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🧪 MASTER GUIDE TO POISONING - With Mnemonics

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PART 1: APPROACH TO THE POISONED PATIENT

Initial Assessment - Mnemonic: "ABCDE TOXIN"

• A - Airway (protect, intubate if needed)
• B - Breathing (O2, ventilate)
• C - Circulation (IV access, fluids, monitor)
• D - Disability/CNS (GCS, pupils, seizures)
• E - Exposure/Eliminate (decontaminate, antidotes)
• T - Toxidrome recognition
• O - Obtain history
• X - eXtra labs (glucose, electrolytes, LFTs, RFTs, TFTs)
• I - Investigations (ECG, imaging, drug levels)
• N - Neutralize / Notify poison control

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PART 2: TOXIDROMES (Toxic Syndromes)

2.1 CHOLINERGIC Toxidrome (Organophosphates, Carbamates)

• M - Muscle weakness/fasciculations
• T - Tachycardia (nicotinic can override bradycardia)
• W - Weakness (paralysis)
• T - Tremors
• F - Flushing

• M - Mydriasis (nicotinic), Muscle fasciculations
• A - Agitation
• T - Tachycardia, Tremors
• C - Cramps
• H - Hypertension

1. Atropine - Competitive antagonist at muscarinic receptors (end point: drying of secretions, not pupil dilation). Initial: 1.2-3 mg IV, doubled every 5 min. Hundreds of mg may be needed.
2. Pralidoxime (2-PAM) - Reactivates cholinesterase BEFORE aging occurs. Must be given early.
3. Benzodiazepines - For seizures

• S - Soman (fastest aging - minutes)
• E - Ethyl Sarin
• P - Parathion (hours to days)
• I - Intermediate
• A - Aging irreversible = 2-PAM won't work

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2.2 ANTICHOLINERGIC Toxidrome

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2.3 SYMPATHOMIMETIC (Adrenergic) Toxidrome

• F - Fever (hyperthermia)
• A - Agitation, Anxiety
• S - Sweating (diaphoresis - key difference from anticholinergic)
• T - Tachycardia, Tremors
• H - Hypertension
• H - Hyperreflexia
• H - Hyperthermia

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2.4 OPIOID Toxidrome

• P - Pinpoint pupils (miosis)
• I - Impaired breathing (respiratory depression)
• N - No consciousness (CNS depression/coma)

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2.5 SEDATIVE-HYPNOTIC Toxidrome

• CNS depression, slurred speech
• Respiratory depression
• Ataxia, confusion, amnesia
• Normal pupils (unlike opioids - important distinction)

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2.6 SEROTONIN Syndrome

• C - Clonus (inducible/spontaneous/ocular) - KEY feature
• L - Long hyperthermia (fever)
• A - Agitation
• M - Myoclonus, hyperreflexia
• P - Pressured speech (autonomic instability)

1. Spontaneous clonus
2. Inducible clonus + agitation OR diaphoresis
3. Ocular clonus + agitation OR diaphoresis
4. Tremor + hyperreflexia
5. Hypertonia + temperature >38°C + ocular or inducible clonus

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2.7 Toxidrome Comparison Table

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PART 3: SPECIFIC POISONS & ANTIDOTES

Mnemonic for Key Antidotes: "N-ACETYL FACTS"

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PART 4: INDIVIDUAL POISON PROFILES

4.1 PARACETAMOL (Acetaminophen) Poisoning

• Therapeutic adult: 500-1000 mg/dose (max 4 g/day)
• Toxic: ≥150 mg/kg (single ingestion)
• Lethal: >350 mg/kg

• pH < 7.3 (after resuscitation), OR
• ALL three: PT >100s + Creatinine >300 µmol/L + Grade III-IV encephalopathy

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4.2 SALICYLATE (Aspirin) Poisoning

• Sodium salicylate / Aspirin: 15-20 g
• Methyl salicylate (oil of wintergreen): 5-15 mL

• Early: Respiratory Alkalosis (hyperventilation from direct brainstem stimulation)
• Late: Metabolic Acidosis (AGMA from lactic acid, ketones)
• Classic picture in adults: Mixed respiratory alkalosis + metabolic acidosis
• Children: metabolic acidosis predominates

• Urinary alkalinization with IV sodium bicarbonate (ion trapping - prevents CNS entry)
• Hemodialysis for severe cases
• No specific antidote

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4.3 ORGANOPHOSPHATE / CARBAMATE Poisoning

• Organophosphates: IRREVERSIBLE cholinesterase inhibition (aging occurs)
• Carbamates: REVERSIBLE inhibition (no aging, 2-PAM generally not needed)

1. Decontamination (remove clothes, copious water wash - protect healthcare workers)
2. Atropine: 1.2-3 mg IV, double every 5 min - end point = dry chest/secretions
3. Pralidoxime: Must be given BEFORE aging - reactivates enzyme
4. Benzodiazepines for seizures
5. Succinylcholine AVOIDED (metabolized by plasma cholinesterase → prolonged paralysis)

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4.4 CYANIDE Poisoning

1. Hydroxocobalamin (preferred) - cobalt binds cyanide; turns urine red
2. Amyl nitrite (inhale) → Sodium nitrite (IV) → create methemoglobin which binds cyanide
3. Sodium thiosulfate - converts cyanide to thiocyanate (renally excreted)
4. HBO for combined CO+cyanide poisoning

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4.5 CARBON MONOXIDE (CO) Poisoning

• 100% O2 via non-rebreather mask (reduces CO half-life from 5h → 1h)
• Hyperbaric O2: 2.5-3 ATA (reduces half-life to 20-30 min) - indicated for LOC, neurologic symptoms, COHb >25%, pregnancy

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4.6 METHANOL & ETHYLENE GLYCOL Poisoning

• Methanol → Formaldehyde → Formic acid (retinal/optic nerve damage → blindness)
• Ethylene glycol → Glycolic acid → Oxalic acid → calcium oxalate crystals (kidney)

• Methanol = BLINDNESS (optic nerve)
• Ethylene glycol = kidney STONES (oxalate crystals)

• Fomepizole (4-MP): Competitive inhibitor of ADH - preferred antidote
• Ethanol: Alternative (competes for ADH - but harder to titrate)
• Hemodialysis: Removes toxic metabolites
• Bicarb for acidosis

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4.7 TRICYCLIC ANTIDEPRESSANT (TCA) Poisoning

• CNS depression (sedation, seizures)
• Cardiac toxicity (wide QRS, VT, VF)
• Cholinergic blockade (anticholinergic features)

• QRS >100ms = seizure risk
• QRS >160ms = VT risk
• Terminal R wave in aVR >3mm (most specific for TCA toxicity)
• Brugada pattern (V1-V3)

• Sodium bicarbonate IV: Narrows QRS, treats arrhythmias (by raising pH and increasing Na+)
• Avoid physostigmine
• Benzodiazepines for seizures
• Lipid emulsion therapy for refractory cases

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4.8 IRON Poisoning

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4.9 HEAVY METAL POISONING

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4.10 DIGOXIN Poisoning

• D - Digitalis effect on ECG (scooped ST "Salvador Dali" sagging)
• I - Increased vagal tone (bradycardia, AV block)
• G - GI symptoms (N/V, anorexia)
• O - Objects appear yellow/green (xanthopsia)
• X - Xtra potassium worsens toxicity (hypokalemia potentiates)

• Avoid cardioversion (may cause refractory VF)
• Treat hyperkalemia carefully (NOT calcium - may worsen)

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4.11 BETA-BLOCKER & CALCIUM CHANNEL BLOCKER Poisoning

• Benzodiazepines (if seizures)
• Resuscitation fluids
• Atropine (for bradycardia)
• Vasopressors (norepinephrine)
• Ampicillin... no - ACLS/glucagon
• D - Dextrose (for insulin-euglycemia)

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PART 5: DECONTAMINATION PRINCIPLES

Mnemonic: "GET SAFE"

• G - Gastric lavage (within 1h of large ingestion, airway protected)
• E - External decontamination (skin/eye exposure)
• T - Triggered emesis - AVOID (ipecac no longer recommended)
• S - Single-dose Activated Charcoal (most useful, within 1-2h)
• A - Alkalinize urine (salicylates, phenobarbital - ionizes drug in urine)
• F - Fluid management
• E - Enhanced elimination (hemodialysis, hemoperfusion, charcoal repeat doses)

Activated Charcoal

• Works by adsorption - most drugs EXCEPT:
• Mnemonic: "CHASM" = NOT adsorbed by charcoal
  • C - Caustics (acids/alkalis)
  • H - Heavy metals (iron, lithium, lead)
  • A - Alcohols (methanol, ethanol, ethylene glycol)
  • S - Solvents
  • M - Minerals (electrolytes, K+)

Multi-Dose Activated Charcoal (MDAC)

• Mnemonic: "CAPS D"
  • C - Carbamazepine
  • A - Amitriptyline/dapsone
  • P - Phenobarbital/phenytoin
  • S - Salicylates/theophylline
  • D - Digoxin

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PART 6: ENHANCED ELIMINATION

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PART 7: COMMON ANTIDOTES - MASTER TABLE

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PART 8: SPECIAL POISONING TOPICS

8.1 Snake Bite Management - Mnemonic: "LMNO"

• L - Local care (immobilize, keep at heart level)
• M - Monitor vitals, coagulation, urine
• N - No tourniquet, No incision, No mouth suction
• O - Offer antivenom if systemic features present

8.2 Food Poisoning - Onset Time Clues

8.3 Botulinum Toxin

• Diplopia
• Dysarthria
• Dysphagia
• Descending paralysis

8.4 Caustic Poisoning

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PART 9: FORENSIC TOXICOLOGY ESSENTIALS

Types of Poisons (Medicolegal)

• C - Corrosives (acids, alkalis)
• O - Organic (plant alkaloids: aconite, digitalis, oleander)
• P - Putrefactive/Gaseous (CO, HCN, H2S)
• S - Systemic (metals: As, Pb, Hg)
• M - Medicinal overdose
• I - Insecticides/Agricultural
• P - Psychoactive/Neurological

Postmortem Clues to Poison Identity

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PART 10: QUICK REFERENCE - MASTER MNEMONIC MAP

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⚡ QUICK-REFERENCE GUIDE: ANTIDOTE DOSING, ADMINISTRATION PROTOCOLS & CLINICAL CASES

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SECTION 1: MASTER ANTIDOTE DOSING TABLE

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1. N-ACETYLCYSTEINE (NAC) - Paracetamol Poisoning

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2. NALOXONE - Opioid Poisoning

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3. ATROPINE - Organophosphate / Carbamate Poisoning

4. PRALIDOXIME (2-PAM) - Organophosphate Poisoning

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5. HYDROXOCOBALAMIN - Cyanide Poisoning

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6. FOMEPIZOLE (4-Methylpyrazole) - Methanol / Ethylene Glycol

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7. DIGOXIN-SPECIFIC FAB (Digibind / DigiFab) - Digoxin Toxicity

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8. SODIUM BICARBONATE - Tricyclic Antidepressant (TCA) Poisoning

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9. DEFEROXAMINE - Iron Poisoning

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10. METHYLENE BLUE - Methemoglobinemia

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11. PYRIDOXINE (Vitamin B6) - Isoniazid (INH) Poisoning

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12. FLUMAZENIL - Benzodiazepine Poisoning

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13. GLUCAGON - Beta-Blocker Poisoning

14. HIGH-DOSE INSULIN (HDI) + Euglycemia Therapy

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SECTION 2: CLINICAL CASES WITH FULL MANAGEMENT

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CASE 1: PARACETAMOL (Acetaminophen) Overdose

A 24-year-old woman presents 5 hours after taking "a whole bottle of Tylenol" (approximately 15 g) after an argument. She appears well with mild nausea. Vitals: BP 118/76, HR 88, RR 16, Temp 37.1°C. Labs: Serum acetaminophen level = 280 µg/mL at 5 hours post-ingestion. LFTs normal. INR 1.0.

1. Plot on Rumack-Matthew nomogram - 280 µg/mL at 5h = above treatment line → NAC indicated
2. IV NAC immediately:
   • Bag 1: 150 mg/kg (9 g for 60 kg patient) in 200 mL D5W over 60 min
   • Bag 2: 50 mg/kg in 500 mL D5W over 4 hours
   • Bag 3: 100 mg/kg in 1000 mL D5W over 16 hours
3. If anaphylactoid reaction (flushing, urticaria) during Bag 1: Stop infusion → diphenhydramine 50 mg IV → restart at slower rate
4. Repeat LFTs, INR, creatinine at 24h
5. Psychiatric evaluation before discharge
6. Discharge criteria: LFTs normal, INR <2, NAC course complete, psychiatry clearance

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CASE 2: ORGANOPHOSPHATE Poisoning

A 45-year-old farmer is brought in by family - found unconscious in his field. On exam: miosis, excessive salivation dripping from his mouth, wheezing, incontinence of urine and stool, HR 48, BP 80/50. Clothes smell of pesticide. Fasciculations noted in arms.

1. Decontaminate FIRST - Remove all clothing (bag in biohazard), copious soap + water wash (staff use nitrile gloves - NOT latex)
2. Airway - 100% O2, suction secretions; intubate early (succinylcholine AVOIDED - use rocuronium instead)
3. Atropine (IMMEDIATELY):
   • Start: 3 mg IV
   • Double every 5 min → 6 mg → 12 mg → 24 mg...
   • Target: Chest clear on auscultation (may need 50-100+ mg)
   • This patient may need 200+ mg if massive ingestion
4. Pralidoxime 2-PAM: 2 g IV over 15-30 min → 500 mg/h infusion (give ASAP - before aging)
5. Benzodiazepines (if seizures): Diazepam 5-10 mg IV
6. Fluids for hypotension
7. Monitor: Cholinesterase levels, ECG, LFTs

• Tachycardia is NOT a contraindication to atropine (reflects bronchospasm/hypoxia)
• Pupil dilation is NOT the end point - dried secretions are
• Do NOT use succinylcholine for intubation

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CASE 3: OPIOID Overdose

A 32-year-old man found unresponsive in a public bathroom. Empty syringe nearby. RR 4/min, GCS 3, pupils pinpoint bilaterally, cyanotic. BP 90/60, HR 52.

1. Jaw thrust, BVM ventilation with 100% O2 immediately
2. Naloxone 0.4 mg IV - (Start low if opioid dependence suspected - precipitates withdrawal)
   • Response in 2 min → if no response → 0.4 mg q2-3 min up to 10 mg
   • This patient responds at 0.8 mg total (RR improves to 14, GCS improves)
3. Caution: Effect wears off in 30-90 min - opioid will still be present
4. Naloxone infusion: "Wake-up dose" was 0.8 mg → infusion = (2/3 × 0.8 mg) = 0.53 mg/h IV
5. Observe minimum 4-6 hours after last naloxone dose (8h for long-acting opioids)
6. Admit to monitored unit with infusion running
7. Pulse oximetry and serial neuro checks

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CASE 4: CYANIDE Poisoning (Fire Victim)

A 38-year-old firefighter rescued from a burning warehouse (synthetic materials). GCS 8, BP 80/50, HR 130, RR 28, O2 sat 88% on room air. Lactate = 14 mmol/L. COHb = 15%.

1. 100% O2 via non-rebreather mask (treats both CO and CN poisoning)
2. Hydroxocobalamin 5 g IV over 15 minutes (preferred - safe with elevated COHb, unlike sodium nitrite)
3. Repeat 5 g if no hemodynamic improvement after first dose (max 10 g)
4. Sodium thiosulfate 12.5 g IV if available (adjunct - accelerates detox)
5. Aggressive fluid resuscitation for shock
6. Vasopressors (norepinephrine) if refractory hypotension
7. Consider hyperbaric O2 if dual CO+CN and inadequate response to antidotes
8. Do NOT give sodium nitrite when CO poisoning coexists (worsens hypoxia)

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CASE 5: METHANOL Poisoning

A 55-year-old homeless man presents with sudden severe visual blurring "like looking through a fog," and abdominal pain 12 hours after drinking from an unlabeled bottle. Visual acuity severely reduced. ABG: pH 7.12, HCO3 8 mEq/L. Anion gap = 28. Osmolar gap = 35.

1. Secure IV access; ABG + electrolytes + osmolar gap + methanol level
2. Fomepizole: 15 mg/kg IV over 30 min (IMMEDIATELY - do not wait for methanol level)
3. Sodium bicarbonate 1-2 mEq/kg IV (temporize severe acidosis - pH 7.12 is life-threatening)
4. Folate/Leucovorin 50 mg IV q4-6h (promotes formic acid metabolism → CO2 + H2O)
5. Hemodialysis - URGENT in this patient (visual deficits = end-organ damage; pH ≤7.15; high levels):
   • Continue fomepizole every 4 hours DURING hemodialysis
   • HD removes methanol AND formic acid
6. Monitor methanol level - stop fomepizole when <20 mg/dL + no acidosis

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CASE 6: TRICYCLIC ANTIDEPRESSANT (TCA) Overdose

A 19-year-old with depression took "all her amitriptyline pills" 2 hours ago. Initially drowsy, now GCS 7, HR 145, BP 80/50. ECG: QRS = 148 ms, right axis deviation, prominent R in aVR. Seizing on arrival.

1. Airway first - intubate (GCS 7 + seizures); hyperventilate to pH 7.50-7.55 (this itself narrows QRS via alkalosis)
2. Benzodiazepines for seizures: Lorazepam 2-4 mg IV
3. Sodium bicarbonate - IMMEDIATELY for QRS >100 ms:
   • 1-2 mEq/kg IV bolus (50-100 mL of 8.4%)
   • Repeat until QRS narrows to <100 ms
   • Maintain pH 7.45-7.55 with infusion
4. IV fluids (1-2 L NS) for hypotension; norepinephrine if refractory
5. Monitor ECG continuously - watch for QRS widening, VT
6. If refractory VT/arrest: 20% Intralipid (Lipid Emulsion) 1.5 mL/kg IV bolus
7. Avoid: Flumazenil (can precipitate seizures), phenytoin (may worsen cardiac toxicity), physostigmine

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CASE 7: SALICYLATE (Aspirin) Poisoning

A 65-year-old man presents confused and tachypneic after reportedly ingesting "a large amount of aspirin." Vitals: Temp 38.8°C, HR 118, RR 32. ABG: pH 7.48, pCO2 20 (low), HCO3 14 (low). Serum salicylate = 520 mg/L. Tinnitus reported by family.

1. IV access, continuous monitoring
2. Activated charcoal 50-100 g PO/NG (aspirin forms concretions in stomach - charcoal helps)
3. Urinary alkalinization (key treatment):
   • 3 ampoules (150 mEq) NaHCO3 in 1L D5W + 40 mEq KCl
   • Run at 200-250 mL/h
   • Target: Urine pH ≥7.5-8.0 (ionizes salicylate in urine → ion trapping → enhanced excretion)
   • MUST replace potassium - hypokalemia prevents alkalinization
4. Forced fluids with bicarb infusion (correct dehydration)
5. Hemodialysis indications: Salicylate >700 mg/L, AMS, pulmonary edema, refractory acidosis, renal failure
6. Do NOT intubate unnecessarily - loss of compensatory hyperventilation (respiratory alkalosis) can rapidly worsen acidosis

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CASE 8: DIGOXIN Toxicity

A 78-year-old woman on digoxin 0.25 mg/day for AF presents with vomiting, yellow-tinged vision, and palpitations. ECG: bidirectional ventricular tachycardia, HR 42, complete heart block. Digoxin level = 4.8 ng/mL, K+ = 6.1 mEq/L, Creatinine = 2.4 mg/dL.

1. IV access; NPO; continuous telemetry
2. Digibind dose calculation:
   • Vials = (4.8 ng/mL × 78 kg) ÷ 100 = 3.7 vials → round up to 4-6 vials (chronic toxicity: use 6 vials empirically)
3. Administer Digibind IV over 30 min (bolus if cardiac arrest)
4. Hyperkalemia management:
   • Sodium bicarbonate (K+ redistribution)
   • Calcium resonium/kayexalate orally
   • Do NOT give calcium chloride/gluconate (classically taught as risk of "stone heart" - ventricular fibrillation in hypercalcemia setting)
5. Pacing (external/transvenous) for complete heart block unresponsive to Fab
6. After Fab: Total serum digoxin level rises (now measures bound Fab-digoxin) - ignore levels
7. Monitor potassium carefully (can fall after Fab given)

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CASE 9: BETA-BLOCKER Overdose

A 50-year-old man with hypertension takes all his metoprolol (approximately 2000 mg). He arrives drowsy, BP 70/40, HR 32, blood glucose 48 mg/dL (hypoglycemia from beta blockade).

1. Dextrose 50% 50 mL IV for hypoglycemia (glucagon alone may cause vomiting without glycogen stores)
2. Atropine 1 mg IV (often ineffective in beta-blocker OD but trial warranted)
3. Glucagon 5 mg IV bolus over 1-2 min; then 3-5 mg/h infusion
   • Premedicate with ondansetron (glucagon causes emesis)
4. Calcium chloride 1 g (10 mL of 10%) IV over 5-10 min (adjunct)
5. If refractory (no improvement):
   • High-dose Insulin (HDI): 1 unit/kg regular insulin IV + 50 mL D50 bolus → insulin infusion 0.5-1 unit/kg/h + 10% dextrose
   • Monitor glucose q15 min + K+ q1h
6. Lipid Emulsion (Intralipid): 1.5 mL/kg 20% IV bolus for refractory arrest (lipid-soluble beta-blockers: propranolol, labetalol)
7. ECMO/mechanical support as last resort for refractory cardiogenic shock

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CASE 10: ISONIAZID (INH) Seizures

A 35-year-old TB patient presents with refractory generalized seizures after accidentally ingesting his entire month's supply of isoniazid. Three rounds of diazepam and lorazepam have failed. Persistent status epilepticus.

1. Airway, breathing, circulation - intubate if needed
2. Pyridoxine (Vitamin B6) IMMEDIATELY:
   • Unknown dose ingested → give 5 g IV (70 mg/kg in children) over 5-10 min
   • If amount known (e.g., 50 × 300 mg tablets = 15 g INH) → give 15 g pyridoxine gram-for-gram
3. Concurrent benzodiazepines (continue alongside pyridoxine)
4. Seizures typically stop within minutes of pyridoxine administration
5. Monitor glucose (INH inhibits gluconeogenesis → hypoglycemia)
6. Supportive care - LFTs (INH is hepatotoxic), monitor for lactic acidosis

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CASE 11: CARBON MONOXIDE Poisoning

A family of four is brought in from their home after their gas heater malfunctioned in winter. Father (40): headache, confusion, COHb 35%. Mother (38): syncope, COHb 28%. Two children (8 and 10 years): nausea/headache, COHb 18%. Mother is 16 weeks pregnant.

1. 100% O2 via tight-fitting non-rebreather mask immediately
2. Hyperbaric O2 (HBO) indicated:
   • COHb >25% + neurological symptoms
   • Reduces CO half-life: Room air 5h → 100% O2 = 60-90 min → HBO 2.5 ATA = 20-30 min
3. ECG (CO causes myocardial injury - troponin)
4. Neurological assessment - "delayed neurological sequelae" can occur weeks later

1. HBO therapy regardless of COHb level - fetus is more susceptible; fetal COHb clears more slowly
2. HBO for ALL pregnant patients with CO poisoning regardless of severity

1. 100% O2 via pediatric NRB mask
2. HBO threshold lower in children (more sensitive CNS)

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CASE 12: IRON Poisoning (Pediatric)

An 18-month-old (12 kg) is found with an empty children's chewable iron tablet bottle (50 tablets × 18 mg elemental iron = 900 mg). Currently vomiting blood and has bloody diarrhea 3 hours post-ingestion. BP 70/40 (shock). Serum iron = 620 µg/dL.

1. Resuscitate: 20 mL/kg NS IV bolus; repeat as needed
2. Deferoxamine immediately (serum iron >500 µg/dL + symptomatic shock):
   • 15 mg/kg/h IV (max 35 mg/kg/h)
   • = 15 × 12 kg = 180 mg/h for this child
3. Monitor urine - "vin rosé" (orange-pink) color confirms ferrioxamine excretion; continue until urine clears
4. Abdominal X-ray (iron tablets are radiopaque - confirm tablets present)
5. Activated charcoal NOT effective for iron
6. Gastric lavage within 1h if large ingestion still in stomach
7. Watch for Phase 2 "honeymoon" period (apparent improvement 6-12h) - do NOT discharge, Phase 3 cardiovascular collapse follows
8. LFTs, coagulation, glucose q4-6h

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SECTION 3: SPECIAL ANTIDOTE PROTOCOLS - QUICK REFERENCE CARD

┌─────────────────────────────────────────────────────────────────┐
│           CRITICAL ANTIDOTES - MEMORY CARD                      │
├────────────────┬────────────────────┬───────────────────────────┤
│ POISON         │ ANTIDOTE           │ KEY DOSE                  │
├────────────────┼────────────────────┼───────────────────────────┤
│ Paracetamol    │ NAC                │ 150 mg/kg IV load         │
│ Opioids        │ Naloxone           │ 0.4-2 mg IV; 2/3 rule    │
│ OP/Carbamate   │ Atropine + 2-PAM   │ Atropine: double q5min   │
│ Cyanide        │ Hydroxocobalamin   │ 5 g IV over 15 min        │
│ CO             │ 100% O2 / HBO      │ 2.5 ATA if neurological  │
│ Methanol/EG    │ Fomepizole         │ 15 mg/kg load; q12h      │
│ Digoxin        │ Digibind           │ Level × wt ÷ 100 = vials │
│ TCA            │ NaHCO3             │ 1-2 mEq/kg IV; pH 7.50   │
│ Iron           │ Deferoxamine       │ 15 mg/kg/h IV             │
│ Beta-blocker   │ Glucagon + HDI     │ 5 mg bolus; 1 u/kg ins   │
│ BZD            │ Flumazenil         │ 0.2 mg q1min up to 3 mg  │
│ INH            │ Pyridoxine B6      │ Gram for gram; 5 g if ?  │
│ MetHb          │ Methylene Blue     │ 1-2 mg/kg IV              │
│ Heavy metals   │ BAL / DMSA         │ BAL: 3-5 mg/kg IM q4h    │
│ Warfarin       │ Vit K + 4-factor   │ Vit K 10 mg IV slow      │
│ Heparin        │ Protamine          │ 1 mg per 100 units hep   │
│ Dabigatran     │ Idarucizumab       │ 5 g IV (2 × 2.5 g)       │
│ Rivaroxaban    │ Andexanet alfa     │ Weight/dose-based         │
│ Sulfonylurea   │ Octreotide         │ 50 µg SC/IV q6-12h        │
└────────────────┴────────────────────┴───────────────────────────┘

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SECTION 4: MONITORING PARAMETERS AFTER ANTIDOTE ADMINISTRATION

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