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ORIGINAL ARTICLE • Sao Paulo Med. J. 135 (01) • Jan-Feb 2017 • https://doi.org/10.1590/1516-3180.2016.00171120816 copy

Antidote availability in the municipality of Campinas, São Paulo, Brazil

Disponibilidade de antídotos no município de Campinas, São Paulo

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

CONTEXT AND OBJECTIVE:

The lack of availability of antidotes in emergency services is a worldwide concern. The aim of the present study was to evaluate the availability of antidotes used for treating poisoning in Campinas (SP).

DESIGN AND SETTING:

This was a cross-sectional study of emergency services in Campinas, conducted in 2010-2012.

METHODS:

The availability, amount in stock, place of storage and access time for 26 antidotal treatments was investigated. In the hospitals, the availability of at least one complete treatment for a 70 kg adult over the first 24 hours of admission was evaluated based on stock and access recommendations contained in two international guidelines.

RESULTS:

14 out of 17 functioning emergency services participated in the study, comprising pre-hospital services such as the public emergency ambulance service (SAMU; n = 1) and public emergency rooms for admissions lasting ≤ 24 hours (UPAs; n = 3), and 10 hospitals with emergency services. Six antidotes (atropine, sodium bicarbonate, diazepam, Phytomenadione, flumazenil and calcium gluconate) were stocked in all the services, followed by 13 units that also stocked activated charcoal, naloxone and diphenhydramine or biperiden. No service stocked all of the recommended antidotes; only the regional Poison Control Center had stocks close to recommended (22/26 antidotal treatments). The 10 hospitals had almost half of the antidotes for starting treatments, but only one quarter of the antidotes was present with stocks sufficient for providing treatment for 24 hours.

CONCLUSION:

The stock of antidotes for attending poisoning emergencies in the municipality of Campinas is incomplete and needs to be improved.

KEY WORDS:
Antidotes; Brazil; Poisoning; Strategic stockpile; Emergency medical services

Item	Antidote, route	Pharmaceutical preparation	Recommended stockpile	Clinical indication^* *In cases of treatment for a specific type of poisoning, only the name of the agent is shown.
1	Acetylcysteine, IV Acetylcysteine, PO	100 mg/ml; 3 ml ampoule 600 mg sachet	70 ampoules 155 sachets	Paracetamol
2	Activated charcoal, PO	10 g, 25 g or 50 g sachets	300 g (e.g., 6 × 50 g sachets)	Adsorbent for gastrointestinal decontamination
3	Anti-digoxin antibodies, IV	38 mg vial	10 vials	Cardioactive steroids
4	Atropine, IV	250 μg/ml; 1 ml ampoule	300 ampoules	Cholinesterase inhibitors
5	Calcium folinate, IV	300 mg vial; 50 mg vial; 3 mg/ml; 1 ml ampoule	3 × 300 mg vials, or 16 × 50 mg vials, or 240 ampoules	Methotrexate; methanol, formic acid
6	Calcium gluconate, IV	10% (100 mg/ml); 10 ml ampoules	12 ampoules	Calcium channel blockers, hydrofluoric acid
7	Calcium gluconate, topic	gel 2.5%; 25 g pack	1 pack	Hydrofluoric acid burns
8	Dantrolene, IV	20 mg vial	35 vials	Neuroleptic malignant syndrome
9	Desferrioxamine, IV	500 mg vial	12 vials	Iron salts
10	Diazepam, IV	5 mg/ml; 2 ml ampoule	4 ampoules	Convulsions, agitation and precordial pain
11	Dimercaprol, IM	100 mg/ml; 1 ml ampoule	15 ampoules	Mercury, arsenic, gold
12	Diphenhydramine, IV Biperiden, IV	50 mg/ml; 1 ml ampoule 5 mg/ml; 1 ml ampoule	4 ampoules 4 ampoules	Dystonic reactions
13	Flumazenil, IV	100 μg/ml; 5 ml ampoule	4 ampoules	Benzodiazepines
14	Fomepizole, IV Ethanol, IV	5 mg/ml; 20 ml ampoule 100%; 10 ml ampoule	25 ampoules 30 ampoules	Methanol, ethylene glycol
15	Glucagon, IV	1 mg vial	50 vials	Beta blockers, calcium channel blockers, tricyclic antidepressants
16	Hydroxocobalamin, IV Sodium nitrite, IV and sodium thiosulfate, IV	5 g pack 3% (30 mg/ml); 10 ml ampoule 25% (250 mg/ml); 10 ml ampoule	2 packs 1 ampoule 8 ampoules	Cyanide
17	Methylene blue, IV	1-2 mg/ml; 5 ml ampoule	3-6 ampoules	Methemoglobin-inducing agents
18	Naloxone, IV	0.4 mg/ml; 1 ml ampoule	25 ampoules	Opioids
19	Octreotide, IV	0.1 mg/ml; 1 ml ampoule	2 ampoules	Oral hypoglycemic agents
20	Physostigmine, IV	1 mg/ml; 2 ml ampoule	2 ampoules	Anticholinergic agents
21	Phytomenadione (vitamin K), IV	10 mg/ml; 1 ml ampoule	1 ampoule	Coumarin anticoagulants
22	Polyethylene glycol 3350, PO	Sachets, reconstituted with water (2 l)	12 sachets	Iron salts, lithium, packs of cocaine or heroin (body packers)
23	Pralidoxime, IV	1 g vial	5 vials	Organophosphates insecticides
24	Protamine sulfate, IV	10 mg/ml; 5 ml ampoule	1 ampoule	Heparin
25	Pyridoxine, IV	100 mg/ml; 10 ml ampoule	5 ampoules	Isoniazid
26	Sodium bicarbonate, IV	8.4%; 250 ml vial	750 ml (3 vials or 75 ampoules)	Tricyclic antidepressants, serum and urinary alkalization

Antidotes^* *No emergency service had anti-digoxin antibodies, physostigmine or pralidoxime;	Pre-hospital services		Emergency hospitals			Total n = 14
	SAMU	UPA	Small	Medium	Large
	(ambulance)	(8-21 beds)	(< 50 beds)	(50-250 beds)	(> 250 beds)
	n = 1	n = 3	n = 1	n = 8	n = 1
Atropine	1	3	1	8	1	14
Calcium gluconate 10%	1	3	1	8	1	14
Diazepam	1	3	1	8	1	14
Flumazenil	1	3	1	8	1	14
Phytomenadione (vitamin K)	1	3	1	8	1	14
Sodium bicarbonate	1	3	1	8	1	14
Activated charcoal	0	3	1	8	1	13
Diphenhydramine or biperiden	1	2	1	8	1	13
Naloxone	1	2	1	8	1	13
Acetylcysteine	0	0	1	8	1	10
Dantrolene	0	0	1	8	1	10
Methylene blue	0	0	1	8	1	10
Octreotide	0	0	0	7	1	8
Protamine sulfate	0	0	1	5	1	7
Calcium folinate	0	0	0	3	1	4
Ethanol^† †fomepizole was not available;	0	0	0	3	1	4
Polyethylene glycol 3350	0	0	0	3	1	4
Calcium gluconate gel	0	0	0	0	1	1
Desferrioxamine	0	0	0	0	1	1
Dimercaprol	0	0	0	0	1	1
Pyridoxine	0	0	0	0	1	1
Sodium nitrite and sodium thiosulfate^‡ ‡hydroxocobalamin was not available.	0	0	0	0	1	1
Glucagon	0	0	0	1	0	1

Antidotes	Availability in ED (n = 10)
Antidotes	< 1 hour	Adequate stock
Diazepam	10	10
Phytomenadione (vitamin K)	10	10
Flumazenil	10	10
Calcium gluconate 10%	10	10
Diphenhydramine or biperiden	10	10
Sodium bicarbonate	10	10
Methylene blue	10	10
Acetylcysteine	10	8
Atropine	10	6
Activated charcoal	10	5
Naloxone	10	5
Dantrolene	10	4
Octreotide	8	7
Protamine sulfate	7	7
Calcium folinate	4	4
Polyethylene glycol 3350	4	2
Ethanol^* *Fomepizole was not available;	4	2
Pyridoxine	1	1
Calcium gluconate gel	1	1
Desferrioxamine	1	1
Dimercaprol	1	1
Sodium nitrite and sodium thiosulfate^† †hydroxocobalamin was not available.	1	1
Glucagon	1	0

Exposures (n = 5,362)^* *Exposures could be for one or more agents;	n	%
Pharmaceuticals
Sedatives/anticonvulsants	761	14.2
Benzodiazepines	468	8.7
Carbamazepine	113	2.1
Phenobarbital	61	1.1
Antidepressants	403	7.5
Selective serotonin uptake inhibitors	220	4.1
Tricyclic antidepressants	112	2.1
Antipsychotics	236	4.4
Risperidone	45	0.8
Quetiapine	36	0.7
Analgesics and antipyretics	242	4.5
Paracetamol	120	2.2
Dipyrone	96	1.8
Histamine H₁-receptor antagonists	183	3.4
Venomous animal bites/stings
Scorpion stings	398	7.4
Snake bites	68	1.3
Spider bites	71	1.3
Caterpillars	69	1.3
Cleaning substances (household)
Cleansers/detergents/soaps/softeners	366	6.8
Bleaches	139	2.6
Pesticides
Rodenticides (anticoagulants)	150	2.8
Pyrethroids	122	2.3
Illegal rodenticides (“chumbinho”)^† †“Chumbinho” = illegal rodenticide used in Brazil since the 1990s containing Cholinesterase inhibitors, mainly carbamates such as aldicarb.	74	1.4
Organophosphates/carbamates	66	1.2
Abused drugs
Cocaine	125	2.3
Ethanol	91	1.7

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