BNF for Children (BNFC) 2018-2019

lMEDICINAL FORMS

There can be variation in the licensing of different medicines

containing the same drug. Forms available from special-order

manufacturers include: solution for injection

Solution for injection

▶Sodium thiosulfate (Non-proprietary)

Sodium thiosulfate 250 mg per 1 mlSodium thiosulfate 12. 5 g/ 50 ml

solution for injection vials| 1 vialPs

2.2 Organophosphorus toxicity

Other drugs used for Organophosphorus toxicityAtropine

sulfate, p. 810

ANTIDOTES AND CHELATORS

Pralidoxime chloride

lINDICATIONS AND DOSE

Adjunct to atropine in the treatment of poisoning by

organophosphorus insecticide or nerve agent

▶BY INTRAVENOUS INFUSION

▶Child:Initially 30 mg/kg, to be given over 20 minutes,

followed by 8 mg/kg/hour; maximum 12 g per day

lUNLICENSED USEPralidoxime chloride doses may differ

from those in product literature.

Licensed for use in children (age range not specified by

manufacturer).

lCONTRA-INDICATIONSPoisoning with carbamates.

poisoning with organophosphorus compounds without

anticholinesterase activity

lCAUTIONSMyasthenia gravis

lSIDE-EFFECTSDizziness.drowsiness.headache.

hyperventilation.muscle weakness.nausea.tachycardia.

visual impairment

lRENAL IMPAIRMENTUse with caution.

lDIRECTIONS FOR ADMINISTRATIONThe loading dose may

be administered by intravenous injection (diluted to a

concentration of 50 mg/mL with water for injections) over

at least 5 minutes if pulmonary oedema is present or if it is

not practical to administer an intravenous infusion.

Forintravenous infusion, reconstitute each vial with

20 mL Water for Injections, then dilute to a concentration

of 10 – 20 mg/mL with Sodium Chloride 0. 9 %.

lPRESCRIBING AND DISPENSING INFORMATIONAvailable

from designated centres for organophosphorus insecticide

poisoning or from the National Blood Service (or Welsh

Ambulance Services for Mid West and South East Wales)—

see TOXBASE for list of designated centres).

lEXCEPTIONS TO LEGAL CATEGORYPrescription only

medicine restriction does not apply where administration

is for saving life in emergency.

lMEDICINAL FORMS

There can be variation in the licensing of different medicines

containing the same drug.

Powder for solution for injection

▶Protopam Chloride (Imported (United States))

Pralidoxime chloride 1 gramProtopam Chloride 1 g powder for

solution for injection vials| 6 vialPs

3 Drug toxicity

3.1 Benzodiazepine toxicity

ANTIDOTES AND CHELATORS›

BENZODIAZEPINE ANTAGONISTS

Flumazenil

lINDICATIONS AND DOSE

Reversal of sedative effects of benzodiazepines

▶BY INTRAVENOUS INJECTION

▶Neonate: 10 micrograms/kg every 1 minute if required,

dose to be administered over 15 seconds.

▶Child: 10 micrograms/kg every 1 minute (max. per dose

200 micrograms) if required, dose to be administered

over 15 seconds; maximum 1 mg per course; maximum

50 micrograms/kg per course

Reversal of sedative effects of benzodiazepines (if

drowsiness recurs after injection)

▶BY INTRAVENOUS INFUSION

▶Neonate: 2 – 10 micrograms/kg/hour, adjusted according

to response.

▶Child: 2 – 10 micrograms/kg/hour (max. per dose

400 micrograms/hour), adjusted according to response

Reversal of sedative effects of benzodiazepines in

intensive care

▶BY INTRAVENOUS INJECTION

▶Child: 10 micrograms/kg every 1 minute (max. per dose

200 micrograms) if required, dose to be administered

over 15 seconds; maximum 2 mg per course; maximum

50 micrograms/kg per course

lUNLICENSED USENot licensed for use in children under

1 year. Not licensed for use by intravenous infusion in

children. Not licensed for use in children in intensive care.

IMPORTANT SAFETY INFORMATION

Flumazenil should only be administered by, or under the

direct supervision of, personnel experienced in its use.

lCONTRA-INDICATIONSLife-threatening condition (e.g.

raised intracranial pressure, status epilepticus) controlled

by benzodiazepines

lCAUTIONSAvoid rapid injection following major surgery.

avoid rapid injection in high-risk or anxious patients.

benzodiazepine dependence (may precipitate withdrawal

symptoms).children.ensure neuromuscular blockade

cleared before giving.head injury (rapid reversal of

benzodiazepine sedation may cause convulsions).history

of panic disorders (risk of recurrence).prolonged

benzodiazepine therapy for epilepsy (risk of convulsions).

short-acting (repeat doses may be necessary—

benzodiazepine effects may persist for at least 24 hours)

lSIDE-EFFECTS

▶Common or very commonAnxiety.diplopia.dry mouth.

eye disorders.flushing.headache.hiccups.hyperhidrosis

.hyperventilation.hypotension.insomnia.nausea.

palpitations.paraesthesia.speech disorder.tremor.

vertigo.vomiting

▶UncommonAbnormal hearing.arrhythmias.chest pain.

chills.cough.dyspnoea.nasal congestion.seizure (more

common in patients with epilepsy)

▶Frequency not knownWithdrawal syndrome

lPREGNANCYNot known to be harmful.

lBREAST FEEDINGAvoid breast-feeding for 24 hours.

840 Drug toxicity BNFC 2018 – 2019

Emergency treatment of poisoning

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