Alternate Name(s):
PROTOPAM
Classification:
Antidote, Anticholinesterase; Antidote, Organophosphate Poisoning
Original Date:
January 2016
Revised Date:
June 2016
Indications:
- Organophosphate pesticide or chemical poisoning
- Overdose of anticholinesterase agents used in the treatment of myasthenia gravis
Reconstitution and Stability:
| VIAL SIZE | STERILE WATER for INJECTION REQUIRED | FINAL CONCENTRATION |
| 1000 mg | 20 mL | 50 mg/mL |
Compatibility:
- Solutuion Compatible: 0.9% NaCl
Administration:
(For approved routes of administration by nursing personnel, refer to Policy for the Administration of Intravenous Medications.)
| SC | YES- only if IV route not available |
| IM | YES - only if IV route not available Usual dilution: Dilute 1 g vial with 3.3 mL Sterile Water for Injection to get 300 mg/mL |
| IV Direct | YES Usual dilution: 50 mg/mL Infusion time: 5 minutes or greater, not to exceed 200 mg/minute |
| IV Intermittent Infusion |
YES - preferred Infusion time: over 15 - 60 minutes, rate not to exceed 200 mg/minute |
| IV Continuous Infusion | YES Usual dilution: 20 mg/mL in 0.9% NaCl |
Dosage:
(For neonatal dosages, refer to Neonatal IV Drug Manual.)
Dosage IV
- Children: less than or equal to 16 years
Load: 20 - 50 mg/kg (Maximum 2 g/dose)
May repeat dose after 1 hour is muscle weakness is not relieved and repeated every 10 - 12 hours if muscle weakness persists. Or may start continuous infusion of 10 - 20 mg/kg/hr (Maximum 500 mg/hr) - Adolescents greater than 16 years and adults:
Load: 1 - 2 g
Maintenance: repeat bolus of 1 - 2 g after 1 hour and repeat every 10 - 12 hours PRN or may start continuous infusion of 10 - 20 mg/kg/hr (Maximum 650 mg/hr)
Dosage IM
- less than 40 kg
- mild symptoms - 15 mg/kg/dose, repeat every 15 minutes prn to a maximum total of 45 mg/kg
- severe symptoms - 15 mg/kg/dose, repeat twice in rapid succession to deliver a total dose of 45 mg/kg
- persistent symptoms - repeat the entire series (45 mg/kg in 3 divided doses) beginning around 1 hour after administration of last injection - greater than or equal to 40 kg
- 600 mg, repeat every 15 minutes prn to maximum of 1800 mg
- severe symptoms - 600mg, repeat twice in rapid succession to deliver a total dose of 1800 mg
- persistent symptoms - may repeat entire series (1800 mg in 3 divided doses) beginning around 1 hour after administration of last injection
Dosage adjustment
- Use with caution and in reduced dosage in patients with renal dysfunction
Potential hazards of parenteral administration:
- Rapid IV infusion may be associated with temporary worsening of cholinergic manifestations (eg tachycardia, laryngospasm, muscle rigidity, cardiac arrest) in adults: in children, muscle fasiculations, apnea and convulsions have also been reported.
- Cardiovascular: cardiac arrest, hypertension, tachycardia
- Central nervous system: dizziness, drowsiness, headache, paralysis, seizure
- Dermatologic: rash
- Gastrointestinal: Nausea
- Hepatic: increased ALT and AST
- Local: Pain at injection site (IM)
- Neuromuscular and skeletal: fasciculations, increased creatinine phosphokinase, laryngospasm, muscle rigidity, weakness
- Ophthalmic: accommodation disturbance, blurred vision, diplopia
- Renal: renal insufficiency
- Respiratory: apnea, hyperventilation
Notes:
- Monitor heart rate, respiratory rate, muscle fasciculations and strength, pulse oximetry, blood pressure and cardiac monitoring