In critically ill patients, resuscitation should take priority over antidotal therapy.For patients in peripheral locations, it is often safer and less expensive to transport an antidote to the patient, rather than the opposite.This is best coordinated on a regional basis.
some antidotes have fixed doses to ensure complete receptor/ pathway blockage (e.g.repeated naloxone doses or an infusion may be required with long-acting opioids) repeated doses and the duration required may vary according to the duration of action of the toxic agent, which may be different from the duration of action of the antidote (e.g.Most antidote doses should be titrated to the required effect are not suitable for enhanced elimination.cannot be safely and effectively decontaminated before absorption.cannot be managed by standard resuscitation, supportive care and monitoring.cause significant toxicity, that exceeds the potential harms of the antidote.the nature of the toxic agent(s) may be uncertain at the time of presentationĪntidotal therapy should be reserved for agents that.can be difficult given the paucity of evidence of clinical effectiveness for many antidotes and the relative rarity of their use.Also, decontamination with Fuller’s Earth and Activated Charcoal is priority following significant paraquat exposure (highly life threatening, difficult to treat) However, certain antidotes may have benefit in cardiac arrest and during resuscitation (see below). Many antidotes have an excellent safety profile (e.g. Calcium channel blockers: IV calcium, High-dose Insulin Euglycaemic Therapy (HIET).Butyrophenones (haloperidol): Benztropine.Bupivacaine/ local anaesthetics: sodium bicarbonate, intralipid.Beta-blockers: High-dose Insulin Euglycaemic Therapy (HIET), Adrenaline.Amphetamines: Benzodiazepines + consider dantrolene.Amanita phalloides deathcap mushroom toxicity : Silibinin.intralipid may decrease the effectiveness of lipid soluble therapeutic agents) Interference with other therapies (e.g.digoxin levels increase after digibind intralipid may cause spurious biochemistry results) interference with laboratory assays (e.g.NAC may worsen hypotension in a mixed paracetamol / cardiotoxic overdose) unanticipated effects in mixed overdoses (e.g.benzodiazepine withdrawal from flumazenil, sympathetic crisis and pulmonary edema from naloxone) NAC, anaphylactoid reaction to vitamin K, allergy to antivenom) resuscitation, supportive care and monitoring) distraction from other management priorities (e.g.The harms are often well quantified and are an important determinant of the threshold for antidote use.
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