Emergency Preparedness and Poisonings
Transcript of Emergency Preparedness and Poisonings
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Emergency Preparedness and Poisonings
Copyright © 2017, 2014, 2011 Pearson Education, Inc. All Rights Reserved
Drugs Are Powerful Tools
• Prevent or control global disease outbreaks
– Biological, chemical, or nuclear attack
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The Nature of Bioterrorism
• After 9/11 attacks, awareness of outbreaks and treatments expanded to include bioterrorism
• Bioterrorism—intentional use of infectious biologic agents, chemical substances, or radiation to cause widespread harm or illness
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Table 11.1 Deadly Diseases in Human History (1 of 2)
Table 11.1 Deadly Diseases in Human History
Disease/Event Cause Target
Acquired immune deficiency
syndrome (AIDS)
Human immunodeficiency virus
(HIV)
Immune response
Bubonic plague Yersinia pestis, flea and rodent
vectors
Immune response and
respiratory system
Cholera Vibrio cholerae Digestive tract
Dengue fever and yellow fever Flavivirus Entire body (fever)
Ebola Zaire ebolavirus (filovirus) Immune response and
cardiovascular system
Hepatitis B Hepatitis B virus (HBV) Liver
Influenza (flu) Haemophilus influenza, avian and
swine vectors
Respiratory system
Leprosy Mycobacterium leprae Skin, nervous system, muscular
system
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Table 11.1 Deadly Diseases in Human History (2 of 2)
Table 11.1 Deadly Diseases in Human History
Disease/Event Cause Target
Malaria Plasmodium falciparum, female
Anopheles mosquito vector
Blood disorder
Measles Rubeola virus Lungs and meninges
SARS (severe acute respiratory
syndrome)
SARS coronavirus (SARS CoV) Respiratory system
Smallpox Variola virus Skin, mucosa, lymphoid tissue
Syphilis Treponema pallidum Genitalia, mucous membranes,
central nervous system
Tetanus (lockjaw) Clostridium tetani Entire body (infections)
Tuberculosis Mycobacterium tuberculosis Lungs
Whooping cough Bordetella pertussis Respiratory system
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Emergency Preparedness
• Not a new concept
• Hospitals required to have disaster plans
• Plans changed recently to include how health care system might change during a crisis
• Cooperation between different health care professionals is essential during a bioterrorist attack
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Key Roles of Nurse in Preparing for and Responding to Bioterrorist Attack
• Education
– Current knowledge/understanding of emergency management
• Resources
– Current list of contacts in health and law enforcement
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Key Roles of Nurse in Preparing for and Responding to Bioterrorist Attack
• Diagnosis and treatment
– Awareness of signs, symptoms, and treatment of chemical/biological agents
• Planning
– Involvement in emergency-management plans
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Table 11.2 Categories of Infectious Agents (1 of 2)
Table 11.2 Categories of Infectious Agents
Category Description Examples
A Agents that can easily be disseminated or
transmitted person to person; cause high
mortality, with potential for major public health
impact; might cause public panic and social
disruption; or require special action for public
health preparedness
Bacillus anthracis (anthrax)
Clostridium botulinum toxin (botulism)
Francisella tularensis (tularemia)
Variola major (smallpox)
Viral hemorrhagic fevers such as Marburg and Ebola
Yersinia pestis (plague)
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Table 11.2 Categories of Infectious Agents (2 of 2)
Table 11.2 Categories of Infectious Agents
Category Description Examples
B Agents that are moderately easy to
disseminate; cause moderate
morbidity and low mortality; or require
specific enhancements of
the CDC’s diagnostic capacity and
enhanced disease surveillance
Brucella species (brucellosis)
Burkholderia mallei (glanders)
Burkholderia pseudomallei (melioidosis)
Chlamydia psittaci (psittacosis)
Coxiella burnetii (Q fever)
Epsilon toxin of Clostridium perfringens
Food safety threats such as Salmonella and E. coli
Ricin toxin from Ricinus communis
Staphylococcus enterotoxin B
Viral encephalitis
Water safety threats such as Vibrio cholerae and
Cryptosporidium parvum
C Emerging pathogens that could be
engineered for mass dissemination
because of their availability, ease of
production and dissemination, and
potential for high morbidity and mortality
rates
and major health impacts
Hantaviruses
Multidrug-resistant tuberculosis
Nipah virus (NiV)
Tick-borne encephalitis viruses
Yellow fever
Source: Emergency Preparedness & Response: Bioterrorism Agents/Diseases, Centers for Disease Control and Prevention, 2014. Retrieved from
http://www.bt.cdc.gov/agent/agentlist-category.asp
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Strategic National Stockpile (SNS)
• Managed by the U.S. Centers for Disease Control and Prevention (CDC)
– Stockpile consists of antibiotics, vaccines, and medical, surgical, and patient supplies
– Designed to ensure immediate deployment of essential medical materials in case of biologic or chemical attack
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SNS Has Two Components
• Push package—first component
– Supplies and pharmaceuticals for unknown chemical or biological threat
– Arrives within 12 hours after attack
• Vendor-managed inventory (VMI) package—second component
– Supplies and pharmaceuticals for specific chemical or biological agent
– Arrives within 24 to 36 hours
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Anthrax
• Used as part of bioterrorist attacks in 2001
• Caused by Bacillus anthracis
• Can cause serious damage to body tissues
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Table 11.3 Clinical Manifestations of Anthrax
Table 11.3 Clinical Manifestations of Anthrax
Type Description Symptoms
Cutaneous anthrax Most common but least complicated
form of anthrax; almost always
curable if treated within the first few
weeks of exposure; results from
direct contact of contaminated
products with an open wound or cut
Small skin lesions develop and turn
into black scabs; inoculation takes less
than 1 week; cannot be spread by
person-toperson contact
Gastrointestinal
anthrax
Rare form of anthrax; without
treatment, can be lethal in up to 50%
of cases; results from eating
anthrax-contaminated food, usually
meat
Sore throat, difficulty swallowing,
cramping diarrhea, and abdominal
swelling
Inhalation anthrax Least common but the most
dangerous form of anthrax; can be
successfully treated if identified
within the first few days after
exposure; results from inhaling
anthrax spores
Initially, fatigue and fever for several
days, followed by persistent cough and
shortness of breath; without treatment,
death can result within 4–6 days
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Transmitted to Humans
• Exposure to open wound
• Through contaminated food
• By inhalation
• Causes disease by emission of two types of toxins—edema toxin and lethal toxin
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Anthrax Survivability
• Bacterium can form spores
– Spores can be viable in soil for hundreds or thousands of years
• Resistant to drying, heat, and some harsh chemicals
• Found in contaminated animal products such as wool, hair, dander, and bonemeal, but can also be packaged in other forms
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Clinical Manifestations of Anthrax
• Cutaneous anthrax
– Small skin lesions that turn into black scabs
• Gastrointestinal anthrax
– Sore throat, difficulty swallowing
– Cramping diarrhea, abdominal swelling
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Clinical Manifestations of Anthrax
• Inhalation anthrax
– Initially fatigue and fever
– Then persistent cough and shortness of breath
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Treatment for Anthrax
• Ciprofloxacin (Cipro)
– Prophylaxis—500 mg PO, every 12 hours for 60 days
– Confirmed case—400 mg IV, every 12 hours
• Other antibiotics that are effective
– Penicillin, vancomycin, ampicillin, erythromycin, tetracycline, and doxycycline
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Treatment for Anthrax
• Combination of ciprofloxacin and doxycycline approved
– For inhalation anthrax
• Discourage use of antibiotics where anthrax has not been found
– Can promote antibiotic-resistant strains
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Treatment for Anthrax
• Vaccines licensed by FDA for about 40 years, but little used because of low incidence of anthrax infection
– Recommended for very few people, such as laboratory staff who work with anthrax
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Polio and Smallpox Viruses
• Polio virus mostly eliminated, still found in some underdeveloped pockets of world
• Fear that bioterrorists will engineer a strain for use
– Mutated strain would not have a vaccine
• Smallpox virus maintained in some labs
– Highly contagious, easily spread
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Ebola Virus
• Bioterrorists have easy access to the Ebola virus
– Multiple ways to spread infection
– Ebola has 21-day incubation period (enough time for terrorists to infect selves and enter U.S.)
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Possible Responses to Ebola Outbreak
• Brincidofovir: given to first patients with Ebola without success
• Favipiravir: tested on Ebola patients in Guinea
• ZMapp: mixture of three synthetic antibodies to Ebola virus, some success, but some failures in 2014
• TKM-Ebola: used after ZMapp was exhausted, undergoing FDA phase one clinical trials
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Possible Responses to Ebola Outbreak
• Convalescent serum: contains Ebola-fighting antibodies, to be given to patient who has survived Ebola incident
• AVI-7537: experimental Ebola antiviral drug, targets protein responsible for replicating Ebola virus in host
• BCX4430: antiviral drug from Biocryst Pharmaceuticals, targets a key enzyme in Ebola virus
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Vaccination
• No effective therapies for patients infected by most viruses that could be used in a bioterrorist attack
• Vaccines can be created for some viruses
– Stimulate immune system to produce antibodies to prevent disease
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Contraindications to Receiving Smallpox Vaccine
• History of atopic dermatitis or eczema
• Acute, active, or exfoliative skin conditions
• Altered immune states
• Pregnant/breast-feeding women
• Children younger than 1 year
• Serious allergy to any component of the vaccine
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Disadvantages of Vaccination
• Concern about effectiveness against mutant strains of viruses
• Side effects possible
• Could provide terrorists with partial virus that could be engineered further
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Nerve Agents
• Can cause convulsions and loss of consciousness within seconds, respiratory failure within minutes
• Relate to overstimulation by the neurotransmitter acetylcholine at central and peripheral sites in body
– Blocks AchE, increasing action of acetylcholine in the synaptic space
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Nerve Agents and Treatment
• GA (Tabun), GB (Sarin), GD (Soman), VX treatment
– Give atropine injection
– Flush eyes with water
– Apply sodium bicarbonate or 5% liquid bleach solution to skin
– Do not induce vomiting
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Blood Agents and Treatment
• Hydrogen cyanide treatment
– Flush eyes and wash skin with water
– Give oxygen and amyl nitrate if mist inhaled
– If ingested, give 1% sodium thiosulfate to induce vomiting
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Blood Agents and Treatment
• Cyanogen chloride treatment
– Give oxygen and amyl nitrate
– Give milk or water; do not induce vomiting
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Choking/Vomiting Agents and Treatment
• Phosgene treatment
– Provide fresh air, and administer oxygen
– Flush eyes with normal saline or water
– Keep patient warm and calm
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Choking/Vomiting Agents and Treatment
• Adamsite (DM) treatment
– Rinse nose and throat with saline, water, or 10% solution of sodium bicarbonate
– Treat skin with borated talcum powder
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Blister/Vesicant Agents Treatment
• Phosgene oxime, Mustard-lewisite, Mixture-HL, Nitrogen mustard (HN-1, HN-2, HN-3), Sulfur mustard agents
– Flush affected areas with water
– Treat skin with 5% solution of sodium hypochlorite or household bleach
– Give milk to drink; do not induce vomiting
– For skin contact with Lewisite, treat with 10% solution of sodium carbonate
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Table 11.4 Chemical Warfare Agents and Treatments (1 of 2)
Table 11.4 Chemical Warfare Agents and Treatments
Category Signs of Discomfort/Fatality Antidotes/First Aid
NERVE AGENTS
GA—Tabun (liquid)
GB—Sarin (gaseous liquid)
GD—Soman (liquid)
VX (gaseous liquid)
Depending on the nerve agent,
symptoms may be slower to appear
and cumulative depending on
exposure time: miosis, runny nose,
difficulty breathing, excessive
salivation, nausea, vomiting,
cramping, involuntary urination and
defecation, twitching and jerking of
muscles, headaches, confusion,
convulsion, coma, death
Nerve agent antidote and Mark I injector kits
with atropine are available. Flush eyes
immediately with water. Apply sodium
bicarbonate or 5% liquid bleach solution to
the skin. Do not induce vomiting.
BLOOD AGENTS
Hydrogen cyanide (liquid)
Cyanogen chloride (gas)
Red eyes, flushing of the skin,
nausea, headaches, weakness,
hypoxic convulsions, death
Loss of appetite, irritation of the
respiratory tract, pulmonary edema,
death
Flush eyes and wash skin with water. For
inhalation of mist, oxygen and amyl nitrate
may be given. For ingestion of cyanide
liquid, 1% sodium thiosulfate may be given
to induce vomiting.
Oxygen and amyl nitrate may be given. Give
the patient milk or water. Do not induce
vomiting.
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Table 11.4 Chemical Warfare Agents and Treatments (2 of 2)
Table 11.4 Chemical Warfare Agents and Treatments
Category Signs of Discomfort/Fatality Antidotes/First Aid
CHOKING/VOMITING AGENTS
Phosgene (gas)
Adamsite—DM (crystalline
dispensed in aerosol)
Dizziness, burning eyes, thirst,
throat irritation, chills, respiratory
and circulatory failure, cyanosis,
frostbite-type lesions
Irritation of the eyes and respiratory
tract, tightness of the chest, nausea,
and vomiting
Provide fresh air. Administer oxygen. Flush
eyes with normal saline or water. Keep the
patient warm and calm.
Rinse nose and throat with saline, water,
10% solution of sodium bicarbonate. Treat
the skin with borated talcum powder.
BLISTER/VESICANT AGENTS
Phosgene oxime (crystalline or
liquid)
Mustard—lewisite
Mixture—HL
Nitrogen mustard—HN-1, HN-2,
HN-3
Sulfur mustard agents
Destruction of mucous membranes,
eye tissue, and skin (subcutaneous
edema), followed by scab formation;
irritation of the eyes, nasal
membranes, and lungs; nausea and
vomiting; formation of blisters on the
skin; cytotoxic reactions in
hematopoietic tissues including bone
marrow, lymph nodes, spleen, and
endocrine glands
Flush affected area with copious
quantities of water. If ingested, do not
induce vomiting. Treat the skin with 5%
solution of sodium hypochlorite or
household bleach. Give milk to drink. Do
not induce vomiting. Skin contact with
lewisite may be treated with 10% solution
of sodium carbonate.
Based on: Detailed Chemical Fact Sheets, U.S. Army Center for Health Promotion and Preventive Medicine, 1998. Retrieved from
https://www.hsdl.org/?view&did=1088
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Ionizing Radiation
• Can result from hundreds of different radioisotopes created by nuclear explosion
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Immediate Symptoms of Acute Radiation Syndrome
• Occur hours or days after exposure
• Nausea, vomiting, diarrhea
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Later Symptoms of Acute Radiation Exposure
• Weight loss, anorexia, fatigue, bone-marrow suppression
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Survivors of Acute Radiation Exposure
• High risk for developing cancers, particularly leukemia
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Treating Radiation Exposure
• Symptoms are some of the most difficult to treat pharmacologically
• Potassium iodide (KI) tablets are one of the few recognized approaches
– Prevents radioactive iodine (I-131) from entering thyroid gland
– Protects only thyroid gland
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Management of Poisoning
• Nurses must be familiar with basic elements of toxicity treatment
• Pharmacologic agents approach toxicity when doses exceed recommended range
• Poisonings intentional or accidental
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Basic Supportive Care for Toxicity
• One of the first elements of toxicity treatment
• Maintain airway, breathing, and circulation
• Maintain proper blood glucose levels
• Provide treatment of developing seizures
• Agents may be used to facilitate removal of some toxins
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Table 11.5 2012 Data: Top 25 Substances
Involved in Human Exposures (1 of 3)
Table 11.5 2012 Data: Top 25 Substances Involved in Human Exposures
Substance Number Percentages*
Analgesics 289,786 28.26
Information calls 130,853 12.76
Sedative–hypnotics/antipsychotics 116,392 11.35
Stimulants and street drugs 59,587 5.81
Unknown drug 46,528 4.54
Muscle relaxants 40,587 3.96
Cardiovascular drugs 40,436 3.94
Invalid/missing 40,358 3.94
Antidepressants 38,479 3.75
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Table 11.5 2012 Data: Top 25 Substances
Involved in Human Exposures (2 of 3)
Table 11.5 2012 Data: Top 25 Substances Involved in Human Exposures
Substance Number Percentages*
Antihistamines 33,683 3.28
Antimicrobials 29,520 2.88
Anticonvulsants 19,069 1.86
Hormones and hormone antagonists 18,528 1.81
Gastrointestinal preparations 17,747 1.73
Pesticides 9,859 0.96
Cold and cough preparations 8,765 0.85
Diuretics 8,344 0.81
Miscellaneous drugs 7,966 0.78
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Table 11.5 2012 Data: Top 25 Substances
Involved in Human Exposures (3 of 3)
Table 11.5 2012 Data: Top 25 Substances Involved in Human Exposures
Substance Number Percentages*
Foreign bodies/toys/miscellaneous 6,634 0.65
Cleaning substances (household) 5,111 0.50
Plants 4,524 0.44
Bites and envenomations 3,902 0.38
Chemicals 3,757 0.37
Other/unknown nondrug substances 3,735 0.36
Cosmetics/personal care products 3,497 0.34
*Percentages are based on 1,025,575 exposures.
Source: ―2012 Annual Report of the American Association of Poison Control Centers’
National Poison Data System (NPDS): 30th Annual Report,‖ by J. B. Mowry, D. A. Spyker,
L. R. Cantilena, J. E. Bailey, and M. Ford, 2013, Clinical Toxicology, 51, pp. 940–1229.
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Surface Decontamination
• Remove clothes
• Flush with water
• Soap-and-water and alcohol washes for undamaged skin
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Syrup of Ipecac
• Used to induce vomiting
• Benefits questionable, especially with caustic poisonings
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Further Poisoning Treatments
• Gastric lavage and aspiration
– Used if patient has ingested a potentially life-threatening amount of poison
– Must be done within 60 minutes
• Single-dose activated charcoal
– Used if poison is carbon-based
– Greatest benefit within 60 minutes
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Further Poisoning Treatments
• Whole-bowel irrigation
– For potentially toxic ingestions of sustained-release or enteric-coated drugs
– For toxic ingestions of iron, lead, zinc, or illicit drugs
• Specific antidotes counter effects of poisons or toxins in cases such as heavy metal poisoning
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Table 11.6 Specific Antidotes for Overdosed Substances or Toxins (1 of 2)
Table 11.6 Specific Antidotes for Overdosed Substances or Toxins
Generic Name Trade Name Overdosed Substance or Toxin
(Pharmacologic/Toxicity Group)
acetylcysteine Acetadote Acetaminophen (nonopioid analgesic)
atropine sulfate Acetylcholine; cholinergic receptor agents;
acetylcholinesterase inhibitors (parasympathomimetic)
calcium EDTA Calcium Disodium Versenate Lead toxicity (heavy metal poisoning)
deferoxamine Desferal Iron toxicity (heavy metal poisoning)
digoxin immune Fab Digibind Digoxin (cardiac glycoside)
dimercaprol BAL in Oil Arsenic, gold and mercury toxicity (heavy metal poisoning)
flumazenil Romazicon Benzodiazepines (sedative–hypnotic)
fomepizole Antizole Ethylene glycol toxicity (antifreeze poisoning)
glucagon Insulin (hypoglycemia)
leucovorin Wellcovorin Methotrexate; folic acid blocking agents
(antineoplastic/antimetabolite)
naloxone Narcan Opioid agents; morphine (opioid analgesic)
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Table 11.6 Specific Antidotes for Overdosed Substances or Toxins (2 of 2)
Table 11.6 Specific Antidotes for Overdosed Substances or Toxins
Generic Name Trade Name Overdosed Substance or Toxin
(Pharmacologic/Toxicity Group)
neostigmine Prostigmin Neuromuscular blocking agents (nondepolarizing blocker)
penetrate calcium trisodium Radioactive plutonium, americium and curium (radioactive
exposure)
penetrate zinc trisodium Radioactive plutonium, americium and curium (radioactive
exposure)
penicillamine Cuprimine, Depen Copper, iron, lead, arsenic, gold and mercury toxicity (heavy metal
poisoning)
physostigmine Antilirium Cholinergic blocking agents; atropine sulfate (anticholinergic)
potassium iodide Radioactive iodine toxicity (nuclear bomb; radioactive exposure)
pralidoxime Protopam Cholinesterase inhibitors; organophosphates; neostigmine;
physostigmine (parasympathomimetic)
protamine sulfate Heparin (parenteral anticoagulant)
prussian blue Radiogardase Radioactive cesium-137; nonradioactive thallium (radioactive
cesium exposure; thallium poisoning)
succimer Chemet Lead, mercury, and arsenic toxicity (heavy metal poisoning)
vitamin K Coumadin; warfarin (oral anticoagulant)