NATIONAL
CALIFORNIA
VENTURA
category
Antidote
mechanism
  • Reactivates cholinesterase that had been inactivated by organophosphate pesticides and cholinesterase-inhibiting nerve agents (eg, terrorism and chemical warfare agents such as sarin) by displacing the organophosphate or nerve agent from cholinesterase.
indications
  • Anticholinesterase overdose: Treatment of overdose of anticholinesterase medications used to treat myasthenia gravis (ambenonium, neostigmine, pyridostigmine).
  • Organophosphate poisoning (eg, pesticides, nerve agents): Treatment of muscle weakness and/or respiratory depression secondary to poisoning due to organophosphate anticholinesterase pesticides and terrorism nerve agents.
contraindications
  • No absolute contraindications.
  • Use with caution in patients with myasthenia gravis because it may precipitate a myasthenic crisis.
dosing

See NOTES section below for examples of mild vs severe symptoms

Adult:

Mild symptoms: IM, SUBQ: 600 mg; repeat as needed for persistent mild symptoms every 15 minutes to a maximum total dose of 1,800 mg; may administer doses in rapid succession if severe symptoms develop.

Severe symptoms: IM, SUBQ: 600 mg; repeat twice in rapid succession to deliver a total dose of 1,800 mg.

Pediatric:

Mild symptoms: IM, SUBQ: 15 mg/kg/dose; repeat as needed for persistent mild symptoms every 15 minutes to a maximum total dose of 45 mg/kg; may administer doses in rapid succession if severe symptoms develop.

Severe symptoms: IM, SUBQ: 15 mg/kg/dose; repeat twice in rapid succession to deliver a total dose of 45 mg/kg.

administration
May administer IM if IV administration is not feasible. If using the auto-injector, remove gray safety cap and place black end against outer thigh. Push hard until injector administers, hold in place for 10 seconds, then remove and massage area of injection.
onset

peak

IV: 5 to 15 minutes

IM: 35 minutes

duration

3 hours

notes
  • Exposure protection: Ensure safety and protection of rescue personnel so that they are not exposed as well.
  • Atropine for respiratory depression: Pralidoxime is less effective in relieving depression of the respiratory center so atropine is always required concomitantly to block the effect of accumulated achetylcholine at this site.
  • Mild Exposure Symptoms: Miosis, rhinorrhea, drooling, sweating, blurred vision, nausea, bradypnea or tachypnea, nervousness, fatigue, minor memory disturbances, irritability, unexplained tearing, wheezing, tachycardia, bradycardia, dyspnea, muscle weakness and fasciculations, GI effects.
  • Severe Exposure Symptoms: Strange or confused behavior, severe difficulty breathing, twitching, unconsciousness, seizing, flaccidity, apnea, pinpoint pupils, involuntary defecation or urination
  • DuoDote: DuoDote contains Atropine Sulfate and Pralidoxime Chloride
dosage form
IM Solution Auto-injector: 600 mg/2 mL (2 mL)
Duodote: Atropine 2.1 mg/0.7 mL and pralidoxime chloride 600 mg/2 mL
brand name
DuoDote Kit
adverse reactions
  • Cardiovascular
    • Cardiac arrest
    • Hypertension
    • Tachycardia
  • Central nervous system
    • Dizziness
    • Drowsiness
    • Headache
    • Paralysis
    • Seizure
  • Dermatologic
    • Rash
  • Gastrointestinal
    • Nausea and vomiting
  • Local
    • Pain at injection site (IM)
  • Neuromuscular & skeletal
    • Fasciculations
    • Increased creatine phosphokinase
    • Laryngospasm
    • Muscle rigidity
    • Weakness
  • Ophthalmic
    • Blurred vision
    • Diplopia
  • Respiratory
    • Apnea
    • Hyperventilation
structure
pralidoxime.svg molecular structure