% (unlicensed in UK)
Discussion with National Poisons Information Service recommendedHeavy metal poisoning especially leadNot stocked at NUH, stocked at SFH A&EHeld supra-regionally for treatment of heavy metal poisoning
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Sodium nitrite
(antidote)
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Formulary
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Injection
Discussion with National Poisons Information Service recommended
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Sodium thiosulfate
(antidote)
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Formulary
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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.
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| 18 |
Body Temperature |
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| 18 |
Pesticides |
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Prevention of absorption |
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Specific Drugs |
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Analgesics (non-opioid) |
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Analgesics (opioid) |
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Antidepressants |
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Beta Blockers |
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Calcium-channel blockers |
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Hypnotics and anxiolytics |
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Iron Salts |
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Phenothiazines and related drugs |
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Stimulants |
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Other poisons |
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Cyanides |
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Ethylene glycol and methanol |
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Heavy Metals |
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| .... |
Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Traffic Light Status Information
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Description |
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Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
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Medicines which should normally be prescribed by specialists only. eg hospital only.
For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
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Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
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Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
*Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
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Primary care/ non specialist may initiate as per APC guideline.
The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
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Medicines suitable for routine use within primary care.
Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing. |
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