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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 as140 beats/minute).
  • Initial dose: 25 - 50 mg/kg loading dose IV over 30 minutes (maximum 1 g) followed by:
  • Infusion: 10 - 20 mg/kg/hour (maximum rate 650 mg/hr). Duration of treatment depends on symptoms and the chemical in question
    • Reduce dose in patients with renal dysfunction.


  • Reconstitution: Reconstitute each 1g vial with 20 mL of sterile water for injection providing a concentration of 50 mg/mL.
  • Initial dose: Further dilute to a final concentration of 20 mg/mL as per the following chart. 

Step 1

Calculate dose and then determine total volume (IV + Drug) to be infused

Step 2

Determine volume of  pralidoxime 50 mg/mL needed

Step 3

Determine volume of NaCl 0.9% needed


 Dose (mg)  
20 mg/mL (final conc)


total volume to be infused (mL)


 Dose (mg) 
50 mg/mL


volume of drug (mL)

total volume (step 1) Minus drug volume (step 2)
volume of NaCl 0.9% (mL)

Infusion: There is little information available regarding the use of continuous pralidoxime infusions in pediatric patients. For a final concentration of 20 mg/mL: add 1 g (20 mL of 50 mg/mL solution) to 30 mL sodium chloride 0.9% for a final volume of 50 mL. The IV bag should be changed every 4 hours due to lack of stability data. Duration of treatment depends upon 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, blurred vision, diplopia, headache, impaired accommodation, nausea and bradycardia.
  • Tachycardia, hypertension, rash, hyperventilation, laryngospasm, muscle rigidity, weakness, and transient increases in AST & ALT.


  • Pralidoxime salts may interfere with (and usually increases) 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.

Goldfrank, L. R., Nelson, L. S., Lewin, N. A., Howland, M. A., Hoffman, R. S., (2015). Goldfrank's toxicologic emergencies(Tenth ed.). New York: McGraw Hill.

Micromedex, T. H. A. (2014). Micromedex health care systems. Retrieved from http://www.micromedexsolutions.com

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.

Olson, K. R. (2007). Poisoning & drug overdose (Sixth ed.). New York: McGraw Hill.

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.