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Poisoning Information for the Public & Health Care Professionals
Last updated: 01/2020


Protopam®, 2-PAM

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Protopam®, 2-PAM


  • Poisoning by organophosphate pesticides and other anticholinesterase chemicals (nerve agents, carbamates). Used in addition to atropine.


  • Atropine effects should be established prior to the administration of pralidoxime (e.g.dry, flushed skin, drying of secretions and tachycardia as high as 140 beats/minute).
  • Initial Dose: 1 - 2 g IV over 30 minutes followed by:
  • Infusion: 8 - 10 mg/kg/hour (maximum rate 650 mg/hour). Duration of treatment depends on symptoms and the chemical in question.
    • Reduce dose in patients with renal impairment.


  • Reconstitution: Reconstitute 1 g vial with 20 mL sterile water for injection to provide a concentration of 50 mg/mL.
  • Infusion, intermittent: Dilute 1 g or 2 g in 100 mL sodium chloride 0.9% and administer over 15 - 30 minutes.
  • Infusion, continuous: For a final concentration of 8 mg/mL: dilute 2g (40 ml) in 210 ml sodium chloride 0.9% and administer at the prescribed rate. Duration of treatment depends on symptoms and the chemical in question. Cardiac monitoring, blood pressure monitoring, respiratory support, and an infusion device are required.

Compatibility, Stability

  • Compatible with sodium chloride 0.9%.

Potential Hazards of Administration

  • Dizziness, drowsiness, blurred vision, diplopia, impaired accommodation, headache, nausea.
  • Tachycardia, hypertension, rash, hyperventilation, laryngospasm, muscle rigidity, weakness, transient increases in AST and ALT.
  • Precipitation of myasthenic crisis in patients with myasthenia gravis.


  • Pralidoxime salts may interfere with (and usually increase) the following lab tests if ultraviolet absorption spectrophotometry method is used: glucose, alanine aminotransferase (ALT), blood urea nitrogen (BUN), creatine kinase (CK), lactate dehydrogenase (LDH), cholinesterase.
  • Treatment is most effective if given within a few hours after poisoning.
  • The concurrent use of morphine, theophylline, aminophylline and succinylcholine are contraindicated.
  • Antipsychotics such as reserpine or phenothiazines are to be avoided.
  • When atropine and pralidoxime are used concurrently, signs of atropinism may occur earlier.
  • This medication is provided via the Special Access Program, Health Canada. Appropriate forms must be filled out.

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Borron, S. W., Bronstein, A. C., Fernandez, M. C., & et all. (2014). Walter F. G. (Ed.), AHLS advanced hazmat life support, provider manual (4th ed.). Tucson, Arizona: The University of Arizona College of Medicine.

Eddleston, M., Buckley, N. A., Eyer, P., & Dawson, A. H. (2008). Management of Acute Organophosphorous pesticide poisoning: Lancet, 371 (9612)(February), 597-604.

Goel, P., Gupta, N., Singh, S., Bhalla, A., Sharma, N., & Gill, K. D. (2012). Regeneration of red cell cholinesterase activity following pralidoxime (2-pam) infusion in first 24 h in organophosphate poisoned patients. Indian Journal of Clinical Biochemistry, 27, 34-39.

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Nagase, S., Kohguchi, K., Tohyama, K., Watanabe, M., & Iwatani, Y. (2012). Interference by pralidoxime (2-pam) salts in clinical laboratory tests. International Journal of Clinical Chemistry, 416, 72-79.

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Parvez, Y., Mathew, A., & Kutti, S. K. (2012). Case report: Recurrent neonatal organophoshorus poisoning. Indian Pediatrics, 49, 752-753.

Phelps SJ, C. C. (2013).  Teddy bear, pediatric injectable drugs. Retrieved from http://www.pharmpress.com/product/MC_PED/pediatric-injectable-drugs

Shannon, M. W., Borron, S. W., & Burns, M. J. (2007). Haddad and Winchester's clinical management of poisoning and drug overdose (Fourth ed.). Philadelphia: Saunders Elsevier.

Tang, X., Wang, R., Xie, H., Hu, J., & Zhao, W. (2013). Repeated pulse intramuscular injection of pralidoxamine chloride in severe acute organophosurus pesticide poisoning. American Journal of Emergency Medicine, 31, 946-949.

Trissel, Lawrence, A,. (2013). Handbook on injectable drugs (17th ed.). Bethesda, Maryland: American Society of Health-System Pharmacists

White, M. L., & Liebelt, E. L. (2006). Update on antidotes for pediatric poisoning. Pediatric Emergency Care, 22(11), 740-746.