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 Formulary Chapter 18: Emergency Treatment of Poisoning - Full Chapter
Notes:

In the event of poisoning please phone the National Poisons Information Service (0344 892 0111) rather than Medicines Information.

For any additional advice please contact Pharmacy (contact details are available on the home page)

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18  Expand sub section  Poisoning
Acetylcysteine (Parvolex)
(Paracetamol overdose)
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Restricted Drug Restricted
Red Hospital
Injection
  • Paracetamol overdose 
  • Link  CUH Acetylcysteine dose calculator for paracetamol overdose in adults and children over 12 years
    Link  Manufacturers data sheet (SPC)
    Link  MHRA information page about the changes in Sept 2012
    Link  Treating paracetamol overdose with intravenous acetylcysteine: new guidance
       
    Activated charcoal
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
  • Reduction of absorption of poisons in the gastro-intestinal system or for active elimination techniques
  • Actidose-Aqua® Advance - Oral suspension, activated charcoal 1.04 g/5 mL
  • Carbomix® - 50g Granules, activated charcoal
     
  •    
    Antivenoms for non-indigenous venomous animals
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    Restricted Drug Restricted
    Red Hospital
    Discussion with National Poisons Information Service recommended.
  • 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
       
    Atropine
    (Antidote)
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    Restricted Drug Restricted
    Red Hospital
  • 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
     
  •    
    Botulism antitoxin (antidote)
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    Restricted Drug Restricted
    Red Hospital
  • Not routinely stocked.
  • 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 
  •    
    Calcium chloride
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Discussion with National Poisons Information Service recommended for serious cases
  • calcium channel blocker antidote
  • 10% injection or infusion 
  •    
    Calcium folinate
    (Poisoning)
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    Restricted Drug Restricted
    Red Hospital
    Methotrexate, methanol or formic acid overdose
  • See also section 8.1
  • Discussion with National Poisons Information Service recommended for methanol poisoning
  • Also known as folinic acid
     
  •    
    Calcium gluconate
    (Poisoning)
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    Restricted Drug Restricted
    Red Hospital
    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  
  •    
    Calcium gluconate gel
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    2.5% Gel
  • Discussion with National Poisons Information Service recommended in primary care, and for serious cases in secondary care
  • For hydrofluoric acid burns 
  •    
    Cyproheptadine (Periactin®)
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    Restricted Drug Restricted
    Red Hospital
    Tablets
  • Discussion with National Poisons Information Service recommended
  • For the treatment of serotonin syndrome
  • Link to SPC 
  •    
    Dantrolene
    (Poisoning)
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    Restricted Drug Restricted
    Red Hospital
    See also section 15.1.8
  • Discussion with National Poisons Information Service recommended if treating drug related malignant hyperpyrexia unless due to anaesthetic
     
  •    
    Desferrioxamine
    (Poisoning)
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    Restricted Drug Restricted
    Red Hospital
    Injection
  • Discussion with National Poisons Information Service recommended
  • Iron poisoning
  • Also see section 9.1.3 
  •    
    Diazepam
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Rectal tube
    Injection
  • Convulsions or agitation related to overdose / poisoning 
  •    
    Dicobalt edetate
    (cyanide poisoning)
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    Restricted Drug Restricted
    Red Hospital
    Injection
  • Discussion with National Poisons Information Service recommended.
  • Stock sodium nitrate 3%, sodium thiosulphate 50% and hydroxocobalamin 5g. Contact NPIS for advice if required. 
  •    
    Digoxin specific antibody fragments (Digifab®)
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine
  • See section 2.1.1 for information
  • Contact pharmacy for supply.  
  •    
    Dimercaprol
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    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
       
    DMPS (unithiol)
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Injection - unlicensed
    Hard capsules - unlicensed
  • Discussion with National Poisons Information Service recommended.
  • Held supra-regionally for treatment of heavy metal poisoning 
  • Link  Toxbase: National Poisons Information Service
       
    DMSA (succimer)
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Capsules - unlicensed
  • Discussion with National Poisons Information Service recommended.
  • Held supra-regionally for treatment of heavy metal poisoning 
  • Link  Toxbase: National Poisons Information Service
       
    Ethanol (alcohol) injection
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Injection (unlicensed)
  • Used in the treatment of antifreeze (ethylene glycol) or methanol poisoning
  • Discussion with National Poisons Information Service recommended.
  • Ethanol 100% 
  • Link  CUH: Use of antidotes in ethylene glycol / methanol poisoning
       
    European Viper Venom Antivenom
    (antiserum / antidote)
     Track Changes
    Restricted Drug Restricted
    Red Hospital
    Vial (for intravenous infusion)
  • Vipera berus (European adder) envenomation


    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.  
  •    
    Flumazenil
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    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
     
  •    
    Fomepizole
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    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine
    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
       
    Glucagon (GlucaGen® Hypokit)
    (Poisoning)
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    Restricted Drug Restricted
    Red Hospital
    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
     
  •    
    Glyceryl Trinitrate
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    Restricted Drug Restricted
    Red Hospital
    Injection
    Treatment of hypertension associated with poisoning or overdoses
  • Injection (secondary care only)- Use Polyethylene (PE), giving set for infusion (NOT PVC!).
  • Also see section 2.6.1 
  •    
    Hydroxocobalamin (Cyanokit®)
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Injection (for infusion)
  • Used for the treatment of cyanide poisoning
  • Discussion with National Poisons Information Service recommended.

     
  •    
    Lorazepam
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Injection
  • Convulsions or agitation related to overdose / poisoning. 
  •    
    Macrogol '3350' (Klean-Prep®)
    (Poisoning)
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    Restricted Drug Restricted
    Red Hospital
    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 
  •    
    Mesna
    (antidote)
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    Formulary
    Red Hospital
    See also section 8.1
  • Treatment of cyclophosphamide induced haemorrhagic cystitis 
  •    
    Methylthioninium chloride (Proveblue®)
    (methylene blue antidote)
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    Restricted Drug Restricted
    Red Hospital
  • 10ml 0.5% (50mg) for IV use
    - For Methaemoglobinaemia or prior to parathyroid surgery. (approx £50 each)
     
  • Link  MHRA safety update April 2009
       
    Naloxone
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Injection
  • For treatment of opioid overdose / poisoning
  • See also section 15.1.7
     
  • Link  CUH: Protocol for the use of IV naloxone in opioid toxic patients > 40kg
       
    Octreotide
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    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 
  •    
    Phentolamine
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Injection (unlicensed)
  • Resistant hypertension due to amphetamines and other sympathomimetic drugs of abuse, MAOIs, clonidine etc
  • Digital ischaemia related to injection of epinephrine (adrenaline)
     
  •    
    Phytomenadione (Vitamin K1)
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Injection
  • Vitamin K dependent anticoagulant reversal / poisoning
  • Konakion MM Paediatric formulation can be given orally
  • See section 9.6.6 for more details 
  •    
    Procyclidine
    (Poisoning)
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    Restricted Drug Restricted
    Red Hospital
    Injection
  • Treatment of extrapyramidal symptoms
  • See also section 4.9.2 
  •    
    Protamine Sulphate
    (Heparin overdose / reversal)
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    Restricted Drug Restricted
    Red Hospital
    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 
  •    
    Pyridoxine
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Injection 50 mg in 2mL (unlicensed)
  • Convulsions in isoniazid poisoning
  • Discussion with National Poisons Information Service recommended in severe cases 
  •    
    Sodium bicarbonate
    (Poisoning)
     Track Changes
    Restricted Drug Restricted
    Red Hospital
    Injection
  • Sodium bicarbonate 8.4%: Tricyclic antidepressant overdose or treatment of class 1a and 1c antiarrhythmic drugs.
  • Sodium bicarbonate 1.26%: Urinary alkalinisation (See attached on how to dilute 8.4% polufusor).
  • Discussion with National Poisons Information Service recommended for severe cases
    See also section 9.2.2.1
     
  •    
    Sodium nitrite
    (antidote)
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    Restricted Drug Restricted
    Red Hospital
    Injection
  • UK product discontinued by manufacturer July 2013
  • Discussion with National Poisons Information Service recommended
     
  •    
    18  Expand sub section  Body Temperature
    18  Expand sub section  Pesticides
    18  Expand sub section  Prevention of absorption
    18  Expand sub section  Specific Drugs to top
    18  Expand sub section  Analgesics (non-opioid)
    18  Expand sub section  Analgesics (opioid)
    18  Expand sub section  Antidepressants
    18  Expand sub section  Beta Blockers
    18  Expand sub section  Calcium-channel blockers to top
    18  Expand sub section  Hypnotics and anxiolytics
    18  Expand sub section  Iron Salts
    18  Expand sub section  Phenothiazines and related drugs
    18  Expand sub section  Stimulants
    18  Expand sub section  Other poisons to top
    18  Expand sub section  Cyanides
    18  Expand sub section  Ethylene glycol and methanol
    18  Expand sub section  Heavy Metals
     ....
     Non Formulary Items
    Benzatropine
    (antidote)

    Track Changes
    Non Formulary
    Non Formulary
    Injection (unlicensed)
  • For extrapyramidal symptoms / acute dystonic reactions
  • See section 4.9.2
  • See Toxbase for guidance and dosing information
  • Link  Toxbase: National Poisons Information Service
     
    Methionine
    (paracetamol overdose)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Non 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.
  •  
    Penicillamine  (Distamine)
    (antidote)

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    Non Formulary
    Non Formulary
    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

  •  
    Potassium ferric hexacyanoferrate  (Berlin / Prussian Blue)
    (antidote)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Non Formulary
    Discussion with National Poisons Information Service recommended.
  • Also known as Berlin blue or Prussian blue
  • Held supra-regionally for treatment of thallium poisoning
  • Link  Toxbase: National Poisons Information Service
     
    Pralidoxime chloride  (Protopam®)
    (antidote)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Non Formulary
    Injection 1g
    Organophosphorus insecticide and nerve agent poisoning (adjunct to atropine)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
     
    Sodium calcium edetate
    (antidote)

    Track Changes
    Non Formulary
    Non Formulary
    Injection 5% (unlicensed in UK)
  • Discussion with National Poisons Information Service recommended
  • Heavy metal poisoning especially lead
  • Held supra-regionally for treatment of heavy metal poisoning
  •  
    Sodium thiosulphate
    (antidote)

    Track Changes
    Non Formulary
    Non Formulary
    Injection (50%)
  • Discussion with National Poisons Information Service recommended
  • Cyanide poisoning (in conjunction with sodium nitrite) if dicobalt edetate is not available
  • Link to SPC.
  •  
      
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to children's BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    OTC

    Available Over the Counter. Consider Self Care   

    Green

    Formulary - Can be prescribed in both secondary and primary care.   

    Advice

    Formulary - Specialist Advice, secondary care advice provided for primary care initiation.  

    Amber No SCG

    Formulary - Specialist initiation without shared care guidance.  

    Amber SCG

    Formulary - Specialist initiation with shared care guidance.  

    Red Hospital

    Restricted - Hospital only, not to be prescribed in primary care.  

    Switch

    Not recommended for prescribing. Switch to alternative cost-effective option.   

    Black

    Not recommended for prescribing in primary or secondary care.  

    Grey

    Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.   

    Non Formulary

    Non-Formulary (category under review).  

    netFormulary