What antidotes should my hospital stock?

December 15, 2009, 1:24 pm

★★★★★

EXPERT CONSENSUS GUIDELINES FOR STOCKING OF ANTIDOTES IN HOSPITALS THAT PROVIDE EMERGENCY CARE Dart RC et al. Ann Emerg Med 2009;54:386.

Abstract

This article is essential reading for all physicians and clinical pharmacists who participate in or plan for the care of poisoned patients.  Inadequate stocking of crucial antidotes in hospitals and emergency has been a persistent and well-documented problem.  In this study an expert panel, following detailed and careful methods, established a set of guidelines (which they state specifically are “not intended to create a standard of care”) to aid in such stocking decisions. The amount of antidote recommended was that sufficient to treat one 100-kg patient.

The panel considered 24 antidotes.  They recommended that 12 antidotes be available immediately (that is, stocked in the emergency department). These are: atropine, calcium gluconate, cyanide antidote kit OR hydroxocobalamin, digoxin immune Fab, flumazenil, glucagon, methylene blue, naloxone, physostigmine, pyridoxine, and sodium bicarbonate. The also recommended that another 9 antidotes be available within one hour: acetylcysteine, Wyeth polyvalent Crotalidae antivenin OR Crotalidae Polyvalent immune Fab, coral snake antivenin, deferoxamine, dimercaprol, ethanol OR fomepizole, octreotide, potassium iodide, and pralidoxine.

It’s certainly possible to challenge some of these recommendations.   Since the Crotalidae antivenin is the most expensive of the recommended antidotes ($18,000 – $36,000 for an 8-hour course) it would not make sense for every hospital to stock it. The panel did take this into consideration, and recommended that each hospital carry out an antidote hazard risk assessment to determine individual needs.  The paper also notes that the coral snake antivenin has been discontinued by the manufacturer. In addition, I don’t think that flumazenil and physostigmine would be considered by all clinicians as antidotes that absolutely must be stocked in the emergency department. (They are both, however, relatively inexpensive.)  But despite these points of contention, the guidelines serve as a very valuable starting point for considering antidote purchasing and stocking.

One interesting fact I learned from this paper: glucagon is incredibly expensive.  The cost of an 8-hour course of treatment ($7875) is much greater than that for hydroxocobalamin, IV acetylcysteine, fomepizole, and pralidoxime combined.

5 Comments:

  1. precordialthump Says:

    Hi Leon,

    I’d chuck out glucagon and add in insulin/glucose!

    I wonder if intralipid will find its way onto this list in the future…

    Cheers,
    Chris

  2. Leon Says:

    Chris:

    I’d agree that having 8 hours worth of glucagon on hand might be a bit much considering the price. Having enough to treat for an hour or two might come in handy for the severe beta-blocker overdose, especially if reliable agreements to get some more fast can be worked out with nearby hospitals. Insulin/glucose is a must — the authors might not have mentioned it because they assumed it would be available in any case.

    I also look forward to seeing what the future holds for intralipid. While in my opinion it’s not yet ready for prime time as first-line treatment, the experience so far looks good, especially in the crashing tox patient with cardiovascular instability that is not responding to standard therapy.

  3. Potassium Iodide Says:

    potassium iodide is not an antidote as it is to be taken prior to exposure. However, it should be stocked by every hospital.

  4. Mycyk Says:

    Yes, I agree, essential 5-star (skull) reading for all clinicians. A terrific update of their earlier paper. I especially appreciate the use of a 100kg patient for their recommendations — it shows this expert panel is really in touch with clinical reality in the 21st Century.

  5. Leon Says:

    Potassium Iodide: that’s an excellent point. Unfortunately, the paper. Unfortunately, the paper did not give detailed explanations for all their decisions, including that concerning KI. Perhaps they envisioned a situation where a radioactive iodine release at a nearby facility might send people flocking to the ED, even before actual exposure. In that case, it’s difficult to see why they recommended stocking only a single adult dose, especially since KI is so inexpensive.

    Mycyk: I think the panel probably realized the obvious — if you have enough antidote available to treat only a single 70-kg patient, you’ll end up underdosing a large part of the population.