BNF for Children 2011-2012

32 Emergency treatment of poisoning BNFC 2011–2012Emergency treatment of poisoningCyanidesOxygen should be administered to children with cyanidepoisoning. The choice of antidote depends on theseverity of poisoning, certainty of diagnosis, and thecause. Dicobalt edetate is the antidote of choice whenthere is a strong clinical suspicion of severe cyanidepoisoning. Dicobalt edetate itself is toxic, associatedwith anaphylactoid reactions, and is potentially fatal ifadministered in the absence of cyanide poisoning. Aregimen of sodium nitrite followed by sodium thiosulphateis an alternative if dicobalt edetate is not available.Hydroxocobalamin (Cyanokit c —no other preparationof hydroxocobalamin is suitable) can be considered foruse in victims of smoke inhalation who show signs ofsignificant cyanide poisoning.DICOBALT EDETATECautions owing to toxicity to be used only for definitecyanide poisoning when patient tending to lose, or haslost, consciousness; not to be used as a precautionarymeasureSide-effects hypotension, tachycardia, and vomiting;anaphylactoid reactions including facial and laryngealoedema and cardiac abnormalitiesIndication and doseSevere poisoning with cyanides. By intravenous injectionConsult the National Poisons Information Service1Dicobalt Edetate (Non-proprietary) AInjection, dicobalt edetate 15 mg/mL, net price 20-mL (300-mg) amp = £13.751. A restriction does not apply where administration is forsaving life in emergencyHYDROXOCOBALAMINSide-effects gastro-intestinal disturbances, transienthypertension, peripheral oedema, dyspnoea, throatdisorders, hot flush, dizziness, headache, restlessness,memory impairment, red coloration of urine, lymphocytopenia,eye disorders, pustular rashes, pruritus,reversible red coloration of skin and mucous membranesIndication and dosePoisoning with cyanides see notes above. By intravenous infusionChild body-weight 5 kg and over 70 mg/kg(max. 5 g) over 15 minutes; a second doseof 70 mg/kg (max. 5 g) can be given over15 minutes–2 hours depending on severity ofpoisoning and patient stabilityAdministration for intravenous infusion, reconstitute2.5-g vial with 100 mL Sodium Chloride 0.9%; gentlyinvert vial for at least 30 seconds to mix; do not shakeCyanokit c (Swedish Orphan) TAIntravenous infusion, powder for reconstitution,hydroxocobalamin, net price 2 2.5-g vials = £772.00Note Deep red colour of hydroxocobalamin may interferewith laboratory tests (see Side-effects, above)SODIUM NITRITESide-effects flushing and headache due to vasodilatationIndication and dosePoisoning with cyanides (used in conjunctionwith sodium thiosulphate)See under preparation1Sodium Nitrite AInjection, sodium nitrite 3% (30 mg/mL) in water forinjectionsDose. By intravenous injection over 5–20 minutesChild 1 month–18 years 4–10 mg/kg max. 300 mg(0.13–0.33 mL/kg, max. 10 mL, of 3% solution) followedby sodium thiosulphate injection 400 mg/kg, max. 12.5 g(0.8 mL/kg, max. 25 mL, of 50% solution) over 10 minutesAvailable from ‘special-order’ manufacturers or specialistimporting companies, see p. 8091. A restriction does not apply where administration is forsaving life in emergencySODIUM THIOSULPHATEIndication and dosePoisoning with cyanides (used in conjunction withsodium nitrite)See above under Sodium Nitrite1Sodium Thiosulphate AInjection, sodium thiosulphate 50% (500 mg/mL) inwater for injectionsAvailable from ‘special-order’ manufacturers or specialistimporting companies, see p. 8091. A restriction does not apply where administration is forsaving life in emergencyEthylene glycol and methanolFomepizole (available from ‘special-order’ manufacturersor specialist importing companies, see p. 809) isthe treatment of choice for ethylene glycol and methanol(methyl alcohol) poisoning. If necessary, ethanol (bymouth or by intravenous infusion) can be used, but withcaution. Advice on the treatment of ethylene glycol andmethanol poisoning should be obtained from theNational Poisons Information Service. It is importantto start antidote treatment promptly in cases of suspectedpoisoning with these agents.Heavy metalsHeavy metal antidotes include succimer (DMSA) [unlicensed],unithiol (DMPS) [unlicensed], sodium calciumedetate, and dimercaprol. Dimercaprol in the managementof heavy metal poisoning has been superseded byother chelating agents. In all cases of heavy metal poisoning,the advice of the National Poisons InformationService should be sought.SODIUM CALCIUM EDETATE(Sodium Calciumedetate)Renal impairment use with caution in mild impairment;avoid in moderate to severe impairment—contact the National Poisons Information Service foradvice