Pediatric emergency medicine trisk 3053 3053
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Snake, crotalidae (all
North American
rattlers and
moccasins)
Snake, coral
Spider, black widow
Crotalidae polyvalent immune Fab (BTG International)
Antivenin (Micrurus fulvius ), monovalent (Wyeth)
Antivenin Latrodectus mactans (Merck Sharp &
Dohme)
a Dosing
b See
for lead poisoning/encephalopathy. Chelation regimens vary for other heavy metal poisonings.
package insert for dosage and administration.
The mechanism of action of naloxone is by competitive displacement of
narcotic analgesics at central opioid receptor sites. It can be used as a diagnostic
test when faced with a questionable history. Current dosage recommendations
reflect the proven safety of naloxone in large doses and the necessity of such
doses to reverse effects of synthetic opioids such as propoxyphene, pentazocine,
oxycodone, and methadone. If severe respiratory depression is present and the
likelihood of opioid dependence is not known, the initial dose should be 0.4 mg
IV. Young children in whom long-term opioid exposures are not a concern may be
given an initial empiric dose of 1 to 2 mg. Repeat doses may be given every 2
minutes until 10 mg has been administered for adolescent patients with suspected
opioid overdose who fail to respond to the lower dosages. Of course, concomitant
airway management is vital. In patients without respiratory depression, an initial
dose of 0.4 to 1 mg can be used. In adolescents suspected of chronic opiate abuse,
smaller initial doses (e.g., 0.05 to 0.4 mg) are warranted. Again, if there is no
response but a strong clinical suspicion, 2-mg doses can be repeated up to a total
of 10 mg before concluding that further dosing will be of no benefit. Naloxone
can also be given intramuscularly (IM), sublingually, intranasally, or by
endotracheal tube if no IV access is available.
If a patient demonstrates a response to naloxone, repeat the effective total dose
every 20 to 60 minutes. An alternative approach is to provide a continuous IV
infusion; generally about two-thirds of the total reversal dose will need to be
infused per hour initially, with subsequent adjustments as necessary. This is more
likely to be needed in long-acting opioid overdoses.
Nalmefene and naltrexone are longer-acting opioid antagonists that may have
use in some clinical situations in which a longer duration of action (4 to 6 hours
for nalmefene, 24 hours for naltrexone) is beneficial, such as in reversal of
procedural/postoperative opioid depression or as aids in opioid detoxification
programs. However, as antidotes for acute opioid overdose in the adolescent or
