special routes of drug administration, drug reaction, toxicology, antidotes

1. Special routes of drug administration,
Drug reaction and Toxicity
- Mrs. Dashami, Msc 2nd year, CMC, Vellore

2. • The Swiss physician and chemist Paracelsus noted
nearly 500 years ago that
‘‘All substances are poison; there is nothing which is
not a poison. The right dose differentiates a poison
and a remedy.’’

3. • Adverse drug events due to accidental dosing errors
are estimated to affect nearly 775,000 people each
year, with associated hospital costs of $1.5 to $5.5
billion annually. US, 2013

4. FAERS Reporting by Patient Outcomes over
Years
(FDA Adverse events reporting system)

5. • These data describe the outcome of the patient as
defined in U.S. reporting regulations (21 CFR 310.305,
314.80, 314.98, 600.80) and Forms FDA 3500 and 3500A
(the MedWatch forms).
• Serious means that one or more of the following
outcomes were documented in the report: death,
hospitalization, life-threatening, disability, congenital
anomaly and/or other serious outcome.

6. This figure illustrates the patient outcome(s) for reports in FAERS since the year 2006
until the first quarter of 2015. Serious outcomes include death, hospitalization, life-
threatening, disability, congenital anomaly and/or other serious outcome.

8. Special routes of drug administration

9. Intra thecal
• administration for drugs via an
injection into the spinal canal
• Or into the subarachnoid space so that
it reaches the cerebrospinal fluid (CSF).
• useful in spinal anaesthesia,
chemotherapy, or pain management
applications.

11. Intra articular
• An intra-articular injection is a term used
to describe a shot delivered directly into a
joint with the primary aim of relieving
pain.
• Corticosteroids (steroids) were the first
substances used for this purpose. Other
types of drug are now commonly used
including local anesthetics, hyaluronic
acid, and even Botox.

13. Intra osseous
• Intra osseous infusion (IO) is the process
of injecting directly into the marrow of a
bone.
• This technique is used to provide fluids
and medication when intravenous access
is not available or not feasible.
• Intra osseous infusions allow for
the administered medications and fluids
to go directly into the vascular system

15. • first introduced by Drinker in 1922 as a
method for accessing noncollapsible
venous plexuses through the bone
marrow cavity to the systemic circulation.
• With the development of IV catheters,
this method was abandoned until the
1980s, when intraosseous access was
reintroduced, particularly for rapid fluid
infusion during resuscitation.

17. Intra cardiac
• Intracardiac drug administration are given
directly into the heart muscles or
ventricles. They are used in emergencies.
• The procedure is performed by inserting a
long spinal needle into the ventricular
chamber. The needle is inserted in the
fourth intercostal space between the ribs.

19. Intra peritoneal
• It is the injection of drug into
the peritoneum (body cavity).
• The method is widely used to
administer chemotherapy drugs to
treat some cancers, particularly ovarian
cancer and peritoneal dialysis.

21. Intra vesical
• Intravesical therapy involves instillation
of a therapeutic agent directly into the
bladder via insertion of a urethral
catheter.

23. Intra vaginal
• intra-vaginal controlled-release drug
delivery system is an effective means for
achieving a continuous delivery of
therapeutic agents, not only the
systemically active drugs, such as
contraceptive steroids, but also the locally
active drugs, such as metronidazole and
other drugs like Zidovudine, Lamivudine

25. • The advantage of intra-vaginal controlled
drug administration over
conventional/traditional oral
administration is the drug absorbed
systemically, because due to the presence
of dense network of blood vessels in
vaginal wall.
• A range of drug delivery platforms suitable
for intra-vaginal administration are hydro-
gels, vaginal tablets, pessaries
/suppositories, particulate systems, and
intra-vaginal rings.

26. Intra cerebroventricular
• Intracerebroventricular drug administration is
a method that bypasses the blood-brain
barrier and other mechanisms that limit drug
distribution into the brain, allowing high drug
concentrations to enter the central
compartment.
• Instillation of drugs directly into the
ventricles of the brain must be done carefully
and with full consideration of factors affecting
the efficacy and safety of this route of
administration.

28. Epidural
• Epidural techniques frequently
involve injection of drugs through
a catheter placed into the epidural space.
• The injection can result in a loss
of sensation—including the sensation
of pain—by blocking the transmission of
signals through nerve fibres in or near the
spinal cord.

30. Intracavernous
• An intracavernous injection is
an injection into the base of the penis.
• This injection site is often used to
administer medications to check for or
treat erectile dysfunction in adult men
• Priapism is also often treated with
intracavernous injections, usually
with sympathomimetic vasoconstricting
drugs like adrenaline or phenylephrine.

32. Extra amiotic
• Extra-amniotic administration is a route
of administration to the space between
the fetalmembranes and endometrium
inside the uterus of a pregnant woman.
• It can be used to administer drugs
affecting uterus motility, such
as oxytocin and prostaglandins, e.g.
in labor induction or medical abortion.

33. Drug Reactions…

34. • It is defined as
“Any noxious change which is suspected
to be due to a drug, occurs at doses
normally used in man, requires treatment
or decrease in the dosage or indicated
caution in the future use of the same
drug”

35. Types
Predictable (Type
A or Augmented)
reaction
Unpredictable
(Type B or Bizarre)
reaction

36. Predictable/ Type A reaction
• More common
• Dose related
• Can be preventable and reversible
• Side effects, toxic effects,
consequences of drug withdrawal

37. Unpredictable / Type B reaction
• Based on peculiarities of the patient
and not on the drugs known action.
• Less common
• Non-dose related
• Generally more serious and require
withdrawal of the drug immediately

38. Severity of drug reaction
Lethal – directly or indirectly contributes to the death of
the patient
Severe – potentially life threatening, causes permanent
damage or requires intensive medical treatment
Moderate – requires change in the drug therapy, specific
treatment or prolongs hospital stay by at least one day
Minor – No therapy, antidote and prolongation of
hospitalization is required

39. Types of drug
reaction…..

40. Side effects
Secondary
effects
Toxic effects Intolerance
Idiosyncrasy Drug allergy Photosensitivity
Drug
dependency
Drug
withdrawal
reaction
Teratogenicity
Mutagenicity /
carcinogenicity
Drug induced
diseases

41. Side effects
• ‘Unwanted and unavoidable’
pharmacodynamic effects that occur at
therapeutic doses
• Reduction in dosage, usually ameliorates the
symptoms
e.g
• Atropine – antisecretory action – dryness of
mouth.
• Glyceryl trinitrate – angina pectoris – postural
hypotension & throbbing headache

42. Secondary effects
• These are indirect consequences of the
primary action of the drug
Eg
• Suppression of bacterial flora by
tetracyclines paves way to superinfections
• Corticosteroids weaken host defence
mechanism so that latent tuberculosis
gets activated

43. Toxic effects
• Overdosage or prolonged use.
• Predictable and dose related
Overdosage
Absolute Relative
E.g Atropine – delerium
• Paracetamol – hepatic necrosis

44. Eg.
• Morphine – Respiratory failure
• Imipramine – cardiac arrhythmia
• Streptomycin – Vestibular damage (
prolonged used)

45. Intolerance
• It is the appearance of the
characteristics toxic effect of the drug
in an individual at therapeutic doses.
• Converse of tolerance.
• Low threshold of the individual to the
action of a drug.

46. Eg
• Single dose of triflupromazine induces
muscular dystonia in some individuals,
specially children.
• Few doses of carbamazipine may cause
ataxia.
• One tablet of chloroquine may cause
vomiting and abdominal pain

47. Idiosyncrasy
• It is genetically determined abnormal
reactivity to a chemical.
• Drug interacts with some unique
features of the individual, not found in
the majority of the subjects, and
produces the uncharacteristic reaction.

48. Barbiturates causes excitement and
mental confusion in some individuals
Quinine/quinidine causes cramps,
diarrhoea, asthma, vascular collapse in
some patients.
Chloramphenicol – non dose related
serious aplastic anaemia in rare individuals

49. Drug allergy
• Drug hypersensitivity
• It is an immunological mediated
reaction producing stereotype
symptoms which are unrelated to the
pharmacodynamic profile of the drug
• Smaller doses
• Different time course of onset

50. Humoral
• Type-l
(anaphylactic
reaction)
• Type-ll ( cytotoxic
reaction)
• Type-lll ( retarded
reaction)
Cell mediated
• Type- iv (delayed
hypersensitivity)

51. Photosensitivity
• It is a cutaneous reaction resulting from
drug induced sensitization of the skin
to UV radiation.
• Two types
• Phototoxic
• photoallergic

52. • Drug or metabolite accumulates in the skin,
absorbs light and undergoes a photochemical ,
photobiological reaction.
• Local skin damage – erythema, edema, blistering.
phototoxic
• Drug or its metabolites induces a cell mediated
immune response which on exposure to light of
longer wave lengths ( 320-400 nm, UV-A)
produces a papular or eczematous contact
dermatitis
Photoallergic

53. Drug dependency.
• Drugs capable of altering mood and feelings,
repetitive use to derive euphoria, recreation,
withdrawal from reality, social adjustment.
1. Psychological dependency
2. Physical dependency
3. Drug abuse
4. Drug addiction
5. Drug habituation

54. Psychological dependency
• Individual believes that optimum state of well being is achieved
only through the action of the drug
Physical dependency
• Repeated administration of the drug necessitates the
continued presence of the drug to maintain the physiological
equilibrium.
Drug abuse
• Self medication in a manner and amount that deviates from the approved
medical and social patterns in a given culture at a given time

55. • It is a pattern of
compulsive drug useDrug
addiction
• Less intensive involvement
with the drug, withdrawal
produces only mild
discomfort.
Drug
habituation

56. Drug withdrawal reaction
• Sudden interruption of the therapy with
certain drugs results in adverse
consequences.
eg
• Corticosteroids – acute adrenaline
insufficiency
• Clonidine – severe HTN, restlessness and
sympathetic over activity
• Beta blockers – worsening angina pectoris,
precipitation of MI

57. Teratogenicity
• Capacity of the drugs to cause foetal
abnormalities when administered to
the pregnant mother.
• Thalidomide disaster (1958-61)
• Phocomelia( seal like limbs)

58. Mutagenicity and carcinogenicity
• Capacity of the drugs to cause genetic
defects and cancer respectively.
• Oxidation of the drugs – reactive
intermediates – affect the genes –
structural changes in the chromosomes
– induce mutations- heritable defects
in the next generation.

59. Drug induced diseases
• These are also called iatrogenic
(physician induced ) diseases, and are
functional disturbances, caused by
drugs even after the drug has been
withdrawn and largely eliminated.

60. • Salicylates and corticosteroids – peptic
ulcer.
• Parkinsonism – antipsychotics,
phenothiazines
• Isoniazid – hepatitis

61. Pharmocovigilance

62. • “The science and activities relating to
the detection, assessment,
understanding, and prevention of
adverse effects or any other drug
related problem”
WHO,2012

63. • 1999 Report of the institute of
medicine, which estimated 44,000 to
98,000 death each year in the US
because of medication errors and drug
reaction!!`

64. • Recommendations to prevent
medication errors and drug reactions –
• IOM – Institute of Medicine
• AHRQ – agency for healthcare Research and
Quality
• JCAHO – joint commission on Accreditation of
Healthcare Organizations
• ISMP – Institute for safe medication Practices
• NCCMERP – national coordinating council for
medication error reporting and prevention

65. Roles and steps on
prevention of drug
reactions

66. Drug manufacturers
• Similar names, packing
• Error prescribing,
dispensing or
administration
• Lamictal – Lamisil -
Lamivudine
• FDA – 10% ( drug name
confusion) ,2013
• FDA Evaluation
• While choosing drug names
avoid using similar to drugs
already in market
• Design packing – don’t look
alike in terms of colour
appearance.
• Use Tall Man letters on drug
labels to distinguish between
generic drugs with similar
names
• Eg. NICARdipine / NIFEdipine

67. Healthcare agencies
• Heavy work load
(prescriber,
pharmacist,nurses)
• Distractions (noise,
interruptions ..)
• Computerized order entry
technology
• Sufficient staff
(pharmacy/nursing)
• Adequate equipment
• Work environment

68. Prescriber
• Illegible orders
• Drug not indicated,
• Fail to consider patient age,
size, kidney function, liver
function, toxicity levels.
• Lack of knowledge
• Computerized order
• Hand written order legible
• Avoid use of abreviation
• Use generic names
• Avoid verbal orders, counter
sign with another nurse
• Review therapeutic effects
• Update knowledge

69. Pharmacists
• Dispense incorrect
medication
• Mislabel containers
• Illegible order
• Promote or assist computerized
drugs orders
• Verify/ request clarification of order
• Verify patient weight and
recalculate dosage
• Separate LASA drugs
• Encourage to report medication
errors
• Update knowledge

70. Nurses
• Inadequate knowledge
• Not following 10 rights and
checking's
• Fail to question medication
order when indicated
• Polices and procedures about
medication storage,
administration and recording.
• Up date knowledge
• Patients health status
• Question/clarify unclear drugs
• Verify orders with another
nurse

71. • Recording
• Handing over
• Storage of medications
• Perform three checks
before administration
• Report ADR
• Follow standing orders,
protocols, policies
• Report errors

72. TOXICITY

73. • Drug toxicity results from excessive
amounts of a drug and may damage
body tissue.
• It results from a single dose or
prolonged ingestion of smaller doses
and may involve alcohol or
prescription, over-the-counter or illicit
drugs.

74. • Physicians prescribe drugs to prevent or
treat disease. Those same drugs can be
toxic to certain patients, however, because
of genetic predisposition, nonselective
action, or inappropriate use or
administration of the drug.
• The United States Food and Drug
Administration (FDA) spends a significant
portion of its $1 trillion budget yearly to
ensure that new drugs are not overtly or
unnecessarily dangerous

75. Factors affecting drug toxicity
• Age
• Genetic factor
• Pathological condition
• Dosage
• Drug-drug interactions

76. EXAMPLES
• The very young and the very old may be more
susceptible to the toxic effects of a drug because
of age-dependent differences in pharmacokinetic
profiles or in drug metabolizing enzymes.
• Liver or kidney dysfunction will affect drug
pharmacokinetics
• Genetic difference may yield difference in drug
metabolism or in receptor activity, as well
differences in activities of repair mechanism

77. Mechanism of drug toxicity
• ‘‘On-target’’ adverse effects”, which are the result of
the drug binding to its intended receptor, but at an
inappropriate concentration, with suboptimal kinetics,
or in the incorrect tissue
• ‘‘Off-target’’ adverse effects”, which are caused by the
drug binding to a target or receptor for which it was
not intended
• Production of toxic metabolites
• Production of harmful immune responses
• Idiosyncratic responses

78. • Toxicities that derive from
inappropriate activation or inhibition of
the
1. intended drug target (on-target
adverse effects)
2. unintended targets (off-target
adverse effects)

79. On-target adverse effect…
• EXAMPLE: ANTIHISTAMINE
DIPHENHYDRAMINE
• Used to reduce allergic reaction
• Minimize histamine release by interacting
with H1 receptors.
• Pass the blood-brain barrier
• Causes drowsiness by interacting with H1
receptor in the brain.
•

80. Off-target adverse effect
• EXAMPLE: ANTIHISTAMINE TERFENADINE
• Inhibits histamine release in the blood
• Also inhibits cardiac potassium channels
• Causes fatal cardiac arrhythmias
• Withdrawn from the market
• Now usage of fexofenadine
• Have affinity to cardiac potassium
channels but to a much lesser degree than
terfenadine

81. TYPES
Two types
• Acute toxicity
• Chronic toxicity

82. Acute toxicity
• It results from a single exposure to a drug,
with adverse effects resulting in minutes
to hours.
• Examples
• Hepatic necrosis that can occur after a
single toxic dose of acetaminophen and
exacerbations of acute
bronchoconstriction in patients with
aspirin-intolerant asthma.

83. Chronic toxicity
Adverse effect of a drug that occurs over
a prolonged period of time.
Example
Long-term treatment with dopamine
receptor antagonists for schizophrenia
can result in tardive dyskinesia.

84. Pathology

85. Standing orders…

86. Anaphylactic shock
• Elevate foot end of the bed
• Give inj.Adrenaline 1/2cc (1 in 1000) IV
(Repeat every two minutes until the pulse is
recordable
• Administer oxygen by mask or nasal prongs
(4-6L/mt)
• Start IV infusion with 5% dextrose check
whether N/S can be started
• Give 200mg of inj. Hydrocortisone IV

87. Allergic reaction
• Stop administering all drugs given
earlier
• Start IV line
• Inj. Avil 1 ampule (2cc) IV
• Administer Inj. Hydrocortisone 100mg.
(IV)

88. Hypoglycemic attack
• If GRBS < 50 mg% administer 50 ml of
50% Dextrose (IV) Stat. (slow IV bolus)
• Check blood sugar with the glucometer
• Dextrose 25% / 50% up to 50ml
• Start IV line with 5% Dextrose

89. Hyperglycemic attack
• If GRBS is > 200mg %
• Disconnect dextrose infusion
• Connect one pint of NS 0.9%
• Administer insulin as per sliding scale
authorised by the doctor

90. IV medications – Non emergency
situation
• All drugs including DDA drugs should
be administered only on written order
by the doctor in charge DDA drugs have
to be checked administered and
countersigned by two registered nurses
at all times.
•

91. Seizure attack
• Position the patient in lateral position
• Insert an oropharyngeal airway and provided suction if
necessary
• Administer oxygen 4-6 L/min by face mask
• Do not restrain the patient
• Connect to pulse oximeter
Following drugs can be administered with the doctors
verbal order and ensure that these orders are obtained in
writing after the emergency
• Administer inj. Valium 10 mg I.V / inj. Phenytoin Sodium
(Dilantin) 600 mg (10-15 mg/kg) or inj Lorazepam 4mg
intravenously
• Check GRBS after the seizure attack if required

92. c/o patient with dyspnea
• Administer oxygen 4-6 L/min by face mask
( consult the doctor if the patient is
diagnosed / has a history of COPD)
Following drugs can be administered with
the doctors verbal order and ensure that
these orders are obtained in writing after the
emergency
Administer inj. Frusemide 40-60mg IV if BP >
100/70 mmHg

93. C/O patient with fever
• Administer Tab. Parecetamol 500mg to
1000mg for adults if temperature is 100
degree F or 38.3 degree C and above
• Ensure that a written order is obtained
from the doctor

94. Patient with suspected myocardial
infarction are admitted in the chest
pain unit
• Tab Angised 0.5 mg or Tab. Sorbitrate 5
mg S/L if the systolic blood pressure is
greater than 100 mmHg
• Tab Aspirin 300mg ( chewable)
• Tab. Atorvastatin 80 mg and Tab.
Clopidogrel 600mg for patients with MI
• Inj. Clexane 30 mg IV and 30mg S/C if
patient is thrombolysed with tPA

95. Policy….

96. ADR Reporting protocol
• The suspected adverse drug reaction is
reported to the doctor
• It is documented in the nurses record
• The nurses ADR reporting form is filled
and dropped in the feedbackbox kept
in the ward

97. Medication error
• Drug error is reported to the immediate
supervisor and the doctor (Night- ANS,
Weekend- Supervisor)
• The patient is monitored and the doctor’s
order is followed ,if any.
• Incident report is filled by the staff nurse, the
charge nurse, the nurse manager and the
HOD
• Form is to reach the office of Nursing
Superintendent with 24 hours of the incident

98. Antidotes

99. • Acetylcysteine
• Indication: Paracetamol, Carbon tetrachloride
Mode of Action: Protects against liver damage by
enhancing production of glutathione thereby
increasing microcirculation and increasing blood
flow.
Dosage: Initial dosage is 150mg/kg in 200 mL of
5% dextrose through slow IV injection in a period
of 15 minutes. Initial dose should be followed by
50mg/kg in 500 mL of 5% dextrose for 4 hours
then 100mg/kg in 1000 mL of 5% dextrose for 16
hours.

100. • Activated Charcoal
• Indication: Most poisons
Mode of Action: Inhibits systemic
absorption of toxin through its high
adsorptive capacity.
Dosage: 50 gram orally every 4 hours
until it appears in the stool for adult
and 10-15 gram orally every 4 hours for
children until it appears in the stool.

101. • Amyl Nitrite
• Indication: Cyanide
Mode of Action: Facilitates conversion
of hemoglobin to methemoglobin to
inhibit cyanide’s affinity to cytochrome
oxidase enzymes thereby inhibiting its
toxic effects.
Dosage: Ampoule contents should be
inhaled for 30 seconds every minute.
Use new ampoule every three minutes.

102. • Atropine
• Indication: Organophosphates and
carbamate poisoning
Mode of Action: Inhibits the action of
acetylcholine at the muscarinic sites to
interrupt initial effects of
organophosphate and carbamate
poisoning.
Dosage: 2 mg through IV

103. • Benzylpenicillin
• Indication: Amatoxin poisoning
Mode of Action: Protects the liver by
inhibiting entry of amatoxins into the
hepatic cells.
Dosage: 600mg/kg on the first day and
300mg/kg on the second and third day

104. • Cholestyramine
• Indication: Anti-coagulants
Mode of Action: Inhibits the absorption
of anti-coagulants in the system by
forming non-adsorbable complex with
bile acids in the intestines.
Dosage: 4 grams orally for up to three
times daily

105. • Calcium Gluconate
• Indication: Hydrofluoric acid, calcium
channel blockers and oxalates
Mode of Action: Increases calcium
concentration to overcome calcium
channel blockade in the cells and upkeep
with depletion of calcium concentration in
the system.
Dosage: 3grams for a 10% calcium
gluconate that can be repeated every 10
to 20 minutes for a total of three to four
doses

106. • Cyanokit (Hydroxocobalamin)
• Indication: Cyanide poisoning
Mode of Action: Binds with cyanide
ions to facilitate excretion into the
urine.
Dosage: 5 grams through intravenous
infusion for 15 minutes

107. • Dicobalt edetate
• Indication: Cyanide toxicity
Mode of Action: Forms stable ion-
complexes with cyanide to facilitate its
excretion in the urine.
Dosage: 300mg through intravenous push
for 1 minute followed by 50mL of 50%
dextrose. Initial dose may be repeated if
inadequate and can be further followed by
a 300mg dose.

108. • Dimercaprol
• Indication: Arsenic, gold and inorganic
mercury poisoning
Mode of Action: Binds with heavy metals to
form dimercaprol-metal complex which can
be readily excreted in the urine.
Dosage: 2.5mg – 3mg per kilogram weight
through deep IM every four hours for two
days then 2-4 times daily on the third day and
1-2 times daily for 10 days until recovery.

109. • Ethanol
• Indication: Ethylene glycol and methanol
poisoning
Mode of Action: Inhibits formation of toxic
metabolites so the toxic alcohol ingested can
be excreted in the urine. It doesn’t directly
affect the presence of the toxic metabolites
that have already formed so hemodialysis is
also recommended.
Dosage: Adult dosage for 5% ethanol is
2.76/mL/kg/hr either through oral or
intravenous route

110. • Glucagon
• Indication: Beta blockers, calcium channel
blockers and hypoglycemic toxicity
Mode of Action: Increases myocardial
contractility and heart rate similar to beta-
agonist effects. It also decreases vascular
resistance to improve cardiac output. Glucagon
works on improving glucose levels by activating
hepatic glycogen.
Dosage: 2-10mg through IV push and may be
repeated as required for beta blocker and
calcium channel blocker toxicity. For
hypoglycemic toxicity, 1-2mg through
intramuscular injection.

111. • Methionine
• Indication: Paracetamol poisoning
Mode of Action: Protects against liver and
renal toxicity in cases of paracetamol
poisoning. It acts as a precursor of
glutathione to replenish gluthione stores
in the liver cells.
Dosage: 2-5 grams followed by three 2.5
grams doses every 4 hours.

112. • Naloxone
• Indication: Opioid overdose
Mode of Action: A specific opioid
antagonist that acts directly at opioid
receptors to inhibit its toxicity effects.
Dosage: 0.4 mg through intravenous push
as initial dose which can be further
repeated every 2-3 minutes to a maximum
bolus of 2 mg.

113. • Phentolamine
• Indication: Alpha-adrenergic poisoning, cocaine
toxicity
Mode of Action: Blocks alpha1 adrenoreceptors to
inhibit vasoconstriction and decrease peripheral
resistance thereby reducing blood pressure. For
cocaine toxicity, it acts as an alpha-blocker to
reduce cocaine-induced coronary vasoconstriction
thereby resolving cocaine-induced myocardial
ischemia.
Dosage: 2.5mg IV bolus and maybe repeated if
necessary.

114. • Phytomenadione (Vitamin K)
• Indication: Anti-coagulant poisoning
Mode of Action: Interrupts anti-
coagulant’s antagonistic effects on
vitamin-dependent coagulation factors
thereby reducing anti-coagulant
poisoning effects.
Dosage: 10-20mg orally

115. • Pralidoxime
• Indication: Organophosphorous
insecticides
Mode of Action: Restores
acetylcholinesterase activity by removing
phosphate compounds in the
phosphorylated acetylcholinesterase to
reestablish normal acetylcholinesterase
activities.
Dosage: 30mg/kg through intravenous for
five to ten minutes and may be repeated
at 4-6 hour intervals.

116. • Procyclidine
• Indication: Induced dystonia caused by
anti-psychotic drugs and metoclopramide
Mode of Action: Elicits anti-muscarinic
actions to relieve parkinsonian symptoms
caused by antipsychotic drugs and
metoclopramide
Dosage: 5-10mg through oral, IV or IM
routes. Additional oral doses may be
required for 2-3 days.

117. • Protamine sulfate
• Indication: Heparin poisoning
Mode of Action: Binds with heparin to
neutralize anti-coagulative effects in
the bloodstream.
Dosage: Maximum of 50mg dosage in a
ten-minute period.

118. • Prussian blue
• Indication: Thallium poisoning
Mode of Action: Mobilizes intracellular
thallium by absorbing thallium into the
insoluble crystal lattice of Prussian blue in
the gastrointestinal tract.
Dosage: 250mg/kg per day orally in
divided doses administered through a
nasogastric tube

119. • Silibinin
• Indication: Amatoxin poisoning
Mode of Action: Protects the liver by
blocking entry of amatoxins into the
hepatic cells.
Dosage: 20mg/kg daily divided into 4
infusions with each infusion running on
two-hour duration

120. • Sodium Calcium Edetate
• Indication: Lead toxicity
Mode of Action: Binds with divalent and
trivalent metals like lead to form water
soluble ring-compound to be readily
excreted in the urine.
Dosage: 30-40 mg/kg through intravenous
infusion either in 5% Dextrose or 0.9%
saline twice daily for up to 5 days.

121. • Sodium nitrite
• Indication: Cyanide/acrylonitrite
Mode of Action: Nitrites facilitate
conversion of hemoglobin to
methemoglobin. Methemoglobin has
higher binding affinity to cyanide which
further facilitates its excretion.
Dosage: 10mL of 3% sodium nitrite
solution through IV for 5-20 minutes
followed by sodium thiosulphate

122. • Sodium thiosulphate
• Indication: Cyanide/acrylonitrite
Mode of Action: Acts as a precursor for
the enzyme rhodanase which facilitates
conversion of cyanide to non-toxic
thiocyanate and thereby promoting its
excretion.
Dosage: 50mL of 25% sodium
thiosulphate through IV for ten minutes

123. • Starch
• Indication: Iodine
Mode of Action: Converts iodine to
iodide which is less harmful.
Dosage: 15gram starch in 500 mL
water orally

127. Slide Title
Product A
• Feature 1
• Feature 2
• Feature 3
Product B
• Feature 1
• Feature 2
• Feature 3