CBD for Medical Conditions

UNITED NATIONS ENVIRONMENT PROGRAMME

INTERNATIONAL LABOUR ORGANISATION

WORLD HEALTH ORGANIZATION

INTERNATIONAL PROGRAMME ON CHEMICAL SAFETY

 

MANAGEMENT OF POISONING

A handbook for health care workers

The issue of this document does not constitute formal publication.

It should not be reviewed, abstracted, or quoted without the written

permission of the Manager, International Programme on Chemical Safety,

WHO, Geneva, Switzerland.

 

This report contains the collective views of an international group of

experts and does not necessarily represent the decisions or the stated

policy of the United Nations Environment Programme, the International

Labour Organisation, or the World Health Organization.

Management of Poisoning

 

First draft prepared at the National Institute of Health Sciences, and the Institute of Terrestrial Ecology

Published under the joint sponsorship of the United Nations

Environment Programme, the International Labour Organisation, and the

World Health Organization

World Health Organization

Geneva, 1997

 

The International Programme on Chemical Safety (IPCS) is a joint

venture of the United Nations Environment Programme, the International

Labour Organisation, and the World Health Organization. The main

objective of the IPCS is to carry out and disseminate evaluations of

the effects of chemicals on human health and the quality of the

environment. Supporting activities include the development of

epidemiological, experimental laboratory, and risk-assessment methods

that could produce internationally comparable results, and the

development of manpower in the field of toxicology. Other activities

carried out by the IPCS include the development of know-how for coping

with chemical accidents, coordination of laboratory testing and

epidemiological studies, and promotion of research on the mechanisms

of the biological action of chemicals.

 

WHO Library Cataloguing in Publication Data

 

Henry J.A.

Management of poisoning:  a handbook for health care workers /

J.A. Henry Wiseman.

 

1.Toxicology – handbooks  2.Poisons – handbooks  3.Poisoning –

prevention & control  I.Wiseman, H.M.  II.International Programme on

Chemical Safety  III.Title

3. I.Series

 

ISBN 92 4 154481 3  (NLM Classification: QV 600)

ISSN 0250-863X

 

The World Health Organization welcomes requests for permission to

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Applications and enquiries should be addressed to the Office of

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(c) World Health Organization 1997

 

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protection in accordance with the provisions of Protocol 2 of the

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Secretariat of the World Health Organization concerning the legal

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or concerning the delimitation of its frontiers or boundaries. The

mention of specific companies or of certain manufacturers’ products

does not imply that they are endorsed or recommended by the World

Health Organization in preference to others of a similar nature that

are not mentioned. Errors and omissions excepted, the names of

proprietary products are distinguished by initial capital letters.

 

Contents

Preface

Acknowledgements

Introduction

How to use this book

Poisons centres and poison control programmes

 

Part 1. General information on poisons and poisoning

1. Poisons and poisoning

Objectives

What is a poison?

Exposure to a poison

How poison gets into the body

What happens when poison is inside the body The effects of

poison

When systemic effects happen

2. How poisoning happens

 

Objectives

Accidental poisoning

Self-poisoning

Using poison to harm other people

Poison in food or drink

Medical poisoning

Abuse of drugs, chemicals or plants

The benefits and dangers of using chemicals

 

3. How to prevent poisoning

Objectives

How you can help people make their homes,

workplaces, and the community safer

What can be done to prevent poisoning?

How to make homes safe

How to prevent poisoning with pesticides

 

What employers can do to prevent poisoning at work

How to avoid snake bites

How to prevent insect, spider and scorpion stings

and bites

How to avoid eating poisonous plants, mushrooms

and fish

How to avoid infection from food contaminated

with germs

 

4. What to do in an emergency

Objectives

The dangers to look out for

What to do in an emergency

 

5. First aid

Objectives

Give first aid at once

First aid for poisoning

Using traditional medicines to treat

poisonous bites and stings

 

6. Getting medical help

Objectives

If you can get to a hospital in less than two hours

If you are a long way from a hospital

If you cannot get medical help quickly

Taking the patient to hospital

What to do after you have read this chapter

 

7. Examining the patient Objectives Symptoms and signs

What the examination cannot tell you

When the patient does not have any symptoms or signs

How to examine a patient and find out the symptoms

and signs

Patterns of symptoms and signs

 

8. Finding out what happened

Objectives

Talking to people

Look for the poison or other things that show you

what happened

What to do next

 

9. How to look after a poisoned patient outside hospital

Objectives

What to do when the patient has swallowed poison

How to stop poison getting into the blood after it

has been swallowed

Making the patient vomit

Giving activated charcoal

Giving a laxative

How to look after a very sick patient

 

10. Medicines and equipment

How to care for medicines and first aid equipment

Medicines

First aid equipment

 

Part 2. Information on specific poisons

 

Introduction

The information in each section

 

Pesticides

Aluminium phosphide and zinc phosphide

Arsenic and arsenic-containing chemicals

Chlorophenoxyacetate weedkillers

Dinitro-o-cresol (DNOC), dinitrophenol, dinoseb and

pentachlorophenol

Insect repellent

Metaldehyde

Organochlorine pesticides

Organophosphorus and carbamate insecticides

Paraquat

Phenol and related substances

Pyrethrins and pyrethroid insecticides

Rat poisons

Sodium chlorate

Strychnine

Thallium

Warfarin and other pesticides that stop blood clotting

 

Chemicals and chemical products used in the home and the

workplace

Aerosol sprays

Air-fresheners, deodorant blocks and moth-balls

Benzene, tetrachloroethylene, toluene, trichloroethane,

trichloroethylene and xylene

Borax, boric acid and sodium perborate

Button batteries

Carbon monoxide

Carbon tetrachloride

Caustic and corrosive chemicals

Cosmetics and toiletties

Cyanide

Disinfectants and antiseptics

Ethanol and isopropanol

Ethylene glycol and methanol

Glue

Lead

Petroleum distillates

Phosgene

Soap and detergents

Tobacco products

Volatile oils

Products that are not usually harmful

 

Medicines

Acetylsalicylic acid, choline salicylate, methyl salicylate,

salicylic acid

Amfetamine-like medicines, atropine-like medicines,

antihistamines, cocaine, ephedrine, and pseudoephedrine

Aminophylline and theophylline

Amitriptyline-like medicines, chloroquine,

quinidine and quinine

Barbiturates, chlorpromazine-like medicines, diazepam-

like medicines and meprobamate

Carbamazepine, phenytoin and valproic acid

Chlorpropamide-like medicines and insulin

Colchicine

Dapsone

Digitalis, digitoxin and digoxin

Glyceryl trinitrate, hydralazine, and propranolol-like

medicines

Ibuprofen

Iron-containing medicines

Isocarboxazid, phenelzine and tranylcypromine

Isoniazid

Lithium carbonate

Magnesium hydroxide, magnesium sulfate,

phenolphthalein, and senna

Opiates

Oral contraceptives

Paracetamol

Penicillin and tetracycline antibiotics

Proguanil

Rifampicin

Salbutamol

 

Plants, animals and natural toxins

Plants that contain atropine

Cannabis

Irritant plants

Oleanders

Ornamental beans

Mushrooms

Snakes

Spiders

Venomous fish

Poisoning from eating seafood

 

Word list

 

Index

 

Preface

 

This handbook has two main aims: to give people living in rural

places, far from medical help, information on what to do when someone

is poisoned; and to suggest ways of preventing poisoning in the

community.

 

It is written for people with little or no medical training who

are likely to be the first to come into contact with someone who has

been poisoned, such as community health workers (CHWs), first-aiders,

or professionals in other sectors working in rural communities. Some

information has also been included for health workers with a knowledge

of clinical medicine and diagnostic procedures, working in rural

health stations and health centres where there may be some medical

equipment and medicines available.

 

The handbook is meant to be used as a practical reference book in

an emergency. It can also be used by people who teach community health

workers and others practical skills, such as mouth-to-mouth

respiration and heart massage, that can only be learnt by practising

under trained supervision. It may also be useful as a teaching aid for

student doctors, nurses, and paramedical personnel.

 

The book will be most useful if it is translated into local

languages and adapted to local conditions, which may vary in terms of:

the tasks authorized for CHWs, such as giving injections; the

functions assigned to CHWs; the functions assigned to local health

centres and doctors at rural hospitals; the availability of medicines;

and the particular problems prevalent in the area.

 

Only a small amount of information is given about chronic

poisoning, which is often caused by using chemicals at work. Readers

who wish to know more about chronic poisoning should find a book that

deals with the health of people at work (occupational health).

 

The intended readership

 

Community health workers. CHWs can generally read, write, and do

simple arithmetic, and have basic training in:

 

– first aid,

– taking body temperature,

– counting the pulse,

– dispensing medicines.

 

CHWs may also be trained to give intramuscular and subcutaneous

injections.

 

First-aiders. First-aiders are trained to rescue people from danger,

and to give immediate help to the victims of accidents until a trained

health care worker can take charge. People who are likely to be the

first on the scene of an accident, such as workers in factories or

offices, firefighters, or policemen, are often trained in first aid.

 

Professionals with no medical training. Many highly educated

professional workers, such as teachers, agricultural advisors,

pharmacists, scientists and technologists, know about the use and

effects of chemicals. In communities where there are no doctors, they

may be the only people who know about chemicals and poisons. They may

be first on the scene of an accident or they may be called upon to

help someone who is thought to have been poisoned. They need to know

the first aid for poisoning due to pesticides, medicines, household

products, and other substances. They should also be able to advise

people on how to prevent poisoning.

 

In some countries professional people with no medical training

may attend courses run by poisons centres to learn basic first aid

skills.

 

Nurses, medical students and paramedical staff. The book may be

useful as a handbook and training manual.

 

Doctors. Some information has been included specifically for doctors

working in rural health stations and health centres where there may be

some medical equipment and medicines available. This information has

been separated from the main text. It does not include details of

medical treatment that can be given only in a hospital.

 

Acknowledgements

 

This handbook has been prepared on the recommendation of a group

of experts convened by the International Programme on Chemical Safety

(IPCS)1 in February 1987. A draft text was prepared by Dr J.A. Henry

and Ms H.M. Wiseman, and commented on by a number of experts, in

particular Dr E. Fogel de Korc (Montevideo, Uruguay), Dr G.R.

Gardiner, Dr J. Jackson and Mr W. Tardoir (Brussels, Belgium), and

colleagues from UNEP’s International Register of Potentially Toxic

Chemicals (IRPTC) and the Occupational Safety and Health Branch of

ILO. An editorial group, convened by the IPCS to review the text,

consisted of Dr J.-C. Berger (Luxembourg), Dr N. Besbelli (Ankara,

Turkey), Professor M. Ellenhorn (Los Angeles, USA), Professor B. Fahim

(Cairo, Egypt), Dr Sming Kaojarern (Bangkok, Thailand), Professor A.

Furtado Rahde (Porto Alegre, Brazil), Dr N.N. Sabapathy (Fernhurst,

England), Professor A.N.P. van Heijst (Utrecht, Netherlands), and Dr

1. David (ILO). The text was tested at an IPCS Workshop, held in

Harare, Zimbabwe, from 28 January to 1 February 1991, and subsequently

in two training workshops in Zimbabwe. Parts of the text were also

reviewed at an IPCS Workshop held in Dakar, Senegal, 24-27 January

1995. For the IPCS, Dr J. Pronczuk de Garbino provided the editorial

inputs and Dr J.A. Haines coordinated the work.

 

The first aid manual of the Joint Voluntary Aid Societies in the

United Kingdom, and publications of the Global Crop Protection

Federation, were particularly useful as source materials for the first

draft. The United Kingdom Department of Health, through its financial

support to the IPCS, provided the resources for the drafting of the

text and for the editorial group to meet. The illustrations were

prepared by Picthall & Gunzi, London.

__________

 

1    The IPCS is a cooperative venture of the World Health

Organization (WHO), the International Labour Organisation (ILO)

and the United Nations Environment Programme (UNEP). WHO is the

executing agency for the programme, which aims to provide the

internationally evaluated scientific data basis for countries to

develop their own chemical safety measures, and to strengthen

national capabilities to prevent and treat harmful effects of

chemicals and to manage chemical emergencies.

 

Introduction

 

How to use this book

 

This book is in two parts. Part 1 gives general information on

poisons and poisonings, how poisonings happen and how you can prevent

them. It also gives guidance on how to deal with poisoning

emergencies. Part 2 gives specific information on the effects of

poisoning with various pesticides, medicines, household chemical

products, and poisonous plants and animals, and guidance on what to do

when you think someone has been poisoned. A word list and an index are

also provided.

 

To be ready for emergencies

 

1. Keep a first aid kit, like the one recommended in Chapter 10, in

the house, in the community, or at work.

 

2. Study this book before it is needed, especially Part 1, Chapters

4-9, which tell you what to do when someone is poisoned.

 

3. Practise some of the first aid, so that you know what to do in an

emergency.

 

To look up a chemical, plant or animal

 

Use Part 2 when you see someone who is poisoned. Look in the

index at the end of the book to find the medicine, chemical, plant or

animal you think may have caused the poisoning.

 

Information for doctors

 

In Chapter 5, “First aid”, and Chapter 9, “How to look after a

poisoned patient outside hospital”, and in Part 2, parts of the text

are separated off by horizontal lines. This information is meant for

doctors.

 

If you do not understand the meaning of some of

the words in this book

 

Look for the word in the word list (medical words used in the

boxes of information for doctors are not explained in the word list).

 

Poisons centres and poison control programmes

 

In many countries there are poisons centres which give advice

about the treatment and prevention of poisoning. They have information

about medicines, pesticides, poisonous plants, venomous animals, and

household products, and chemicals used at work. The doctor in the

poisons centre can tell you what to do when someone has swallowed or

breathed in a chemical, spilt it on the skin, or splashed it in the

eyes.

 

Most poisons centres can be contacted at any time of day or night

by telephone or, in some countries, by radio. They may have supplies

of special antidotes (for example snake or spider antivenoms). Some

poisons centres have hospital wards where they can treat poisoned

patients.

 

In many countries, other organizations work with poisons centres

in a national poisons control programme to improve the treatment and

prevention of poisoning. These organizations include:

 

–    hospitals and other places where poisoned patients are treated;

 

–    organizations that collect information on poisoning;

 

–    organizations that make or use substances which might cause

poisoning;

 

–    government authorities that control the use of chemicals within

the country;

 

–    universities and colleges where doctors and other people are

taught about poisoning.

 

There is space in the back of this book where you can write the

addresses of organizations in your country that might help you deal

with cases of poisoning or give advice on how to prevent poisoning.

 

PART 1

 

General information on poison and poisoning

 

CHAPTER 1

 

Poisons and poisoning

 

Objectives

 

After studying this chapter you should:

 

1. Know what a poison is.

 

2. Understand what is meant by local poisoning and systemic

poisoning. Understand all the ways poison can get into the body,

and be able to recognize circumstances where poisoning might

happen.

 

3. Understand what is meant by acute poisoning and chronic

poisoning, and be able to explain to people that continued

exposure to small amounts of poison for several days, weeks or

months can be harmful, even if they do not immediately feel

unwell.

 

4. Be able to explain to people that taking too much medicine may be

dangerous.

 

5. Be able to explain to people why it is important to take care

when handling dangerous chemicals and why it is important to wash

chemicals off the skin as soon as possible.

 

6. Be able to explain how petroleum distillates, such as kerosene,

cause harm if they are swallowed.

 

7. Understand why people who have swallowed poison may be helped if

they are made to vomit or given activated charcoal.

 

8. Recognize that people are more likely to be harmed by poison if

they are very old, very young or in poor health.

 

9. Know why a person who has been exposed to poison may appear to be

unaffected by it, and why it is often a good plan to watch a

person for 12-24 hours after they have been exposed to poison,

even if they seem well.

 

What is a poison?

 

A poison is any substance that causes harm if it gets into the

body. Harm can be mild (for example, headache or nausea) or severe

(for example, fits or very high fever), and severely poisoned people

may die.

 

Almost any chemical can be a poison if there is enough in the

body. Some chemicals are poisonous in very small amounts (for example,

a spoonful by mouth or a tiny amount injected by a snakebite); others

are only poisonous if a large amount is taken (several cupfuls, for

example).

 

The amount of a chemical substance that gets into the body at one

time is called the dose. A dose that causes poisoning is a poisonous

dose or toxic dose. The smallest amount that causes harm is the

threshold dose. If the amount of a chemical substance that gets into

the body is less than the threshold dose, the chemical will not cause

poisoning and may even have good effects. For example, medicines have

good effects if people take the right doses, but some can be poisonous

if people take too much.

 

Exposure to a poison

 

When people are in contact with a poison they are said to be

exposed to it. The effect of exposure depends partly on how long the

contact lasts and how much poison gets into the body, and partly on

how much poison the body can get rid of during this time.

 

Exposure may happen only once or many times.

 

Acute exposure is a single contact that lasts for seconds,

minutes or hours, or several exposures over about a day or less.

 

Chronic exposure is contact that lasts for many days, months or

years. It may be continuous or broken by periods when there is no

contact. Exposure that happens only at work, for example, is not

continuous.

 

Chronic exposure to small amounts of poison may not cause any

signs or symptoms of poisoning at first. It may be many days or months

before there is enough chemical inside the body to cause poisoning.

For example, a person may use pesticide every day. Each day the person

is exposed to only a small amount of pesticide, but the amount of

pesticide in the body gradually builds up, until eventually, after

many days, it adds up to a poisonous dose. Only then does the person

begin to feel unwell.

 

How poison gets into the body

 

The way poison gets into the body is called the  route of

exposure or the  route of absorption. The amount of poison that

gets into the blood during a given time depends on the route.

 

Through the mouth by swallowing (ingestion)

 

Most poisoning happens this way. Small children often swallow

poison accidentally, and adults who want to poison themselves may

swallow poison. If people eat, drink or smoke after they have been

 

handling poisons, without first washing their hands, they may

accidentally swallow some of the poison. This is a common cause of

pesticide poisoning.

 

FIGURE 1

 

When poisons are swallowed they go to the stomach (Fig. 1). Some

poisons can pass through the gut walls and into the blood vessels. The

longer a poison stays in the gut the more will get into the blood and

the worse the poisoning will be.

 

If a person vomits soon after swallowing a poison, it may be

expelled from the body before a poisonous dose gets into the blood.

So, if the person does not vomit straight away, it is sometimes useful

to make the person vomit. There are two other ways to stop poisons

passing from the gut into the blood: (1) give activated charcoal

because this binds some poisons so that they cannot pass through the

gut walls; or (2) give laxatives to make the poison move through the

gut and out of the body more quickly. The circumstances when it is

useful to make a patient vomit or to give activated charcoal or

laxatives, and the circumstances when these procedures may be

dangerous, are described in Chapter 9.

 

Poisons that do not pass through the gut walls do not get into

the blood and so cannot affect other parts of the body. They move

along the gut and leave the body in the faeces. For example, mercury

metal cannot pass through the gut walls; if mercury from a thermometer

is swallowed, it passes out of the body in the faeces and does not

cause poisoning.

 

FIGURE 2

 

Through the lungs by breathing into the mouth or nose (inhalation)

 

Poisons in the form of gas, vapour, dust, fumes, smoke or fine

spray droplets may be breathed into the mouth and nose and go down the

air passages into the lungs (Fig. 2). Only particles that are too

small to be seen can pass into the lungs. Larger particles are trapped

in the mouth, throat and nose and may be swallowed. A person may

breathe in poison when working with a poisonous substance inside a

building without fresh air, or when spraying pesticide without wearing

adequate protection. Oil or gas heaters, cookers, and fires give off

poisonous fumes which may reach dangerous concentrations if the smoke

cannot get outside or if the room does not have a good supply of fresh

air.

 

Poison that gets into the lungs passes into the blood vessels

very quickly because the air passages in the lungs have thin walls and

a good blood supply.

 

Through the skin by contact with liquids, sprays or mists

 

People working with chemicals such as pesticides may be poisoned

if the chemical is sprayed or splashed onto the skin, or if they wear

clothes soaked with chemical.

 

The skin is a barrier that protects the body from poisons.

However, some poisons can pass through the skin (Fig. 3). They pass

through warm, wet, sweaty skin more quickly than through cold, dry

skin, and they pass through skin damaged by scratches or burns more

quickly than through undamaged skin. A poison that damages the skin

will pass through more quickly than one that does not damage the skin.

It may be possible to wash poison off the skin before a poisonous dose

gets into the body.

 

FIGURE 3

 

By injection through the skin

 

Poisons can be injected through the skin from a syringe, or a

pressure gun, or during tattooing, or by the bite or sting of a

poisonous animal, insect, fish or snake. The injection may go directly

into the blood vessels, or under the skin into muscle or fatty

tissues. Poison injected into the blood has a very quick effect.

Poison injected under the skin or into muscle has to pass through

several layers of tissue before reaching the blood vessels, so it acts

more slowly.

 

What happens when poison is inside the body

 

How poison is carried round the body

 

Once a poison gets into the blood it is carried to the whole body

as the blood is pumped round the body by the heart (Fig. 4).

 

How poison is broken down by the body

 

Some poisons are changed by the body into other chemicals. These

are called metabolites, and may be less poisonous or more poisonous

than the original substance. The metabolites are more easily passed

out of the body than the original chemicals. These changes take place

mostly in the liver.

 

FIGURE 4

 

How poison leaves the body

 

Unchanged poisons or their metabolites usually leave the body in

the urine, faeces or sweat, or in the air that a person breathes out.

The movement of poison from the blood into urine takes place in the

kidneys, and the movement of poison from blood into breathed-out air

takes place in the lungs. Poison in the faeces may have passed down

the gut without being absorbed into the blood or it may have been

absorbed into the blood and then passed out into the gut again. Some

poisons, like DDT, pass into body tissues and organs where they may

stay for a long time.

 

The effects of poison

 

The effects of a chemical substance on the body may be described

as either local or systemic.

 

A local effect is limited to the part of the body in contact with

the chemical: the skin, the eyes, the air passages or the gut.

Examples of local effects are skin rashes, skin burns, watery eyes,

and irritation of the throat causing coughing. Many poisons cause

local effects, but there are also many poisons that do not. Further

details about local effects are given below.

 

A systemic effect is a more general effect that occurs when a

poison is absorbed into the body.

 

Some poisons cause both local effects and systemic effects. If

someone has local effects from exposure to a chemical it is important

to check whether they also have signs or symptoms of systemic

poisoning.

 

Local effects

 

On the skin

 

Chemicals that damage the skin cause reddening or a rash, pain,

swelling, blisters or serious burns. The burns are like the burns

caused by fire.

 

An irritant chemical causes itching, a burning feeling, or pain

when it first touches the skin, but does not cause burns if washed off

straight away. However, if it is in contact with the skin for a long

time, for example when people wear contaminated clothes for several

hours, it might cause burns.

 

Some irritant chemicals have no effect the first few times they

touch the skin, but with continued contact they cause reddening or a

rash. This might happen with repeated use of a household cleaner.

 

Sometimes people become sensitive to a chemical after they have

used it many times. They may have no effects at first but after a few

weeks or months they get a rash every time they use it.

 

A corrosive or  caustic chemical very quickly causes painful

burns and destroys the skin. There may be blisters and the skin may

turn grey-white or brown.

 

On the eyes

 

Irritant or corrosive chemicals can cause severe pain if they get

into the eyes. They may very quickly burn the surface of the eye and

cause scars or even blindness. The eyes will look red and watery. The

person may not want to open the eyes and bright light will hurt.

 

Inside the gut

 

Irritant or corrosive chemicals may damage the mouth and throat

or the inside of the gut. The person will have belly pain, vomiting

and diarrhoea, and the vomit and faeces may contain blood. If the

throat is burnt it may swell very quickly, so that the person cannot

breathe.

 

Inside the air passages and lungs

 

Some gases and vapours can irritate the nose, throat and upper

air passages and cause coughing and choking.

 

Some gases and vapours damage the lungs in a way that causes them

to fill with water. This may happen very soon after a person breathes

in the substance, or it may happen up to 48 hours afterwards. A person

with water in the lungs cannot breathe properly and may drown. He or

she must be taken to a hospital as quickly as possible. Water in the

lungs is called lung oedema.

 

Some of the gases that cause lung oedema also irritate the nose,

throat and upper air passages, and make people cough and choke. When

people start to cough and choke, they will quickly move away from the

gas into fresh air, if possible. This often means that they are not

exposed to the gas for long enough to get poisoned.

 

Some poisonous gases, such as carbon monoxide, have no effect on

the nose and throat. Poisonous gases that do not cause coughing and

choking are very dangerous because people may not know they are

breathing poison.

 

Petroleum distillate liquids, such as kerosene, may cause lung

oedema when swallowed. When people swallow any liquid or solid, the

air passage closes and keeps most of it out of the lung but small

amounts of liquid may still get in. With most liquids this does not

harm the lungs because the amount is too small, but even very small

amounts of petroleum distillates can cause lung oedema.

 

More importantly, when people are unconscious the air passage

does not close, so there is nothing to stop food, drink or vomit

getting into the lungs and blocking the air passages or causing lung

oedema. That is why it is very dangerous to try to give any food,

drink or medicine to unconscious people.

 

At injection sites

 

Irritant poisons that are injected into the skin, such as poisons

from insect stings and snake bites, may cause pain and swelling where

they are injected. People who accidentally inject themselves with

veterinary products, when giving injections to animals or birds, may

get local effects.

 

Systemic effects

 

There are many ways in which poisons can cause harm:

 

*    By damaging organs such as the brain, nerves, heart, liver,

lungs, kidneys, or skin. Most poisons have a greater effect on

one or two organs than on other parts of the body. The organs

that are most affected are called the target organs.

 

*    By blocking messages between nerves.

 

*    By stopping the body working properly, for example, by blocking

energy supply or oxygen supply.

 

Effects on unborn babies

 

Some poisons can harm a baby inside the womb. This is most likely

during the first three months of pregnancy when the nervous system and

all the major organs begin to form. The parts of the baby usually

affected are the bones, eyes, ears, mouth and brain. If the damage is

very bad the baby will stop growing and die. Some poisonous chemicals

may harm a baby in the womb without harming the mother. This is

serious because there is nothing to warn the mother that her baby is

in danger.

 

If a mother drinks alcohol or smokes during pregnancy it may harm

her baby. Medicines may also harm a baby in the womb. Pregnant women

should never take medicines unless they are prescribed by a doctor.

 

When systemic effects happen

 

Systemic effects only happen when the amount of poison in the

body is greater than the amount the body can get rid of, and the

poison builds up and reaches the threshold level.

 

Usually, when contact with a poison lasts only a short time

(acute exposure), the effects happen soon after exposure and do not

last very long. But, in some cases, the effects of a poison are not

seen for several hours or even days after an acute exposure. When

people have been exposed to a poison for a long time (chronic

exposure), the effects may last for a long time.

 

Sometimes a person may be exposed to a poison yet not seem to

have any ill effects. This may be because the person has not been

exposed for long enough to absorb a toxic dose. Or it may be that the

person has absorbed a toxic dose but appears well because it is too

soon to see any effects of poisoning.

 

Sometimes it can be hard to know whether a person who has been

exposed to a poison is going to develop any ill effects. Before you

send a person home always check:

 

–    how long ago the exposure to poison happened;

 

–    how long it usually takes before the effects of the poison

can be seen (check in Part 2 of this book or contact a

poisons centre).

 

When you suspect someone has been poisoned it is often a good

idea to watch the person for 12-24 hours to see if any ill effects

develop. In some cases you may need to watch them even longer than

that.

 

Exposure to a chemical does not affect everyone in exactly the

same way. Some people may be more sensitive than others. For example,

young children and old people are more likely to be severely poisoned

than young adults; and people who are sick because they are not eating

well, or because they drink a lot of alcohol or have a disease, are

more likely to be severely poisoned than healthy people.

 

CHAPTER 2

 

How poisoning happens

 

Objectives

 

After studying this chapter you should be able to:

 

1. Recognize when there is a danger of poisoning from chemical

products, medicines, carbon monoxide, pesticides, or contaminated

food, at home or at work.

 

2. Explain to other people how poisoning happens so that they are

aware of the dangers.

 

3. Warn people about the danger of taking a chemical product out of

its original container and putting it in another one.

 

4. Explain to people why it is important to use a product in the way

the manufacturers mean it to be used.

 

5. Explain to people why it is dangerous to abuse drugs.

 

6. Discuss with people the usefulness and dangers of using

chemicals.

 

Some poisonings happen by accident but some happen when people

try deliberately to harm themselves (self-poisoning) or others. There

are other circumstances that may result in poisoning:

 

–    eating food containing poison;

 

–    taking, or being given, the wrong kind of medicine or the wrong

dose;

 

–    taking drugs because they change mood or behaviour, or using

plants or chemical products for this purpose.

 

Accidental poisoning

 

Accidental poisoning may happen when:

 

–    young children or old people handle poisons not knowing what

they are;

 

–    people mistake poison for food or drink because it is not in

its original container;

 

–    people misuse chemical products or medicines;

 

–    people use or misuse pesticides;

 

–    people work with chemicals;

 

–    people are exposed to carbon monoxide, usually at home.

 

Poisoning in childhood

 

Many poisoning accidents in the home happen to small children

aged between 1 and 4 years. At this age children want to explore. They

can crawl or walk round the house on their own and by the age of 2

they can probably climb onto a chair to reach a high shelf. They can

open drawers and cupboards, and they may be able to open screw-top

bottles.

 

They like to put things in their mouths but they are not old

enough to understand that some things might be harmful. They seem to

have a different sense of taste from adults, and often like to swallow

things that to adults taste strange or bitter. They may swallow

medicines that look like sweets or motor oil that looks like syrup. If

they are thirsty they may swallow a liquid, such as a household

cleaner, that looks like a soft drink or fruit juice.

 

The chemical products most often swallowed by children are:

 

–    household cleaners such as bleach, detergent and disinfectant;

 

–    paraffin and kerosene used as household fuels;

 

–    cosmetics;

 

–    medicines;

 

–    paint and products for household repairs;

 

–    household pesticides.

 

These chemicals are often used around the home. They are often

kept in places where a small child can see and reach them, for

example, on shelves or tables, or on the ground.

 

Many accidents happen when people looking after young children

are too busy to watch them all the time. They may be looking after a

large family with several young children, or doing housework. If an

open container is left within easy reach, it may take only a few

seconds for a child to grab it and swallow the contents.

 

It is especially dangerous if a child is left alone, or in the

care of slightly older brothers or sisters, for several hours at a

time.

 

Poisoning in old age

 

Old people may poison themselves accidentally. If they cannot see

very well, they may pick up the wrong bottle and swallow a household

cleaner, for example, instead of a drink or a medicine. Old people

tend to be forgetful and confused. They may forget to take their

medicine, or they may take too much and poison themselves because they

cannot remember how much to take or when they took the last dose.

 

Taking products out of their own containers

 

Accidents can happen when someone takes a chemical product out of

its container and puts it in another one. The new container does not

have the right label so nobody else will know what is inside. Even the

person who did it may forget. It is specially dangerous to pour any

chemical or medicine into a drinking cup, or drink bottle, or any

container where it might be mistaken for food or drink. Young children

cannot tell the difference between harmful chemicals and food or

drink, and even adults may drink from bottles without checking to see

what is inside.

 

That is why it is dangerous for shopkeepers to take chemicals

from large containers and then sell them in smaller containers.

 

Poisoning from misuse of chemical products or medicines

 

Poisoning accidents can happen when safety warnings are ignored

and chemicals are used in the wrong way. For example, there is usually

a warning on a bleach container that bleach should not be mixed with

any other cleaner. If people ignore the warning and use bleach with

another household cleaner, they may be poisoned by the gases given

off. Another example of misuse of a product is when insecticides that

are meant to be used on plants or buildings are used to kill insects

living on people, in their hair or on their bodies.

 

Sometimes people poison themselves by misusing medicines. They

may take more than the doctor prescribed because they think, wrongly,

that a larger dose will make them better more quickly. Taking someone

else’s medicine is also a kind of misuse. People who take someone

else’s medicine may be harmed if they take the wrong dose or take a

medicine that is not meant for treating their condition. Women who

take medicine to try to end a pregnancy are misusing the medicine, and

may poison themselves.

 

Pesticide poisoning

 

Pesticides are chemicals made to poison insects, weeds or other

pests. Most pesticides are also poisonous or harmful to humans if they

get on the skin, or if they are breathed into the lungs in the form of

gases, fumes, dust or fine spray droplets, or if they are swallowed.

 

These are some of the ways people may be poisoned:

 

–    if they use pesticides in the wrong way; for example,

children may be poisoned if pesticides are sprayed on their bed-

clothes;

 

–    if they do not use protective equipment; for example, they may

splash pesticide on their clothes or skin, or may breathe in

pesticide;

 

–    if they eat, drink or smoke after working with pesticides, and

have the chemicals on their hands – they should wash their hands

first;

 

–    if empty pesticide containers are used to store food or drink –

it is impossible to wash all the pesticide out of an empty can,

and some pesticide will get into the food or drink;

 

–    if food containers or drink bottles are used to store pesticides

– someone may mistake the contents for food or drink.

 

Poisoning at work

 

Many chemicals that are made, used, or stored in workplaces are

poisonous. People who work with these chemicals need to know how to

handle them safely to avoid being poisoned.

 

Sometimes workers may not know that they are handling a poisonous

chemical, or they may know that the chemical is poisonous but not have

been told or shown how to handle it safely. They may not have read the

label or the safety information. Sometimes they may know the dangers

but be too lazy or careless to use safe methods.

 

Accidents, fires or explosions at work may result in chemicals

spilling or leaking out of their containers onto roads or into rivers,

or vapours and gases being released into the air. Sometimes chemicals

spread over a large area and poison many people.

 

Chemical waste and empty chemical containers may be serious

safety hazards if they are not dealt with in the right way.

 

Carbon monoxide poisoning

 

When oil, gas, wood, coal or other fuels burn they give off a gas

called carbon monoxide, which can cause serious poisoning and often

causes death. This can happen when fires, stoves, heaters, or ovens

are used in rooms, huts or tents where there is no open window or

chimney to let fresh air in and carbon monoxide out. Petrol engines

also give off carbon monoxide, and people may be poisoned if they run

a car engine inside a garage when the doors are shut.

 

Self-poisoning

 

People may try to harm themselves by deliberately taking poison –

this is called self-poisoning. In some countries people take medicines

to poison themselves, but people living in rural communities are more

likely to take pesticides.

 

People suffering from depression, serious illness, or alcohol

dependence may try to kill themselves by taking poison. They may

swallow large amounts of medicine, pesticide or other poisons. If they

recover they might try to poison themselves again unless they receive

appropriate treatment.

 

Many young people who try to poison themselves are unhappy

because of problems they do not know how to deal with, such as unhappy

love affairs or arguments with boyfriends or girlfriends.

 

Using poison to harm other people

 

Sometimes people use poison to harm others. They may do it as a

joke or they may want to frighten or even kill a person. If you have

evidence that this is happening or has happened, tell the police.

 

Poison in food or drink

 

Food or drink can be contaminated by poison from microscopic

organisms such as bacteria, viruses, or mould, or by chemical poisons.

Some plants, mushrooms, animals or sea-creatures contain poisonous

chemicals. Poisons made by plants, animals or microorganisms are

called toxins.

 

Poisons made by microscopic organisms

 

Food may be contaminated by bacteria before or after cooking,

during preparation or storage, by contact with hands that have not

been thoroughly washed, or with contaminated surfaces, containers or

kitchen utensils. It may also be contaminated by animals or insects,

particularly flies. Heating food thoroughly destroys most – but not

all – bacteria and bacterial toxins. However, if cooked food is kept

warm or at room temperature for any length of time, any bacteria

present will multiply and may cause disease.

 

Moulds grow on foods that are damp or damaged by insects, and

some moulds produce poisons. Moulds growing on nuts or grain that has

been gathered and stored before it is dry may cause serious poisoning.

Some ways of drying and preserving food do not stop moulds growing on

the food.

 

People can catch diseases from eating food infected with worms or

other organisms, but this is not poisoning and is not dealt with in

this book.

 

Chemical poisons

 

There are many ways chemical poisons can get into food and drink,

for example:

 

–    when people working with chemicals eat in the workplace or do not

wash their hands before eating;

 

–    when chemicals spill onto food as it is being moved from place to

place, or when it is in a storeroom;

 

–    when food or drink is stored or cooked in containers that are

contaminated with chemicals;

 

–    when people make flour from grain that has been treated with

pesticide because it was meant to be used for seed or bait, not

for food;

 

–    when people brew their own alcoholic drinks and produce poisonous

alcohols, such as methanol;

 

–    when water supplies are polluted by accidental spills of

chemicals, or by chemical waste from factories or waste dumps

near watercourses.

 

Poisonous plants, mushrooms, animals and sea-creatures

 

Some plants, mushrooms, animals and sea-creatures contain toxins.

Sometimes it is very hard to tell the difference between plants or

fish that are good to eat and those that are poisonous.

 

Medical poisoning

 

Sometimes people are poisoned by medicines given to them by a

doctor or another health care worker. They may be given the wrong

medicine or be given the wrong dose of the right medicine. There are

many reasons why this can happen. The doctor may not know the patient

is allergic to a medicine, or may give the wrong dose because of a

mistake in measuring it.

 

Abuse of drugs, chemicals or plants

 

People may take drugs to change their mood or behaviour, to feel

relaxed, or to get more energy. This is called drug abuse because it

is not a medical use of the drug. Some people abuse drugs such as

heroin, cocaine or barbiturates. Drinking too much alcohol is an

important kind of drug abuse.

 

Other substances may produce some of the same effects. Some

people breathe in chemicals such as glue, paint, nail varnish remover,

cigarette lighter gas, petrol or dry-cleaning fluid. This is sometimes

called solvent sniffing or solvent abuse. People may breathe fumes

from a cloth soaked in liquid or put chemicals or glue into a plastic

bag and breathe deeply from the bag.

 

In many societies people use plants or fungi for their

hallucinogenic, stimulant or relaxing effects. Some plants may be

eaten raw, others are cooked, made into drinks, or smoked. Two plants

commonly used in this way are tobacco and cannabis.

 

Many of the drugs, chemicals and plants that are abused are

poisonous if people take too much at one time or use them for many

months or years. For example, alcohol causes liver damage, smoking

causes lung cancer and cannabis can affect people’s memory.

 

The benefits and dangers of using chemicals

 

All countries use a large number of different chemicals in

agriculture, in industry, in medicines and in the home. There are many

good reasons for using them. Pesticides and fertilizers have helped

farmers grow more crops. Medicines can cure or prevent disease, and

they can give people longer and more comfortable lives. Cleaning

products have made household tasks easier.

 

Useful chemicals can also be dangerous. People may have to use

amounts that could be poisonous if they got into the body. Some

chemicals can also cause harm if they get into the air people breathe,

into the soil where people work or grow food and animals live, and

into the rivers and streams that supply water for drinking, washing,

or irrigating crops. The danger can be made smaller if chemicals are

used safely, and efforts are made to prevent accidents, but the danger

will never completely go away.

 

Communities must decide whether the benefit of using the

chemicals is large enough and the danger small enough for them to live

with. There are many things to think about:

 

*    How useful is the chemical?

 

*    What kind of harm can the chemical cause?

 

*    Will the chemical affect the environment?

 

*    Can the chemical be handled safely?

 

*    How many people will use the chemical, and how many people might

be exposed to it because they work or live near the place it is

made or used?

 

*    Can a less poisonous chemical be used instead?

 

*    How much money could be saved by using the chemical and how much

would it cost to stop using it?

 

CHAPTER 3

 

How to prevent poisoning

 

Objectives

 

After studying this chapter you should be able to:

 

1. Discuss with people how to prevent poisoning.

 

2. Help people make their homes, their workplaces, and the community

safer.

 

It is better, safer and cheaper to prevent poisoning than to cure

1. Most poisonings can be prevented.

 

Everyone – children, parents, farmers, schoolteachers, factory

workers and health care workers – can do things to make their homes,

their workplaces, and the community safer.

 

How you can help people make their homes, workplaces, and

the community safer

 

There are three steps you should take:

 

1. First of all, find out about the poisonings that have happened in

your community in the last few years. Find out how they happened,

where they happened and what the poisons were. Think about why

the poisonings happened.

 

2. Think about how poisonings that have happened in your community

could have been prevented. This chapter lists many ways to

prevent poisoning. Talk to your poisons centre about the

poisonings in your community. The poisons centre may be able to

suggest ways to prevent them.

 

3. Discuss with people how poisonings can be prevented. Share what

you know with others and help them understand why poisonings

happen and what can be done to stop them happening again.

 

*    Talk with families and mother-and-child health groups about

preventing poisoning at home. Talk about how to teach

children, even at an early age, not to touch, eat or play

with medicines or household chemicals.

 

*    Talk to schoolteachers about how to teach children about the

dangers of poisoning in their homes and the dangers from

poisonous snakes, plants and animals. For example, teachers

could ask the children to find out about accidents that have

happened in the community and to suggest ways to prevent

such accidents.

 

*    Talk to community leaders or committees about the accidents

that have happened. Discuss with them and the people what

you think can be done to make your community safe.

 

*    Make friendly visits to homes and workplaces from time to

time, not to find fault, but to help people to see where

there are dangers and how to make them safe.

 

This chapter gives some “dos” and “do nots” to help you when you

talk to people about how to prevent poisoning.

 

The first time you read this chapter you may think “It is

impossible for people in my community to do that. How can I tell

people to wear boots to protect themselves from snake bites, when they

cannot even afford shoes? How can I tell them to keep medicines in a

locked cupboard, when we do not have cupboards in our homes?”

 

The community should know the best ways of preventing poisoning

and aim to use them. But when you talk to people about how to prevent

poisoning, discuss how to adapt the advice to your local situation.

There may be other ways that will work just as well. For example,

people may tell you that there are other places in their homes that

are as safe as locked cupboards. There may be a local carpenter who

could make boxes or cupboards that lock, if the community wants them.

 

Work towards your target in stages. For example, if people cannot

afford boots, start by encouraging them to wear simple, locally made

shoes or sandals.

 

What can be done to prevent poisoning?

 

It is important to handle all chemicals safely, not just the ones

you know are poisons. Many chemicals that you might not think are

poisonous could make someone ill or cause burns.

 

It is very important to protect children, because they cannot

protect themselves and they do not understand that some things can be

poisonous.

 

Many poisonings could be prevented if chemicals were kept safely,

used safely and got rid of safely.

 

Keep chemicals safely

 

*    Do keep medicines, cleaners and pesticides where children cannot

see or reach them (Fig. 5).

 

*    Do not keep chemicals you no longer need.

 

*    Do not put chemicals in containers that once contained food or

drink; people may eat or drink the chemicals by mistake.

 

Use chemicals safely

 

*    Do use medicines, cleaners, pesticides and other chemicals in the

right way, and use the right amount (not more or less). Read the

label and follow carefully the instructions for use (Fig. 6). A

person who cannot read it should find someone who can. It may be

dangerous to use chemicals from unlabelled containers. Ask the

supplier for another container with a label.

 

FIGURE 5

 

FIGURE 6

 

Get rid of left-over chemicals and empty containers safely

 

*    Do find out whether it is better to bury or burn the

chemicals you want to get rid of. Choose a place to bury or burn

chemical waste where there will be as little danger as possible

to the people living nearby or to the environment (Fig. 7).

 

*    Do find out from environmental health officers or community

leaders the local arrangements for getting rid of chemical waste.

Seek professional advice about how to get rid of large amounts of

unwanted chemicals.

 

*    Do not use empty bottles, cans or other containers that have

been used for storing chemicals to store or cook food or drink.

Do not give them to children to play with.

 

*    Do not leave left-over chemicals or empty containers where

children might find them.

 

*    Do not throw left-over chemicals or empty containers near a

river, pond or spring. Chemicals might get into the water and

poison fish, or poison people or animals that drink the water or

wash in it. This may also happen if chemical waste is poured into

drains that empty into waterways.

 

The rest of this chapter gives more detailed guidelines on how to

prevent the different types of poisoning described in Chapter 2.

 

FIGURE 7

 

How to make homes safe

 

How to keep chemicals safely

 

*    Do keep all household chemicals where children cannot see

them or reach them. Keep medicines, insecticides, weedkillers and

rat poison in a locked cupboard or locked suitcase or in a high

cupboard.

 

*    Do keep household products, pesticides and medicines in their

own containers.

 

*    Do keep caps and tops on bottles and keep them properly closed

(Fig. 8). Keep boxes closed. A child who finds an open container

may swallow the contents before anyone can stop him or her. A

child may try to open a closed container, but this may take time

and a young child will often find it difficult. An adult may see

what is happening and stop the child before he or she can open

the container.

 

*    Do not keep household cleaners on the floor, under the

kitchen sink, or in low cupboards that a child can easily open

(Fig. 9).

 

*    Do not keep medicines, pesticides or household products

next to food or drink. A child may think they are something to

eat or drink. Even an adult may swallow the contents of some

containers without first checking what is inside. A chemical may

spill onto food, and someone may be poisoned by eating the

contaminated food.

 

FIGURE 8

 

FIGURE 9

 

*    Do not keep medicines, pesticides or household products in

drink bottles, cups or containers normally used for food or

drink.

 

*    Do not keep chemicals or empty containers you no longer need. For

drink guidelines for getting rid of them safely, see chapter 3.

 

How to use medicines and household products safely

 

Medicines

 

*    Do be sure to take or give the right dose of medicine. Find out

the right dose by reading the label or asking a health care

worker. Be very careful not to take or give too much. Too large a

dose of medicine may make a person very sick. It is a mistake to

think that if you take all the medicine at once you will get

better more quickly.

 

*    Do put the medicine away safely as soon as you have given the

dose.

 

*    Do not take medicine or give medicine to others without taking

advice from a doctor or health worker.

 

*    Do not give children medicine that was not prescribed for them.

 

*    Do not pretend to children that medicines are sweets. They cannot

tell the difference and might later poison themselves if they

think medicines are sweets.

 

Household chemicals, such as cleaners or pesticides

 

*    Do read the label. Make sure you know how to use the product and

how much to use, and look for advice about how to use the product

safely.

 

*    Do hold on to a product while you are working with it. If you put

it down, leave it where you can see it all the time. A child can

quickly grab an open bottle and swallow the liquid, or spill it

onto the skin or into the eyes.

 

*    Do wipe up any of the chemical that gets spilt, and make sure the

outside of the bottle or container is clean and dry.

 

*    Do put chemicals away as soon as you have finished using them.

While they are out of their usual storage place, children may get

hold of them.

 

*    Do not spray household pesticides over food or children’s toys.

 

*    Do not mix different cleaners or other products together.

 

*    If the product has to be added to water before it is used, do not

mix it in a container that is used for food and drink.

 

Get rid of household products safely

 

*    Do put lids on household rubbish bins so that children cannot

take things out.

 

*    Do use the local arrangements for getting rid of household

rubbish. Do not leave rubbish lying around the house or dump it

anywhere else.

 

*    Do not puncture, heat or burn pressurized containers. If the

community burns household rubbish, do not put pressurized

containers into the fire. They should be buried instead.

 

Other ways to prevent poisoning in the home

 

*    Do keep the floors and walls clean. Fill holes or cracks so that

there is nowhere for insects to live and no way snakes can get

into the house.

 

*    Do keep gas or liquid fuel heaters, stoves and ovens in good

working order so that they do not produce dangerous amounts of

carbon monoxide gas.

 

*    Do keep chimneys or flues clear and open to the outside air so

that fumes containing carbon monoxide gas from fires and stoves

do not stay inside the house.

 

*    Do not use heaters, stoves or ovens in rooms with no chimney,

flue or open window to let in fresh air and let out the fumes

containing carbon monoxide gas.

 

How to prevent poisoning with pesticides

 

Pesticides are very widely used and in some countries many people

get sick or die because of poisoning with pesticides. Poisoning can be

prevented if pesticides are used safely and proper precautions are

taken.

 

People working where pesticides are used or stored – on

plantations, on farms, in factories or in shops – should know how to

handle and use pesticides safely. Every member of the community needs

to know about the hazards of using pesticides and how to avoid them.

 

Most of these guidelines can be applied wherever chemicals of any

kind are stored or used. If you want to know more about safety at work

ask someone with expert knowledge about health problems at work.

 

Store pesticides safely

 

*    Do keep pesticides in their original containers. It is dangerous

to transfer pesticide from one container to another. The

pesticide may be mistaken for food or drink.

 

*    Do keep pesticides in a safe and secure store. Seek advice from

agricultural advisers on where to site the store and how to build

1. It should be marked with warning signs and have locked doors

and barred windows, to keep out unauthorized people, especially

children.

 

*    Do make a list of all products in the store and update it

regularly. Do not keep the list in the store but keep it in a

safe place where it will be accessible in the event of a fire. In

the store, keep chemical safety data sheets and emergency

telephone numbers.

 

*    Do keep pesticides, particularly rodenticide baits and pesticide

treated seeds, away from foodstuffs so they are not mistaken for

food.

 

*    Do not keep agricultural pesticides in living areas. Keep them in

a separate shelter. The only pesticides that should be kept at

home are those for killing household pests.

 

*    Do not keep pesticides in drink bottles or other containers

normally used for food or drink.

 

Use pesticides safely

 

Everyone who applies pesticide should first have training in the

method of application, the operation, cleaning and maintenance of the

equipment and the safety precautions to be taken.

 

A pesticide, or any other chemical product, should have a label

saying what it is, who made it and how to use it safely and

effectively. There should also be information about possible hazards,

safety precautions, first aid instructions and advice to health

workers. If the container is small, this information may be given in a

leaflet attached to the container. There may also be a product

information leaflet and a chemical safety data sheet.

 

*    Do read the label and any other product information you have been

given, before you use the product. If you do not understand the

information, ask someone who knows, such as your employer or the

person who supplied the product. Never use a product until you

have read and understood the label. If the product does not have

a label ask the supplier to give you a labelled container. Make

sure you know:

 

–    what the contents are,

 

–    how much pesticide to use and how to dilute it,

 

–    how to use the product safely, and what equipment and

clothing to use,

 

–    the hazards associated with its use, and the first aid to

give if there is an accident,

 

–    when the pesticide should be used and how often.

 

If you cannot find this information on the label ask the

supplier, another user, a community leader, or an agricultural

extension worker to give you the information.

 

*    Do warn your neighbours before you spray pesticides.

 

*    Do make sure machinery and equipment are in good working order

and regularly checked.

 

*    Do wear lightweight work clothes that cover as much of your skin

as possible when you mix or apply pesticide, when you clean

equipment and empty containers, and when you get rid of left-over

pesticide. Wear boots or shoes to cover your feet. Gloves and

goggles will give extra protection from splashes. Do have a clean

change of clothing.

 

*    Do wear protective clothing and use protective equipment if the

label tells you to. If the label tells you to use protective

clothing or equipment it is because the product could harm or

even kill you if you do not have that protection. Make sure all

protective clothing and equipment are properly checked,

maintained and stored.

 

*    Do mix only the amount of chemical that can be used in one day.

Then you will not need to get rid of left-over pesticide or leave

it overnight.

 

*    Do have plenty of soap and water available for washing.

 

*    Do wash gloves before you take them off.

 

*    Do wash your hands thoroughly with soap and water after handling

or using pesticides. Wash your hands with soap and water before

you eat, drink, chew tobacco, smoke, rub your eyes or touch your

mouth.

 

*    Do make sure that you are never alone when you are mixing or

using very poisonous pesticides.

 

Stop work immediately if you are using a chemical and you get a

rash or feel sick, if your eyesight troubles you, or you begin to

sweat more than usual or feel unusually thirsty, or even if you

have a headache or cold or flu symptoms. Tell your employer and

go to a doctor at once. Show the product label, information

leaflet or data sheet to the doctor.

 

*    Do find out when it is safe to harvest and eat food that has been

sprayed with pesticide.

 

*    Do bury or burn food that has been contaminated by pesticide.

 

*    Do not use dirty or damaged protective equipment, or dirty or

torn protective clothes, or leaking gloves or boots. They may be

more dangerous than using nothing.

 

*    Do not use bare hands to scoop powder out of packs, or dip bare

arms or hands into liquids to stir mixtures. Use measures and

mixing vessels for making up solutions (Fig. 10). Do not use

these for anything except pesticides.

 

*    Do not measure out or mix pesticides in or near houses, or where

animals are kept.

 

FIGURE 10

 

*    Do not blow through or suck spray nozzles to clear blockages.

Clean the nozzle with water or a grass stem.

 

*    Do not spray pesticide when a strong wind is blowing because it

may drift over you, or nearby animals or houses.

 

*    Do not leave pesticides unattended while they are out of the

store.

 

*    Do not let anyone go into fields when pesticides are being

sprayed.

 

*    Do not let children drink or play near spray equipment or near

places where pesticides are mixed, or near a field that is being

sprayed.

 

*    Do not let children use pesticides.

 

Get rid of empty containers and left-over pesticide safely

 

*    Do ask agricultural advisers about the safest way to get rid of

stocks of unwanted pesticide and empty pesticide containers. Most

waste can be buried but this is not safe for all chemicals and

may not be allowed in some areas. It is very important to choose

both the method used and the place where waste is burnt or buried

so as not to cause danger to people or to the environment. Do not

get rid of pesticides or pesticide-contaminated waste in

community waste pits used for household rubbish. More specific

recommendations for getting rid of chemical waste are outside the

scope of this book.

 

*    Do use all the pesticide in a sprayer if possible, to avoid

having to get rid of unused pesticide. If that is not possible,

empty all unused pesticide out of spray tanks and get rid of

small amounts of left-over diluted pesticide by tipping it into a

hole in the ground away from dwellings, wells, waterways and

crops. Ask professional advice about where to dig the hole, and

check how much waste can be put in it and how often it can be

used. Put a fence round the hole to keep children away, and put a

sign on the gate showing that poisons have been buried there.

 

*    Do wash all equipment after use and put it back in the store.

Collect the washing water in an empty container and pour it into

the hole used for small amounts of left-over diluted pesticide.

 

*    Do wash out empty containers three times with water. Usually you

empty containers when you are mixing pesticides for use. If you

wash out the containers straight away you can get rid of the

washings by adding them to the spray tank. Washings which cannot

be reused should be collected and got rid of in the hole used for

small amounts of diluted pesticide. After they have been cleaned,

store empty containers in the pesticide store until they can be

got rid of safely.

 

*    Do wash yourself thoroughly after work, and put on clean clothes.

 

*    Do wash all work clothes well every day. Wash work clothes

separately from other clothes. Never wear work clothes at home,

or leave dirty clothes in the house.

 

*    Do not take home left-over chemicals. Put them back in the store.

 

*    Do not use empty containers to cook food or to store food or

drinking-water for humans or animals, as it is impossible to

clean out all the pesticide and to make the containers safe.

Plastic containers should be washed as described above and holes

punched in the base or sides so that they cannot be used again

(Fig. 11). Treat steel drums and small tin containers in the same

way (but do not make holes in pressurized containers).

 

What employers can do to prevent poisoning at work

 

General measures

 

Employers should protect workers from the dangers of using

chemicals. There are several things they can do to protect them.

 

*    Comply with local and national health and safety regulations.

 

*    Choose the least dangerous chemicals. If there are several

different chemicals that do the same job, choose the least

poisonous one.

 

*    Choose safe equipment and safe ways of using it.

 

*    Make sure workers are exposed to chemicals as little as possible.

For example, where appropriate, use mechanical ventilators in

buildings where chemicals are used or stored.

 

FIGURE 11

 

*    Provide workers with equipment and clothing, where appropriate,

to protect them from exposure to chemicals. Maintain clothing and

equipment in good condition.

 

*    Use safety signs and notices.

 

Employers should also:

 

–    tell workers if they are using dangerous chemicals;

 

–    teach workers about the dangers and make sure that they

understand fully;

 

–    train and encourage workers to use safety equipment and

clothing and to use chemicals safely;

 

–    check from time to time to see if the workers are using the

safety equipment and clothing and are using chemicals

safely. Warn those who are not doing so about the dangers.

 

Checking the health of workers and their exposure to chemicals

 

Workers should not be exposed to amounts of chemicals that might

make them ill or damage their health. In the workplace the amount of

chemicals in the air should be measured and recorded. Workers should

be offered regular medical checks if appropriate, to see if they are

being harmed by chemicals at work and to see whether measures need to

be taken to prevent exposure.

 

First aid and emergencies

 

*    First aid should be available at every workplace.

 

*    Training in first aid should always be a part of work training.

 

In every workplace the possible dangers from the use of poisonous

substances should be assessed, and workers should be given the

training, first aid equipment, and supplies they need to deal with the

dangers, as well as some means of communication and transport in case

of an accident.

 

Training

 

Employers should train all workers in what to do after any kind

of accident, emergency or injury. They should teach workers how to

give first aid. From time to time they should check that workers still

remember what to do.

 

In every workplace there should be one or more trained first

aiders always on the site, to give first aid in an emergency, such as

poisoning, injury or sudden sickness. In many countries, national

labour regulations say that there must be a person trained in first

 

aid in each workforce of a certain size, but trained first aiders are

needed even in smaller organizations not covered by regulations. Even

a person working alone should know first aid and know if the work is

dangerous. The number of people who should be trained in first aid

depends on the size of the danger. These people may be workers or

supervisors or, if a person works at home, other adults in the family.

 

Equipment

 

First aid equipment should always be kept in workplaces where

there are dangerous chemicals. For example, where there are corrosive

liquids, an eye-wash fountain or a plastic bottle with an eye-wash may

be needed. If there is a danger that the corrosive liquid could be

spilt on the skin, an emergency shower may be needed. Emergency

breathing equipment should be kept where irritant or poisonous gases,

such as chlorine or carbon dioxide, are used, so that workers can

escape or rescue others if there is a gas leak. In some cases special

equipment may be needed to rescue people after an accident.

 

Supplies

 

Antidotes may need to be added to first aid kits in workplaces

where very quick-acting poisonous chemicals are used. For example,

amyl nitrite capsules should be kept in places where cyanide is used.

 

Getting help and taking people to hospital

 

The easiest way to get help when there is an accident at work is

to shout to a fellow-worker or, for those working at home, a member of

the family or a neighbour.

 

Employers should know what to do and who to contact if there is

an accident or emergency with dangerous chemicals.

 

Where appropriate, there should be posters with clear

instructions about what to do and who to contact if there is an

accident or emergency with dangerous chemicals. The posters should

give telephone numbers of the nearest emergency service, health

service, or poisons centre, or instructions about how to contact them.

They should also have pictures and instructions on how to give first

aid and how to get medical help after first aid has been given.

Employers should check from time to time that these procedures still

work, and find out, for example, whether the people to contact have

changed.

 

Cooperation between employers and workers

 

Employers, workers and their representatives should cooperate

closely to apply these safety measures. Workers should take care of

their own health and safety by following training and instructions

given by their employers, by using protective equipment and clothing

properly and by reporting at once to their supervisor any situation

that could be dangerous.

 

Workers should be given information about the dangers of using

chemicals in their work, and be trained in ways of working that will

protect them from those dangers.

 

How to avoid snake bites

 

When a person and a snake meet, the snake will usually try to get

away if given the chance. Snakes usually bite only when they are

surprised by a sudden movement and cannot get away.

 

*    Do wear shoes when walking outdoors. Tall leather boots give the

best protection for walking in long grass or undergrowth. Wear

them with long trousers hanging outside the boots (Fig. 12).

 

*    Do learn about the poisonous snakes in your area. Learn what they

look like and where they live. Most snakes live on the ground but

some live in trees or bushes. Find out if there are any snakes

that spit venom and how they attack.

 

FIGURE 12

 

*    Do take care at night because that is when many snakes are

active. Tell children to wear shoes and use a torch when walking

around at night. Teach them to leave snakes alone.

 

*    Do not go near snakes. Run away if you can. If you cannot run

away, do not make sudden movements.

 

*    Do not touch a snake even if it looks dead. Some snakes pretend

to be dead to avoid attack.

 

*    Do not turn over stones or logs, or put your hand or foot into a

hole in the ground. Before stepping over a log look for snakes on

the other side.

 

*    Do not sleep on the ground. You might roll over onto a snake

while asleep, or a snake may move next to you to get warm.

 

How to prevent insect, spider and scorpion stings and bites

 

*    Do find out about the poisonous insects, caterpillars, spiders,

and scorpions in your area. Learn what they look like and where

they live.

 

*    To protect yourself from bee stings when working among flowers or

fruits, do wear long trousers, long-sleeved shirts and gloves,

and cover your head and face as much as possible (Fig. 13). Avoid

wearing things that attract bees, such as bright flowery

clothing, bright shiny jewellery, buttons or buckles, or using

scented perfume, soap or shampoo.

 

FIGURE 13

 

*    Do not walk outdoors in bare feet or open shoes.

 

*    Do not touch insects, caterpillars, spiders, scorpions, or

centipedes.

 

*    Do not put your hands in leaf litter, rotten tree trunks or holes

where insects, caterpillars, spiders, scorpions or centipedes

might live.

 

How to avoid eating poisonous plants, mushrooms and fish

 

*    Do find out which plants and mushrooms in your community are

poisonous and what they look like. Make sure you can recognize

them – some edible plants, mushrooms and fish are very hard to

distinguish from poisonous ones.

 

*    Do learn how to prepare foods correctly. Some plants (like

cassava) are poisonous if not properly prepared or cooked, and

some plants and fish have poisonous parts that must not be eaten.

 

FIGURE 14

 

*    If you are preparing tropical fish, do separate the flesh from

the head, skin and gut as soon as possible, because these may

contain large amounts of poison.

 

*    Do not buy mushrooms from people who are selling them by the

roadside.

 

*    Do not eat fish that is not fresh. Some fish are good to eat when

they are fresh, but become poisonous when they have been dead for

some time.

 

How to avoid infection from food contaminated with germs

 

*    Do keep kitchens clean. Keep tables and other surfaces on which

food is prepared clean, and keep kitchen utensils clean.

 

*    Do protect food by keeping it covered or in boxes or cupboards

with wire screens (Fig. 14).

 

*    Do wash your hands well with clean soap and water before touching

or preparing food. Cuts or sores on fingers should be covered

with a clean dressing.

 

*    Do boil plates and eating utensils used by  sick people before

anyone else uses them.

 

*    Do not keep food for a long time in a warm place. Do not keep

left-over cooked food if you cannot keep it cool or keep it in a

refrigerator.

 

*    Do not let flies, other insects, worms, rats or other animals

touch or crawl on food. They carry germs and spread disease.

 

*    Do not let dust get on food or let people touch food.

 

*    Do not leave food scraps or dirty dishes lying around, as these

attract flies and let germs breed.

 

*    Do not leave clean utensils lying on the ground.

 

*    Do not eat raw or undercooked meat. Cook it right through.

 

*    Do not eat food that is old or smells bad.

 

*    Do not eat food from cans that are swollen or that squirt out

when opened. Be especially careful with canned fish.

 

CHAPTER 4

 

What to do in an emergency

 

Objectives

 

After studying this chapter, you should be able to:

 

1. Decide quickly and calmly what to do in an emergency.

 

2. Check for danger at the scene of an accident, fire or explosion,

and warn other people.

 

3. Decide quickly when to get help to rescue a person who is

overcome by poisonous gas, or trapped inside a burning building.

 

A poisoned person may suddenly become very sick and need

immediate first aid. When you help someone who has been poisoned or

injured in a chemical accident, fire or explosion, or by carbon

monoxide, you should be aware of the dangers, so that you can protect

yourself and warn others.

 

The dangers to look out for

 

There may be a danger of poisoning:

 

–    inside a room or building where there is a heater or cooker

burning wood, oil or gas, where there is not enough fresh air;

 

–    inside a garage where a car engine is running;

 

–    inside an empty chemical storage tank;

 

–    inside a grain store or silo;

 

–    near a chemical fire or explosion, or a spill or leak of gases,

solids or liquids, especially in a pit, trench or cellar;

 

–    inside a burning building. Fires give off smoke and hot air,

which may damage the lungs if breathed in, and poisonous gases,

especially if chemicals or plastics are burning. The poisonous

gases quickly build up in a closed space;

 

–    from contact with skin or clothes of people who have been

contaminated by very poisonous chemicals, such as cyanide or

organo-phosphorus pesticides.

 

There may also be a danger of injury at the scene of a chemical

accident. For example, there may be a danger from traffic if the

accident happened on the road, or a danger from collapsing buildings

at the scene of a fire or explosion.

 

What to do in an emergency

 

When there is an emergency:

 

*    Keep calm.

 

*    Make sure you are safe.

 

*    Raise the alarm and call for help.

 

*    Move the victims away from danger.

 

*    Give first aid.

 

Keep calm

 

Try to calm yourself before you approach a victim or an incident.

Most people are frightened if they are injured or suddenly taken ill.

By remaining calm you will help to relieve their fear. Act quickly and

quietly.

 

Make sure you are safe

 

Before you do anything else, make sure that you are safe. If

there is danger, you must protect yourself.  If you become another

victim there may be no one to help you.

 

Quickly check that there is no danger from:

 

–    poisonous gas, smoke or fumes,

 

–    poisonous liquids,

 

–    fire and collapsing buildings,

 

–    traffic.

 

Check which way the wind is blowing and keep out of areas where

smoke or fumes from leaks or spills might blow over you.

 

Raise the alarm and call for help

 

If you are the first person on the scene, shout to others in the

area to warn them of any danger and to call for help.

 

If there is more than one victim always shout for help before you

do anything else.

 

If there is a nurse, doctor, health worker or first aider living

or working nearby, send someone to get help.

 

Move the victim away from danger, if it is safe for you to do so

 

If someone is unconscious in a room or building that might be

full of poisonous gas:

 

*    Open the door and open or break the windows from the outside, to

let in fresh air. Wait until the room is full of clean air before

you go in.

 

*    Do not switch on an electric light and do not let anyone go into

the room with a lighted cigarette or naked flame. These may cause

an explosion.

 

If someone is trapped inside a burning building:

 

*    Do not go in unless you are wearing proper breathing equipment

that you have been trained to use. If you go into a burning

building with nothing to protect you from breathing poisonous gas

and smoke, you may become unconscious and not be able to get out.

A wet rag over the mouth and nose will not protect you.

 

If someone is unconscious inside an empty storage tank:

 

*    Use an air compressor to blow fresh air into the tank. Wait until

the tank is full of clean air before you go in.

 

*    If the storage tank cannot be cleared with a compressor, do not,

go in unless you are wearing proper breathing equipment that you

have been trained to use. If you go into an empty storage tank

with nothing to protect you from breathing poisonous gas, you may

become unconscious and not be able to get out.

 

Protect yourself from being poisoned by contact with the victim.

Put on gloves before you touch people who have been poisoned with

cyanide, crowd-control gases, or organophosphorus pesticides. Poison

on their skin or clothes could poison you.

 

Give first aid

 

Give first aid before you move the victim, unless it is dangerous

to stay there (see Chapter 5).

 

If there will be a delay in getting the victim to a doctor or to

hospital, you may need to do more to help him or her (see Chapter 9).

 

CHAPTER 5

 

First aid

 

Objectives

 

After studying this chapter, you should be able to:

 

1. Tell when a person:

 

– is unconscious,

– is not breathing,

– has no heartbeat.

 

2. Decide what to do and give first aid in each case.

 

3. Give first aid when a person:

 

– has fits (convulsions),

 

– has chemical in the eyes,

 

– has chemical on the skin,

 

– has been bitten or stung by a poisonous or venomous animal.

 

First aid is the help a person gives straight away in a medical

emergency.

 

This chapter can help you learn first aid, but you also need

someone to teach you first aid, and check that you are doing it

correctly. It is important to have someone show you the right way to

do mouth-to-mouth respiration and heart massage. You should practise

on a special training manikin (a life-size model). Never practise

heart massage on another person, only on a manikin.

 

It is dangerous to use heart massage if you have not had proper

training.

 

People who are poisoned may:

 

– be unconscious,

 

– stop breathing,

 

– have no heartbeat,

 

– have fits (convulsions).

 

They need immediate first aid to help them to breathe and to

start the heart beating.

 

When people get chemical in the eyes or on the skin, it may cause

burns. These people need immediate first aid to wash the chemicals out

of the eyes and off the skin. The chemical may also get into the body

and cause poisoning.

 

People who have been bitten or stung by a poisonous or venomous

animal need first aid:

 

– to remove stings, spines or tentacles,

 

– to clean the wound and stop infection,

 

– to slow the spread of poison through the body.

 

Give first aid at once

 

Immediate first aid may stop serious poisoning and may save life.

If breathing and the heart stop, the person will die within a few

minutes unless you give first aid at once.

 

First aid for poisoning

 

Here is an action list. Each step is explained in more detail

below the list. Start with the first step and follow each step in the

order given. Act as quickly as you can, but stay calm.

 

1. Check if the patient is conscious.

 

2. Open the airway and make sure the tongue is not blocking the

throat.

 

3. Check if the patient is breathing.

 

4. Clean out the mouth and clear the throat.

 

5. Give mouth-to-mouth respiration.

 

6. Check if the heart is beating.

 

7. If the heart is beating, but the patient is still not breathing,

carry on with mouth-to-mouth respiration.

 

8. If the heart is not beating, give heart massage.

 

9. If the patient is breathing but is unconscious, turn him or her

onto one side, into the recovery position.

 

10. Give first aid for fits if necessary.

 

11. Wash any chemical out of the eyes.

 

12. Remove contaminated clothing and wash any chemical off the skin

and hair.

 

13. Give first aid for poisonous bites and stings.

 

Check if the patient is conscious

 

Try to make the patient wake up. Shout “Are you all right?” and

gently shake the shoulders, but take care not to make any injuries

worse (Fig. 15). Pinch the skin on the neck and watch the face. A

patient who is just sleeping will wake up, but an unconscious patient

will not.

 

Open the airway

 

The airway is the tube through which air passes from the mouth

and nose to the lungs. If it is blocked the patient cannot breathe and

air cannot get into or out of the lungs. A patient who cannot breathe

will die within four minutes.

 

In an unconscious patient the tongue may block the throat and the

airway. Make sure the airway is open and air can get down the throat

(Fig. 16):

 

*    Place the patient on his or her back.

 

*    Tilt the head back and lift the chin up with the finger and thumb

of one hand on the bony part of the chin, while pressing the

forehead back with the other hand (Fig. 17). This will open the

airway and stop the tongue blocking the throat.

 

Check whether the patient is breathing

 

After opening the airway, quickly check whether the patient is

breathing (Fig. 18):

 

*    Look for the belly or the chest moving up and down.

 

*    Feel the chest moving up and down.

 

FIGURE 15

 

FIGURE 16

 

FIGURE 17

 

*    Feel the patient’s breath on your cheek.

 

*    Listen for breath sounds. Put your ear close to the patient’s

mouth.

 

Use all four checks. Remember that the chest may move up and down

even when the throat is completely blocked and air cannot get to the

lungs.

 

FIGURE 18

 

A person may stop breathing because:

 

*    Something is stuck in the throat.

 

*    The throat is blocked by the tongue, or by blood, spit, vomit,

food, or false teeth. (If you have tilted the head back, the

tongue will not block the throat.)

 

*    The throat is blocked because the patient has swallowed poison

which has burnt the throat and made it swell.

 

*    The patient has been poisoned.

 

*    The patient has been hit on the head or chest.

 

*    The patient has had a heart attack.

 

*    The patient has nearly drowned.

 

Clean out the mouth and clear the throat

 

If the patient is not breathing after you have tilted the head

back, something may be blocking the throat.

 

Turn the head to one side. With one or two fingers (and

preferably wearing gloves) scoop deeply round the mouth and throat to

clear any blockage such as vomit (see Fig. 19). Take out the patient’s

false teeth.

 

If the patient starts breathing turn him or her onto one side,

into the recovery position. Check breathing and pulse frequently.

 

Whatever the cause, if the patient does not start breathing you

must act immediately to help the patient to breathe.

 

Give mouth-to-mouth respiration

 

You can help the patient to breathe by blowing air from your

lungs into his or her lungs through the patient’s mouth (mouth to

mouth) or nose (mouth to nose). This is called mouth-to-mouth (or

mouth-to-nose) respiration.

 

FIGURE 19

 

*    Do not give mouth-to-mouth respiration if the patient is still

breathing.

 

If there is poison on the patient’s lips, or if corrosive

chemicals have burnt the lips and chin, wipe the chemical off, cover

the mouth with a cloth to protect yourself from getting poison on your

lips or hands, and give mouth-to-nose respiration. Breathe into the

patient’s nose (see Fig. 20).

 

FIGURE 20

 

How to give mouth-to-mouth respiration or mouth-to-nose respiration

to an adult

 

1. With the patient lying flat on his or her back, clear any

blockage from the mouth. Kneel beside the patient’s head.

 

2. Tilt the head back.

 

3. Pinch the nose with one hand. With the other hand pull the mouth

open (Fig. 21). Do not press on the neck. For mouth-to-nose

respiration, close the patient’s mouth with your thumb.

 

4. Breathe in deeply. Cover the patient’s mouth completely with your

own mouth and breathe out steadily and smoothly so that all your

breath goes into the patient’s mouth. Breathe out strongly to

fill the chest (see Fig. 22). Look for the patient’s chest

rising. For mouth-to-nose respiration put your mouth around the

patient’s nose.

 

5. Lift your mouth away so that the patient can breathe out and you

can take another breath of air. Turn your head, look for the

chest falling, feel the breathed-out air on your cheek, and

listen for the sound of the patient breathing out (see Fig. 23).

For mouth-to-nose respiration you may have to open the patient’s

mouth to let air out.

 

FIGURE 21

 

FIGURE 22

 

FIGURE 23

 

6. Take another breath of air. Once the chest has fallen, blow into

the patient’s mouth (or nose) again. Watch the patient breathe

out again. Then check that the heart is beating.

 

If the chest does not rise with each breath, and you cannot feel

or hear the patient breathing out, then either the airway is blocked

or some of your breath is not going into the patient’s chest. Check

that the head is held well back and clear the airway again. Make sure

there is no air escaping when you breathe into the patient’s mouth (or

nose).

 

How to give mouth-to-mouth respiration to a child or a baby

 

Open the airway in a child or baby in the same way as for an

adult, but do not tilt the head too far back or the soft airway may

kink.

 

If you can see something blocking the throat carefully remove it,

but do not sweep your finger inside a baby’s mouth if you cannot see

anything there. If the throat is swollen because of an infection, you

might make the swelling worse.

 

Do not pinch the nose. Put your lips over both the nose and the

mouth (Fig. 24). Breathe gently, just enough to move the chest. For a

very small baby only small puffs are needed. Do not blow hard or you

may harm the baby’s chest. Blow into the chest every 3 seconds.

 

FIGURE 24

 

Check if the heart is beating

 

Feel for the pulse in the neck, in the hollow between the voice

box and the muscle. Place two fingers on the voice box (Adam’s apple)

and slide your fingers into the groove under the jaw (Fig. 25). Keep

your fingers there for at least five seconds to feel if there is a

pulse.

 

If you cannot feel a pulse, the heart has stopped. This is called

cardiac arrest. The patient will be unconscious and will probably have

large pupils. If the patient has white skin it will probably have a

blue-grey colour. If the patient has black or brown skin look for a

blue colour to the nails, lips and the inside of the lower eyelids. If

the heart stops, breathing will also stop and the patient will need

both heart massage and mouth-to-mouth respiration.

 

If the heart is beating, but the patient is still not breathing,

carry on with mouth-to-mouth respiration

 

Take a deep breath and blow once every 5 seconds, until the

patient starts to breathe without help. You may have to do this for

more than one hour.

 

If the patient has breathed in an irritant gas, the mouth and

throat may be full of froth. You cannot remove this froth by wiping,

so do not waste time trying to remove it. As this froth is air

bubbles, all you have to do to move air in and out of the lungs is to

blow the froth into the lungs. So blow as usual.

 

When the patient starts to breathe, turn him or her onto one side

into the recovery position. The patient may vomit when breathing

starts again but the vomit will not block the throat if the patient is

lying on one side. Let the vomit come out and clear it out of the

mouth with your finger.

 

FIGURE 25

 

Watch carefully in case the patient stops breathing again. If

breathing stops turn the patient onto his or her back and start mouth-

to-mouth respiration again.

 

If the heart is not beating give heart massage

 

If you cannot feel a pulse in the neck, you should try to start

the heart beating again by giving heart massage (see below).

 

Heart massage (or chest compression) means pressing down on the

heart to push blood out of it and round the body. This may start the

heart beating again. It will only be effective if the patient is lying

on a hard surface.

 

If there is no heartbeat, the patient will have stopped

breathing. Always start mouth-to-mouth respiration before heart

massage.

 

Do not give heart massage if the heart is beating, even faintly.

Stop as soon as you feel a pulse in the neck, but carry on with mouth-

to-mouth respiration if the patient is still not breathing.

 

How to give heart massage to an adult

 

1. Check that there is no heartbeat.

 

2. Lay the patient on his or her back on a firm surface. Kneel

beside the patient’s chest.

 

3. Find the right place to put your hands. Find the lower edge of

the ribs. Follow the edge of the ribs to where they meet the

breastbone. Place your middle finger on the base of the

breastbone, and the index finger next to it (Fig. 26), then place

the heel of your other hand next to these two fingers, on the

breastbone in the midline of the chest (Fig. 27).

 

4. Now cover this hand with the heel of your other hand, lock your

fingers together, keeping them off the chest (Fig. 28). Put your

shoulders above the patient’s chest and keep your arms straight.

 

5. Press down on the lower half of the breastbone 4-5 centimetres,

keeping your arms straight. Then stop pushing. While counting

“one and two and three and…”, press 15 times, in time with the

numbers (80 presses a minute). Presses should be regular and

smooth, not jerky and jabbing.

 

6. Remember that both mouth-to-mouth respiration and heart massage

are needed. After 15 presses tilt the head back again so that air

can get down the throat, put your mouth round the patient’s mouth

and give two breaths.

 

7.    Continue with 15 presses followed by two full breaths. After one

minute check the heartbeat, then after 3 minutes or every 12

cycles check the heartbeat again. As soon as the heartbeat

returns stop heart massage immediately. You may see the patient’s

colour become more normal and the pupils return to normal size.

 

8. Continue mouth-to-mouth respiration at 12 breaths a minute, until

the patient breathes without help. It may be some time before

breathing starts again, even after the heart has started beating.

When breathing starts again put the patient onto his or her side

in the recovery position.

 

If another person is with you, get him or her to do the breathing

while you do the heart massage (Fig. 29). The other person should

kneel by the patient’s head while you kneel by the middle of the

chest. The other person should give two breaths and check the

heartbeat. If there is no heartbeat you should give five presses on

the chest. Continue with the other person giving one breath and you

giving five presses on the chest. Check the heartbeat after one minute

then after every three minutes or 12 cycles.

 

FIGURE 26

 

FIGURE 27

 

FIGURE 28

 

How to give heart massage to a child or a baby

 

The best place to feel the pulse in a small child or a baby is on

the inside of the upper arm. With your thumb on the outside of the arm

press your first and middle fingers into the groove below the muscle.

 

FIGURE 29

 

FIGURE 30

 

When giving heart massage to a child or baby, press with less

force but slightly faster than you would for an adult.

 

For a child use one hand only and press lightly on the chest

(Fig. 30). Press down 2.5-3.5 cm.

 

FIGURE 31

 

For a small child or a baby press on the chest with just two

fingers. Press down 1.5-2.5 cm (Fig. 31).

 

Keep your hand or fingers below the level of the nipples.

 

Press down at a rate of 100 presses a minute giving 15

compressions followed by two breaths.

 

If the patient is breathing but is unconscious, turn him or her onto

one side, into the recovery position

 

An unconscious patient should be turned to lie on one side to

stop the tongue blocking the throat and to allow fluid to come out of

the mouth. This is called the recovery position.

 

Before you turn the patient over:

 

*    If breathing is noisy, sweep your finger round the mouth to

remove anything blocking the airway, and take out the patient’s

false teeth if they are loose.

 

*    Empty the patient’s pockets of anything that would be

uncomfortable to lie on.

 

*    Take off the patient’s spectacles in case they injure the eyes.

 

*    Look for injury to the head or neck, and feel with your fingers

to see whether the back of the neck or the backbone is bent or

swollen.

 

*    Get help if the patient has an injury to the head or neck. Three

people should roll the patient keeping the head, neck and body in

a straight line. Do not let the patient sit up when he or she

wakes up.

 

The patient should be turned onto one side with:

 

–    the head, neck and body in a straight line,

 

–    the head placed so that the tongue will not block the throat, and

vomit or saliva can come out of the mouth;

 

–    the arms and legs placed so that the patient stays in the same

position.

 

One way of turning a patient

 

1. Kneel beside the patient, turn the patient’s face towards you,

and tilt it back, with the jaw jutting forward so the airway

stays open. Place the arm nearest you above the head. Place the

patient’s other arm across the chest. Raise the patient’s far leg

under the knee, to bend it (Fig. 32).

 

2. Protect the patient’s face with one hand. With your other hand,

grasp the patient’s clothes at the hip and pull the patient

towards you until he or she is resting on one side, against your

knees (Fig. 33). The patient’s head should be resting on the

lower arm. Check that the airway is still open.

 

3. Take the patient’s upper arm and place the hand under the face

(Fig. 34). This will help to keep the head tilted back and the

airway open. Now position the upper leg so that the bent knee

rests on the ground and supports the patient’s body.

 

FIGURE 32

 

FIGURE 33

 

FIGURE 34

 

If the patient is too heavy for you, get help. Someone else can

support the patient’s head while you do the turning, or can push the

patient towards you as you pull.

 

Give first aid for fits (convulsions) if necessary

 

1. If the patient has a fit, make him or her lie down in a safe

place. Make sure there are no hard or sharp objects nearby and

protect the patient from injury.

 

2. Turn the patient to lie on one side so that the tongue comes to

the front of the mouth and froth can come out of the mouth

easily.

 

3. Put a folded cloth under the patient’s head, or hold the head so

that it does not bang on hard things.

 

4. Do not try to stop the shaking movements.

 

5. Loosen any tight clothing.

 

6. Do not put anything in the patient’s mouth or try to open it.

 

7. After the fit, let the patient rest in the recovery position.

 

Wash any chemical out of the eyes

 

Wash chemicals out of the eyes at once, with plenty of cool,

clean water, before you wash the skin. Even a delay of a few seconds

can make the injury worse.

 

1. Immediately gently brush or wipe any liquid or powdered chemical

off the face. Let the patient sit or lie down with the head

tilted back and turned towards the worst affected side. Gently

open the eyelids of the affected eye or eyes and run cold water

over from a tap or pour water from a jug. Make sure the water

drains away from the face and does not go into the unaffected

eye. Wash out the eye or eyes in this way for 15-20 minutes,

timed with a watch if possible.

 

The patient may be in great pain and may want to keep his or her

eyes closed, but you must wash the chemical out of the eyes in

order to prevent permanent damage. Gently pull the eyelids wide

open, and keep them apart (Fig. 35).

 

2. While you are rinsing the eyes check that the inside of the

eyelids has been well washed. Check that there are no solid

pieces of chemical in the folds of skin round the eyes, or on the

eyelashes or eyebrows. If you are not sure whether all the

chemical has been removed, wash out the eyes for 10 more minutes.

 

3. Do not let the patient rub the eyes.

 

FIGURE 35

 

4. The patient’s eyes should be examined by a doctor even if there

is no pain, because damage may be delayed.

 

5. If light hurts the patient’s eyes, cover them with a sterile eye

pad, a dry gauze pad, or a pad of clean cloth. Bandage the pad in

place securely, but not too tightly. This will protect the eyes

and help them to heal.

 

6. If the patient is in pain, give aspirin or paracetamol every four

hours.

 

Medical treatment of chemical contamination of the eye

 

*    If the pain is severe the patient may need an intramuscular

injection of morphine.

 

*    Look for burns. Put drops of fluorescein in the eye. Burns will

stain yellow.

 

*    Prevent infection. If there are yellow stains with fluorescein,

put chloramphenicol 1% eye ointment in the eye. Put more ointment

into the eye every two hours. Continue until the eye is no longer

red and the sclera is white, and then for another 24 hours.

 

Remove contaminated clothing and wash any chemical off the skin

and hair

 

1. Take the patient immediately to the nearest shower or source of

clean water. If there is no water nearby dab or gently wipe the

skin and hair with cloths or paper. Do not rub or scrub the skin.

 

2. Immediately wash the affected part of the body under cold or

lukewarm running water, using soap if you have some. If there is

no running water use buckets of water. Do it quickly and use a

lot of water (Fig. 36). Wear gloves and an apron if needed, to

protect yourself from splashes of chemical. Some chemicals give

off vapour: be careful not to breathe it in.

 

FIGURE 36

 

3. At the same time quickly remove any of the patient’s clothes

contaminated with chemical or vomit, as well as shoes and wrist

watch if necessary. Speed is important – cut the clothes off if

the chemicals are very poisonous or corrosive.

 

4. If large areas of the body are contaminated with chemical, wash

the patient under a shower or a hose. Remember to clean the hair

and under the fingernails, in the groin and behind the ears, if

necessary.

 

5. Continue to pour water over the patient for 10 minutes, or longer

if you can still see chemicals on the skin. If the skin feels

sticky or soapy, wash it until the feeling disappears. This may

take an hour or more.

 

6. Make sure the water drains away freely and safely as it will have

chemical in it.

 

7. Dry the skin gently with a clean, soft towel. If clothing stays

stuck to the skin even after water has been poured over it, do

not remove it.

 

8. Remember that many chemicals can pass through the skin very

quickly. Look for signs of poisoning (see Chapter 7).

 

9. Put contaminated clothes in a separate sealed container and do

not use them again until they have been washed. Throw away shoes

contaminated with chemical. If you have used cloths or paper to

wipe the skin, put these in a container and burn them.

 

If the patient has burns, and there is no doctor:

 

1. Do not break open blisters or remove skin. Where the skin is red

and painful or raw, cover it and the skin round it with a

sterile, dry dressing and bandage. Keep the bandage loose. This

will protect the burn and speed up healing.

 

2. Dress the patient in clean clothes or cover with a sheet.

 

3. Replace fluid loss: if a large area is burnt give the patient

half a cup of water every 10 minutes until the patient reaches

hospital.

 

4. Treat pain: give aspirin every four hours until the pain is

better.

 

5. Get the patient to a doctor or hospital as soon as possible.

 

Give first aid for poisonous bites and stings

 

This section gives general advice first, followed by specific

advice for dealing with:

 

–    snake bites,

 

–    stings or bites by bees, wasps, hornets, fire ants, scorpions,

spiders or ticks,

 

–    stings by jellyfish,

 

–    stings by venomous fish.

 

General advice

 

1. People often panic if they have been bitten or stung. You should

tell the patient that many snakes, spiders, insects and sea

creatures are harmless and that even the bites and stings of

dangerous animals often do not cause poisoning.

 

2. Keep the patient calm and still. Moving the bitten or stung limb

speeds up the spread of venom to the rest of the body. Fear and

excitement also make the patient worse. The patient should be

told not to use the limb and to keep it still and below the level

of the heart. The limb may swell after a while, so take off the

patient’s rings, watch, bracelets, anklets and shoes as soon as

possible. A splint and a sling may help to keep the limb still.

 

3. The following measures should not be used. They may cause

infection, or make the effects of the venom worse.

 

–    Do not cut into the wound or cut it out.

 

–    Do not suck venom out of the wound.

 

–    Do not use a tourniquet or tight bandage.

 

–    Do not put chemicals or medicines on the wound or inject them

into the wound (potassium permanganate crystals for example).

 

–    Do not put ice packs on the wound.

 

–    Do not use proprietary snake bite kits.

 

Time spent giving traditional remedies and herbal medicines would

be better spent getting the patient quickly to hospital. Such

“remedies” are often of no use and may be dangerous or even life-

threatening.

 

4. The patient should lie on one side in the recovery position so

that the airway is clear, in case or vomiting or fainting.

 

5. Do not give the patient anything by mouth – no food, alcohol,

medicines or drinks. However, if it is likely to be a long time

before the patient gets medical care, give the patient water to

drink to stop dehydration.

 

6. Try to identify the animal, but do not try to catch it or keep it

if this will put you, the patient or others at risk. If the

animal is dead take it to hospital with the patient, but handle

it very carefully, because even dead animals can sometimes inject

venom.

 

7. As soon as possible, take the patient to a hospital, medical

dispensary, or clinic where medical care can be given. The

patient should not walk but should keep as still as possible. If

there is no ambulance or car, carry the patient on a stretcher or

trestle, or on the crossbar of a bicycle.

 

8. Antivenom should only be given in a hospital or medical centre

where resuscitation can be given, because the patient may have an

allergic reaction. If available, antivenom should be used if

there is evidence of severe poisoning. It should not be used when

there are no signs of poisoning.

 

Using traditional medicines to treat poisonous bites and stings

 

No home remedy or traditional cure for poisonous bites or stings

(from snakes, scorpions, spiders or other poisonous animals) has any

effect beyond that of the healing power of belief.

 

Anyone who says that a traditional medicine kept a snake’s venom

from harming him or her was probably bitten by a snake that did not

inject poison.

 

Some traditional medicines may do some good. If a person believes

in them he or she will feel less afraid, the pulse will slow down, the

person will move and tremble less, and as a result, the poison will

spread through the body more slowly. So there is less danger.

 

But the benefit of these traditional medicines is very limited.

Even when they are given traditional medicines, many people still

become very ill or die from snake bite. Using traditional medicine may

delay more effective treatment. It is better to use hospital

treatment.

 

Do not use traditional remedies that contain animal or human

waste or that involve eating animals not usually used as food. They do

not help at all. They are often dangerous and can cause serious

infections.

 

Medical treatment of poisonous bites and stings

 

1.    Antivenom should only be given in a hospital or medical centre

where resuscitation can be given, because the patient may develop

an allergic reaction. If available, antivenom should be used if

there are signs of severe systemic envenoming. It should not be

used when there are no signs of systemic envenoming.

 

2. To decide whether venom has been injected, and how serious the

poisoning is, look for these signs:

 

–    swelling and local tissue injury at the site of the bite;

 

–    blood that does not clot, causing bleeding from gums, nose,

wounds and injection sites;

 

–    shock caused by circulatory failure;

 

–    neurotoxic paralysis (ptosis, ophthalmoplegia, dysarthria,

peripheral muscle weakness, respiratory distress);

 

–    generalized muscle pain and local tissue damage;

 

–    kidney failure, red or black urine;

 

–    tender swollen lymph nodes near the bite site.

 

To test clotting time of whole blood: Place 2-3 ml of whole

venous blood in a clean, dry, glass test-tube and leave

undisturbed for 20 minutes at room temperature. Normal blood

should have clotted by this time. Tip the tube to see if the

blood is still liquid.

 

3. If the wound becomes infected, treat as for any other local

infection. Use antibiotics if needed.

 

4. If there is local tissue injury, do not cover the wound but leave

it open.

 

What to do if someone is bitten by a snake

 

Venomous snakes often bite without injecting venom. In other

words, the bites are “dry”. Many people survive being bitten by

venomous snakes, even the most dangerous species, without being

poisoned.

 

1. Keep the patient lying on one side, in the recovery position, to

lessen the risk of vomit blocking the throat. Check breathing and

heartbeat.

 

2. Do not use any of the harmful measures listed on page 62.

 

3. Clean the wound gently so that there is no venom left on the

skin. Use clean water and soap, or wipe the wound gently with a

clean cloth.

 

4. Give first aid as follows for the bites of elapid snakes that do

not cause local tissue injury or swelling (coral snakes, kraits,

mambas, some cobras, but not African and some Asian cobras or

vipers). Apply a broad, firm bandage over the bite site, then

bandage as much of the bitten limb as possible over the patient’s

clothing. The bandage should be firm but not so tight that it

acts as a tourniquet. You should still be able to feel the pulse

in the lower part of the limb. Severe pain in the bandaged limb

may mean that the bandage is too tight. It is important to use a

splint so that the patient cannot move the limb. Once the patient

is in a hospital or medical centre the bandage should be taken

off. It should not be taken off before then because, once the

bandage is removed, venom may spread rapidly through the body.

 

5. Some snake bites cause severe pain, although most do not.

Paracetamol can be given for the pain, but aspirin should not be

given, as it may make the patient bleed.

 

6. If the snake has been killed, take it to the hospital with the

patient so that it can be identified. Handle the dead snake very

carefully, because it can still inject venom, even after the head

has been cut off.

 

Medical treatment of snake bites

 

Snake bites may cause tetanus (lockjaw). The patient should be

given an injection of tetanus antitoxin if possible.

 

Do not give unnecessary injections because of the risk of

bleeding if the blood does not clot.

 

A patient with respiratory paralysis may need artificial

ventilation for hours, days or even weeks.

 

If the patient has kidney failure, make sure the patient is given

the right amount of fluids and carefully monitor fluid balance.

Dialysis may be needed, preferably haemodialysis or, if this is not

possible, peritoneal dialysis.

 

Shock and low blood pressure may be caused by fluid moving out of

the blood vessels that have been damaged by the snake venom. This

happens especially with viper bites. Intravenous fluids may be life-

saving.

 

Usually there is no need for surgery, and unnecessary surgery

could cause complications or permanent damage to the bitten limb.

 

What to do if someone is stung or bitten by bees, wasps, hornets, fire

ants, scorpions, spiders or ticks

 

1. Scorpion stings and insect stings or bites cause local pain and

swelling. Spider bites may cause deep ulcers or blisters. The

greater the number of stings or bites, the more severe is the

effect. Some spiders (for example, the brown recluse or violin

spider, widow spiders) and at least one scorpion  (Hemiscorpion

lepturus found in the Islamic Republic of Iran and Iraq) may

cause local tissue injury and ulcers at the bite site, which may

spread over the bitten limb.

 

2. Some people are sensitive to insect venom. They may get a local

or generalized rash, itching, and red skin. In serious cases the

patient will feel sick and as if there is a tight band around the

chest, the face may swell, the patient may not be able to breathe

properly, may wheeze and gasp for air, and may become

unconscious. If breathing becomes difficult, lie the patient on

his or her side in the recovery position. If breathing and

heartbeat stop, give mouth-to-mouth respiration and heart

massage. Patients should be given an intramuscular injection of

epinephrine (adrenaline).

 

3. Bees leave their sting behind and can only sting once, but wasps

and hornets do not leave their sting behind and can sting many

times. If the sting has been left, remove it, but be careful not

to squeeze the venom sac on the end. Either use tweezers to grasp

the sting as near to the skin as possible and remove it (Fig.

37), or scrape the sting off the skin. Take off the patient’s

rings, bracelets and anklets in case the limb swells.

 

4. A tick can sometimes be washed off with alcohol, or removed with

the heat from a cigarette. If not, lever the tick off the skin

using fine tweezers or forceps, but try not to squeeze its body.

 

5. A cold compress, using cold water but not ice, may help lessen

the swelling, itching and pain.

 

6. Paracetamol may be given for pain, but aspirin should not be

given.

 

Medical treatment for scorpion stings and insect stings or bites

 

1. Antivenom is available in South America for some spiders: brown

recluse spiders  (Latrodectus spp.), widow spiders ( Loxosceles

spp.),  Phoneutria spp., and some scorpions (for example

species of  Centruroides, Tityus, Buthotus, and  Leiurus).

 

2. Antivenom may be useful in treating local tissue injury by

Loxosceles spp., and  Hemiscorpion lepturus, even when there

are no signs of general poisoning. The wound should be treated

open as for a burn.

 

3. Pain can be treated with local analgesia (e.g. lidocaine, digital

nerve block, peripheral nerve block), or with systemic

analgesics. Morphine should not be used to treat pain because of

the risk of respiratory depression. Antivenom may be useful in

treating pain caused by bites from  Latrodectus spp.

 

FIGURE 37

 

What to do if someone is stung by jellyfish

 

1. Jellyfish tentacles cling to the skin and can be hard to get

off. Keep the patient calm and still to avoid the tentacles

causing more stings.

 

2. There is no sure way to stop the tentacles stinging if they are

moved, so it is best not to touch them until the first effect of

the sting has worn off.

 

3. To stop the cells from stinging, immediately flood the area with

vinegar (5% acetic acid), unless the jellyfish is known to be a

bluebottle (Portuguese man-of-war;  Physalia species). If you do

not have vinegar, use seawater. Do not use alcohol, methylated

spirits, petrol or fresh water. Cold packs or crushed ice wrapped

in a cloth may help to relieve pain caused by stings from

Physalia and other jellyfish. Stings from box jellyfish and

similar species  (Chironex) often have very serious effects.

Patients may need mouth-to-mouth respiration and heart massage.

 

4. Gently scrape off the tentacles with a knife.

 

Medical treatment of jellyfish stings

 

Tetanus antitoxin should be given by intramuscular injection if

available.

 

What to do if someone is stung by a venomous fish

 

Many venomous fishes, such as stonefish, lionfish, scorpion fish,

and weever fish, have spines that puncture the skin. Venom is injected

into the wound through the spines. The stingray may cause cuts that

bleed a lot.

 

1. If the patient is stung while in the water, rescue from the

water.

 

2. At once soak the wounded part of the body in a bowl or bath of

water as hot as the patient can safely bear (not more than 45°C),

until the pain goes, but for no longer than 30 minutes. The venom

may be destroyed by heat and pain may disappear.

 

3. Clean the wound and remove any broken spines.

 

Medical treatment of fish stings

 

Tetanus antitoxin should be given by intramuscular injection if

available,.

 

Pain can be treated with local anaesthetics or pain killers such

as paracetamol. It may be dangerous to give morphine because it may

depress respiration.

 

CHAPTER 6

 

Getting medical help

 

Objectives

 

After studying this chapter, you should be able to:

 

1. Decide on the best action to take after you have given first aid

to a poisoned patient.

 

2. Decide whether a poisoned patient should see a doctor before

going to hospital.

 

3. Decide when it would be useful to obtain help by telephone from a

poisons centre or hospital.

 

Someone who has been poisoned should always be seen by a doctor

as quickly as possible. After you have given first aid the best course

of action is to get the patient to hospital without delay. However, if

it is likely to take many hours to get to hospital, it may be better

to try to get medical help more quickly somewhere else before you make

the journey to hospital.

 

If you can get to a hospital in less than two hours

 

Take the patient to hospital without delay as soon as you have

given first aid.

 

Do not move an unconscious patient until he or she can breathe

without help. Keep an unconscious or drowsy patient in the recovery

position.

 

If you are a long way from a hospital

 

If there is a health centre or doctor nearby, send the patient

there. Treatment given by a doctor outside hospital may be life-saving

if the journey to hospital takes a long time. If it is difficult to

move the patient, send someone to ask the doctor to come to the

patient.

 

If there is no doctor nearby, telephone a poisons centre. The

more you are able to tell the doctor in the poisons centre about how

the poisoning happened and about the patient’s signs and symptoms, the

more help the doctor will be able to give. Before you go to the

telephone examine the patient quickly but carefully (see Chapter 7),

and look for any medicines, pesticides or other chemical products,

plants or animals that might have caused the poisoning (see

Chapter 8).

 

If you think you know what might have caused the poisoning, take

it to the telephone if you can, so that you will be able to describe

it accurately and read the label on the container. (If poisoning has

been caused by an animal, try to catch it and keep it, if you can do

this without putting yourself or others at risk. Handle dead animals

carefully; they may still be dangerous.)

 

The doctor will be able to tell you if there is anything more you

can do to help the patient before you take him or her to hospital. In

some cases the doctor may be able to tell you that the chemical, plant

or animal involved is not poisonous, and that the patient does not

need to go to hospital.

 

If you cannot telephone a poisons centre, telephone a hospital.

 

If you cannot get medical help quickly

 

Use this book to help you decide what to do next. Make a more

thorough examination of the patient (see Chapter 7) and find out more

about what happened (see Chapter 8). If you know what substance the

patient was exposed to, look in Part 2 for more specific information

about what to do.

 

Chapter 9 describes how to look after the patient until he or she

can get to a hospital. In some cases you may be able to prevent

serious poisoning by making the patient vomit, or by giving activated

charcoal, a laxative, or an antidote.

 

Taking the patient to hospital

 

Some poisons centres or hospitals may be able to arrange

transport to hospital. If there is no ambulance ask someone with a

car, lorry, truck, or cart to take the patient to hospital.

 

If you have to carry the patient on a stretcher, make sure he or

she is as comfortable as possible and cannot fall off. If the sun is

very strong, fix a sheet above the stretcher to provide shade and let

fresh air pass underneath.

 

Someone should look after the patient during the journey to

hospital. If you cannot go yourself, send someone who knows how to

look after the patient.

 

Send with the patient any chemical products, medicines,

pesticides, plants or animals that might have caused the poisoning,

and the notes you have made about the patient’s condition and about

what happened.

 

What to do after you have read this chapter

 

Make sure that you know the quickest way to the nearest hospital,

and that you can explain it to someone else. Estimate how long it

should take to get there.

 

Make a list of telephone numbers and addresses of places such as

the nearest hospital and poisons centre, where you might be able to

get help if there is a case of poisoning. Write them in the back of

this book.

 

CHAPTER 7

 

Examining the patient

 

Objectives

 

After studying this chapter, you should be able to:

 

1. Examine a patient for symptoms and signs of poisoning.

 

2. Describe the patient’s condition to a doctor over the telephone

or in writing.

 

3. Decide whether a patient is seriously ill.

 

4. Recognize common poisoning syndromes.

 

If you are more than two hours journey from a hospital and there

is no doctor or health centre nearby, your next step, after giving

first aid, should be to examine the patient.

 

It is important to examine the patient so that you can decide how

to help the patient until he or she gets to hospital and so that you

can give a clear account of the patient’s condition if you contact a

poisons centre or hospital by telephone or radio.

 

This chapter describes how someone without medical training can

examine a patient for the effects of poisoning. Reading it can help

you learn what to do and what to look for, but it is best if a trained

health care worker shows you how to carry out an examination. Practise

counting the pulse and reading a thermometer until you are confident

you can do both accurately.

 

Poisons may cause many changes inside the body that can only be

measured using medical equipment. Such changes are not discussed here.

 

Symptoms and signs

 

The effects of poisoning are known as symptoms and signs.

 

Symptoms are effects that the person feels or senses, for

example, pain, nausea, or thirst. To find out what symptoms the

patient has, ask the patient these questions: “How do you feel?” “What

do you feel?”

 

Signs are effects that you can see, feel, hear or measure, for

example, vomiting, fever, a fast pulse, noisy breathing and

unconsciousness.

 

Most poisons cause several symptoms and signs because they affect

more than one part of the body.

 

For each of the signs described in this chapter there is a box

with a list of some of the common chemicals that cause it. To keep the

lists short, some of the names are those of groups of chemicals (for

example: atropine-like medicines) rather than the names of individual

chemicals. The names used here are also used in Part 2, so you can

check in Part 2 to see which individual chemicals are included in a

group. The lists do not include every chemical that causes a

particular effect, so it is possible that a person with one of the

signs or symptoms could have been poisoned by a chemical that is not

listed.

 

Do not expect a patient to have all the signs and symptoms listed

for a poison. Often it depends how badly poisoned the patient is. For

example, ethanol (alcohol) can cause unconsciousness, but someone

poisoned with ethanol may not be unconscious. He or she may simply be

drunk and be unsteady and talkative.

 

Remember, the patient may have taken more than one poison.

 

What the examination cannot tell you

 

If you have no clue about what the poison might be, the

examination is unlikely to give you information that will point to one

particular poison, because many poisons cause similar symptoms and

signs. However if you already think you know what the poison might be,

and what happened, you can check whether you might be right by

comparing the patient’s symptoms and signs with those listed for

specific poisons in Part 2 of this book.

 

You may not be able to tell, just by examining the patient, if

the patient is poisoned or if he or she is suffering from another

illness or injury, because:

 

–    many poisons cause symptoms and signs that are similar to

the symptoms and signs of diseases or injuries;

 

–    sometimes a patient may be poisoned and suffering from the

effects of another illness or injury.

 

For this reason, when you examine the patient it is important to

ask if he or she has now, or used to have, any sickness or disease,

and to look for cuts and bruises and other signs of injury.

 

When the patient does not have any symptoms or signs

 

A patient who seems well may not have been poisoned. Remember,

exposure to poison will not result in poisoning if a poisonous dose

does not get into the body (see Chapter 1).

 

Someone who has been poisoned may seem well because it is too

soon for the poison to take effect. Some poisons may not cause any

effects for many hours.  For example, a person who takes a poisonous

 

dose of paracetamol may be well for up to 48 hours afterwards. So it

is important to ask what happened and how long ago.

 

How to examine a patient and find out the symptoms and signs

 

Carry out the examination in the order given in this chapter. As

you examine the patient, write down all your findings with a note of

the date and time. At regular intervals while you are looking after

the patient, check how he or she is and write down any changes in

signs and symptoms and the time when you notice them. Give your report

to the doctor when you hand over the patient.

 

Talk to the patient

 

If the patient is conscious and can answer questions talk to the

patient.

 

Ask what happened

 

Try to find out:

 

–    what the poison is;

 

–    whether the poison was swallowed, breathed in, injected, or in

contact with the skin or the eye, or whether the patient was

bitten or stung;

 

–    how long ago the patient was poisoned. Did it happen a few

minutes ago, or was it several hours or even days ago?

 

–    how long the patient was exposed; for example, if the patient

breathed in poison, for how long was it breathed in, or if the

poison was spilt on the skin or clothes, how long was it before

the patient washed or took off the clothes.

 

–    if the patient feels sick, how long he or she has been feeling

like this.

 

Ask the patient if he or she has had a fall or injury. Ask if the

patient knows anybody else in the family, in the village or at work

who has had the same sickness.

 

Sometimes the patient can tell you what happened. For example,

people usually know if they have been bitten or stung by an animal and

they will often tell you when they have taken an overdose of medicine.

They may tell you that a chemical product or a pesticide they were

using has made them ill.

 

In some circumstances people do not know what happened. For

example, people who have been poisoned by carbon monoxide gas may not

know what has made them feel sick, because carbon monoxide has no

smell and is invisible. People who are sick after using a chemical

 

product or pesticide may not realize that their sickness is due to

poisoning.

 

Even when people know what happened they may not be able to tell

you much about the poison. People often use chemicals or take

medicines without knowing what they contain. Even if they give you the

bottle, there may not be any information on the label about the

contents. People who have been bitten by a snake may not know what

kind of snake it was, and may not be able to give a good enough

description for anyone else to identify it. Sometimes people who think

they know about wild plants and mushrooms make mistakes in

identification.

 

Sometimes people do not know how much poison they have taken.

People who take poison because they want to harm themselves may not

count how many tablets they take, or measure how much liquid they

drink.

 

Some people may not want to tell you the truth and may lie about

what they have taken. A child may be too frightened to tell the truth.

 

The patient may be dazed, in shock or confused and not able to

answer properly. People who are unconscious cannot tell you anything,

and children may be too young to talk or to understand.

 

Later, you may be able to find out more about what happened by

asking other people and looking for evidence (see Chapter 8), but

examine the patient first.

 

Ask the patient about symptoms

 

Ask if the patient feels pain. Ask where the pain is. Ask whether

the patient feels cold, hot, thirsty, weak, sick, dizzy, or faint. Ask

how long the patient has felt like this. Ask whether the patient has

been unconscious or asleep.

 

A patient who is confused:

 

–    may be agitated and frightened;

 

–    may not be able to remember what day it is, what time of year it

is, or where he or she is;

 

–    may not be able to think properly or to remember things;

 

–    may have hallucinations, which means seeing things that are not

real, or feeling things like ants crawling on the skin.

 

Some chemicals that may cause confusion or hallucinations

 

Medicines: aminophylline, amitriptyline and other tricyclic

antidepressants, antihistamines, atropine-like medicines,

dapsone, ephedrine, insulin, propranolol and other ß-blockers,

pseudoephedrine.

 

Drugs of abuse: amfetamines, cannabis, cocaine.

 

Pesticides: chlorophenoxyacetate weedkillers, organophosphorus

and carbamate pesticides.

 

Other chemicals: camphor, camphorated oil, ethanol, turpentine

and other volatile oils.

 

The patient may not be able to hear you. A person poisoned by

aspirin or quinine may hear a ringing sound in the ears, or may become

deaf.

 

Look for signs of poisoning

 

This section describes how to examine a patient for some common

signs of poisoning:

 

–    unconsciousness,

 

–    changes in the skin, breathing, pulse, temperature, eyes, or

behaviour,

 

–    vomiting and diarrhoea,

 

–    dehydration,

 

–    not passing urine,

 

–    fits,

 

–    signs of liver damage.

 

Watch the way the patient behaves

 

Some poisons make the patient restless, overactive, or

aggressive. This can also happen when people suddenly stop abusing

drugs or drinking alcohol after doing so for a long time.

 

Some chemicals that may cause overactivity, restlessness or

irritability

 

Medicines: aminophylline, atropine-like medicines,

chlorpromazine and other phenothiazines, ephedrine.

 

Drugs of abuse: amfetamines, cocaine.

 

Strange behaviour may be a sign that the patient abuses drugs or

other substances, or it may be a sign of mental illness.

 

The unconscious patient

 

A person who is losing consciousness may seem very drowsy, may

only be able to say yes or no if you ask questions, or may only be

able to obey commands such as “open your eyes” or “lift up your arm”.

The patient may soon become unconscious.

 

Unconsciousness is a sign of dangerous illness. Put an

unconscious patient in the recovery position so that the tongue does

not block the airway.

 

Try to find out whether the patient became unconscious suddenly

or gradually became drowsy and fell asleep. Most poisons cause gradual

unconsciousness if they have been swallowed.

 

Some chemicals that may cause unconsciousness

 

Medicines: amitriptyline and other tricyclic antidepressants,

antihistamines, atropine-like medicines, barbiturates,

carbamazepine, chloroquine, chlorpromazine and other

phenothiazines, chlorpropamide-like medicines, diazepam and other

benzodiazepines, insulin, iron-containing medicines, meprobamate,

quinidine, quinine, sodium valproate.

 

Other chemicals: benzene, carbon monoxide, carbon

tetrachloride, cyanide, ethanol, ethylene glycol, methanol,

toluene, trichloroethane, trichloroethylene, xylene.

 

Many other medicines and chemicals taken in large amounts.

 

Other common causes of unconsciousness are head injury, fainting,

heavy bleeding, heart attack, stroke, lack of air, epilepsy, fits, and

diabetes.

 

Unconsciousness is probably caused by a head injury if the

patient also has any of these signs:

 

–    bleeding from the ears or nose,

 

–    bruises or cuts on the body or head,

 

–    pupils that are different sizes.

 

Look at the patient

 

Does the patient look ill or weak? Look at the patient’s clothes

to see if they are damp or stained with chemicals, urine or vomit.

Look at the vomit to see whether there is blood, or pieces of tablets,

plants, or food in it.

 

Look at the skin

 

Cuts, scratches, bruises, or bleeding may mean the patient is ill

because of an injury.

 

Bruises may be caused by a fall. The patient may have been dizzy,

unsteady, or very drowsy because of alcohol or drugs.

 

Cuts on the insides of the wrists or on the neck may have been

made by the patient trying to kill himself or herself, and scar lines

could mean that the patient tried to do this in the past.

 

Marks on the arms near the inside of the elbow, or on the ankles

or knees, with swollen veins, ulcers and abscesses may have been

caused by injecting drugs. The patient may be dependent on drugs.

 

Burns and stains may have been caused by corrosive or irritant

liquids. Someone who has been working with a chemical may have burns

on the legs, arms, chest, back, or feet. Someone who has swallowed a

corrosive substance may have burns and stains on the chin and lips,

and on the chest if liquid spilt out of a bottle.

 

Blisters or red patches on the sides of fingers, ankles, knees,

shoulders, or other parts of the body show that the patient has been

lying unconscious in the same position for several hours.

 

Scaly rashes may be caused by working with irritant chemicals,

such as pesticides, or handling irritant plants. Rashes are also

caused by some diseases and parasites.

 

A hot pink skin may be caused by some medicines. If the patient

has a black or brown skin, feel the skin and look at the hands and

inside the lips.

 

A blue colour to the skin and inside the eyelids and lips means

that there is not enough oxygen in the blood. Usually this means that

the patient cannot breathe properly, but some chemicals make the

patient look blue even though breathing is good. If the patient has a

brown or black skin it may be difficult to see a blue colour to the

skin, but the lips, nails and inside of the lower eyelids will look

blue and the skin will lose its shine. Blue-coloured skin is a sign of

dangerous illness.

 

A yellow skin may be caused by jaundice or by chemicals that

stain the skin. Jaundice is caused by liver damage. The liver damage

may be due to poisoning or infection, or damage to the blood. The

whites of the eyes will also be yellow. It can take up to 48 hours

after poisoning before the skin turns yellow.

 

Some yellow or orange substances turn the skin yellow or orange.

The medicine called rifampicin gives an orange-red colour to the skin

(the stain washes off), urine, stools, tears, and whites of the eyes.

 

Some chemicals that may make the skin change colour

 

Pink, hot skin: atropine-like medicines, amfetamines, and borax.

 

Yellow skin caused by jaundice: carbon tetrachloride, iron

containing medicines, paracetamol, pentachlorophenol,

trichloroethylene, and some poisonous mushrooms.

 

Yellow or orange stain: dinitrophenol, dinoseb, DNOC, rifampicin

(the stain washes off).

 

Blue skin: dapsone, naphthalene, paradichlorobenzene, phenol,

sodium chlorate, sodium nitrite.

 

Feel the skin

 

Poisons may cause sweating. Other causes of sweating are

infection, shock, heart attack, and low blood sugar in diabetic

patients.

 

Some substances cause hot dry skin. A hot dry skin may also be

caused by being in a very hot place, or by sickness that causes fever.

 

Look inside the mouth

 

*    Burns and stains inside the mouth and throat show the patient has

swallowed a corrosive or coloured substance.

 

*    Pieces of tablets in the mouth show the patient has swallowed

tablets.

 

*    A coloured tongue may be caused by coloured tablets, berries or

liquids.

 

*    Pieces of leaves or berries in the mouth show the patient has

eaten a plant that may be poisonous.

 

Smell the breath

 

Many substances make the breath smell, even if only a small

amount is swallowed. People may smell of alcohol but not be drunk.

People often take alcohol when they take other poisons. If the patient

smells of alcohol, look for evidence and signs of other poisons too.

Look for evidence of head injury too.

 

Some chemicals that may make breath smell

 

Camphor, camphorated oil, carbon tetrachloride, cyanide, ethanol,

methyl salicylate, paraffin, petrol, toluene, trichloroethylene,

turpentine and other volatile oils, and many pesticides.

 

Watch and listen to breathing

 

*    Is the patient breathing more or less deeply than usual?

 

*    Is breathing more noisy than usual?

 

*    Is breathing difficult?

 

Count how many times the patient breathes in one minute. If the

patient sees what you are doing he or she may breathe faster, so a

good plan is to count breathing after taking the pulse, while you are

still holding the wrist. Always count for a full minute.

 

Most adults breathe 12-18 times per minute, children and infants

breathe 20-30 times per minute. People breathe more quickly when they

are taking exercise or when they are excited or upset; they breathe

more slowly when they are asleep or resting.

 

In most cases changes in breathing are dangerous and the

patient’s life may be in danger.

 

Slow and irregular breathing or fast and shallow breathing may be

caused by poisoning, substances like vomit or kerosene getting into

the lungs, unconsciousness, head injury, stroke, lung oedema (see

below), lung infection, asthma, or diabetes.

 

Noisy breathing, with gurgling or snoring noises, may mean that

the throat is blocked and not enough air is getting through. The

throat may be blocked by food or a foreign body. If the throat is

burnt it swells and blocks the airway. In an unconscious patient the

throat may be blocked by the tongue, vomit or saliva if the patient is

not in the recovery position.

 

Coughing or wheezing may be caused by irritant gases, smoke, or

dust. The patient may also have stinging or severe pain in the eyes

and nose. Kerosene and similar liquids cause coughing and choking if

they are swallowed. Other causes of coughing and wheezing are

infections of the lungs, asthma and cigarette smoking.

 

Same chemicals that may change breathing

 

Shallow breathing

 

Medicines: amitriptyline and other tricyclic antidepressants,

antihistamines, atropine-like medicines, barbiturates, diazepam

and other benzodiazepines, meprobamate, chlorpromazine and other

phenothiazines.

 

Pesticides: carbamate and organophosphorus insecticides.

 

Other chemicals: carbon monoxide, ethanol.

 

Slow or irregular breathing

 

Medicines: opiates.

 

Pesticides: carbamate and organophosphorus insecticides.

 

Fast breathing

 

Medicines: aminophylline, aspirin and other salicylates, cocaine,

chloroquine.

 

Pesticides: dinoseb, DNOC, organochlorine pesticides,

pentachlorophenol.

 

Other chemicals: carbon monoxide (at first), ethanol, ethylene

glycol, methanol, phenol.

 

Lung oedema

 

Lung oedema is a condition in which fluid fills the lungs and

eventually stops the patient breathing. Lung oedema is a very serious

condition and the patient’s life may be in danger. The signs of lung

oedema are:

 

–    fast breathing (20-40 times per minute), which is often noisy;

 

–    coughing with frothy spit so that the patient foams at the mouth

and makes a gurgling noise in the throat;

 

–    grey or blue skin colour;

 

–    fast pulse;

 

–    sweating;

 

–    anxiety and fear;

 

–    crackling noises in the lungs, if you listen with a stethoscope

or put your ear to the patient’s chest;

 

–    difficulty in lying flat.

 

Some poisons cause lung oedema after a few minutes, others after

several hours. As the patient gets tired, breathing may become very

slow and may eventually stop.

 

The lungs may fill with fluid in conditions such as heart

disease, but it happens in a different way.

 

Some chemicals that may cause lung oedema

 

Medicines: aspirin and other salicylates, chlorpromazine and

other phenothiazines, opiates.

 

Pesticides: carbamate and organophosphorus insecticides, dinoseb,

DNOC, paraquat, pentachlorophenol.

 

Other chemicals: ethylene glycol, petroleum distillates,

turpentine and other volatile oils, irritant gases.

 

Check the pulse

 

The heart is a pump. It pushes blood through the blood vessels.

Each time the pump pushes out blood a wave of pressure passes along

the blood vessels. This is the heartbeat or pulse. It can be felt

wherever the blood vessels are close to the surface of the body, by

pressing the blood vessel gently against a bone.

 

Have a watch with a second hand in front of you. To take the

pulse at the wrist, press two fingertips of your right hand lightly on

the patient’s wrist on the same side as the thumb (Fig. 38). You

should feel a regular beat; this is the pulse. Count for a full minute

looking at your watch. The number of beats you count in one minute is

the pulse rate.

 

In children and babies, try to find the pulse on the inside of

the upper arm between the elbow and the shoulder. With your thumb on

the outside of the child’s arm, press your first and middle fingers

gently into the groove between the muscles, until you feel a pulse.

Sometimes it is easier to feel the heartbeat directly on the left of

the chest.

 

A normal pulse is regular and strong. In an adult the pulse rate

is between 60 and 80 per minute. In healthy young adults it may be

slower (50-60 per minute). In young babies it is faster (120 per

minute). The pulse rate is slower than normal during sleep, and faster

than normal if the person is excited or moving about, so take the

pulse when the person is resting.

 

Note if the pulse is:

 

–    fast or slow;

 

–    strong or weak, or with some beats stronger than others;

 

FIGURE 38

 

–    regular, with the same time between each beat, or irregular,

with missed beats so that you cannot tap your foot in time

to it.

 

If the pulse is very irregular when you feel it at the wrist,

count the heartbeat by listening over the heart. You can hear the

heartbeat if you put your ear against the nipple on the left side of

the chest. The count may be higher this time because you will be able

to hear heartbeats that were too weak to be felt at the wrist.

 

Write down what you find.

 

A change in the pulse can mean that the patient is dangerously

ill.

 

Poisons may cause a slow pulse or a fast pulse. Any very bad

poisoning may affect the heart, so that the pulse becomes irregular or

very slow and may even stop altogether.

 

Some chemicals that may cause a slow pulse

 

Medicines: barbiturates, digitalis, digitoxin, digoxin,

meprobamate, opiates, propranolol and other ß-blockers.

 

Pesticides: carbamate and organophosphorus insecticides.

 

A fast, weak pulse can mean shock, bleeding, heart attack, heat

exhaustion or fever.

 

A fast, strong pulse can mean heat stroke, stroke, or heart

disease.

 

Some chemicals that may cause fast pulse

 

Medicines: aminophylline, amitriptyline and other tricyclic

antidepressants, antihistamines, aspirin and other salicylates,

atropine-like medicines, ephedrine, isocarboxazid and other

monoamine oxidase inhibitors, pseudoephedrine.

 

Drugs of abuse: amfetamines, cannabis, cocaine.

 

Pesticides: arsenic, chlorophenoxyacetate weedkillers, dinoseb,

DNOC, pentachlorophenol.

 

Other chemicals: carbon monoxide (at first).

 

A slow pulse may be caused by a low body temperature.

 

Measure body temperature

 

It is wise to take a patient’s temperature, even if there does

not seem to be a fever. If the patient is very sick, take the

temperature every 3 or 4 hours.

 

If you do not have a thermometer, feel the temperature by placing

the back of one hand on the patient’s forehead and your other hand on

your own forehead. The forehead of a patient with a fever will feel

warmer than yours. If the forehead feels cooler than yours the patient

may have a low body temperature.

 

A thermometer can be used to measure temperature in the mouth,

armpit, groin or rectum. You should not use the same thermometer in

the rectum as you use for taking oral or armpit temperatures. Always

use a thermometer with a round end for taking the temperature in the

rectum as this will not damage the rectum.

 

To measure temperature:

 

*    Make sure that the column of mercury inside the thermometer is

below about 35°C. If it is not, shake the thermometer until the

level has gone down.

 

*    If the patient is awake, put the bulb of the thermometer in the

mouth, under the tongue, for 2 minutes.

 

*    If the patient is drunk, agitated, confused or likely to have a

fit, and might bite the thermometer, put it in the armpit, and

place the arm firmly across the chest, for 5-10 minutes.

 

*    If the patient is unconscious, use a thermometer for taking

temperature in the rectum. Push it gently into the rectum for a

distance of 5 cm, and leave for 2 minutes before reading it.

 

*    If the patient is a child, take the temperature in the armpit,

groin or rectum.

 

A normal body temperature is usually 36-37°C. The temperature in

the mouth is 37.5°C. The temperature in the groin or under the arm is

0.5°C lower, and the temperature in the rectum is 0.5°C higher.

 

If the temperature is above 37.5°C the patient has a fever; the

higher the temperature, the greater the fever. A temperature higher

than 39°C is a sign of dangerous illness. Fever may be caused by

infection or illness such as malaria. Only a few poisons cause fever.

 

Some substances that may cause a high body temperature and warm

dry skin

 

Medicines: atropine-like medicines, antihistamines (more commonly

in children than adults).

 

Plants: plants containing atropine.

 

Some chemicals that may cause a high body temperature and sweating

 

Medicines: aspirin and other salicylates (more commonly in

children than adults), ephedrine, colchicine, isocarboxazid and

other monoamine oxidase inhibitors, pseudoephedrine.

 

Drugs of abuse: amfetamines, cocaine.

 

Pesticides: dinoseb, DNOC, pentachlorophenol.

 

Other chemicals: naphthalene, phenol.

 

A low body temperature may be caused by a long period of

unconsciousness, especially if the patient has been lying in an open

or cold place.

 

Some chemicals that may cause a low body temperature

(less than 35°C)

 

Medicines: amitriptyline and other tricyclic antidepressants,

barbiturates, chlorpromazine and other phenothiazines,

meprobamate, opiates.

 

Other chemicals: carbon monoxide, ethanol.

 

Look at the eyes

 

Examine both the patient’s eyes together. See if the pupils are

the same size.

 

Cover one eye at a time with your hand and see if the pupil

changes size when the light changes. If you have a light you can shine

it into the eyes and see if the pupils get smaller.

 

Unequal pupils-pupils that are not the same size-may be caused by

a chemical splashed in one eye. If there has not been chemical in the

eye, this is usually a sign of eye disease or brain disease.

 

Large pupils may be a sign of poisoning, or of severe lack of

oxygen, or of very low body temperature.

 

Look at the whites of the eyes. If these are yellow this usually

means the patient has jaundice.

 

Some chemicals that may affect the eyes

 

Very small “pinpoint” pupils

 

Medicines: opiates.

 

Pesticides: organophosphorus and carbamate insecticides.

 

Large pupils

 

Medicines: amitriptyline and other tricyclic antidepressants,

antihistamines, atropine-like medicines, carbamazepine,

ephedrine, isocarboxazid and other monoamine oxidase inhibitors,

quinine.

 

Drugs of abuse: amfetamines.

 

Other chemicals: methanol.

 

Blurred vision

 

Medicines: atropine-like medicines, ephedrine, pseudoephedrine.

 

Other chemicals: ethanol, methanol.

 

Loss of sight or complete blindness

 

Medicines: chloroquine, quinine.

 

Other chemical: methanol.

 

Other signs of poisoning

 

Vomiting and diarrhoea may be caused by almost any poison.

Other causes of vomiting with diarrhoea are infections caused by

bacteria, viruses, or worms, and malaria. Other causes of diarrhoea

are allergies to certain foods, side-effects from certain medicines,

such as antibiotics or laxatives, or eating too much unripe fruit or

heavy, greasy foods. Other causes of vomiting are appendicitis or

something blocking the gut, or almost any other sickness with high

fever or severe pain, especially migraine headache, and infections of

the liver, ears, and brain.

 

Black stools. The black colour may be caused by blood from the

gut if the gut has been damaged by corrosive fluids. Iron tablets may

colour stools black or dark green, and activated charcoal also colours

them black.

 

Dehydration. Vomiting and diarrhoea may lead to dehydration. A

person with vomiting or diarrhoea loses a lot of water from the body.

If he or she does not drink enough to replace the lost water, the body

dries out. People of any age can become dehydrated, but dehydration

develops more quickly and is most dangerous in small children. People

with burns, or people who are unconscious and unable to drink, may

also become dehydrated.

 

Signs of dehydration are as follows:

 

*    The patient passes very little or no urine, and the urine is dark

yellow.

 

*    The patient has a dry mouth and dry lips. The patient may be very

thirsty (but very dry people may not complain of thirst).

 

*    When the skin is lifted between two fingers the skin fold does

not fall back again at once but stays raised for a few seconds.

 

*    Children may have sunken eyes.

 

Very severe dehydration may cause a rapid weak pulse, fast deep

breathing, fever, or fits.

 

The patient does not pass urine. If a person does not pass

urine this could mean any of the following:

 

*    The kidneys are not making urine because the patient is

dehydrated. The person has lost a lot of water through vomiting,

sweating, diarrhoea, or from a bad skin burn.

 

*    The kidneys are not making urine because they have been damaged

and are not working. This is kidney failure. It may be caused by

poisons or illness. Patients with kidney damage may have vomiting

and lung oedema.

 

Some chemicals that may cause kidney failure

 

Medicines: aspirin and other salicylates, colchicine, iron

containing medicines, isocarboxazid and other monoamine oxidase

inhibitors, quinine, rifampicin.

 

Pesticides: arsenic, dinoseb, dinitrophenol, DNOC, paraquat,

pentachlorophenol, sodium chlorate, thallium.

 

Other chemicals: boric acid, camphor, camphorated oil, carbon

tetrachloride, ethylene glycol, methanol, naphthalene, phenol,

sodium perborate, turpentine and other volatile oils.

 

*    The kidneys are making urine but the bladder is not working; the

bladder muscles will not relax and let the urine out. Do not

confuse this reason for not passing urine with kidney damage. If

the bladder is full you should be able to feel a rounded swelling

in the lower part of the belly. Some medicines stop people

emptying the bladder. This may also happen when a person has been

unconscious a long time.

 

Some medicines that may stop the patient emptying his or her bladder

 

Amitriptyline and other tricyclic antidepressants,

antihistamines, atropine-like medicines.

 

Fits (convulsions). These are jerking movements that the

patient cannot control. The patient may be just twitching or the whole

body may move. The patient may suddenly become unconscious and foam at

the mouth. The longer the fit lasts, the greater the danger to life.

In severe cases, the patient does not stop having fits and finds it

difficult to breathe.

 

There are some kinds of fit where first the jaw and then the

whole body becomes very stiff. This may be tetanus.

 

Fits may be caused by poisoning, lack of oxygen – which may be a

result of exposure to poison or of something blocking the airway –

epilepsy, meningitis, malaria, or low blood sugar in a diabetic

person. People dependent on alcohol or drugs may have fits if they

suddenly stop taking them.

 

In small children, fits may be caused by high fever or severe

dehydration.

 

Some chemicals that may cause fits

 

Medicines: aminophylline, amitriptyline and other tricyclic

antidepressants, antihistamines, aspirin and other salicylates,

atropine-like medicines, chloroquine, colchicine, dapsone,

ephedrine, insulin and other antidiabetic drugs, iron salts,

isocarboxazid and other monoamine oxidase inhibitors, opiates,

phenothiazines, propranolol and other ß-blockers,

pseudoephedrine, quinidine, quinine.

 

Drugs of abuse: amfetamine, cocaine.

 

Pesticides: arsenic, carbamate and organophosphorus insecticides,

metaldehyde, sodium chlorate, strychnine, thallium.

 

Other chemicals: borax, boric acid, camphor, camphorated oil,

carbon monoxide, cationic detergents, ethylene glycol, methanol,

sodium perborate.

 

Signs of liver damage. The liver is the place where the body

changes many poisons into less harmful substances. If there is more

poison than the liver can deal with, the poison that does not get

changed may damage the liver. The symptoms and signs of liver damage,

which do not show for 2 or 3 days after poisoning, are as follows.

 

*    There is often nausea, vomiting and fever at first.

 

*    The whites of the eyes may become yellow, then the skin becomes

yellow.  This is often the first specific sign of liver damage.

 

*    There may be pain in the belly.

 

*    If the patient does not recover, and the liver damage gets worse,

the patient becomes drowsy then unconscious, and may die within a

few days.

 

Some chemicals that may cause liver damage

 

Medicines: iron-containing medicines, paracetamol, rifampicin.

 

Pesticides: aluminium phosphide and zinc phosphide,

pentachlorophenol,

 

Other substances: benzene, camphor, camphorated oil, carbon

tetrachloride, phenol, tetrachloroethane, toluene,

trichloroethane, trichloroethylene, xylene.

 

Poisonous mushrooms

 

Signs that the patient is severely ill

 

*    The patient is not breathing.

 

*    Breathing is wheezy or noisy after you have cleaned the mouth and

put the patient in the recovery position.

 

*    The patient is unconscious and does not wake up when you pinch

the hand.

 

*    The pupils do not change size when you shine a light into them.

 

*    The pulse is very slow (less than 50 beats per minute), or very

fast (more than 110 beats per minute), or irregular, or very

weak.

 

*    The patient has continuous fits.

 

*    The temperature in the mouth or rectum is over 39°C, or

temperature under the arm or in the groin is more than 38°C.

 

*    The patient has severe belly pain.

 

*    There are signs of kidney failure.

 

*    There are signs of liver damage.

 

Patterns of symptoms and signs

 

Some poisons cause patterns of symptoms and signs that could not

be caused by anything else. These patterns are often called poisoning

syndromes. The chemicals and medicines that cause some common

poisoning syndromes are listed in Table 7.1.

 

Table 7.1.  Poisoning syndromes

 

 

 

Poisons                                    Symptoms and signs

 

 

Atropine, amitriptyline,                   dry, hot skin, fever, thirst, dry mouth,

antihistamines, Datura stramonium,         large pupils, fast pulse, difficulty in passing

Atropa belladonna, some kinds of           urine, hallucinations, fits, shallow breathing,

mushrooms                                  unconsciousness

 

Organophosphorus and                       small pupils, wet mouth, sweating, wet eyes,

carbamate insecticides, some kinds         vomiting, slow pulse, diarrhoea, fits,

of mushrooms                               unconsciousness

 

Opiates                                    small pupils, slow breathing, unconsciousness,

low temperature, sbw, weak pulse, vomiting

 

Amfetamines, cocaine,                      large pupils, fever, fast pulse, hallucinations,

theophylline                               fits, anxiety, sweating, flushed skin, over-

activity, confusion

 

Barbiturates, diazepam and                 unconsciousness, low blood pressure, shallow

similar drugs, meprobamate                 breathing, low temperature

Drug withdrawal (a sudden stop in          diarrhoea, gooseflesh, fast pulse, watering

taking ethanol (alcohol),                  eyes, yawning, cramps, hallucinations,

barbiturates, diazepam and similar         restlessness, shaking

medicines, opiates)

 

 

CHAPTER 8

 

Finding out what happened

 

Objectives

 

After studying this chapter, you should be able to:

 

1. Find out what the poison is when you suspect someone has been

poisoned.

 

2. Find out how the poisoning happened.

 

When a person has been poisoned it is important to know what

happened. It is easier for a doctor to treat the patient if the poison

and the circumstances of the poisoning are known, and it is more

likely that the treatment will be successful. Also, it may be possible

to take steps to prevent someone else being poisoned in the same way.

 

There are two ways to find out what happened. You can ask people

for information, and you can look for the poison and other things that

show you what might have happened.

 

However, your first priorities are to give first aid and then to

get medical help. You should never delay taking the patient to

hospital or to a local doctor. You may spend about ten minutes talking

to people and looking for the poison, if you can do so without leaving

the patient alone. You may be able to spend longer if you have to wait

for a local doctor to visit, or for an ambulance. It may be possible

to go back and have another look after you have handed the patient

over to a doctor. When there is another person to help you, one of you

can find out what happened, while the other looks after the patient or

takes him or her to hospital.

 

Remember!

 

Never leave the patient alone while you talk to people or search

for the poison.

 

Do not delay in getting medical help.

 

You need to find out as much as possible about:

 

–    how the poisoning happened. Was the poison swallowed, breathed

in, injected, or in contact with the skin or the eye, or was the

patient bitten or stung?

 

–    where the poisoning happened;

 

–    what the poison is;

 

–    how long ago the patient was poisoned. Did it happen a few

minutes ago, or was it several hours or even days ago?

 

–    how long the exposure lasted. For example, if the poison was

breathed in, for how long was the patient breathing it in? If the

poison was spilt on the skin or clothes, how long was it before

the patient washed or took off the clothes?

 

–    how many people were affected.

 

You may be able to find out some information by talking to

people, and you may be able to find things that show you what happened

or what the poison is.

 

As you gather information you may need to make notes to help you

to remember all the facts.

 

Talking to people

 

The patient

 

In some cases the patient is the best person to tell you what

happened. You may have found out some of the facts by talking to the

patient as you examined him or her, but a small child or a confused

person may not be able to tell you much, and an unconscious patient

cannot tell you anything. Some people who poison themselves may not

want to tell you the truth.

 

Other people

 

You may be able to find out more about what happened from other

people. Compare their story with what the patient tells you.

 

If the patient is a child:

 

*    Talk to anyone who was looking after the child, or playing with

him or her. Someone may have seen the child drink from a bottle

containing chemicals, open a bottle of medicine, or eat some

leaves from a plant. Ask whether the child was left alone at any

time, even if it was only for a few minutes, and ask where the

child was left alone.

 

If the accident happened at work:

 

*    Talk with other workers who were with the patient. They may know

what happened and they may know what substances the patient was

using.

 

*    Talk with the supervisor or nurse. They may know if this kind of

accident has happened before and what chemicals are used or kept

in the workplace.

 

If you think the patient meant to take poison:

 

*    If the patient cannot or will not tell you what happened, ask the

patient’s friends or family if he or she was unhappy or had

problems.

 

If no-one knows what happened:

 

*    Find out if there are any chemicals or medicines the patient

could have been exposed to in the home or at work. Ask people the

following questions:

 

–    Has the patient been taking medicines or home cures? Does

anyone else in the family take medicines? What medicines,

pesticides and cleaning products are kept at home? Where are they

kept? Are they locked away? If the patient is a child, find out

whether a child could reach them.

 

–    Has the patient been in a place where poisonous snakes or animals

are found?

 

–    Has the patient eaten a plant, mushroom, or fish that might have

been poisonous? Talk to the family, fellow workers or friends who

may have eaten with the patient in the past two days. Ask them

what food the patient ate. Is anyone else who ate the same meals

also ill?

 

–    Is it possible that the patient ate food contaminated with

poison? Has food been near poisonous chemicals such as

pesticides, in the shop, at home or when it was moved from one

place to the other?

 

–    Does the patient use chemicals, cleaning products or pesticides

at home or at work? Where are these chemicals kept? Are they

locked away or can anyone use them?

 

–    Has the patient used chemicals recently, either at home or at

work? How long for? Has the patient used the same chemicals

before and in the same way? Was the patient wearing protective

clothing if it was needed?

 

–    Was anyone nearby using a chemical? For how long?

 

Look for the poison or other things that show you what happened

 

Sometimes nobody can tell you what happened and the only way to

find out is to look for the poison or for things that show you what

might have happened.

 

Even if people have been able to tell you what happened, you may

still need to look for the poison. If the poison is a medicine, a

pesticide, a household product or industrial chemical, you need to see

 

the container so that you can check the exact name on the label, and

see if there is any information about the chemicals in the product. Do

not rely on the names that people tell you; they may read the label

wrongly or be confused by the chemical names.

 

Take a pencil and a notebook with you when you look for poisons,

in case you find products that you cannot take away with you, such as

large drums of pesticide. Carefully write down the information from

the product label. Look for the name of the product, the names of

chemicals, the name and address of the manufacturer, and any

information about what to do in case of poisoning. Try to copy any

symbols or pictures on the label, and write down any numbers. This

information may help a poisons centre to identify the product.

 

If the patient has been harmed by an animal that has been caught

or killed, ask to see it. It is important to identify the animal.

Snakes and spiders can be recognized by their colour and markings.

Keep them in a safe container so that nobody else is harmed.

 

If the patient has eaten a wild plant or mushroom, ask for a

sample so that you can identify it. If necessary, ask where it was

found and send a responsible person to get some.

 

What to look for and where to look

 

Search the place where the patient was found. Ask members of the

patient’s family if they will help you search the home. Ask the

patient’s employer if you can search the workplace.

 

Look for:

 

–    bottles, packets, boxes or other containers that might have

contained tablets, medicine, household chemicals, or pesticides.

Read the labels of any containers you find;

 

–    drinks bottles that have been filled with pesticide or kerosene,

which could be mistaken for fizzy drink or alcohol;

 

–    old pesticide containers that are being used to store food or as

toys;

 

–    liquid fuel burners that are not working properly (you can

usually see that they are not working properly because there will

be black sooty marks near the air vent and outlet pipe);

 

–    poisonous snakes, insects, or plants; rosaries or beads made from

plant seeds.

 

If the patient is a child:

 

*    Look inside high cupboards as well as low cupboards because the

child might have climbed onto a chair or table.

 

*    Look inside the waste bin for containers that might not have been

completely empty, and for button batteries.

 

*    Look for chemicals that have been spilt on the floor or on the

child’s clothes. Look for stains or wet patches. When small

children try to drink from bottles they often spill the liquid.

 

*    Look for tablets on the floor and look for staining or pieces of

tablets in the child’s mouth. Look for the child’s own medicines

to see if the containers are open.

 

*    Look for household products and pesticides in open bottles, jars,

cups or buckets, for example, paint brush cleaner in ajar or cup,

laundry detergent or another cleaner that has been added to a

bucket of water, or rat poison in an open dish on the floor.

 

If the patient is an adult:

 

*    Look for poison on the patient’s clothes or skin, and look for

pieces of tablets, plants, or food in the vomit or inside the

mouth.

 

*    Look in the patient’s pockets. Search the room where the patient

was found and look in waste bins.

 

*    Look for tablets, medicines, pesticides, or household chemicals.

Look for a syringe, which could mean the patient abuses drugs and

has just injected some. Look for a suicide note.

 

Remember that some people take care to leave no evidence of the

poison they have taken. Some people do not tell you the truth when you

ask them what poison they took.

 

What to do next

 

When you telephone a hospital or poisons centre, have with you

the chemical products, medicines, plants or animals, or the notes that

you have made about them, so that you can describe them accurately and

read product labels. Describe what happened and the condition of the

patient.

 

When the patient goes to hospital make sure the chemicals,

medicines, plants or animals you have found go also, if it is possible

to move them, together with the notes you have made.

 

CHAPTER 9

 

How to look after a poisoned patient outside hospital

 

Objectives

 

After studying this chapter, you should be able to:

 

1. Decide what to do when someone has swallowed poison.

 

2. Explain when a patient who has swallowed poison can safely:

 

–    drink water,

 

–    be made to vomit,

 

–    be given activated charcoal.

 

Explain when it is dangerous for a patient to be given anything

by mouth, and when it is dangerous to make a patient vomit.

 

3. Decide when it is safe and useful to give a laxative to a patient

with suspected poisoning.

 

4. Look after a patient until he or she gets to a hospital and know

what to do if the patient:

 

– has bad diarrhoea,

 

– vomits for a long time,

 

– does not pass urine,

 

– is unconscious,

 

– has a low temperature,

 

– has fever,

 

– has liver damage,

 

– has lung oedema.

 

This chapter describes how someone with no medical training can

look after a person who has been poisoned, when there is no doctor.

 

If you can get the patient to a local doctor or hospital within

two hours, it is more important to go without delay than to do any of

the things described here, except perhaps to give the patient some

water to drink.

 

The actions described in this chapter are not first aid. They are

best carried out under the direct supervision of a doctor. You should

undertake them only when it is impossible to get the patient to a

local doctor or hospital within two hours.

 

If possible contact a doctor or poisons centre by telephone

before you proceed. Sometimes these actions can be dangerous and it

may be difficult to know whether or not the patient will benefit.

 

Make a note of everything you do and of any change in the

patient’s condition, with the time and date. Give the note to the

doctor when you hand over the patient.

 

What to do when the patient has swallowed poison

 

Do not give anything by mouth if:

 

–    the patient is unconscious, drowsy or having fits. Someone who is

drowsy or having fits may choke if given anything by mouth.

 

–    the patient cannot swallow. Do not force the patient to drink. If

the patient has swallowed a corrosive substance and has burns

inside the mouth he or she will not be able to swallow. In this

case water will not help the burns and may make the damage worse.

 

If the patient is awake ask him or her to rinse out the mouth

several times with cold water and spit it out. Give small sips of

water if the patient wants to drink.

 

Do not make the patient drink a lot of liquid at once: the

patient may vomit and this may be dangerous.

 

If you intend to make the patient sick or to give activated

charcoal (see below), do not give large amounts of water before doing

1. The result may be that the poison moves out of the stomach more

quickly and any action taken to stop the chemical getting into the

blood will have less effect and the poisoning will be worse.

 

After you have made the patient vomit, or given activated

charcoal or a laxative, encourage the patient to drink plenty of

liquid to prevent dehydration. Give frequent small drinks throughout

the day. Do not give alcohol or coffee.

 

How to stop poison getting into the blood after it has been swallowed

 

When poisons are swallowed they go to the stomach and gut and

pass through the gut walls into the blood. A poison will not have any

systemic effect until it gets into the blood. If you can stop some or

all of it getting into the blood, this may stop the patient getting

severe poisoning.

 

There are three ways to stop poison getting into the blood after

it has been swallowed:

 

–    make the patient vomit back the poison;

 

–    give activated charcoal to bind the poison and stop it getting

through the gut walls;

 

–    give laxatives to make the poison move through the gut more

quickly.

 

Sometimes it may be dangerous to do any of these things, and it

is usually best to wait until the patient gets to hospital if

possible.

 

However if it is safe and useful to take action it is important

to do so as soon as possible, because the longer the chemical stays in

the gut, the more will get into the blood and the worse the poisoning

will be.

 

So, if it will take several hours to get to a health centre or

hospital, you will have to decide whether the patient would benefit

from any of these treatments and give them yourself. It is therefore

very important to understand when they should be used and when they

should not be used.

 

In each case, before you decide what to do, you should find out

as much as possible about what the poison is and what happened, and if

possible telephone a poisons centre, hospital or doctor and ask for

advice.

 

Making the patient vomit

 

If you make the patient vomit when poison is still in the

stomach, some of the poison may come out in the vomit. This may stop

the patient getting severe poisoning.

 

Do not make the patient vomit if:

 

–    the substance is not likely to cause poisoning;

 

–    vomiting might be dangerous (see below);

 

–    it is more than four hours since the patient took the poison.

Poisons only stay in the stomach for a short time after they have

been swallowed and in most cases none will be left after four

hours, so vomiting will not do any good;

 

–    you do not know what substance the patient has swallowed or what

effect it might have.

 

It is dangerous to make a patient vomit if any one of the

following is true:

 

*    The patient is unconscious or very sleepy. An unconscious person

cannot swallow or cough. If liquid or vomit gets into the airway

it will not be coughed out and may block the airway or get into

the lungs.

 

*    The patient has swallowed a chemical that is likely to burn.

Vomit might burn the throat and lungs.

 

*    The patient has swallowed a petroleum distillate (kerosene,

petrol, gasoline, white spirit), or a product containing these

chemicals, for example, some pesticides and cleaners. The

petroleum distillate may get into the lungs as the vomit passes

the top of the airway. This could cause lung oedema. (A patient

may swallow petroleum distillate with another substance that is

even more dangerous. For example, some liquid pesticides are

dissolved in petroleum distillate. In this case a doctor may tell

you to make the patient vomit because the danger from the other

poison is greater than the danger of lung oedema.)

 

*    The patient has swallowed a substance that is likely to cause

fits. The act of vomiting may start a fit. Vomiting during a fit

may cause choking, or vomit may get into the airway and block it.

 

*    The patient has swallowed a substance that might cause drowsiness

or unconsciousness. The patient might become drowsy or

unconscious before vomiting and choke.

 

If you know what the patient has swallowed, find out what effect

it might have by:

 

–    looking in Part 2 of this book;

 

–    contacting a poisons centre or local hospital.

 

Sometimes it is hard to decide whether you should make the

patient vomit. If you are not sure that it is safe, do not make the

patient vomit.

 

How to make the patient vomit

 

Make the patient vomit by tickling the back of the throat or

giving syrup of ipecacuanha.

 

Do not give salt water to make the patient vomit. Too much salt

is poisonous. In the past, patients given salt water to make them

vomit have died from salt poisoning.

 

Tickling the throat

 

Make the patient lie face down, or sit well forward with the head

lower than the chest, to stop vomit getting into the lungs. Children

should lie face down over your knee.

 

Ask the patient to touch the back of the throat with his or her

fingers. If the patient cannot do it, lightly touch the back of the

throat with your own finger or a blunt object such as a spoon. Take

care not to damage the throat. Use two fingers of your other hand to

force the patient’s cheek between the teeth so that the patient cannot

bite your finger.

 

Giving ipecacuanha syrup

 

Give ipecacuanha syrup or ipecacuanha paediatric emetic draught

or ipecacuanha Adelaide Children’s Hospital formula. Do not use fluid

extract of ipecacuanha.

 

Dose:     Adults: 30 ml (6 teaspoonfuls using a teaspoon that

holds 5 ml).

 

Children 6 months to 12 years: 10 ml (2 teaspoonfuls).

 

Children under 6 months old: do not give ipecacuanha

syrup.

 

Give a drink of water afterwards. The patient should vomit 15-20

minutes after the dose. If the patient does not vomit after 30

minutes, give a second dose of ipecacuanha syrup. Do not give more

than two doses.

 

When the patient starts to retch and vomit, make the patient lie

face down, or sit well forward with the head lower than the chest, to

stop vomit getting into the lungs. Children should lie face down over

your knee.

 

Giving ipecacuanha syrup may remove more poison than tickling the

throat because it makes the patient vomit more. However it may cause

problems:

 

*    The patient may vomit for a long time and become dehydrated.

 

*    Vomiting may be delayed for up to one hour after the dose. If the

patient becomes unconscious before then, or has a fit, there is a

danger that he or she may choke on the vomit.

 

After the patient has vomited

 

Look at the vomit. You may be able to see small pieces of

tablets, leaves, or berries, which could be the poison. Note the

colour and smell of the vomit.

 

Save some of the vomit in a small, closed container and take it

to hospital with you so that the doctor can see it. The hospital may

be able to test the vomit to show what the patient swallowed.

 

Giving activated charcoal

 

Activated charcoal is a fine black powder that binds most poisons

so that they pass out of the body with the charcoal in the faeces. It

may stop the patient getting worse and can prevent serious poisoning.

 

It takes 10 g of activated charcoal to bind 1 g of chemical, so

it is most useful when only a few grams of poison produce severe

effects. Activated charcoal is most effective if it is given within 4

hours of the poison being swallowed, while most of it is still in the

stomach. You can give activated charcoal after you have made the

patient vomit, but not until vomiting has stopped.

 

Do not give activated charcoal:

 

*    If the patient is unconscious, drowsy or having fits. Someone who

is drowsy or having fits may choke if given anything by mouth.

 

*    At the same time as, or just before, a dose of ipecacuanha syrup

or any antidote by mouth. Charcoal binds ipecacuanha and some

antidotes and stops them from working.

 

*    For poisoning caused by acids, alkalis, boric acid, ethanol,

iron-containing medicines such as ferrous sulfate, lithium,

methanol or petroleum distillates.

 

How to give activated charcoal

 

Use activated charcoal that has been given to you by a pharmacist

or a doctor. Charcoal that you make by burning bread or burning wood

is not the same and will not work.

 

Dose: Mix 5-10 g of activated charcoal with 100-200 ml of water.

Stir the activated charcoal with the water until it looks like a thick

soup. Make sure all the powder is wet.

 

Adults: Give one 10-g dose every 20 minutes up to a maximum of

50 g.

 

Children: Give one 5-g dose every 20 minutes up to a maximum of

15 g or 1 g/kg of body weight (whichever is lower).

 

Sometimes people vomit after drinking charcoal. If this happens

do not give any more. Tell the patient, or tell the parents if the

patient is a child, that charcoal colours the faeces black.

 

For some poisons, repeated doses of activated charcoal given over

many hours remove a larger amount from the body than a single dose. If

the poison is only slowly absorbed from the gut, additional doses of

charcoal may remove poison still present in the gut after the first

dose. Charcoal given after the poison has been absorbed from the gut

may remove any poison that passes back into the gut from the blood.

Repeated doses of activated charcoal can be given after poisoning from

aspirin, carbamazepine, phenobarbital or theophylline.

 

Dose:     Adult: 50 g every 4 hours for up to 2 or 3 days.

 

Children: 15 g or 1 g/kg of body weight (whichever is lower)

every 4 hours for up to 2 or 3 days.

 

Activated charcoal may cause mild constipation. If giving

repeated doses of charcoal, give one dose of laxative with the first

dose of charcoal.

 

Giving a laxative

 

Laxatives are usually used to treat constipation but they may be

used when someone has swallowed poison to make the poison move through

the gut and leave the body more quickly. A laxative may be useful up

to 24 hours after the patient swallowed poison.

 

Do not give a laxative if:

 

*    The patient is unconscious, drowsy or having fits. Patients who

are drowsy or having fits may choke if they try to swallow

anything.

 

*    The patient has swallowed a corrosive substance and has burns

inside the mouth. Giving a laxative may cause more damage to the

gut.

 

*    The patient has signs of dehydration. Diarrhoea will make the

body lose more water and make the problem worse.

 

*    The patient does not pass urine. This could mean the kidneys are

not working properly. Laxatives can be dangerous if given to a

patient with kidney damage.

 

There are many medicines that are given as laxatives to treat

constipation. Magnesium sulfate (Epsom salts), sodium sulfate or

magnesium citrate are the only laxatives that should be used when

someone has swallowed poison. Magnesium sulfate (Epsom salts) is the

best one to give and the one you are most likely to have.

 

Dose:    Give one dose only. Mix the following amount of magnesium

sulfate in a glassful of water:

 

Adults: 20-30 g.

 

Children over 2 years: 250 mg/kg of body weight.

 

Children under 2 years: not to be given.

 

How to look after a very sick patient

 

Keep the patient at rest in a quiet, comfortable place with

plenty of fresh air and light. Watch for any change in the patient’s

condition that tells you if the patient is getting better or worse.

Four times a day write down the temperature, pulse, and the number of

breaths per minute.

 

If the patient is awake and able to drink, encourage the patient

to drink plenty of liquid. Give simple fluids, such as water, soup,

maize porridge, or rice-water. Do not give alcohol or coffee. Give

frequent small drinks throughout the day. An adult needs to drink two

litres or more every day.

 

Watch for signs of dehydration. Write down the amount of liquid

drunk and the number of times the patient passes urine or has a bowel

movement. Keep this information for the doctor.

 

If the patient is dehydrated because of vomiting, diarrhoea, or

skin burns, you will need to give more fluids.

 

Do not give anything by mouth if

 

–    the patient cannot swallow,

 

–    the patient is unconscious, drowsy or having fits.

 

What to do if the patient has bad diarrhoea

 

Diarrhoea may be useful for getting poison out of the body but if

it is very bad or lasts a long time the patient may lose too much

water and become dehydrated. This problem is more likely to be caused

by eating food contaminated by microorganisms than by poisoning from

chemicals or medicines. Although many poisons cause diarrhoea it does

not usually last long enough to cause dehydration.

 

People of any age can become dehydrated but it happens more

quickly and is most dangerous in small children. A child with

diarrhoea very quickly loses large amounts of water and may die in a

few hours.

 

If the diarrhoea lasts a long time another danger is not getting

enough food. It is very important to prevent dehydration and

malnutrition by giving plenty of good food and drink.

 

Diarrhoea can be very dangerous if:

 

–    a small child with severe diarrhoea does not get better in 24

hours or if a well nourished adult does not get better in 36

hours;

 

–    the patient is dehydrated and getting worse;

 

–    the patient was very sick, weak or undernourished before the

diarrhoea started, or if the patient is very young or very old.

 

Medicines should not be given for diarrhoea, especially to small

children.

 

To prevent dehydration

 

If a person with diarrhoea is given plenty of liquids from the

start, water loss should not be a problem. A patient with watery

diarrhoea must drink large amounts of liquid as soon as the diarrhoea

starts in order to replace the water and salts lost from the body.

 

Give simple fluids, such as water, soup, maize porridge, rice-

water or whatever liquid is available that the patient will take. Give

one or two cupfuls (200 ml) of fluid after every loose stool. Even if

the patient does not want to drink, gently insist (unless the patient

is unable to swallow).

 

Do not stop giving the patient food. When you give large amounts

of liquid for diarrhoea, keep giving food as well unless the patient

is vomiting, and keep giving breast milk to babies. A baby, a small

child, or anyone who is thin, weak and undernourished should eat as

soon as they can. An older child or adult who is well nourished should

begin taking food after 24 hours.

 

To treat dehydration

 

If the patient is already dehydrated, simple fluids will not be

enough. Sugar and salts lost from the body (sodium, potassium and

bicarbonate) must be replaced. If you have a packet of oral

rehydration salts (ORS) mix it with water and give it to the patient

to drink.

 

To make up a drink with oral rehydration salts:

 

*    Wash your hands. Measure one litre (or the amount stated on the

packet) of clean drinking-water into a clean container. If

possible use boiled water, but try not to lose time. Pour all the

powder from one packet into the water and mix well until the

powder is completely dissolved. Give the patient some of this to

drink at once. Give at least 2 litres in the first 4 hours, if

the patient is an adult; give 75 ml per kg of body weight if the

patient is a child. The patient should continue to take frequent

drinks of the mixture until the diarrhoea stops. Make up fresh

ORS solution each day in a clean container and keep the container

covered.

 

If you do not have a packet of ORS you can make rehydration fluid

with two teaspoonfuls of sugar and one two-finger pinch of salt in one

cupful or mugful of water. This does not contain any potassium, so if

possible, give orange juice, coconut water or a little mashed ripe

banana, because these fruits contain potassium.

 

What to do if the patient vomits for a long time

 

A patient who vomits for a long time will lose a lot of water and

become dehydrated.

 

Give water or whatever liquids the patient will drink. Give sips

every 5-10 minutes for 36 hours, or until the patient stops vomiting.

 

Continue to give drinks even if the patient is vomiting. Give the

drink a little at a time, very frequently – several sips or swallows

every few minutes (not all of the drink will be vomited).

 

Do not give food while the patient is vomiting a lot.

 

Information for doctors

 

If vomiting does not stop, the patient may need to be given a

medicine like promethazine, diphenhydramine, or metoclopramide by

injection.

 

What to do if the patient does not pass urine

 

With the patient fiat on his or her back, and the head tilted

back so that the airway is open, feel the lower part of the belly. If

the bladder is full, you should be able to feel a rounded swelling in

the lower part of the belly.

 

The patient has an empty bladder

 

If the patient does not pass urine and has an empty bladder this

means that:

 

–    the patient is dehydrated; or

 

–    the kidneys have been poisoned and have stopped working.

 

Look for other signs of dehydration. If the patient is

dehydrated, give fluids following the advice given above.

 

To find out if the kidneys are working:

 

*    Give liquids – water, tea, soup, fruit juice or any non-alcoholic

drink. (Do not give anything by mouth if the patient is

unconscious or cannot swallow.) Give sips of drink every five

minutes and keep a record of how much the patient drinks.

Continue to give drink often in small sips; even if the patient

vomits, not all of the drink will be vomited.

 

*    Measure the amount of urine passed during six hours.

 

–    If the amount is more than 500 ml, the kidneys are working. Keep

giving sips of drink every five minutes day and night until the

patient begins to pass urine normally. A large person needs three

or more litres a day. A small child needs at least one litre a

day.

 

–    If the amount of urine is less than 500 ml the kidneys are not

working and it is dangerous to carry on giving large amounts of

liquid. If the kidneys are not working, for the next six hours

give fluid to drink equal to the amount of urine passed in the

previous six hours, plus 200 ml. Give 200 ml more if the patient

is sweating a lot (that is 400 ml plus the amount of urine

passed). Carry on measuring the amount of urine passed. At the

end of six hours again measure the amount of urine passed, and

for the next six hours give fluid to drink equal to the amount of

urine passed in the last 6 hours, plus 200 ml. Repeat this until

the patient gets to hospital.

 

The patient has a full bladder

 

If the bladder is full you should be able to feel a rounded

swelling in the lower part of the belly. If the bladder is full but

the patient does not pass urine this means the kidneys are working but

the bladder is not working and will not let the urine out. Do not give

anything to drink. If the patient is awake, he or she should sit in a

hot bath, and try to relax and to pass urine. You do not need to

measure urine output in this case.

 

What to do if the patient is unconscious

 

Keep the patient in the recovery position. Do not leave an

unconscious patient alone, as he or she may turn to lie on the back

and then the airway might be blocked by vomit or the tongue.

 

Check the level of consciousness, breathing and pulse every 10

minutes until the patient shows signs of recovery, and every half hour

after that. If breathing stops, give mouth-to-mouth or mouth-to-nose

respiration and if the heart stops give heart massage.

 

Make sure that the patient cannot fall onto the floor or hit

against a hard edge or surface. Do not put pillows or other padding

near the patient’s face, as they may suffocate him or her.

 

Gently roll the patient from one side to the other at least every

three hours to prevent pressure sores. As you turn the patient keep

the head back with the chin up and do not let the head fall forwards

with the chin on the chest. This is to keep the airway clear and to

prevent neck injuries.

 

Make sure that all the joints are neither fully straight nor

fully bent. Ideally they should all be kept in mid-position. Place

pillows under and between the bent knees and between the feet and

ankles.

 

Make sure that the eyelids are closed and that they stay closed

at all times, otherwise the eyeballs will get dry. Boil some water and

let it cool. Every two hours open the lids slightly and drip some of

the water gently into the corner of each eye so that the water runs

across the eye and drains from the other corner.

 

An unconscious patient must not be given anything to drink. If a

patient is unconscious for more than 12 hours he or she will become

dehydrated unless fluid can be given intravenously or via the rectum.

 

What to do if the patient has a low temperature

 

If the body temperature falls below 35°C measured in the mouth or

rectum, cover the body, head and neck, but not the face, with

blankets. If the patient is awake give hot sweet drinks. Put an

unconscious patient in the recovery position. Keep the room warm, but

do not try to warm the patient near a fire, or with hot water bottles

next to the body. If the patient is very cold, the pulse and breathing

may be very slow. If breathing and the heartbeat stop completely, give

mouth-to-mouth respiration and heart massage. Check for the pulse for

at least one minute before starting heart massage, because it is

dangerous to give heart massage to a very cold patient if the heart is

still beating.

 

What to do if the patient has a fever

 

A patient with a temperature higher than 38.5°C, measured by

mouth, should lie down, undressed, with no covering, in a cool place.

If the temperature becomes very high (over 40°C) it must be lowered at

once. Undress the patient and sponge the whole body with cool water or

cover the body with a cold, wet sheet and keep it wet. Fan the

patient, until the patient’s temperature drops to 38.5°C. If the

patient is awake give sips of cold water to drink. Do not give aspirin

for fever caused by poisoning.

 

Check for other causes of fever besides poisoning. The patient

may have malaria.

 

What to do if the patient has liver damage

 

The signs of liver damage are given in chapter 7.

 

Keep the patient resting in bed and warm. If the patient is awake

and can swallow, mix at least two tablespoonfuls of sugar in a glass

of water or tea and give it to the patient every 2 hours. Get the

patient to take these drinks with bread or rice, even if he or she

feels very sick. Do not give foods containing protein such as meat,

fish, eggs, milk or cheese.

 

If the patient is also drowsy or unconscious, this means that the

patient is very ill.

 

What to do if the patient has lung oedema

 

A patient with lung oedema will not be able to breathe properly.

This is very serious and the patient should be taken to hospital,

where oxygen can be given.

 

If the patient is unconscious put him or her in the recovery

position. If breathing and the heartbeat stop, give mouth-to-mouth

respiration and heart massage.

 

If the patient is awake, use pillows to support the patient

sitting up at an angle of 45°. If the patient is able, he or she can

sit up with his or her legs over the side of the bed.

 

All patients who have had lung oedema must rest in bed for at

least 48 hours after they seem to be completely recovered.

 

If the spit becomes green or yellow after an attack of lung

oedema, the patient may have an infection of the lungs and may need an

antibiotic.

 

CHAPTER 10

 

Medicines and equipment

 

This chapter gives suggestions about the medicines and first aid

equipment you might want to keep to deal with poisoning and the other

problems described in this book.

 

A poisons centre will be able to tell you which antidotes and

antivenoms you should keep, and how to get them. If there is no

poisons centre in your region, ask the pharmacy of your district

hospital.

 

The amount of medicines you keep will depend on how many people

you serve and how far you have to go to get more supplies.

 

How to care for medicines and first aid equipment

 

1. Keep all medicines out of the reach of children.

 

2. Be sure that all medicines are properly labelled and that the

directions for use are kept with each medicine. Keep this book in

the same place as the medicines.

 

3. Keep all medicines and medical supplies together in a clean, dry,

cool place, away from light and protected from cockroaches and

rats. Some medicines need to be kept in a refrigerator. Protect

instruments, gauze and cotton by wrapping them in sealed plastic

bags.

 

4. Medicine containers should be marked with an expiry date. The

medicines should not be used after this date. Some medicines may

be dangerous if they are used after the expiry date. Check the

date on each medicine container before you use the medicine.

Regularly check the medicines in your kit. If the date has passed

or the medicine looks spoiled, destroy it and get new medicine.

 

Medicines

 

*    Medicines that may be useful when poisons have been swallowed

(see Chapter 9):

 

–    syrup of ipecacuanha to cause vomiting,

 

–    activated charcoal to bind poison,

 

–    magnesium sulfate (Epsom salts) to use as a laxative to make

poisons move through the gut quickly; it can also be used as an

antidote when hydrofluoric acid has been swallowed.

 

*    Antidotes that can be given by a person without medical training,

when there is no doctor:

 

–    calcium gluconate gel, to put on the skin when hydrofluoric acid

has been in contact with the skin,

 

–    magnesium hydroxide, to be given by mouth when hydrofluoric acid

has been swallowed,

 

–    methionine tablets, to be given by mouth for paracetamol

poisoning,

 

–    naloxone, to be given by intramuscular injection, for opiate

poisoning.

 

*    Medicines to treat some of the effects of poisoning:

 

–    aspirin, 300 mg tablets, for fever or pain,

 

–    hydrocortisone cream, for itching rash caused by irritant plants,

 

–    paracetamol, 500 mg tablets for adults, and paracetamol elixir

for children, for fever or pain,

 

–    rehydration drink, prepackaged mix, for dehydration,

 

–    tetanus antitoxin, for use after snake bite, spider bite or fish

sting, when there is a danger of tetanus.

 

First aid equipment

 

The following will be useful for dealing with patients who have

been exposed to a poison, bitten by a snake or stung by a spider,

insect or fish:

 

–    thermometers for taking temperature in the mouth,

 

–    thermometers for taking temperature in the rectum,

 

–    cotton wool and dressings,

 

–    bandages and sticking plaster,

 

–    cups and spoons to measure accurate doses of medicine: 1 litre,

´ litre, 5 ml,

 

–    syringes and needles (if you are trained to give injections),

 

–    soap, towels, nail brush,

 

–    scissors,

 

–    tweezers with pointed ends,

 

–    sterile bottles for keeping samples of blood, urine or vomit,

 

–    sterile bags,

 

–    sterile gloves,

 

–    notebook, pencils and pens.

 

Medicines and antidotes that can be given by doctors outside hospital

 

Antidotes+

 

This is not a complete list of antidotes. It includes only those

that can be given outside hospital.

 

Acetylcysteine: given by mouth in paracetamol poisoning and carbon

tetrachloride poisoning. Acetylcysteine should be given by injection

only in a hospital or medical centre where resuscitation can be given

if the patient has an allergic reaction.

 

Ascorbic acid: given by mouth to treat methaemoglobinaemia from

sodium chlorate poisoning.

 

Atropine: for injection in poisoning from carbamate or

organophosphorus pesticides.

 

Calcium gluconate solution: for injection under the skin when

hydrofluoric acid has been in contact with skin.

 

Deferoxamine (desferrioxamine): for injection in iron poisoning.

 

Dicobalt edetate, 1.5% solution: for injection in cyanide poisoning.

 

Dimercaprol (also called British anti-Lewisite (BAL) compound): for

arsenic poisoning and lead poisoning.

 

4-Dimethylaminophenol (4-DMAP), 5% solution: for injection in

cyanide poisoning.

 

DMPS (dimercaptopropanesulfonate): for arsenic poisoning

and lead poisoning.

 

Hydroxocobalamin, 40% solution: for intravenous injection in cyanide

poisoning.

 

Methylthioninium (methylene blue): for cyanosis caused by

methaemoglobin in dapsone poisoning.

 

Obidoxime chloride: for poisoning from organophosphorus pesticides.

 

Penicillamine: for lead poisoning.

 

Phytomenadione (vitamin K): for injection in warfarin poisoning.

 

Potassium ferricyanoferrate (Prussian blue) or ferric ferrocyanide:

for thallium poisoning.

 

Pralidoxime mesilate (P-2-S) or pralidoxime chloride (PAM2): for

poisoning from organophosphorus pesticides.

 

Pyridoxine: for intravenous injection in isoniazid poisoning.

 

Sodium calcium edetate: for lead poisoning.

 

Sodium hydrogen carbonate (sodium bicarbonate): given by mouth with

sodium thiosulfate to treat methaemoglobinaemia from sodium chlorate

poisoning.

 

Sodium nitrite, 3% solution: for intravenous injection in cyanide

poisoning.

 

Sodium thiosulfate, 25% solution: for intravenous injection in

cyanide poisoning; also given by mouth, with sodium hydrogen carbonate

(sodium bicarbonate), to treat methaemoglobinaemia from sodium

chlorate poisoning.

 

Succimer (DMSA; dimercaptosuccinic acid): for arsenic poisoning and

lead poisoning.

 

Other medicines

 

Antibiotic eye ointment: when there is a risk of infection after

burns or injury to the eye.

 

Antivenoms: as appropriate for snakes, spiders, scorpions and

stinging fish that are found in the area.

 

Antihistamine such as chlorphenamine or promethazine: for

intravenous injection, in case of allergic reactions.

 

Diazepam: for injection, to treat fits.

 

Diphenhydramine: for injection or for giving by mouth, for itching

rash caused by irritant plants.

 

Epinephrine (adrenaline) injection, 1 in 1000 (1 mg/ml) for

intramuscular injection: for severe allergic reactions (for example,

to insect stings).

 

Fluorescein: to detect damage to the eye from irritant or corrosive

poisons.

 

Metoclopramide: for intravenous injection, to stop persistent

vomiting.

 

Morphine: for severe pain.

 

Salbutamol: for inhalation (or theophylline for intravenous

injection) for asthma or wheezing caused by severe allergic reactions

(for example, to insect stings).

 

PART 2

 

Information on specific poisons

 

Introduction

 

This part gives information about the effects of poisoning by

specific substances and what to do if you are called on to help

someone who might have been poisoned. The substances are in four main

groups: pesticides, chemical products used in the home, medicines, and

natural poisons including plants and animals.

 

The information in each section

 

Some sections cover more than one substance if the first aid for

poisoning is more or less the same.

 

Each section is arranged in the same way so that you can find

information quickly. The information you will find under each heading

is as follows:

 

Uses: the common uses for the substance. Abuse is also covered under

this heading.

 

How it causes harm: how a poisonous dose affects the body.

 

How poisonous it is: whether the substance is likely to cause harm and

whether the harm is likely to be severe. It is not possible to give

exact indications because the amount that causes severe poisoning may

differ greatly for people of different age or weight, or in different

circumstances.

 

Special dangers: any special dangers in the way the chemical is used,

the way it looks, or the way it is packed.

 

Signs and symptoms: the effects of poisoning that you can find out by

looking, feeling, and listening, and by talking to the patient. This

part does not include information about signs and effects that can

only be found out using tests or equipment in hospital.

 

Information about how to examine the patient and look for these

effects is given in Part 1. Part 1 describes the signs and symptoms of

liver damage, kidney damage and lung oedema.

 

The list of signs and symptoms starts with mild effects and ends

with severe effects. The larger the dose or the longer the person has

been exposed, the more likely you are to see the signs and symptoms

further down the list. The list includes the more severe signs and

symptoms that might happen if the patient had a very large dose and

was not given any first aid or medical treatment.

 

What to do: the first aid and things that can be done outside hospital

by people with basic first aid and nursing skills. Information is also

given for primary health care workers who can give injections.

 

Look back to Part 1 for more information about how to give first aid

and how to look after a patient outside hospital.

 

What to do if there is a delay in getting to hospital: in most cases

the patient should go to hospital and should begin the journey at

once, but it may take some time to get there. This part tells you what

you can do to try to stop severe poisoning if it is going to take more

than 3-4 hours to get to hospital.

 

Before you do anything listed under this heading check that the

patient’s signs and symptoms are roughly the same as those listed.

 

Additional information for doctors about clinical effects and

treatment is given in boxes. As this book is mainly concerned with

treatment that can be given outside hospital it does not give details

of hospital treatment. However, some information is given to indicate

the kind of treatment, including antidotes or antivenoms, that the

patient may need.

 

Pesticides

 

Aluminium phosphide and zinc phosphide

 

Uses

 

Aluminium phosphide and zinc phosphide are used to preserve

grain, especially wheat, and to kill rats. Grain preservative is

usually sold as tablets, and rat killer is sold as pellets or bait.

 

How they cause harm

 

When damp, phosphides release poisonous phosphine gas. When aluminium

phosphide or zinc phosphide is swallowed, poisonous effects are due to

phosphine released in the gut. Phosphine affects the gut, liver,

kidneys, lungs and heart.

 

How poisonous they are

 

Phosphine is very poisonous. People who swallow phosphides or

breathe in phosphine may die within a few hours. High concentrations

of phosphine in a closed space can kill almost immediately. Low

concentrations of phosphine may cause chronic poisoning. As aluminium

phosphide or zinc phosphide tablets and pellets give off phosphine

when exposed to air, the tablets themselves soon become less

poisonous.

 

Special dangers

 

In some countries, anyone can buy aluminium phosphide or zinc

phosphide rat killers, and many people use these to try to kill

themselves. Phosphine poisoning can also happen when:

 

–    people work in the holds of boats carrying cargo treated with

phosphides;

 

–    welders use acetylene containing phosphine as an impurity;

 

–    people live or work near grain warehouses where phosphide is

used.

 

Signs and symptoms

 

From swallowing phosphide or from breathing in phosphide dust or

fumes

 

*    Acute poisoning:

 

– severe vomiting and belly pain,

 

– chest pain,

 

– low blood pressure,

 

– signs of shock: fast weak pulse and cold wet skin,

 

– unconsciousness,

 

– signs of lung oedema in 6-24 hours,

 

– signs of kidney and liver failure within 12-24 hours.

 

*    Chronic poisoning:

 

– toothache,

 

– weakness,

 

– loss of weight and loss of appetite,

 

– changes to bones causing them to break easily, particularly the

jaw bone (phossy jaw).

 

What to do

 

If there are poisonous dusts, gases or fumes, move the patient

into fresh air. Wear breathing equipment to protect yourself from

being poisoned.

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes and keep the patient warm.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if the patient is fully awake and

breathing normally, and is not vomiting, give activated charcoal and

water to drink.

 

If the patient has signs of kidney failure treat as recommended

in chapter nine; if there are signs of liver damage treat as

recommended in chapter nine; if there are signs of lung oedema treat

as recommended in chapter nine.

 

Information for doctors outside hospital

 

As well as the effects listed above, acute poisoning may cause

disorders of heart rhythm, and chronic poisoning may cause liver

and kidney damage, and anaemia.

 

Monitor pulse, breathing and blood pressure. Monitor liver and

kidney function. Supportive care, including oxygen and mechanical

ventilation, should be given as needed:

 

*    Give fluids and electrolytes to replace losses due to vomiting.

 

*    Treat for shock.

 

There is no antidote. In chronic poisoning, blood cell counts and

other blood tests should be done.

 

Arsenic and arsenic-containing chemicals

 

Chemicals covered in this section

 

This section covers arsenic and chemical compounds containing

arsenic with other substances, for example:

 

arsenic trioxide         dimethylarsinic acid

 

arsenic pentoxide        lead arsenate

 

calcium arsenate         methylarsonic acid

 

copper acetoarsenite     sodium arsenite

 

Uses

 

Chemicals containing arsenic are used:

 

–    in farming and forestry to kill weeds, ants, termites, insects,

rats, and mice;

 

–    to protect wood from decay;

 

–    in the microelectronics industry;

 

–    for worming animals;

 

–    in some herbal and traditional remedies: for example, arsenic

trioxide is used in herbal medicines; in India chemicals

containing arsenic are prescribed by Ayurvedic practitioners;

kushtay is an Indian aphrodisiac containing arsenic (these uses

are not recommended).

 

Exposure to arsenic may occur during copper smelting and

industrial manufacture of glass, pigments, pesticides, wood

preservatives, and silicon chips.

 

How it causes harm

 

Arsenic is irritant to skin, lungs and gut. It interferes with

life-processes in cells in many parts of the body.

 

How poisonous it is

 

Arsenic and chemicals containing arsenic are very poisonous if

swallowed, breathed in or in contact with skin. A very small amount

can kill. Chronic poisoning can occur from repeatedly swallowing

arsenic (for example, by eating contaminated food, or taking

traditional remedies containing arsenic) or breathing in dust or

fumes. Arsenic can also cause cancer of the skin, lungs or liver a

long time after exposure.

 

Special dangers

 

People exposed to arsenic fumes or dust are at risk of chronic

arsenic poisoning. They should wear protective clothing and may need

to use a respirator.

 

Signs and symptoms

 

Acute poisoning

 

*    If swallowed

 

Within 30 minutes, or after several hours if taken with food:

 

–    sudden belly pain and vomiting,

 

–    severe diarrhoea,

 

–    sore throat,

 

–    dry mouth and thirst,

 

–    the breath may smell of garlic,

 

–    signs of shock: weak fast pulse, cold damp skin, low blood

pressure and blue skin,

 

–    delirium and sudden unconsciousness,

 

–    fits.

 

The patient may die within 24 hours. If not, after 24 hours there

may be:

 

–    jaundice and signs of liver damage,

 

–    signs of kidney damage,

 

*    If breathed in:

 

–    same effects as when swallowed, but without belly pain, vomiting

or diarrhoea.

 

*    On the skin:

 

–    same effects as when breathed in,

 

–    redness, blisters.

 

*    In the eyes:

 

–    severe irritation with pain and redness.

 

Chronic poisoning

 

Long-term exposure to small doses over many weeks or years, by

swallowing or breathing in, may result in:

 

– weakness,

 

– loss of appetite, nausea and vomiting,

 

– diarrhoea or constipation,

 

– skin rash,

 

– thick skin on the palms of the hands or the soles of the feet,

 

– hoarse voice and sore throat,

 

– sometimes the patient can taste metal, and the breath and sweat

smell of garlic,

 

– yellow skin as a result of liver damage,

 

– blood in the urine as a result of kidney damage,

 

– numbness or pain in the soles of the feet because the nerves

have been damaged,

 

– hair loss,

 

– white lines on the nails,

 

– cancer of the skin, lungs or liver.

 

What to do

 

Acute poisoning

 

If there are poisonous dusts, gases or fumes, move the patient

into fresh air. Wear breathing equipment to protect yourself from

being poisoned.

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes and keep the patient warm.

 

In the eyes

 

Wipe the face gently with a cloth or paper to soak up chemical.

Wash the eyes for at least 15-20 minutes with water. Check that

there are no solid bits of chemical on the lashes or eyebrows, or

in the folds of skin round the eyes.

 

On the skin

 

Immediately remove contaminated clothing, shoes, socks

and jewellery. Do not get any of the chemical on your own skin or

clothes or breathe in vapours. Wash the patient’s skin, nails and

hair thoroughly with soap and cold or lukewarm water, for at

least 15 minutes, if possible using running water. If a large

area is affected use a shower or a hand-held hose but protect the

patient’s eyes.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the patient is awake, give water to drink, two cupfuls per

hour for 12 hours, to replace the water lost in diarrhoea.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if it happened less than 4 hours ago,

and if the patient is fully awake, breathing normally, and has not had

muscle twitching or fits:

 

*    Make the patient vomit, unless he or she has already vomited a

lot.

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until vomiting has stopped.

 

Chronic poisoning

 

Take the patient to hospital.

 

Information for doctors outside hospital

 

Monitor breathing, pulse, blood pressure, fluid and electrolyte

balance, and liver and kidney function. Supportive care,

including oxygen and ventilation, should be given as needed:

 

*    Fluid and electrolyte balance should be corrected.

 

*    Low blood pressure should be treated with intravenous fluids

and the patient kept lying with the feet raised higher than

the head.

 

*    For repeated fits diazepam should be given by intravenous

injection.

 

Dose:     Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30

seconds, repeated if necessary after 30-60 minutes; this may

be followed by intravenous infusion to a maximum of 3 mg/kg

of body weight over 24 hours.

 

Children: 200-300 µg/kg of body weight.

 

If the patient has symptoms, an antidote should be given as soon

as possible. Dimercaprol can be given by deep intramuscular injection.

 

Dose:     Days 1 and 2: 2.5-3 mg/kg of body weight every 4 hours.

 

Day 3: 3 mg/kg of body weight every 6 hours.

 

Days 4-10: 3 mg/kg of body weight every 12 hours until

symptoms of poisoning are gone.

 

Side-effects of dimercaprol: pain at the injection site, itchy

rash, burning feeling in lips, mouth and throat, fever, headache, low

blood pressure or high blood pressure, vomiting, and fits.

 

Succimer (DMSA; dimercaptosuccinic acid) or DMPS

(dimercaptopropane-sulfonate) can be used instead of dimercaprol if

available. They are less toxic than dimercaprol and can be given by

mouth. Contact a poisons centre for more information.

 

Chlorophenoxyacetate weedkillers

 

Chemicals covered in this section

 

This section covers a group of weedkillers known as

chlorophenoxyacetate weedkillers (sometimes shortened to phenoxy or

chlorophenoxy weedkillers). The following list gives the commonly used

short names and the full chemical names of some of these products:

 

2,4-D               2,4-dichlorophenoxyacetic acid

 

MCPA                (4-chloro-2-methylphenoxy)acetic acid

 

mecoprop (MCPP)     2-(2-methyl-4-chlorophenoxy)propionic acid

 

dichlorprop (DCPP)  2-(2,4-dichlorophenoxy)propionic acid

 

2,4,5-T             2,4,5-trichlorophenoxyacetic acid

 

Many products are mixtures of more than one of these weedkillers.

 

Uses

 

They are used to kill broad-leaved weeds in cereal crops,

grassland, parks and gardens, and weeds in ponds, lakes and irrigation

canals.

 

How they cause harm

 

They irritate the skin, mouth and gut, cause heat exhaustion, and

damage the muscles, nerves and brain. Some liquid products also

contain petroleum distillates which may cause lung oedema if

swallowed.

 

How poisonous they are

 

Most cases of poisoning are a result of people swallowing large

amounts of concentrated liquid product. Some deaths have been

reported. These chemicals can cause harm if they are breathed in or

brought into contact with the skin, but only if people are exposed to

very large amounts.

 

Signs and symptoms

 

*    If swallowed:

 

–    burning pain inside the mouth,

 

–    coughing and choking if the product contains petroleum

distillate,

 

–    belly pain, vomiting and diarrhoea,

 

–    fever or low temperature,

 

–    confusion,

 

–    muscle pain, muscle weakness and twitching,

 

–    low blood pressure,

 

–    fast breathing and blue skin,

 

–    unconsciousness,

 

–    fits.

 

Death may occur within a few hours.

 

If the patient survives more than a few hours:

 

–    lung oedema within 12-24 hours, if the product contains petroleum

distillates,

 

–    dark urine and signs of kidney damage.

 

–    signs of liver damage.

 

*    On the skin:

 

–    redness and irritation.

 

If large areas of skin are covered:

 

–    muscle pain, muscle weakness and twitching,

 

–    unconsciousness.

 

*    If breathed in (large doses):

 

–    muscle pain, muscle weakness and twitching,

 

–    unconsciousness.

 

*    In the eyes:

 

–    redness and irritation.

 

What to do

 

Give first aid. If the patient stops breathing open the airway,

wash chemical off the patient’s lips, then give mouth-to-mouth or

mouth-to-nose respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the patient has a fever, wash the body with cool water. If the

patient has a low temperature, keep him or her warm.

 

In the eyes

 

Wash the eyes with water for at least 15-20 minutes. Check that

there are no solid bits of chemical on the lashes or eyebrows, or

in the folds of skin round the eyes.

 

On the skin

 

Immediately remove contaminated clothing, shoes, socks

and jewellery. Wash the patient’s skin thoroughly with soap and

cold water for 15 minutes, if possible using running water.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the pesticide was swallowed: if it happened less than 4

hours ago, and if the patient is fully awake, breathing normally, and

has not had muscle twitching or fits:

 

*    Make the patient vomit unless he or she has already vomited a

lot.

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until vomiting has stopped.

 

Keep the patient in a quiet place.

 

Information for doctors outside hospital

 

As well as the effects listed above, there may be metabolic

acidosis, and myoglobin and blood in the urine.

 

Monitor breathing, pulse, blood pressure, fluid and electrolyte

balance. Supportive care, including oxygen and ventilation, should be

given as needed:

 

* Fluid and electrolyte balance should be corrected.

 

* For repeated fits give diazepam by intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Give sodium bicarbonate, 10-15 g daily, to make the urine alkaline and

increase elimination.

 

Dinitro-o-cresol (DNOC), dinitrophenol, dinoseb and pentachlorophenol

 

Chemicals covered in this section

 

This section covers:

 

*    dinitro-o-cresol (DNOC), dinitrophenol and dinoseb  (2-sec-butyl

4,6-dinitrophenol);

 

*    pentachlorophenol, also called chlorophen, PCP, and

pentachlorphenol;

 

*    sodium pentachlorophenate, also called pentachlorphenate sodium,

pentachlorophenoxy sodium, sodium PCP, sodium pentachlorphenate,

sodium pentachlorophenolate, and sodium pentachlorophenoxide.

 

Uses

 

They are used to kill weeds, insects and fungi, and to preserve

wood from rot and decay.

 

How they cause harm

 

They speed up chemical processes in the body so that the body

overheats, causing heat stroke or heat exhaustion. They also damage

the liver and kidney and the nervous system. Liquid products may

contain petroleum distillates or methanol.

 

How poisonous they are

 

Spray, dust and fumes are poisonous if breathed in or swallowed,

or if they come into contact with the skin. Poisoning is worse if the

patient is hot.

 

Special dangers

 

People may be poisoned by breathing in fumes or spray if

pentachlorophenol is used inside buildings where there is too little

fresh air. It is dangerous to use these chemicals without wearing

protective clothing to cover the body and prevent skin absorption.

 

Signs and symptoms

 

*    If swallowed

 

Within a few hours:

 

–    yellow skin, especially on the palms of the hands, and yellow

hair, but the whites of the eyes do not turn yellow (dinitro-o-

cresol and dinoseb only),

 

–    sweating and thirst,

 

–    nausea and vomiting,

 

–    high fever,

 

–    dehydration,

 

–    tiredness,

 

–    anxiety, restlessness, headache and confusion,

 

–    fast deep breathing,

 

–    fast pulse,

 

–    bright yellow urine (dinitro-o-cresol and dinoseb only),

 

–    the patient passes very little urine, as a result of kidney

damage,

 

–    fits,

 

–    unconsciousness,

 

–    lung oedema.

 

*    On the skin:

 

–    rash,

 

–    same effects as when swallowed.

 

*    In the eyes:

 

–    severe irritation, redness and watering.

 

*    If breathed in:

 

–    irritation of the nose and throat,

 

–    shortness of breath and chest pain,

 

–    same effects as when swallowed.

 

What to do

 

If there are poisonous sprays, dusts, gases or fumes, move the

patient into fresh air. Wear breathing equipment to protect yourself

from being poisoned.

 

Give first aid. If the patient stops breathing open the airway,

wash chemical off the patient’s lips, then give mouth-to-mouth or

mouth-to-nose respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the patient is awake, give water to drink, to replace the

water lost by sweating.

 

If the patient has a fever, wash the body with cool water. Do not

give aspirin to treat the fever.

 

Keep the patient lying down and resting.

 

In the eyes

 

Dab the face very gently with a cloth or paper to soak up

chemical. Wash the eyes for at least 15-20 minutes with water.

Check that there are no solid bits of chemical on the lashes or

eyebrows, or in the folds of skin round the eyes.

 

On the skin

 

Immediately remove contaminated clothes, shoes, socks and

jewellery. Wash the skin, nails and hair thoroughly with soap and

cold or lukewarm water for at least 15 minutes, if possible using

running water. If a large area is affected use a shower or a

hand-held hose but protect the patient’s eyes. Do not try to

remove all the yellow colour – it is in the skin and will not

wash off.

 

Take the patient to hospital at once. Do not let the patient

walk, as it will quickly exhaust him or her and make the poisoning

worse.

 

What to do if there is a delay in getting to hospital

 

Keep the patient lying down in a cool place.

 

If the chemical was swallowed: if it happened less than 4 hours

ago, and if the patient is fully awake, breathing normally, and has

not had muscle twitching or fits:

 

*    Give activated charcoal and water to drink.

 

*    Give 2 cupfuls of water every hour for the first 24 hours.

 

Do not make the patient vomit. The patient may choke on the vomit

if he or she becomes unconscious or has a fit.

 

If the patient has lung oedema, treat as recommended in chapter

nine. If the patient has signs of liver damage, treat as

recommended in chapter nine. If the patient has signs of kidney damage,

treat as recommended in chapter nine.

 

Information for doctors outside hospital

 

As well as the effects listed above, there may be metabolic

acidosis. Monitor breathing, pulse, blood pressure, rectal

temperature, blood glucose, and liver and kidney function. Supportive

care, including oxygen and ventilation, should be given as needed:

 

*    Intravenous glucose or frequent meals to make sure the patient

has a good supply of energy.

 

*    Fluid and electrolyte balance and acid-base balance should be

corrected.

 

*    For repeated fits diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Insect repellent

 

Chemicals covered in this section

 

Diethyl toluamide, also called N,N-diethyl-3-toluamide or deet.

 

Uses

 

Diethyl toluamide is used on the skin as an insect repellent to

prevent bites from mosquitos, fleas and biting flies. It has no effect

against stinging insects. Products may be in the form of lotions,

cream sticks, aerosol sprays or towelettes. The concentration may vary

from 5% to 100%.

 

How it causes harm

 

It damages the brain. Repeated use on the skin may cause rashes

and dermatitis.

 

How poisonous it is

 

Severe poisoning does not happen very often. It is usually a

result of swallowing a large amount of a highly concentrated product,

or putting too much on the skin over a period of several weeks.

Poisoning is reported more often in children than adults, and girls

seem more likely to be poisoned than boys. Rarely, acute poisoning may

cause brain damage in children.

 

Special dangers

 

Children have been poisoned by insect repellents that were

sprayed on their skin over several weeks, and by sleeping in beds

sprayed with deet. Acute poisoning in children may be mistaken for a

viral infection.

 

Signs and symptoms

 

*    If swallowed

 

From small amounts or products containing a low concentration:

 

–    nausea and vomiting,

 

–    belly pain,

 

–    diarrhoea.

 

From large amounts of highly concentrated products, within 30

minutes to 6 hours:

 

–    unconsciousness,

 

–    fits,

 

–    signs of liver damage.

 

Rarely, acute poisoning in children may cause brain damage with:

 

–    slurred speech,

 

–    staggering walk,

 

–    abnormal movements of fingers and toes,

 

–    trembling,

 

–    fits,

 

–    shallow breathing,

 

–    low blood pressure,

 

–    fast pulse.

 

*    In the eyes:

 

–    irritation, which may be severe if the product is concentrated.

 

*    On the skin

 

If the solution is concentrated (>50% deet):

 

–    a burning feeling,

 

–    blisters and ulcers.

 

After repeated use:

 

–    redness and rash,

 

–    signs of poisoning if large amounts have been used.

 

What to do

 

Give first aid. If the patient stops breathing open the airway

and give mouth-to-mouth or mouth-to-nose respiration. If the patient

is unconscious or drowsy, lay him or her on one side in the recovery

position, check breathing every 10 minutes and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with running water.

 

On the skin

 

If skin contact is greater than for normal use of insect

repellent, immediately remove contaminated clothing. Wash skin,

nails and hair thoroughly with soap and cold or lukewarm water,

for at least 15 minutes, if possible using running water.

 

Patients who have signs and symptoms showing that a large amount

might have been swallowed, or who have severe irritation of skin or

eyes, should go to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if a large amount was swallowed

less than 4 hours ago, and if the patient is fully awake, breathing

normally, and has not had fits:

 

*    Make the patient vomit unless he or she has already vomited a

lot.

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until vomiting has stopped. Give sodium

sulfate or magnesium sulfate with the charcoal.

 

If the patient has signs of liver damage, treat as recommended

in chapter nine.

 

Information for doctors outside hospital

 

Rarely, children may develop a toxic encephalopathy. This may be

mistaken for viral encephalitis or epilepsy.

 

In severe poisoning, monitor breathing, heart, blood pressure,

fluids and electrolytes. Supportive care, including oxygen and

ventilation, should be given as needed:

 

*    Low blood pressure should be treated with intravenous fluids.

 

*    For fits, increased muscle tone, opisthotonus or tremors,

diazepam or phenobarbital should be given.

 

Dose of diazepam by intravenous injection:

 

Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds, repeated

if necessary after 30-60 minutes; this may be followed by intravenous

infusion to a maximum of 3 mg/kg of body weight over 24 hours.

 

Children: 200-300 µg/kg of body weight.

 

Metaldehyde

 

Uses

 

Metaldehyde is used to kill snails and slugs, and as solid fuel.

Slug and snail killers may be in the form of small pellets containing

metaldehyde and bran, or may be a liquid that needs to be diluted

before use. Solid fuel is made in the form of tablets.

 

How it causes harm

 

Metaldehyde affects the gut, the brain, the liver and the

kidneys.

 

How poisonous it is

 

Metaldehyde is poisonous if swallowed. The pellets used for

killing slugs and snails usually contain very little metaldehyde (less

than 5%) and do not usually cause severe poisoning. Metaldehyde liquid

and solid fuel tablets contain a higher concentration and can cause

severe poisoning and possibly death.

 

Special dangers

 

Metaldehyde pellets are often sold in packs that are easy for

children to open. The pellets are put on top of the soil and children

may pick them up.

 

Signs and symptoms

 

*    If swallowed

 

Effects are usually seen within three hours, but may be delayed

for up to 48 hours:

 

–    nausea, vomiting and belly pain,

 

–    wet mouth,

 

–    flushed face,

 

–    fever,

 

–    drowsiness,

 

–    fast pulse,

 

–    trembling,

 

–    muscle twitching and fits,

 

–    unconsciousness.

 

After 2-3 days:

 

–    jaundice and signs of liver damage,

 

–    the patient passes very little urine showing that the kidneys are

damaged.

 

What to do

 

If the patient has swallowed only one or two pellets of slug bait

containing less than 5% metaldehyde, there is no need to do anything.

If the patient has swallowed more than this, proceed as follows.

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed less than 4 hours ago, and if the

patient is fully awake and breathing normally, and has not had muscle

twitching or fits:

 

*    Make the patient vomit, unless he or she has already vomited a

lot.

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until he or she has stopped vomiting.

 

If the patient has signs of liver damage, treat as recommended

in chapter nine. If the patient has signs of kidney damage, treat as

recommended in chapter nine.

 

Information for doctors outside hospital

 

Monitor pulse, breathing, blood pressure and liver function.

Supportive care, including oxygen and ventilation, should be

given as needed. For repeated fits diazepam should be given by

intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Organochlorine pesticides

 

Pesticides covered in this section

 

There are many organochlorine pesticides. Some of the more well

known ones are aldrin, chlordane, DDT, dieldrin, endosulfan, endrin,

and lindane (also known as gamma benzene hexachloride or gamma-HCH).

 

Uses

 

Organochlorine pesticides are widely used in agriculture, and to

control disease-carrying insects such as malaria mosquitos. Lindane is

also used to kill fleas, head lice, snails and slugs, and is sprayed

on seeds to stop insects eating them.

 

Products may be dusts, wettable powders, pellets or liquids. Some

products are burnt to make smoke that kills insects. Products for

killing head lice are made as lotions or shampoos.

 

How they cause harm

 

They affect the brain and breathing. Liquid products may also

contain solvents such as petroleum distillates which may cause lung

oedema if swallowed.

 

How poisonous they are

 

Organochlorine pesticides are poisonous if they are swallowed,

breathed in, or brought into contact with the skin. The poisonous

amount varies a lot between individual pesticides. Aldrin, dieldrin,

endrin and endosulfan are more poisonous than chlordane, DDT and

lindane.

 

Special dangers

 

People may be poisoned if they do not wash after using the

pesticide, or if they go into houses that are being sprayed. Lindane

shampoo can cause poisoning in young children if too much is used or

if it is used too often. People have been poisoned by eating food

contaminated with these chemicals.

 

Signs and symptoms

 

Effects usually begin after 1-6 hours. Poisoning with DDT may be

delayed for up to 48 hours.

 

*    If swallowed:

 

–    vomiting, diarrhoea and belly pain,

 

–    anxiety, excitement and weakness,

 

–    headache and dizziness,

 

–    shaking and trembling,

 

–    fits,

 

–    unconsciousness,

 

–    fast breathing, blue skin and signs of lung oedema, if the

product contains petroleum distillates.

 

*    If breathed in:

 

–    burning of the eyes, nose or throat,

 

–    anxiety, excitement and weakness,

 

–    headache and dizziness,

 

–    shaking and trembling,

 

–    fits,

 

–    unconsciousness.

 

*    In the eyes:

 

–    irritation may occur.

 

* On the skin:

 

– irritation and rash may occur,

 

– same effects as if breathed in.

 

What to do

 

If there are poisonous dusts, gases or fumes, move the patient

into fresh air. Wear breathing equipment to protect yourself from

being poisoned.

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes, and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the chemical has been swallowed do not give milk to drink, or

anything fatty or oily by mouth.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water. Check that

there are no solid bits of chemical on the lashes or eyebrows, or

in the folds of skin round the eyes.

 

On the skin

 

Immediately remove contaminated clothes, shoes, socks and

jewellery. Wash the skin, nails and hair thoroughly with soap and

cold or lukewarm water for at least 15 minutes, if possible using

running water.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if it happened less than 4 hours

ago, and if the patient is fully awake, breathing normally, and has

not had fits:

 

*    Make the patient vomit, unless he or she has already vomited a

lot.

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until vomiting has stopped. Give sodium

sulfate or magnesium sulfate with the charcoal.

 

If the patient has signs of lung oedema, treat as recommended

in chapter nine.

 

Information for doctors outside hospital

 

These chemicals affect respiratory control, muscle activity and

heart rhythm. Monitor pulse, breathing and blood pressure.

Supportive care, including oxygen and ventilation, should be

given as needed. For repeated fits diazepam should be given by

intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

There is no antidote. Dialysis, haemoperfusion, and diuresis are

not useful.

 

Organophosphorus and carbamate insecticides

 

Insecticides covered in this section

 

This section covers organophosphorus and carbamate insecticides.

Some are listed below.

 

Organophosphorus insecticides:

 

azinphos-methyl          fenthion

 

bromophos-ethyl          formothion

 

bromophos                heptenophos

 

carbophenothion          jodfenphos (iodofenphos)

 

chlorfenvinphos          malathion

 

cythioate                mevinphos

 

demeton-S-methyl         parathion-methyl

 

diazinon                 phorate

 

dichlorvos               phosmet

 

dimethoate               phoxim

 

fenitrothion             pirimiphos methyl

 

Carbamate insecticides:

 

aldicarb                 methiocarb

 

bendiocarb               methomyl

 

carbaryl                 pirimicarb

 

carbofuran               propoxur

 

These insecticides may be in the form of dusts, granules or

liquids. Some products need to be diluted with water before use, and

some are burnt to make smoke that kills insects.

 

Uses

 

They are widely used in agriculture and in the home to kill

insect pests. They are also used to kill malaria mosquitos and insect

parasites living on humans or domestic animals.

 

How they cause harm

 

They poison the nerves that control glands, muscles, breathing

and the brain. Although the clinical effects of the two groups are the

same, organophosphorus insecticides do not affect the body in exactly

the same way as carbamate insecticides, and there are some differences

in the antidotes used to treat poisoning. Some products contain

petroleum distillates, toluene or xylene, which may cause lung oedema.

 

How poisonous they are

 

They may cause serious poisoning and death if they are breathed

in or swallowed, or come into contact with the skin or eyes. They

differ widely from one another in the amount that causes poisoning.

Serious poisoning may occur at lower doses in people who are re-

exposed within a few weeks or months.

 

Carbamate insecticides cause less severe poisoning than

organophosphorus insecticides.

 

Signs and symptoms

 

Effects may occur very quickly or be delayed for up to 12 hours.

 

*    If swallowed, breathed in, or on the skin:

 

–    confusion, weakness and exhaustion,

 

–    headache,

 

–    nausea, vomiting, belly pains and diarrhoea,

 

–    cold sweating, wet mouth,

 

–    tightness in the chest,

 

–    twitching eyelids and tongue, later twitching over the rest of

the body,

 

–    irregular or shallow breathing,

 

–    slow pulse,

 

–    small pupils,

 

–    fits,

 

–    unconsciousness,

 

–    lung oedema,

 

–    incontinence.

 

*    In the eyes:

 

–    irritation, watering and blurred vision,

 

–    same effects as if swallowed or breathed in.

 

What to do

 

If there are poisonous dusts, gases or fumes, move the patient

into fresh air. Wear breathing equipment and protective clothing to

protect yourself from being poisoned.

 

Give first aid. If the patient stops breathing open the airway,

wash chemical off the patient’s lips then give mouth-to-mouth or

mouth-to-nose respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

In the eyes

 

Dab the face very gently with a cloth or paper to soak up

chemical. Wash the eyes for at least 15-20 minutes with water.

Check that there are no solid bits of chemical on the lashes or

eyebrows or in the folds of skin round the eyes.

 

On the skin

 

Immediately remove contaminated clothes, shoes, socks and

jewellery. Be careful not to get any of the chemical on your own

skin or clothes, or to breathe in vapours.

 

Wash the patient’s skin, nails and hair thoroughly with soap and

cold or lukewarm water for at least 15 minutes, if possible using

running water. If a large area is affected use a shower or a

hand-held hose, but protect the patient’s eyes.

 

Make the patient lie down and rest. The poisoning may get worse

if the patient moves around.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting the patient to hospital

 

If the chemical was swallowed: if it happened less than 4 hours

ago, and if the patient is fully awake, breathing normally, has not

had muscle twitching or fits, and is not vomiting, give activated

charcoal and water to drink.

 

If the patient has signs of lung oedema, treat as recommended

in chapter nine.

 

After the patient has recovered

 

The body chemistry may take weeks or months to recover, even

though the patient seems well again. A person who is re-exposed before

the body has properly recovered from the first exposure may be very

seriously poisoned by a dose that would not normally cause harm.

People who have been poisoned with organophosphorus pesticides should

not work with them again until they have been examined by a doctor who

understands this problem.

 

Information for doctors outside hospital

 

As well as the effects listed above, there may be weakness of the

muscles used in breathing, bronchospasm, and accumulation of fluid in

the air passages and lungs.

 

Monitor pulse, breathing, blood pressure and fluid loss.

Supportive care, including oxygen and ventilation, should be given as

needed:

 

*    Secretions should be cleared from the airway.

 

*    Fluid and electrolyte balance should be corrected.

 

*    Diazepam can be given by intravenous injection to relieve anxiety

and control fits.

 

Dose: Adults: 10-20 mg repeated as needed.

 

Children: 0.25-0.4 mg/kg of body weight repeated to a maximum dose of

5 mg in children aged 1 month to 5 years, and to a maximum dose of

10 mg in children aged more than 5 years.

 

Antidotes should be given if there are signs of poisoning.

Organophosphorus and carbamate insecticides act in slightly different

ways, so pralidoxime, which is used to treat organophosphorus

insecticide poisoning is not used to treat poisoning by carbamate

insecticides.

 

For both organophosphorus and carbamate insecticides

 

Give atropine immediately by intravenous injection, until the

patient’s mouth becomes dry, the heart rate is more than 100 beats per

minute, and the pupils are dilated.

 

Dose: Adults: give a first dose of 2-4 mg. If the patient’s mouth is

still wet repeat this dose every 10 minutes until the mouth is dry.

 

Children: give 0.05 mg/kg of body weight repeated every 10 minutes

until the mouth is dry.

 

Keep watching the patient. Repeat the dose as needed to correct

wheezing and excess salivation. Patients may die if they are not given

enough atropine. Large amounts may be needed for several days.

 

For organophosphorus (but not carbamate) insecticides

 

In severe cases and in cases that do not respond to atropine,

give pralidoxime mesilate (P-2-S) or chloride (PAM2) in addition to

atropine, to reactivate the enzyme inhibited by the insecticide. It

may be given at the same time as atropine.

 

Dose: 30 mg per kg of body weight by slow intravenous injection over

5-30 minutes every 4-6 hours. It can be given intramuscularly if an

intravenous dose cannot be given. Obidoxime chloride can be used if

pralidoxime is not available.

 

Paraquat

 

Use

 

Paraquat is used as a weedkiller. It is usually sold as a liquid,

containing a 20% concentration of paraquat, which must be diluted

before use. In some countries a granular solid product is also

available for domestic garden use. This contains 2.5% paraquat and

2.5% diquat, and is mixed with water before use.

 

How it causes harm

 

Paraquat damages the lungs, liver and kidneys. The 20% solution

is corrosive.

 

How poisonous it is

 

Paraquat is very poisonous if swallowed. One mouthful of the 20%

liquid may result in death from lung damage within 1-4 weeks. Larger

amounts may cause death within 12 hours.

 

Skin contact is unlikely to cause poisoning, unless contaminated

clothes are worn for several hours, or a large amount of concentrated

paraquat is in contact with damaged skin, or the patient is a child.

Breathing in paraquat spray may irritate the nose and throat but is

unlikely to cause poisoning.

 

Special dangers

 

Many poisonings have happened by accident when paraquat has been

stored in bottles that previously held beer, wine or soft drinks. This

is a dangerous way to store any poison, as other people may drink from

the bottles by mistake, but it may be quite common in places where

liquid paraquat is supplied only in large containers. People with

small farms or gardens, who only want to buy small amounts, may take a

small amount from the large container and put it into other

containers. Pesticide sprayers can be severely poisoned if they

swallow paraquat while trying to clear blocked spray pipes. Wearing

clothes contaminated with liquid paraquat for several hours may result

in absorption of a poisonous amount.

 

Signs and symptoms

 

*    If swallowed:

 

–    vomiting and belly pain,

 

–    diarrhoea, often bloody.

 

After ingestion of large amounts, severe effects occur within a

few hours:

 

–    drowsiness, weakness, giddiness and headache,

 

–    fever,

 

–    unconsciousness,

 

–    cough and irregular breathing,

 

–    lung oedema within a few hours.

 

The patient may die within 12 hours.

 

After ingestion of smaller amounts, severe effects develop after

24-48 hours:

 

–    sore mouth and throat after 24-48 hours,

 

–    in some cases there are white ulcers in the mouth and throat, the

lining of the mouth and throat peels off, there is pain on

swallowing, and the mouth is wet because the patient cannot

swallow saliva,

 

–    shortness of breath as lung disease develops,

 

–    in some cases the patient passes very little urine, showing that

the kidneys are damaged,

 

–    in some cases, jaundice and signs of liver damage develop.

 

Death may occur after 2-4 weeks from lung disease.

 

*    On the skin

 

Contact with the 20% paraquat solution may cause inflammation and

blisters; nails may crack and fall off.

 

Large amounts in contact with damaged skin for many hours may

result in:

 

–    shortness of breath as a result of lung disease,

 

–    in some cases the patient passes very little urine, showing that

the kidneys are damaged,

 

–    in some cases, jaundice and signs of liver damage develop.

 

The patient may die from lung disease.

 

*    In the eyes:

 

–    severe inflammation from the 20% paraquat solution, but the eyes

recover completely if properly treated.

 

*    If breathed in

 

Spray or dust may make the nose bleed.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes and keep the patient warm.

 

If swallowed

 

Do not give anything by mouth if the patient has bad ulcers

inside the mouth, because the patient will probably not be able to

swallow.

 

For severe pain in the mouth, give mouthwashes or use local

anaesthetic sprays. If the patient can swallow give ice-cold water or

ice cream.

 

If the chemical was swallowed less than 4 hours ago, and if the

patient is fully awake, is not vomiting and can swallow, give

activated charcoal and water to drink. Give sodium sulfate or

magnesium sulfate with the charcoal.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water. Check that

there are no solid bits of chemical on the lashes or eyebrows, or in

the folds of skin round the eyes.

 

On the skin

 

Immediately remove contaminated clothes, shoes, socks and

jewellery. Be careful not to get any of the chemical on your own skin

or clothes. Wash the patient’s skin, nails and hair thoroughly with

soap and cold or lukewarm water for at least 15 minutes, if possible

using running water.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay getting the patient to hospital

 

If the chemical was swallowed, and if the patient is fully awake,

breathing normally, and can swallow, give two cupfuls of water to

drink every hour.

 

If the patient has signs of lung oedema, treat as recommended

in chapter nine.

 

Information for doctors outside hospital

 

Supportive care should be given as needed:

 

– intravenous fluids,

 

– morphine for pain.

 

Oxygen may make lung damage worse, so do not give it unless the

patient is distressed. Patients who are unlikely to recover can be

given oxygen if it makes them more comfortable.

 

There is no successful treatment for moderate or severe paraquat

poisoning.

 

Phenol and related substances

 

Chemicals covered in this section

 

This section covers phenol (also called carbolic acid), creosote

(also called wood tar or coal tar), and cresol.

 

Uses

 

Phenol and cresol are used as disinfectants and antiseptics.

Creosote is used as a wood preservative.

 

How they cause harm

 

These chemicals are corrosive but do not cause such bad burns as

strong acids or alkalis. They affect the heart, the brain, breathing,

the liver and the kidneys.

 

How poisonous they are

 

They are poisonous if swallowed or breathed in or absorbed

through the skin. Exposure to large amounts may cause death.

 

Signs and symptoms

 

*    If swallowed:

 

–    burns round mouth and inside mouth and throat,

 

–    vomiting and diarrhoea,

 

–    fast breathing at first,

 

–    weak fast pulse,

 

–    low blood pressure,

 

–    unconsciousness,

 

–    fits,

 

–    signs of kidney failure: the patient passes very little urine

and the urine is dark,

 

–    signs of liver damage,

 

–    lung oedema.

 

The effects on heart and breathing may cause death.

 

*    If breathed in:

 

–    same effects as if swallowed, but without burning in the mouth

and throat, vomiting or diarrhoea.

 

*    In the eyes:

 

–    severe pain, redness and watering,

 

–    blindness.

 

*    On the skin:

 

–    chemical burns, which are usually painless,

 

–    skin looks white and wrinkled (with cresol, skin looks red),

 

–    same effects as if swallowed, but without burning in the mouth

and throat, vomiting or diarrhoea.

 

What to do

 

Give first aid. If the patient stops breathing open the airway,

wash chemical off the patient’s lips then give mouth-to-mouth or

mouth-to-nose respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes, and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

In the eyes

 

Dab the face very gently with a cloth or paper to soak up

chemical. Wash the eyes for at least 15-20 minutes with water.

 

On the skin

 

Immediately remove contaminated clothes, shoes, socks and

jewellery. Be careful not to get any of the chemical on your own skin

or clothes. Wash the patient’s skin, nails and hair thoroughly with

soap and cold or lukewarm water for at least 15 minutes, if possible

using running water. If a large area is affected use a shower or a

hand-held hose but protect the patient’s eyes.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed less than 4 hours ago, and if the

patient is fully awake and is not having fits, give activated charcoal

and water to drink. Do not make the patient vomit.

 

If the patient has signs of lung oedema treat as recommended in

chapter nine. If the patient has signs of kidney failure, treat as

recommended in chapter nine.

 

Information for doctors outside hospital

 

As well as the effects listed above, these chemicals may cause

corrosive injury to the gut, metabolic acidosis, heart rhythm

disturbances, and methaemoglobinaemia.

 

Monitor breathing, pulse and blood pressure. Supportive care,

including oxygen and ventilation, should be given as needed:

 

*    Low blood pressure should be treated with intravenous fluids.

 

*    For repeated fits diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

There is no antidote.

 

Pyrethrins and pyrethroid insecticides

 

Chemicals covered in this section

 

Pyrethrins are natural insecticides extracted from chrysanthemum

plants; pyrethroids are manufactured insecticides with similar

chemical structures.

 

Pyrethrum and piperonyl butoxide are pyrethrins. The following

chemicals are pyrethroids: bioresmethrin, cypermethrin, deltamethrin,

fenvalerate, permethrin and resmethrin.

 

Uses

 

These chemicals are used in household insecticide sprays and some

mosquito coils and mats. They are also used to control insect pests in

places where food such as grain and flour is stored, and in

agriculture, on vegetables, fruit trees and shrubs. They are sold as

liquids, sprays, dusts and powders.

 

How they cause harm

 

They are irritant to the lungs and may affect the brain.

 

How poisonous they are

 

Pyrethrin and pyrethroid insecticides are not very poisonous to

humans if swallowed, spilt on the skin or breathed in. They sometimes

cause allergic reactions. Severe poisoning happens rarely, if a large

amount of concentrated product is swallowed.

 

Signs and symptoms

 

*    If swallowed:

 

–    nausea and vomiting,

 

–    rarely, fits may occur after a very large dose.

 

*    On the skin:

 

–    irritation,

 

–    skin rash and blistering.

 

*    If breathed in:

 

–    runny nose and sore throat,

 

–    some people may get wheezing, sneezing, and shortness of breath.

 

*    In the eyes:

 

–    some may cause severe irritation.

 

*    Allergic reactions:

 

–    shock: pale skin, sweating, fast weak pulse,

 

–    wheezing and shortness of breath.

 

What to do

 

If the patient has an allergic reaction

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

Put the patient flat on his or her back, with the head turned to

one side, and the legs raised higher than the head (by resting the

feet on a box, for example). This will help the blood to reach the

brain and lessen the danger of vomit blocking the airway.

 

A patient with an allergic reaction should go to hospital as soon

as possible.

 

If the patient has a fit, treat as recommended in chapter five.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water. Check that

there are no solid bits of chemical on the lashes or eyebrows, or in

the folds of skin round the eyes. If there is severe irritation take

the patient to hospital.

 

On the skin

 

Immediately remove contaminated clothes, shoes, socks and

jewellery. Be careful not to get any of the chemical on your own skin

or clothes. Wash the patient’s skin, nails and hair thoroughly with

soap and cold or lukewarm water for at least 15 minutes, if possible

using running water.

 

Information for doctors outside hospital

 

If the patient has a severe allergic (anaphylactic) reaction

 

Give oxygen by face-mask in as high a concentration as possible.

Insert an airway if the patient is unconscious.

 

Give epinephrine (adrenaline), 1 in 1000 (1 mg/ml) as soon as

possible by intramuscular injection, unless there is a strong central

pulse and the general condition is good. Any delay may be fatal.

 

Dose:

 

Age                 Volume of epinephrine, 1 in 1000

 

<1 year             0.05 ml

 

1 year              0.1 ml

 

2 years             0.2 ml

 

3-4 years           0.3 ml

 

5 years             0.4 ml

 

6-12 years          0.5 ml

 

Adults              0.5-1 ml

 

These doses may be repeated every 10 minutes until blood pressure

and pulse improve. Doses should be reduced for underweight children.

 

It is useful to give antihistamines such as chlorphenamine or

promethazine, by slow intravenous injection, after the epinephrine, to

treat skin rash, itching or swelling and prevent relapse.

 

If the patient does not get better, supportive care should be

given as needed:

 

–    oxygen and ventilation,

 

–    intravenous fluids,

 

–    inhaled salbutamol or intravenous theophylline may be useful for

asthma or wheezing.

 

Rat poisons

 

Many different chemicals can be used to kill rats, mice and other

small rodents:

 

–    aluminium phosphide,

 

–    arsenic,

 

–    strychnine,

 

–    thallium,

 

–    warfarin and other chemicals that have the same effect

(brodifacoum, bromadiolone, chlorophacinone, coumafuryl,

difenacoum).

 

Sodium chlorate

 

Uses

 

Sodium chlorate is used as a weedkiller, in match heads and in

fireworks. It has sometimes been used in mouthwashes, but this is not

recommended.

 

How it causes harm

 

It stops blood carrying oxygen and damages the liver and kidneys.

It also irritates the skin and eyes.

 

How poisonous it is

 

It is poisonous if swallowed. People have died after swallowing

2-3 teaspoonfuls.

 

Special dangers

 

It looks like white crystals and may be mistaken for sugar or

salt if it is put in a food container, or kept in a place where food

is normally kept.

 

Signs and symptoms

 

*    If swallowed:

 

–    nausea, vomiting, diarrhoea and belly pain,

 

–    shallow breathing,

 

–    unconsciousness,

 

–    fits,

 

–    the skin and the inside of the lower eyelids turn a blue colour,

 

–    the patient stops passing urine and has signs of kidney damage

 

–    death may occur within a few hours.

 

*    On the skin:

 

–    irritation,

 

–    redness,

 

–    ulcers and burns.

 

*    In the eyes:

 

–    irritation,

 

–    redness of the eyelids,

 

–    ulcers and burns.

 

What to do

 

Give first aid. If the patient stops breathing open the airway,

wash chemical off the patient’s lips, then give mouth-to-mouth or

mouth-to-nose respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes, and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water. Check that

there are no solid bits of chemical on the lashes or eyebrows or in

the folds of skin round the eyes.

 

On the skin

 

Immediately remove contaminated clothes, shoes, socks and

jewellery. Wash the skin, nails and hair thoroughly with soap and cold

or lukewarm water for at least 15 minutes, if possible using running

water.

 

Patients who have swallowed the chemical, or who have burns in

the eyes or on the skin, should go to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed less than 4 hours ago and if the

patient is fully awake and breathing normally, has not had muscle

twitching or fits, and is not already vomiting, make the patient

vomit.

 

If the patient has signs of kidney damage, treat as recommended

in chapter nine.

 

Information for doctors outside hospital

 

As well as the effects listed above, there may be blood disorders

including methaemoglobinaemia and intravascular haemolysis, high serum

potassium concentration, and protein and haemoglobin in the urine.

 

Monitor pulse, breathing and blood pressure. Supportive care,

including oxygen and ventilation, should be given as needed:

 

*    Fluid and electrolyte balance should be corrected.

 

*    For repeated fits diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

There are two chemicals that have been used as antidotes. It may

be useful to give one of these.

 

1. Sodium thiosulfate. This is said to work by changing chlorate

into chloride, which is less poisonous, but there is some doubt

about how useful it is.

 

Dose: 2-5 g of sodium thiosulfate in 200 ml of 5% sodium bicarbonate

given as a drink.

 

2. Ascorbic acid. This is said to change methaemoglobin back to

haemoglobin, but it works very slowly.

 

Dose: 1 g every 4 hours given as a drink, or by slow intravenous

injection.

 

In severe poisoning the most useful treatment is exchange

transfusion together with haemodialysis.

 

Strychnine

 

Strychnine is made from the seeds of the tree called  Strychnos

nux-vomica.

 

Uses

 

Strychnine is used to kill rats, mice, and other animals. It used

to be used in medicines such as tonics and laxatives but this is not

recommended. In India,  kuchlla, a product for killing dogs, contains

strychnine.

 

How it causes harm

 

If affects the nerves that control the muscles.

 

How poisonous it is

 

Strychnine is extremely poisonous if swallowed and works very

quickly. Quite small amounts can cause death, but some patients

recover if treated in hospital. It does not pass through the skin.

 

Special dangers

 

Most cases of poisoning happen when people try to kill

themselves. Accidental poisoning is unusual.

 

Signs and symptoms

 

*    If swallowed

 

After about 15 minutes:

 

–    numbness and stiffness of face and neck,

 

–    fear,

 

–    muscle twitching,

 

–    painful fits and muscle spasms lasting 1-2 minutes, occurring

every 5-10 minutes; the arms and legs are stretched out and the

body is arched so that it is supported only by the head and feet,

 

–    the eyes bulge,

 

–    the patient is usually fully awake,

 

–    breathing is difficult and may stop when the patient is having a

fit; the skin is blue,

 

–    high temperature,

 

–    signs of kidney damage.

 

What to do

 

Give first aid. If the patient stops breathing open the airway,

wash chemical off the patient’s lips then give mouth-to-mouth or

mouth-to-nose respiration.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes and

keep the patient warm.

 

Keep the patient as quiet and still as possible, because movement

may set off fits.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

Keep the patient in a quiet, dark room.

 

Do not make the patient vomit because vomiting may set off fits.

 

If the patient has no signs or symptoms, give activated charcoal

and water to drink.

 

Information for doctors outside hospital

 

Repeated fits may cause high temperature, rhabdomyolysis (muscle

breakdown) and kidney failure.

 

Supportive care should be given as needed:

 

*    Oxygen and ventilation may be needed during fits.

 

*    For repeated fits diazepam should be given by intravenous

injection; if this fails the patient may need to be paralysed and

ventilated.

 

Dose of diazepam:

 

Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds, repeated

if necessary after 30-60 minutes; this may be followed by intravenous

infusion to a maximum of 3 mg/kg of body weight over 24 hours.

 

Children: 200-300 µg/kg of body weight.

 

Thallium

 

Uses

 

Thallium salts are used to kill rats, mice and other rodents, and

ants, but in many countries they are banned from being sold as a

pesticide. They have been used as a cream for removing body hair but

this is not recommended. They are widely used in industry.

 

How it causes harm

 

Thallium affects the gut, nerves, skin and hair.

 

How poisonous it is

 

Thallium salts are very poisonous if they are swallowed or

brought into contact with the skin. Exposure to small amounts over

many weeks, by swallowing, skin contact or breathing in metal fumes,

can cause chronic poisoning.

 

Special dangers

 

Thallium rat bait made with grain, biscuit crumbs or honey may be

mistaken for food. Industrial workers may get chronic poisoning from

breathing in fumes or dust, or from handling chemicals without wearing

gloves.

 

Signs and symptoms

 

Acute poisoning

 

*    If swallowed

 

Effects appear slowly over 2-3 days:

 

–    belly pain, nausea, vomiting and constipation,

 

–    pain or numbness in the fingers and toes,

 

–    tiredness,

 

–    fits.

 

After about 7 days:

 

–    pain or numbness in the soles of the feet so that the patient

cannot stand or move,

 

–    dizziness,

 

–    drooping eyelids,

 

–    fever,

 

–    jumbled speech and confused behaviour,

 

–    trembling, strange movements of the arms and legs,

 

–    signs of kidney damage.

 

After 10-14 days:

 

–    hair starts falling out.

 

Death may occur up to five weeks after swallowing thallium.

 

Chronic poisoning (from swallowing, skin exposure or breathing in

fumes):

 

–    hair falls out leaving bald patches,

 

–    wet mouth,

 

–    blue line on the gums,

 

–    nausea, vomiting, belly pain and constipation,

 

–    pain or numbness in the arms and legs.

 

What to do

 

Give first aid. If the patient has a fit, treat as recommended

in chapter five.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water. Check that

there are no solid bits of chemical on the lashes or eyebrows, or in

the folds of skin round the eyes.

 

On the skin

 

Immediately remove contaminated clothes, shoes, socks and

jewellery. Wash the skin, nails and hair thoroughly with soap and cold

or lukewarm water for at least 15 minutes, if possible using running

water.

 

Take the patient to hospital.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed less than 4 hours ago, and if the

patient is fully awake and breathing normally, and has not had muscle

twitching or fits:

 

*    Make the patient vomit unless the patient has already

vomited a lot.

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until vomiting has stopped.

 

Information for doctors outside hospital

 

Monitor breathing, blood pressure, pulse, and liver and kidney

function. Supportive care, including oxygen and ventilation, should be

given as needed. For repeated fits diazepam should be given by

intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

The antidote is potassium ferricyanoferrate (Prussian blue). If

potassium ferricyanoferrate is not available, ferric ferrocyanide can

be used instead. Contact a poisons centre to find out if the antidote

is available.

 

Dose: 250 mg/kg of body weight per day divided into four doses,

by mouth or through a stomach tube, until the concentration of

thallium in the urine is less than 0.5 µg over a 24-hour-period. The

antidote may cause constipation so give a mild purgative (e.g. 50 ml

of 15% sorbitol) with each dose.

 

Haemodialysis should be carried out if there is kidney failure.

 

Warfarin and other pesticides that stop blood clotting

 

Chemicals covered in this section

 

This section covers coumafuryl, warfarin and the “superwarfarins”

(brodifacoum, bromadiolone, chlorophacinone and difenacoum).

 

Uses

 

These chemicals are used to kill rats and mice. The chemicals are

usually mixed with corn, or made into pellets to make a bait that is

often coloured blue or green so that people can see it is not food.

Warfarin is also used as a medicine to stop blood clotting.

 

For information on other chemicals sometimes used to kill rats

and mice see Part Two (Rat poisons).

 

How they cause harm

 

These chemicals stop the blood clotting. This can lead to

bleeding inside the body.

 

How poisonous they are

 

Warfarin, coumafuryl: swallowing a small amount is unlikely to

have an effect. Repeated doses taken over several days or weeks may

cause serious poisoning or even death. Doctors who prescribe long-term

treatment with warfarin medicine should check the patient’s blood

clotting.

 

Brodifacoum, bromadiolone, chlorophacinone and difenacoum:

swallowing one dose may cause signs of poisoning, and the effects of

poisoning may be severe and last for some time.

 

Special dangers

 

Rat poisons are often put on the ground in open dishes where they

are easily found by children.

 

Signs and symptoms

 

*    If swallowed

 

After 12-48 hours, any of these may occur:

 

–    bleeding from cuts takes longer to clot than usual,

 

–    bruising and skin rashes,

 

–    blood in urine,

 

–    patient coughs up blood,

 

–    blood in the stools showing that there is bleeding inside the

gut,

 

–    back or belly pain.

 

For warfarin and coumafuryl: the effects last 3-4 days.

 

For brodifacoum, difenacoum, bromadiolone and chlorophacinone:

the effects may last for weeks or months.

 

What to do

 

If the patient has swallowed just a few mouthfuls of rat bait

containing warfarin or coumafuryl, there is no need to do anything. If

you think the patient may have taken more than this, or if you do not

know what the rat poison contains, take the patient to hospital as

soon as possible.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed less than 4 hours ago and the

patient is fully awake and breathing normally:

 

*    Make the patient vomit. If the patient has been taking warfarin

as a medicine, do not make the patient vomit, because this may cause

bleeding in the gut.

 

*    Give activated charcoal with water to drink. If you have made the

patient vomit, wait until vomiting has stopped.

 

Information for doctors outside hospital

 

To stop active bleeding quickly, transfusions of either whole

blood or fresh frozen plasma should be given. Blood clotting time or

prothrombin time and full blood count should be monitored if possible.

 

Brodifacoum, difenacoum, bromadiolone and chlorophacinone: even

if there are no signs or symptoms, or if poisoning is mild,

prothrombin time ratios should be measured after 24, 48 and 72 hours.

 

The antidote is phytomenadione (vitamin K1). This brings the

prothrombin time back to normal again and stops bleeding. It should

restore the prothrombin time to normal within 12-36 hours, but regular

daily doses may be needed for several weeks depending on which

chemical was taken in overdose.

 

Dose: For severe poisoning: a slow intravenous infusion of

phytomenadione in 9 g/l (0.9%) sodium chloride solution or glucose.

Adults: 100-200 mg per day may be needed for several days or weeks.

Doses can be given every 6-8 hours. Prothrombin times should be tested

frequently until they are normal; this may take weeks or months in

severe cases.

 

If blood clotting time or prothrombin time is longer than normal,

but effects are not severe, give phytomenadione by intramuscular

injection.

 

Dose: adults: 5-10 mg; children: 1-5 mg.

 

Home Page

 

 

Chemicals and chemical products used in the home and the workplace

 

Aerosol sprays

 

Chemicals covered in this section

 

Aerosol sprays, sometimes called pressure packs, are metal cans

containing chemicals under pressure, which form a cloud of tiny

droplets when released from the can. This section covers the chemicals

used as propellants to carry the active chemicals out of the can.

Butane, propane, or chlorofluorocarbons may be used.

 

Uses

 

Many products in the home, such as window cleaner, furniture

polish, air freshener, oven cleaner, hair spray, deodorant and

insecticides, are sold in spray cans. Aerosol abuse is common in many

countries: the spray is breathed in deeply and causes a “high” or

feeling of euphoria.

 

How they cause harm

 

Butane, propane and chlorofluorocarbons quickly affect the heart

if breathed in deeply, as happens when people abuse aerosols. (The

active chemicals in the aerosol may be irritant, corrosive or

poisonous and may also cause harm.)

 

How poisonous they are

 

Abuse of aerosols may cause sudden death as a result of the

effect of the propellants on the heart. Aerosol abuse is habit-forming

and may lead to dependence. People exposed to aerosols during ordinary

use, or by accident, are unlikely to be harmed by the propellant. The

effects of the active chemicals, which may be corrosive or poisonous,

are dealt with elsewhere in the book.

 

Signs and symptoms

 

*    If breathed in deeply, as in aerosol abuse:

 

–    coughing and choking,

 

–    excitement,

 

–    hallucinations,

 

–    sudden unconsciousness.

 

The patient may die suddenly or recover very quickly.

 

*    In the eyes:

 

–    stinging, watering eyes,

 

–    red eyelids.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes and keep the patient warm and quiet.

 

In the eyes

 

Wash the eye for at least 15-20 minutes with water.

 

If the patient has any signs or symptoms, take him or her to

hospital. All patients should be kept lying down in a quiet place for

at least 4 hours.

 

Air-fresheners, deodorant blocks and moth-balls

 

Chemicals covered in this section

 

This section covers naphthalene and  para-dichlorobenzene (also

called  p-dichlorobenzene).

 

Uses

 

para-Dichlorobenzene is used in solid air-fresheners and

deodorant blocks for use in or near lavatories and rubbish bins.

Liquid air-fresheners contain water, perfume and detergent rather than

para-dichlorobenzene (see Soap and detergents). For air fresheners

in aerosol cans see Part Two (Aerosol Sprays).

 

Both  para-dichlorobenzene and naphthalene may be used in

mothballs and other products used to keep moths away. However, some

mothballs are made of camphor (see Volatile oils).

 

How they cause harm

 

Both chemicals are irritant to the gut and may affect the brain.

Naphthalene destroys blood cells and damages the kidneys,  para-

Dichlorobenzene damages the liver. Repeated handling may cause skin

irritation.

 

How poisonous they are

 

Naphthalene is more poisonous than  para-dichlorobenzene. In a

young child, one naphthalene moth-ball may destroy blood cells, and

four may cause fits.

 

The poisonous amount of  para-dichlorobenzene is much larger and

the amount likely to be eaten by children would probably not cause

serious poisoning.

 

Special dangers

 

These products are often placed where children can see and reach

them. For example, moth-balls may be hung in cupboards, and deodorant

blocks on the side of bins, buckets or lavatory bowls.

 

Signs and symptoms

 

Naphthalene

 

*    If swallowed:

 

–    nausea, vomiting, diarrhoea and belly pain,

 

–    sweating,

 

–    fever,

 

–    yellow skin caused by changes in the blood,

 

–    urine becomes dark and may contain blood,

 

–    the patient may stop passing urine,

 

–    fits,

 

–    unconsciousness.

 

*    In the eyes:

 

–    redness and irritation.

 

*    On the skin:

 

–    redness and irritation.

 

para-Dichlorobenzene

 

*    If swallowed:

 

–    nausea, vomiting, diarrhoea and belly pain.

 

*    In the eyes:

 

–    redness and irritation.

 

*    On the skin:

 

–    redness and irritation.

 

What to do

 

Give first aid. If breathing stops, open the airway, wash

chemical off the patient’s lips, then give mouth-to-mouth respiration.

If the patient is unconscious or drowsy, lay him or her on one side in

the recovery position. Check breathing every 10 minutes and keep the

patient warm.

 

If the patient has a fit, treat as recommended in Chapter Five.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water.

 

On the skin

 

Wash the skin thoroughly with soap and cold water, if possible

under running water.

 

If swallowed

 

If the patient is fully awake, give water to drink. Do not give

milk or fatty foods for 2-3 hours.

 

Take the patient to hospital as soon as possible in any of the

following circumstances:

 

*    The patient has swallowed any amount of naphthalene.

 

*    The patient has swallowed a large amount of  para-dichlorobenzene

(several moth-balls or a whole deodorant block).

 

*    The patient has signs of severe poisoning.

 

*    You do not know what the product contains.

 

*    There is possible injury to the eyes.

 

What to do if there is a delay in gelling the patient to hospital

 

If the product was swallowed less than 4 hours ago and if the

patient is fully awake and breathing normally, has not had fits, and

has not already vomited a lot, make the patient vomit.

 

If the patient stops passing urine, treat as recommended in

chapter nine.

 

Information for doctors outside hospital

 

Naphthalene causes haemolysis in patients with

glucose-6-phosphate dehydrogenase deficiency. The haemoglobin can

cause renal tubular necrosis.

 

Supportive care, including oxygen and mechanical ventilation,

should be given as needed:

 

*    If there is evidence of haemolysis, intravenous fluids should be

given to reduce the possibility of renal failure.

 

*    Bicarbonate may be given to make the urine alkaline (pH > 7.5).

 

*    For repeated fits diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours;

 

Children: 200-300 µg/kg of body weight.

 

Benzene, tetrachloroethylene, toluene, trichloroethane,

trichloroethylene and xylene

 

Chemicals covered in this section

 

This section covers three aromatic hydrocarbons – benzene,

toluene and xylene – and three chlorinated hydrocarbons –

tetrachloroethylene (also called perchlorethylene), 1,1,1-

trichloroethane, and trichloroethylene (also called trichloroethene).

 

Note: other chlorinated hydrocarbons and other aromatic hydrocarbons,

for example carbon tetrachloride, may have different poisonous

effects.

 

Uses and abuses

 

Benzene is used in many industrial processes and is also present

in motor fuel. It is not usually put in household products.

 

Toluene and xylene are used in many industrial processes. They

are also used as solvents in glues, paints and thinners used in the

home and in the workplace.

 

Tetrachloroethylene is used in commercial dry-cleaning and

degreasing products.

 

1,1,1-Trichloroethane is used as a cleaner and degreaser and in

typewriter correction fluids.

 

Trichloroethylene is used in many kinds of household products:

cleaners for walls, clothing, and rugs, typewriter correction fluids,

paints, glues, dry-cleaners, insecticides and fungicides. It is also

used in industry as a degreaser and dry-cleaner.

 

Dry-cleaning fluid may contain trichloroethylene or

tetrachloroethylene. Carbon tetrachloride is sometimes used as a

dry-cleaning fluid, but this is not recommended because it is

very poisonous.

 

Some people abuse or “sniff” glues or other products containing

toluene, benzene, trichloroethylene or trichloroethane.

 

How they cause harm

 

These chemicals affect the brain and heart. The kidneys and liver

may also be affected by acute exposure to tetrachloroethylene,

trichloroethylene and trichloroethane and by chronic exposure to

toluene and trichloroethylene. Chronic exposure to benzene affects the

production of red blood cells, resulting in anaemia, and may cause

cancer of the blood cells (leukaemia).

 

In liquid form these chemicals are irritant to the skin and eyes,

and may cause lung oedema if swallowed. The vapour is irritant to

eyes, nose and throat, and toluene and xylene vapour may cause lung

oedema.

 

How poisonous they are

 

All of these chemicals are poisonous if breathed in or swallowed.

Acute exposure may cause sudden death. Skin contact is unlikely to

cause systemic poisoning. Abuse is habit-forming and may lead to

dependence.

 

Special dangers

 

People who abuse solvents not only are at risk from the poisonous

effects of the solvent, but may suffocate by breathing in solvent from

a plastic bag or injure themselves while hallucinating. Working with

these chemicals is dangerous if people do not use proper protection or

safe work practices.

 

Signs and symptoms

 

Benzene

 

Acute exposure

 

*    If breathed in or swallowed:

 

–    euphoria,

 

–    weakness,

 

–    headache,

 

–    nausea,

 

–    blurred vision,

 

–    irritation to nose and eyes,

 

–    shaking,

 

–    uncoordinated movements,

 

–    tight chest and shallow breathing,

 

–    irregular pulse,

 

–    unconsciousness,

 

–    fits,

 

–    lung oedema.

 

*    On the skin:

 

–    redness,

 

–    dry skin and blisters.

 

*    In the eyes:

 

–    pain,

 

–    redness and watering,

 

–    the patient cannot look at light.

 

There may be damage to the eye.

 

Chronic exposure

 

*    If breathed in:

 

–    headache,

 

–    dizziness,

 

–    loss of appetite,

 

–    tiredness.

 

*    On the skin:

 

–    dry skin,

 

–    blisters.

 

Toluene and xylene

 

Acute exposure

 

*    If breathed in:

 

–    excitement, euphoria, headache,

 

–    dizziness,

 

–    nausea,

 

–    weakness,

 

–    drowsiness,

 

–    incoordination and staggering walk,

 

–    confusion,

 

–    irritation to eyes, nose and throat,

 

–    unconsciousness,

 

–    lung oedema,

 

–    irregular pulse,

 

–    heart or breathing may stop.

 

*    If swallowed:

 

–    vomiting and diarrhoea,

 

–    lung oedema and same effects as if breathed in.

 

*    On the skin and in the eyes:

 

–    as for benzene.

 

Chronic exposure

 

If breathed in repeatedly:

 

–    muscle weakness,

 

–    abdominal pain, vomiting blood,

 

–    brain damage,

 

–    liver and kidney damage.

 

Tetrachloroethylene, trichloroethane and trichloroethylene

 

Acute exposure

 

*    If breathed in:

 

–    nausea and vomiting,

 

–    euphoria,

 

–    headache and confusion,

 

–    dizziness,

 

–    weakness,

 

–    drowsiness,

 

–    shaking,

 

–    incoordination,

 

–    fits,

 

–    unconsciousness,

 

–    low blood pressure,

 

–    irregular pulse,

 

–    liver and kidney damage,

 

–    irritation to eyes, nose and throat,

 

–    heart or breathing may stop.

 

*    If swallowed:

 

–    vomiting and diarrhoea,

 

–    lung oedema and same effects as if breathed in.

 

*    On the skin and in the eyes:

 

–    as for benzene.

 

Chronic exposure

 

If breathed in repeatedly:

 

–    weight loss, nausea and loss of appetite,

 

–    tiredness,

 

–    sometimes liver and kidney damage,

 

–    heart disease.

 

What to do

 

Move the patient away from poisonous gases or liquid spills.

Protect yourself by wearing breathing equipment and protective

clothing.

 

Give first aid. If breathing stops, open the airway, wash

chemical off the patient’s lips, and give mouth-to-mouth respiration.

Give heart massage if the heart stops. If the patient is unconscious

or drowsy, lay him or her on one side in the recovery position. Check

breathing every 10 minutes and keep the patient warm.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water.

 

On the skin

 

Immediately remove contaminated clothing, shoes, socks and

jewellery. Wash the skin well with soap and cold water for 15 minutes,

if possible using running water. Be careful not to get any of the

chemical on your own skin or clothing.

 

Take the patient to hospital as soon as possible. If the patient

has swallowed or breathed in chemical, keep him or her lying down

because there is a risk of heart problems.

 

What to do if there is a delay in getting the patient to hospital

 

If the chemical was swallowed: if the patient is fully awake

and breathing normally, and has not had fits:

 

*    Make the patient vomit if more than 2-3 mouthfuls of

chemical were swallowed less than one hour ago, and the patient

is not already vomiting.

 

*    Give activated charcoal and water to drink. Wait

until the patient has stopped vomiting.

 

Do not give any fatty food or drink.

 

If the patient has signs of lung oedema, treat as recommended in

Chapter Nine. If the patient has signs of liver damage, treat as

recommended in Chapter Nine. If the patient has signs of kidney

failure, treat as recommended in Chapter Nine.

 

Information for doctors outside hospital

 

Monitor breathing, heart rate and blood pressure. Supportive

care, including oxygen and mechanical ventilation, should be given as

needed. Do not give stimulant medicines such as epinephrine.

 

In cases of severe poisoning, the heart should be monitored for

12-24 hours after apparent full recovery, if possible, because there

is a risk of arrhythmia. Chronic exposure to benzene may cause anaemia

and leukaemia.

 

Borax, boric acid, and sodium perborate

 

Uses

 

Borax is used in some ant killers, wood preservatives, water

softeners, eye-drops, mouthwashes and skin creams. Boric acid has been

used to disinfect and wash babies’ nappies and has been added to

talcum powder, but this is not recommended because it is too

poisonous. Sodium perborate is used as a bleach, a cleaner for

dentures (false teeth), and a water softener. It is added to some

detergents and products for washing and disinfecting babies’ nappies.

 

How they cause harm

 

Borates are irritant and poisonous if swallowed or in contact

with wet, scratched or damaged skin. They damage the gut, brain and

kidneys.

 

How poisonous they are

 

These chemicals are very poisonous. A single large dose causes

acute poisoning, but the amount in most household products, such as

detergents and ant killers, is small and one small mouthful taken by a

child is unlikely to be poisonous. However, talcum powder containing

borax or boric acid, used over a period of many days or weeks, may

cause severe chronic poisoning in infants, and may result in death.

There is also a danger of chronic poisoning from using mouthwash and

repeatedly swallowing small amounts.

 

Denture-cleaning tablets and powders are corrosive (see caustic

and corrosive chemicals). If swallowed they may stick in the gullet

and cause severe burns; the solution made by dissolving the tablets in

water may also burn if swallowed.

 

Special dangers

 

Skin creams or talcum powders containing boric acid may cause

serious poisoning in infants and young children. Elderly people with

poor eyesight may swallow denture-cleaning tablets in mistake for

sweets.

 

Signs and symptoms

 

Acute poisoning

 

*    If swallowed:

 

–    nausea,

 

–    severe vomiting and diarrhoea,

 

–    restlessness and agitation,

 

–    fits,

 

–    unconsciousness,

 

–    a red skin rash, with peeling skin, particularly on the buttocks,

palms and soles,

 

–    signs of kidney failure.

 

*    In the eyes:

 

–    stinging and a burning feeling,

 

–    watery eyes,

 

–    red swollen eyelids.

 

*    On the skin:

 

–    itching and redness,

 

–    if the skin was wet, cut or scratched, the patient may also have

signs and symptoms as for swallowing.

 

Chronic poisoning

 

Repeated swallowing or skin contact may result in:

 

–    loss of appetite and loss of weight,

 

–    vomiting and mild diarrhoea,

 

–    a red skin rash, with peeling skin, particularly on the buttocks,

palms and soles,

 

–    hair loss,

 

–    signs of kidney failure,

 

–    fits.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes and keep the patient warm and quiet.

 

If the patient has a fit, treat as recommended in Chapter Five.

 

In the eyes

 

Gently brush or dab away any liquid or powder from the face. Wash

the eyes for at least 15-20 minutes with water. Check that there are

no solid bits of chemical on the lashes and eyebrows, or in the folds

of skin round the eyes.

 

On the skin

 

Immediately remove contaminated clothing, shoes, socks and

jewellery. Wash the skin thoroughly with soap and cold water, if

possible using running water. Rinse for at least 15 minutes.

 

Take the patient to hospital as soon as possible.

 

What to do if there is a delay in getting to hospital

 

If the patient passes less urine than normal, treat as

recommended in Chapter Nine.

 

Information far doctors outside hospital

 

Supportive care should be given as needed:

 

*    Give oxygen and mechanical ventilation.

 

*    Take measures to prevent skin infection.

 

*    For repeated fits diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Haemodialysis and peritoneal dialysis remove borate and may be

useful in cases of serious poisoning.

 

Button batteries

 

Chemicals covered in this section

 

Button batteries or disc batteries are small (less than 15 mm

across) and round. There are several different types, each containing

different chemicals, some of which are poisonous or corrosive:

 

–    mercury cell: mercuric oxide, potassium hydroxide;

 

–    silver cell: silver oxide, potassium hydroxide;

 

–    alkaline manganese cell: manganese dioxide, potassium hydroxide;

 

–    lithium/manganese cell: manganese dioxide, lithium perchlorate;

 

–    zinc/air button cell: zinc metal, potassium hydroxide.

 

Uses

 

Button batteries are used in cameras, watches, calculators,

hearing aids, gas-fired hair stylers, and electronic games.

 

How they cause harm

 

Potassium hydroxide and mercuric oxide are corrosive and may burn

the gut if the battery leaks. Burns may also be caused by electric

currents set up inside the body. Mercuric oxide may affect the

kidneys.

 

How poisonous they are

 

In most cases batteries stay intact when swallowed and pass out

of the body without causing harm. However, if a battery lodges in the

gullet or any other part of the gut, there is a danger of burns from

leaking chemicals or electric currents. There is also a danger of

serious burns if batteries are pushed into the ear or nose. Alkaline

manganese and mercury batteries are more dangerous than the other

types. There is less danger of electrical burns from used batteries.

 

Special dangers

 

Children may be able to take batteries out of their packaging or

out of the equipment where they are being used. Button batteries are

small and easily swallowed by children.

 

Signs and symptoms

 

*    If swallowed

 

If the battery is stuck in the gullet:

 

–    difficulty in swallowing,

 

–    coughing,

 

–    vomiting,

 

–    fever,

 

–    loss of appetite and tiredness.

 

If there are burns and injury to the gut:

 

–    chest or belly pain,

 

–    vomiting (vomit may be blood-stained),

 

–    dark or blood-stained faeces.

 

What to do

 

If swallowed

 

Do not make the patient vomit. The battery will not come out in

the vomit.

 

If the patient is well and has no signs or symptoms, let him or

her eat and drink normally. Give a laxative (magnesium sulfate by

mouth) and check the patient’s faeces to see whether the battery has

been passed. It usually takes between 14 hours and 7 days for the

battery to pass out of the body.

 

If the battery has not been passed out in the faeces within 7

days, or if the patient has dark or blood-stained faeces, or any other

signs or symptoms, take the patient to hospital.

 

If the battery is stuck in the ear or nose

 

Do not try to get the battery out. Take the patient to hospital

without delay.

 

Information for doctors outside hospital

 

If there will be a delay in getting the patient to hospital, give

antacids to make the stomach less acid and reduce the risk of the

battery leaking. Give a laxative to make the battery move down the gut

more quickly. Examine the stools to see if the battery has been passed

out.

 

When the patient reaches hospital, an X-ray of the chest and

abdomen should be taken to show where the battery is and if it is

leaking. If the battery does not move quickly down the gut or if it

leaks, it will need to be removed endoscopically or surgically.

 

If a battery containing mercury leaks in the gut, the serum

mercury concentration should be measured. However, the risk of mercury

poisoning in such cases is very low.

 

Button batteries that are stuck in the ear or nose should be

removed without delay because they may seriously damage the eardrum or

burn a hole through the nose. Do not use saline solutions or drops

because this may increase the electric current round the battery.

 

Carbon monoxide

 

Carbon monoxide is a colourless gas with no smell. It is produced

by burning gas, oil, petrol, solid fuel, or wood. Common sources are

fires, stoves, heaters, ovens, and petrol engines.

 

How it causes harm

 

Carbon monoxide affects the blood so that it is not able to carry

as much oxygen as usual, and affects cells so that they are not able

to use all the oxygen that reaches them. The lack of oxygen chiefly

affects the brain and heart.

 

How poisonous it is

 

Carbon monoxide is very poisonous and may cause death. People who

survive serious poisoning may be left with permanent brain damage.

 

Special dangers

 

It is dangerous to have stoves, heaters, boilers or fires burning

in rooms, huts or tents that have no chimney, flue, or other opening

to let carbon monoxide out and fresh air in. Poisoning is particularly

likely in cold weather when people close their doors and windows to

keep out cold air, or if the equipment is not working properly.

 

Often people do not know that there is a danger of poisoning and

so they do nothing to make the situation safe. Carbon monoxide is a

non-irritant gas with no colour or smell. Sometimes the fumes or smoke

can be detected by their colour or smell but there is often nothing to

warn people that they are being poisoned. The symptoms of poisoning

are often mistaken for symptoms of influenza or illness caused by

eating contaminated food.

 

Depending on what is burnt, other poisons may also be present in

the fumes or smoke. Patients may also be poisoned by irritant gases

such as ammonia, chlorine, hydrogen chloride, phosgene or cyanide, as

well as carbon monoxide.

 

Signs and symptoms

 

Mild to moderate poisoning:

 

–    weakness, tiredness and drowsiness,

 

–    headache,

 

–    dizziness and confusion,

 

–    nausea and vomiting,

 

–    chest pain,

 

–    fast pulse at first.

 

Serious poisoning:

 

–    low body temperature,

 

–    unconsciousness,

 

–    shallow irregular breathing; breathing may stop,

 

–    fits,

 

–    slow pulse, which may be irregular,

 

–    low blood pressure.

 

Complete recovery after serious poisoning may take many weeks.

Sometimes people become ill again up to four weeks after they seem to

have recovered. Some people suffer permanent brain damage and have

memory problems.

 

What to do

 

Move the patient away from the poisonous gas. If going into a

room filled with gas, or smoke from a fire, wear breathing equipment

to protect yourself from being poisoned.

 

Give first aid. If the patient has stopped breathing, open the

airway, then give mouth-to-mouth or mouth-to-nose respiration. If the

patient is unconscious or drowsy, lay him or her on one side in the

recovery position. Check breathing every 10 minutes, and keep the

patient warm and quiet.

 

If the patient has a fit, treat as recommended in Chapter Five.

 

Take the patient to hospital as soon as possible.

 

What to do if there is a delay in getting to hospital

 

Keep the patient lying down and at rest for two days so that the

body uses as little oxygen as possible.

 

Information for doctors outside hospital

 

As well as the effects listed above, there may be metabolic

acidosis, disturbances of heart rhythm, cerebral oedema and

rhabdomyolysis (muscle breakdown).

 

Immediately give 100% oxygen if necessary. The patient may need

mechanical ventilation. If the patient has been in a fire, check the

airway for swelling caused by burns or other injury. If it is possible

to measure blood carboxyhaemoglobin concentration, this should be done

as soon as possible.

 

Monitor breathing, heart and blood pressure. Supportive care

should be given as needed. For repeated fits diazepam should be given

by intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Any patient who has had headache and vomiting or loss of

consciousness should have absolute bedrest for at least 48 hours.

 

The use of hyperbaric oxygen treatment should be discussed with a

poisons centre.

 

Patients who survive may develop neurological effects, such as

disorders of personality and memory, within 2-4 weeks. These effects

may be temporary or permanent.

 

Carbon tetrachloride

 

Uses

 

Carbon tetrachloride is mostly used in industry to make other

chemicals. It has been used in fire extinguishers, and as a grease

remover and dry-cleaning fluid, but none of these uses is recommended

nowadays because less poisonous chemicals can be used instead.

 

How it causes harm

 

It is irritant to the skin, eyes and lungs. It is poisonous if

swallowed, breathed in or spilt on the skin, affecting the brain,

liver and kidneys. When it burns it produces phosgene gas which is

also poisonous.

 

How poisonous it is

 

It is very poisonous and may cause death. Poisoning is more

severe in people who smoke.

 

Signs and symptoms

 

*    If swallowed:

 

–    nausea, vomiting and diarrhoea,

 

–    a burning feeling in mouth, throat and belly,

 

–    dizziness and confusion,

 

–    drowsiness and unconsciousness,

 

–    fits,

 

–    low blood pressure,

 

–    slow or irregular heartbeat, which may result in sudden death.

 

After 2-14 days:

 

–    signs of liver damage,

 

–    kidney damage; the patient stops passing urine.

 

*    If breathed in:

 

–    cough, sneezing and mild breathlessness,

 

–    the same effects as if swallowed,

 

–    signs of lung oedema after 2-3 days.

 

*    On the skin:

 

–    redness and irritation,

 

–    blisters if left on the skin for a long time,

 

–    the same effects as if swallowed.

 

*    In the eyes:

 

–    redness and severe irritation.

 

What to do

 

Move the patient away from the source of the poison. Protect

yourself by wearing breathing equipment and protective clothing.

 

Give first aid. If the patient stops breathing, wash chemical off

the patient’s lips, then give mouth-to-mouth or mouth-to-nose

respiration. Give heart massage if the heart stops. If the patient is

unconscious or drowsy, lay him or her on one side in the recovery

position. Check breathing every 10 minutes and keep the patient warm.

 

If the patient has a fit, treat as recommended in Chapter Five.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water.

 

On the skin

 

Immediately remove contaminated clothing, shoes, socks and

jewellery. Be careful not to get any of the chemical on your own skin

or clothes. Wash the patient’s skin thoroughly with soap and cold

water, if possible using running water. Rinse for at least 15 minutes.

 

Take the patient to hospital as soon as possible.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if it happened less than 4 hours

ago, and if the patient is fully awake, breathing normally, and has

not had fits, make the patient vomit. Do not give milk to drink, or

anything containing oil, fat, or alcohol to eat or drink.

 

If the patient has signs of lung oedema, treat as recommended

in chapter nine. If the patient has signs of liver damage, treat as

recommended in chapter nine. If the patient stops passing urine,

treat as recommended in chapter nine.

 

Information for doctors outside hospital

 

Monitor breathing, pulse and blood pressure. Supportive care

should be given as needed:

 

*    Low blood pressure should be treated with intravenous fluids.

 

*    For repeated fits, diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Do not give epinephrine (adrenaline).

 

Antidote: acetylcysteine should be given if available, by intravenous

injection, if the patient was exposed less than 24 hours ago. Dose is

as for poisoning with paracetamol.

 

Carbon tetrachloride is radio-opaque and should be visible on an

abdominal X-ray if swallowed recently.

 

Patients with liver or kidney failure may need haemodialysis or

haemoperfusion.

 

Caustic and corrosive chemicals

 

Chemicals covered in this section

 

Many chemicals irritate, burn or damage skin and other living

tissues. These include mineral and organic acids, alkalis and

oxidizing agents.

 

Examples of acids:

 

acetic acid                                  nitric acid

 

aminosulfonic acid (sulfamic acid)           oxalic acid

 

formic acid                                  phosphoric acid

 

hydrochloric acid                            sulfuric acid

 

hydrofluoric acid

 

Examples of alkalis:

 

ammonia                                      potassium polyphosphate

 

calcium oxide                                sodium carbonate

 

calcium hydroxide                            sodium hydroxide (caustic

soda,

lye)

 

potassium carbonate                          sodium phosphate

 

potassium hydroxide (caustic potash)         sodium polyphosphate

 

Oxidizing agents. These are chemicals that release oxygen.

Oxygen may kill bacteria, bleach coloured substances and damage living

tissue. Examples of oxidizing agents commonly used as bleach are:

calcium hypochlorite, hydrogen peroxide, sodium hypochlorite,

troclosene sodium (sodium dichloroisocyanurate), and sodium perborate.

 

Corrosive gases: chlorine, chloramine, hydrogen chloride and

sulfur dioxide.

 

Many products used in homes and workplaces contain acid or

alkali.

 

*    Bleach

 

–    Household liquid bleach, for cleaning kitchens, bathrooms and

lavatories, usually contains sodium hypochlorite in an alkaline

solution.

 

–    Household bleaching powder usually contains troclosene sodium,

with detergent and small amounts of acid.

 

–    Laundry bleach usually contains sodium hypochlorite, sodium

perborate or troclosene sodium.

 

–    Bleach for swimming-pools usually contains sodium hypochlorite.

 

The concentration of available chlorine in sodium hypochlorite

bleach is usually:

 

–    household bleach <5%;

 

–    concentrated household bleach 10-12%;

 

–    industrial bleach 15-20%.

 

*    Car batteries usually contain sulfuric acid.

 

*    Denture cleaners (cleaners for false teeth) are powders or

tablets that contain sodium perborate. They form a corrosive

solution in water or inside the mouth or gut.

 

*    Descalers, used to remove lime scale from kettles, baths, and

water pipes, are acidic. Liquid products usually contain formic

or phosphoric acid, powder products usually contain aminosulfonic

acid.

 

*    Drain cleaners are alkaline; they usually contain sodium

hydroxide or potassium hydroxide. Drain cleaners are made as

solid crystals or liquids.

 

*    Floor cleaners: some are alkaline. Washes for concrete floors may

contain sodium carbonate; floor-polish removers and strippers may

contain sodium hydroxide.

 

*    General household cleaners: some are alkaline and contain sodium

carbonate or ammonium hydroxide.

 

*    Glass cleaners: some are alkaline and contain sodium hydroxide.

 

*    Grease removers: some are alkaline and contain sodium hydroxide

(but others contain carbon tetrachloride or trichloroethylene).

 

*    Laundry detergents: many contain alkalis such as sodium

carbonate, sodium phosphate, and sodium polyphosphate.

 

*    Lavatory-cleaning liquids, for removing stains and lime scale,

usually contain either hydrochloric acid, sulfuric acid, oxalic

acid, or sodium carbonate. They may be acid or alkaline.

 

*    Lavatory-cleaning powder is usually acid and may contain

troclosene sodium with detergent and small amounts of acid or

sodium bisulfate.

 

*    Oven cleaners are alkaline and usually contain sodium hydroxide

or potassium hydroxide.

 

*    Rust removers, for removing rust from metal or fabric, are acid;

some contain phosphoric acid or hydrofluoric acid.

 

*    Sterilizers for wine-making equipment, drinking-water or babies’

feeding bottles may contain sodium hypochlorite or troclosene

sodium.

 

*    Tablets for checking sugar in urine, used by diabetics, contain

sodium hydroxide and acid.

 

How they cause harm

 

These chemicals are irritant or corrosive. They inflame, burn or

destroy skin and other tissues. Acid fumes or irritant gases, such as

ammonia, chlorine, chloramine, hydrogen chloride, and sulfur dioxide,

irritate the lungs and cause lung oedema. Acid may also upset the

chemical balance of the body if swallowed and cause signs of general

systemic poisoning. Oxalic acid also causes kidney damage.

 

Tablets for detecting sugar in urine not only cause chemical

burns, but also heat burns, because they give out heat as they

dissolve in body fluids.

 

How poisonous they are

 

The injury caused by caustic and corrosive chemicals can range

from mild irritation to severe burns. The severity of injury depends

on:

 

–    the amount swallowed or in contact with the skin. A large amount

of liquid will injure a larger area. If a large amount of liquid

is swallowed, the patient is more likely to vomit.

 

–    how long the chemical is in contact with the tissues. The burns

caused by solids, such as denture-cleaning tablets, sterilizing

tablets or sodium hydroxide crystals, are usually worse than

those caused by liquids, because solids are in contact with the

lining of the mouth and gullet for longer than liquids. The most

serious damage happens when corrosive tablets stick in the gullet

or stomach.

 

–    the concentration of the chemical.

 

If swallowed, strongly corrosive or caustic chemicals may cause

severe burns to the mouth, throat, gullet and gut. Later, scars may

block the gullet so that the patient cannot swallow solid food.

 

Alkali burns are usually more severe than acid burns because

alkalis dissolve the tissues and go deep below the surface of the skin

or lining of the gut. They continue to cause damage even after they

have been washed off the surface of the tissue.

 

The pattern of injury caused by acids differs from that caused by

alkalis. Acids tend to cause more severe injury to the stomach than to

the throat and gullet. Even when the stomach is badly damaged, there

may be only slight injury to the throat and gullet. In contrast,

alkalis usually cause more severe injury to the gullet than to the

mouth, throat and stomach. The lower part of the gullet may be badly

injured even when there are no burns in the mouth and throat.

 

Hydrofluoric acid is different from other acids because it goes

deep below the skin causing severe damage to deep tissues and bone. It

is the fluoride in the acid that makes it so dangerous.

 

Acids cause systemic poisoning only if large amounts are

swallowed.

 

Special dangers

 

Corrosive or caustic household products are a danger to young

children if they are not stored safely locked away from children. It

is particularly dangerous to store such products in bottles that

previously held drink.

 

Denture-cleaning tablets or urine-testing tablets may be mistaken

for sweets or indigestion tablets by old people who cannot see very

well.

 

Dilute kettle descaler may be drunk by mistake from a kettle that

is being descaled. Descaler diluted with water is unlikely to cause

serious harm.

 

Household cleaners, lavatory cleaners, and bleaches are dangerous

if mixed together, but people sometimes misuse them in this way. When

liquid bleach is mixed with acid lavatory cleaner or descaler,

chlorine gas is given off. When liquid bleach is mixed with ammonia,

chloramine gas is given off. Chlorine and chloramine are acid gases.

 

Signs and symptoms

 

*    If swallowed:

 

–    immediate burning feeling in the mouth and throat,

 

–    ulcers inside the mouth; the tongue and lining of the mouth

change colour (grey with hydrochloric acid, yellow with nitric

acid, white or black with sulfuric acid),

 

–    wet mouth,

 

–    pain on swallowing so that the patient does not want to drink

anything,

 

–    great thirst,

 

–    swelling in the throat; this may block the airway so that the

patient wheezes when breathing,

 

–    pain in the chest and belly,

 

–    nausea, retching and vomiting, with blood in the vomit,

 

–    diarrhoea which may be blood-stained,

 

–    signs of shock: weak fast pulse, cold damp skin and low blood

pressure,

 

–    acid or alkali may burn holes in the throat, gullet, or stomach;

if the chemical burns a hole in the stomach the patient will have

fever, a band of pain under the ribs round to the back, severe

belly pain, and a hard rigid belly,

 

–    unconsciousness.

 

*    If fumes or gases are breathed in:

 

–    watering eyes and sneezing,

 

–    coughing and choking,

 

–    tight feeling in the chest or chest pain,

 

–    wheezing and difficulty in breathing,

 

–    rapid breathing,

 

–    headache,

 

–    blue colour to face, lips, and under eyelids,

 

–    dizziness,

 

–    fluid in the lungs (lung oedema) usually many hours afterwards.

 

*    In the eyes:

 

–    stinging or burning,

 

–    watering eyes,

 

–    red, swollen eyelids,

 

–    the patient does not want to open the eyes,

 

–    severe pain and burns on the eyelids and ulcers in the eyes,

 

–    blurred vision, loss of sight,

 

–    permanent blindness.

 

Alkali burns are usually more severe than acid burns.

 

*    On the skin:

 

–    a burning feeling (with hydrofluoric acid there may not be any

pain at first),

 

–    redness and swelling,

 

–    severe burns with severe damage to the skin,

 

–    alkalis cause ulcers, and make the skin feel slippery and soapy,

 

–    shock because of the pain: weak fast pulse, cold damp skin and

low blood pressure,

 

–    unconsciousness.

 

Alkali burns are usually more severe than acid burns. With

hydrofluoric acid severe injury may develop later even if there is no

sign of injury at first.

 

What to do

 

Move the patient away from gases, fumes or spilt liquids. Be

careful not to get any of the chemical on your own skin or clothes or

to breathe in vapours. Wear breathing equipment and protective

clothing as needed to protect yourself.

 

Give first aid. If the patient has stopped breathing, open the

airway, wipe chemical off the patient’s lips, then give mouth-to-mouth

respiration. If the mouth is badly burnt, give mouth-to-nose

respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm and quiet.

 

In the eyes

 

Dab the face very gently with a cloth or paper to soak up

chemical. Gently brush or dab away any liquid or powder from the face.

Wash the eyes for at least 15-20 minutes with water. Check that there

are no solid bits of chemical on the lashes and eyebrows, or in the

folds of skin round the eyes.

 

On the skin

 

Immediately remove contaminated clothing, shoes, socks and

jewellery. Be careful not to get any of the chemical on your own skin

or clothes or to breathe in vapours. Dab the patient’s skin very

gently with a cloth or paper to soak up chemical. Wash the skin

thoroughly with soap and cold water, if possible using running water.

If a large area is affected, wash the patient under a cold or lukewarm

shower or hand-held hose, but protect the patient’s eyes. Rinse for at

least 15 minutes.

 

For alkalis: wash until the skin no longer feels soapy or

slippery. This may take an hour or more.

 

For hydrofluoric acid: in all cases, immediately flood the skin

with water then put calcium gluconate gel on the affected area and

massage it continuously until the pain goes. This will take at least

15 minutes. Cover the area with dressing soaked in the gel and bandage

lightly. If you do not have any calcium gluconate gel, soak the skin

in a solution of magnesium sulfate (Epsom salts), or a calcium salt.

Immediate use of these salts may prevent deep burns, but once the acid

has gone below the skin they will be less effective.

 

If swallowed

 

If the chemical was swallowed less than 10 minutes ago, give four

cupfuls of water to drink at once. If it was swallowed more than 10

minutes ago, do not give anything to drink. Water will not make the

damage any less. If the patient is awake and alert, tell him or her to

rinse the mouth with cold water and spit it out.

 

Do not make the patient vomit. The vomit may burn the throat as

it comes up.

 

Hydrofluoric acid. If the patient is alert and can swallow,

immediately give a drink of milk, or medicine containing calcium or

magnesium, such as magnesium sulfate, magnesium hydroxide or calcium

carbonate.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if the patient is awake and

there are no signs of burning in the mouth, or wetness round the mouth

which shows that he or she cannot swallow, give one or two cupfuls of

water or milk. Take care not to make the patient vomit and stop if the

patient feels sick.

 

Do not try to neutralize the chemical with another chemical.

 

Do not give  fizzy drinks.

 

Do not give anything to drink if the patient is unconscious or if

there are burns inside the mouth.

 

Do not give anything to eat until a doctor has checked that there

is no damage to the throat.

 

If the patient has signs of lung oedema, treat as recommended

in chapter nine.

 

Information for doctors outside hospital

 

Supportive care should be given as needed, including oxygen and

mechanical ventilation, and morphine for severe pain.

 

It is difficult to judge the severity of injury to the oesophagus

or gut from the signs and symptoms. To see how severe the injury is,

endoscopy should be carried out if it is less than 48 hours since

ingestion and the patient has any of the following:

 

–    burns in the mouth,

 

–    signs or symptoms,

 

–    upper airway obstruction.

 

If acids or alkalis perforate the gut or oesophagus, the patient

will probably die.

 

Steroids (for example, prednisolone) may lessen the possibility

of stricture developing, if given within 48 hours. They should not be

given if there is a high risk of perforation, or if the patient has a

history of peptic ulcer or active infection.

 

Hydrofluoric acid

 

Systemic poisoning may cause hypocalcaemia or hyperkalaemia.

 

For pain or burns following skin contact, 10% calcium gluconate

solution can be injected subcutaneously into the affected areas using

no more than 0.5 ml per finger, or 1 ml per cm2 for other areas.

 

Cosmetics and toiletries

 

Products covered in this section

 

This section covers most cosmetics and toiletries, in two groups.

The products in the first group are unlikely to cause harm, but the

products in the second group may be harmful.

 

Cosmetics and toiletries that are unlikely to be harmful

 

The following are not poisonous:

 

–    face make-up, lipstick and eye make-up (but black eye make-up may

be poisonous; see below),

 

–    skin cream, oil and lotion used to soften or protect skin,

 

–    toothpaste.

 

The following contain poisonous chemicals but are usually sold in

small bottles so that it is unlikely that anyone would swallow enough

to be poisoned:

 

–    antiperspirants and deodorants that contain ethanol,

 

–    nail hardeners and nail strengtheners, which contain irritant

chemicals,

 

–    nail polishes and nail lacquers, which contain acetone, toluene,

xylene or ethanol.

 

Cosmetics and toiletries that may cause harm

 

Most accidental acute exposures cause nothing more than nausea,

vomiting and diarrhoea. However, there may be more serious effects in

some cases:

 

*    Black eye make-up, called  surma in India,  tiro in Nigeria, and

kohl in Arab countries, may contain lead and may cause chronic

lead poisoning from long-term use or acute poisoning if swallowed

in large amounts.

 

*    Hair bleaches and hair lighteners contain hydrogen peroxide. Weak

solutions are mildly irritant but some products contain more than

10% hydrogen peroxide, could be corrosive if swallowed and may

give off oxygen gas in the belly causing wind and pain.

 

*    Hair colourants contain dyes, isopropanol, and irritant

chemicals. There is a risk of acute poisoning from the

isopropanol.

 

*    Hairsprays: if breathed in deeply the propellant may cause harm

(see Aerosol sprays).

 

*    Hair straighteners contain caustic soda which could cause burns

(see Caustic and corrosive chemicals.

 

*    Hair-waving lotions and wave neutralizers may contain sodium

perborate, sodium bromate, potassium bromate, or mercuric

chloride.

 

*    Nail-polish removers usually contain acetone or ethyl acetate.

Brands sold in large bottles are a hazard, but it is unusual for

people to be poisoned by these products.

 

*    Perfumes, colognes and toilet waters contain ethanol

and large bottles may contain enough to cause poisoning.

 

*    Talcum powders, baby powders and face powders: if the powder is

spilt on a baby’s face, the fine particles could be breathed into

the lungs and may cause lung oedema. The powders themselves are

not poisonous, unless they contain boric acid.

 

Signs and symptoms (for products not covered in other sections)

 

Hair bleaches and hair lighteners containing hydrogen peroxide

 

*    If swallowed:

 

–    nausea, vomiting and belly pain,

 

–    burns inside the mouth and throat.

 

*    In the eyes:

 

–    redness and stinging or burning,

 

–    possibly severe pain and burns in the eyes.

 

Hair-waving lotions and wave neutralizers containing sodium bromate or

potassium bromate

 

*    If swallowed (effects begin within 2 hours):

 

–    nausea, vomiting and diarrhoea,

 

–    deafness within 4-16 hours,

 

–    low blood pressure,

 

–    unconsciousness,

 

–    fits,

 

–    signs of kidney damage.

 

*    In the eyes:

 

–    redness and stinging.

 

Nail polish removers

 

*    If swallowed:

 

–    nausea and vomiting

 

–    drowsiness or unconsciousness.

 

*    In the eyes:

 

–    redness and stinging.

 

Talcum powder

 

*    If breathed in:

 

–    coughing and choking,

 

–    signs of lung oedema.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes and keep the patient warm and quiet.

 

If the patient has a fit, treat as recommended in chapter five.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water.

 

Take the patient to hospital as soon as possible if he or she has

signs or symptoms of poisoning, has swallowed a cosmetic which may

cause harm, or may have injured the eye.

 

What to do if there is a delay in getting to hospital

 

For hair-waving lotions and wave neutralizers containing sodium

bromate or potassium bromate: if the chemical was swallowed less

than 4 hours ago, and if the patient is fully awake, breathing

normally, has not had fits, and is not already vomiting, make the

patient vomit. Give activated charcoal and water to drink.

 

Information for doctors outside hospital

 

Sodium bromate or potassium bromate:

 

Monitor pulse, blood pressure, breathing, fluid and electrolyte

balance and the patient’s hearing. Supportive care should be given as

needed.

 

There is a danger of renal tubular damage, which may be

permanent. Monitor kidney function.

 

If the patient has repeated fits diazepam should be given by

intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Cyanides

 

Chemicals covered in this section

 

This section covers cyanide, hydrogen cyanide (also called

hydrocyanic acid or prussic acid), sodium cyanide, and potassium

cyanide.

 

Cyanide-releasing substances are found naturally in many plants,

the stones of apricots and peaches, bitter almonds, cassava and

tapioca. Cassava (also called manihot or manioc) is grown throughout

the tropics and is a basic food in parts of Africa and South America.

It is a bush or tree with green flowers and nuts. The root is solid

and white.

 

cyanide when they burn. When people are overcome by breathing

smoke from fires, some of the effects may be due to cyanide poisoning.

 

Uses

 

Cyanide is used in industry and for pest control. Hydrogen

cyanide is used to fumigate buildings, ships and aircraft infested

with rodents or insects. Sodium cyanide and potassium cyanide are used

in metal cleaning, ore extraction in mines, electroplating and the

manufacture of synthetic fibres.

 

A preparation called Laetrile, made from peach stones, has been

used to treat cancer, but there is no evidence that it does any good

and it can cause cyanide poisoning.

 

How they cause harm

 

These chemicals stop living cells taking up oxygen and so the

brain and heart are damaged by lack of oxygen. They are poisonous if

swallowed, breathed in or spilt on the skin or in the eye. Chronic

poisoning, from eating cassava as a major part of the diet, may damage

the nervous system and thyroid gland.

 

How poisonous they are

 

These chemicals are highly poisonous and work very fast.

 

The toxicity of plants containing cyanide varies widely depending

on where they grow and whether fertilizers are used. Some parts of the

same plant may be more poisonous than others. All parts of the cassava

plant are poisonous, but the leaves and skin of the root are the most

poisonous parts. The poison is removed by washing and boiling.

 

Special dangers

 

It is important for people who use cyanide at work to use safe

work practices to avoid being poisoned.

 

Cassava poisoning can happen if the root is not properly prepared

and cooked. Mild cases of poisoning are common in poor areas,

especially in undernourished children.

 

Signs and symptoms

 

Acute poisoning

 

*    If swallowed, breathed in or spilt on the skin

 

Symptoms appear within seconds or minutes, but may be delayed by

1-2 hours if cyanide is swallowed with food.

 

At first:

 

–    burning tongue and mouth (if cyanide is swallowed),

 

–    dizziness,

 

–    throbbing headache,

 

–    anxiety,

 

–    palpitations,

 

–    confusion,

 

–    fast breathing,

 

–    vomiting.

 

These may be the only signs and symptoms in cases of mild

poisoning.

 

In moderate poisoning:

 

–    difficulty in breathing,

 

–    chest pain,

 

–    drowsiness,

 

–    short periods of unconsciousness,

 

–    fits.

 

In severe poisoning:

 

–    deep coma,

 

–    slow pulse,

 

–    low blood pressure,

 

–    large pupils,

 

–    breathing stops.

 

Death may occur within minutes. After a very large dose, the

patient falls to the ground, wheezing, with violent fits and dies

almost immediately.

 

*    In the eyes:

 

–    irritation

 

–    watering

 

–    same effects as if swallowed, breathed in or spilt on the skin.

 

Chronic poisoning

 

Weakness of the legs with pain or numbness, loss of sight,

difficulty in coordination, swollen thyroid gland (in front of the

neck).

 

What to do

 

Do not go into an area thought to be contaminated by cyanide gas

unless you have breathing equipment approved for cyanide exposure, and

protective clothing. Put on gloves and overalls before touching the

patient.

 

Move the patient away from any poisonous gases into fresh air or

away from spilt liquids or solids.

 

Give first aid. If the patient stops breathing open the airway,

wash chemical off the patient’s lips and mouth, then give mouth-to-

mouth or mouth-to-nose respiration. Give heart massage if the heart

stops. Keep on giving mouth-to-mouth respiration and heart massage for

at least 30 minutes, even if the patient seems dead.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing and pulse every 3

minutes.

 

In the eye

 

Gently brush or dab away any liquid or powder from the face. Wash

the eyes with water for at least 15-20 minutes. Check that there are

no solid bits of chemical on the lashes and eyebrows, or in the folds

of skin round the eyes.

 

On the skin

 

Immediately remove contaminated clothing, shoes, socks and

jewellery, cutting them off if necessary. A delay of only seconds may

make the poisoning worse. Wash the skin thoroughly with soap and water

for 15 minutes, using running water if possible. If you have breathing

equipment approved for cyanide exposure, wear this while you wash the

patient, and wear protective clothing and rubber gloves so that none

of the chemical gets on your own skin or clothes.

 

Take all patients with symptoms to hospital as quickly as

possible.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if the patient is fully awake,

breathing normally and has not had muscle twitching or fits, make the

patient vomit.

 

Information for doctors outside hospital

 

Acute poisoning

 

*    Severe poisoning

 

Continue cardiopulmonary resuscitation for at least 30 minutes or

until the patient recovers.

 

General supportive care may be life-saving. Always give oxygen to

patients with cyanide poisoning. If an antidote is not available,

serious poisoning can sometimes be successfully treated with

supportive care and oxygen alone.

 

Low blood pressure should be treated with intravenous fluids and

dopamine.

 

Antidotes: There are four antidotes. They can be harmful if too

much is given or if they are given to people who have not been

poisoned with cyanide.

 

Give an antidote only if the patient is losing consciousness or

is already deeply unconscious and you are sure of the diagnosis.

Give 50 ml (12.5 g) of sodium thiosulfate 25% intravenously over

10 minutes. Then give one of the following:

 

1. Dicobalt edetate solution 1.5%: give 20 ml (300 mg)

intravenously over one minute.

 

2. Sodium nitrite solution 3%: give 10 ml (300 mg)

intravenously over 20 minutes.

 

3. 4-Dimethylaminophenol (4-DMAP) 5%: give 5 ml (250 mg)

intravenously over one minute.

 

4. Hydroxocobalamin solution 40%: give 10 ml (4 g)

intravenously over 20 minutes.

 

Some severely poisoned patients may fail to respond to the

first dose of antidote. While repeat doses of hydroxocobalamin or

sodium thiosulfate are unlikely to cause harm, any other specific

antidote may itself be poisonous if too much is given or if it is

given to someone who has not been poisoned with cyanide, if the

patient does not respond, seek expert advice from a poisons centre

before giving a repeat dose of any specific antidote other than sodium

thiosulfate or hydroxocobalamin.

 

*    Moderate poisoning

 

–    Give 50 ml (12.5 g) of sodium thiosulfate 25%, intravenously over

10 minutes.

 

–    Give 100% oxygen for 12-24 hours, but no longer.

 

*    Mild poisoning

 

No antidote is needed. Give supportive care, including oxygen,

and bed rest.

 

Chronic poisoning

 

Chronic poisoning from cassava is not reversible. It may be due

to poor preparation of the cassava or to too little protein in the

diet. Education is necessary to prevent cases occurring

 

Disinfectants and antiseptics

 

Products covered in this section

 

This section covers household disinfectants and antiseptics,

which usually contain one or more of these chemicals:

 

–    cationic detergents such as benzalkonium, cetrimide,

cetylpyridinium, chlorhexidine,

 

–    ethanol,

 

–    hydrogen peroxide,

 

–    phenol, cresol, chlorocresol, chloroxylenol, or tar acids,

 

–    pine oil,

 

–    soap.

 

Disinfectants and antiseptics used in hospitals or workplaces

such as farms, factories and dairies may contain other chemicals.

 

Uses

 

Disinfectants and antiseptics destroy germs and are widely used

in the home. Disinfectants are used to clean places and objects,

antiseptics are used to clean skin and wounds.

 

How they cause harm

 

Ethanol causes unconsciousness and affects breathing; cationic

detergents burn the inside of the mouth and throat and affect muscles;

 

hydrogen peroxide is irritant; phenol is corrosive and affects the

brain, breathing, heart, liver and kidneys. These chemicals are

poisonous if swallowed. Phenol can also cause poisoning if absorbed

through the skin.

 

How poisonous they are

 

Disinfectants and antiseptics for use in the home do not usually

cause serious harm if a small amount is swallowed. Large amounts may

cause serious poisoning and possibly death. Disinfectants and

antiseptics for use in workplaces are more likely to cause severe

poisoning than those for use in the home. They usually contain greater

concentrations of chemical and may contain other chemicals more

harmful than those listed above. Disinfectants containing a high

concentration of phenol may cause poisoning if large amounts are spilt

on the skin.

 

Signs and symptoms

 

*    If swallowed:

 

–    nausea, vomiting and diarrhoea,

 

–    irritation in mouth and throat.

 

If the product contains cationic detergent:

 

–    burns to mouth, throat and gullet,

 

–    muscle weakness,

 

–    the patient cannot breathe,

 

–    unconsciousness,

 

–    fits,

 

–    low blood pressure,

 

–    lung oedema.

 

If the product contains ethanol:

 

–    drowsiness,

 

–    unconsciousness,

 

–    low body temperature,

 

–    shallow breathing.

 

If the product contains hydrogen peroxide:

 

–    nausea, vomiting and belly pain,

 

–    burns in the mouth and throat.

 

If the product contains phenol:

 

–    there may be burns in the mouth and throat,

 

–    fast breathing,

 

–    fits,

 

–    weak irregular pulse,

 

–    unconsciousness,

 

–    low blood pressure,

 

–    dark urine,

 

–    signs of liver and kidney damage.

 

*    In the eyes:

 

–    redness and watering,

 

–    stinging or burning,

 

–    there may be burns to the eye.

 

*    On the skin:

 

–    redness and irritation,

 

–    concentrated products may cause burns,

 

–    products containing large amounts of phenol may cause fits, fast

breathing and unconsciousness.

 

What to do

 

Give first aid.

 

If the disinfectant was made for use in the home, and if the

patient has swallowed only a small amount, the only effects are likely

to be nausea and vomiting. The patient will recover quickly, and does

not need to go to hospital. Give milk to drink.

 

If the patient stops breathing, open the airway, wipe chemical

off the patient’s lips, then give mouth-to-mouth or mouth-to-nose

respiration.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position, check breathing every 10 minutes and

keep the patient warm and quiet.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible in the

following cases:

 

–    the patient has swallowed a large amount of disinfectant;

 

–    the patient has swallowed a product made for use in hospital or

industry;

 

–    the patient has signs and symptoms of poisoning.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water. Take the

patient to hospital as quickly as possible if there seems to be injury

to the eye.

 

On the skin

 

Remove contaminated clothes, shoes, socks and jewellery. Wash the

skin thoroughly with soap and cold water, if possible using running

water. Take the patient to hospital as quickly as possible if there

are skin burns or signs and symptoms of poisoning.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if the patient is fully awake

give a cup of milk or water to drink. Do not make the patient vomit,

as the disinfectant may burn the throat.

 

Information for doctors outside hospital

 

Monitor breathing, pulse and blood pressure. Supportive care

should be given as needed including oxygen. The patient may need

mechanical ventilation.

 

See also the sections on soap and detergents, ethanol and

isopropano, phenol and related substances and volatile oils, if the

product contains these chemicals.

 

Ethanol and isopropanol

 

Chemicals covered in this section

 

This section covers ethanol (also called ethyl alcohol or grain

alcohol) and isopropanol (also called isopropyl alcohol or rubbing

alcohol). When people talk about “alcohol” they usually mean ethanol.

 

Uses and abuses

 

Alcoholic drinks (beers, wines and spirits) contain ethanol.

Methylated spirit and surgical spirit contain mainly ethanol, with a

small amount of methanol. Ethanol is also an ingredient of some liquid

medicines, mouthwashes, antiseptics, disinfectants, and cosmetics such

as aftershaves, perfumes, and colognes.

 

Alcohol abuse is common in many societies, and chronic abuse can

lead to dependence. People who try to poison themselves by taking

large doses of medicine often take alcohol at the same time.

 

Ethanol content of drinks and other products:

 

Distilled spirits   40-50%

 

Wines               10-20%

 

Beers               2-10%

 

Mouthwashes         up to 75%

 

Colognes            40-60%

 

Isopropanol is used as a sterilizing agent and as rubbing

alcohol, and is added to some antifreezes, car windscreen washes,

window cleaners, aftershaves and disinfectants. Car windscreen washes

may also contain methanol.

 

How they cause harm

 

Both ethanol and isopropanol slow down the brain, causing

unconsciousness and shallow breathing. Isopropanol vapour is irritant

to eyes, nose and throat and poisonous if breathed in. Isopropanol can

cause poisoning if absorbed through the skin. Regularly drinking large

amounts of ethanol causes chronic poisoning, resulting in many changes

in the body, particularly in the brain, the liver, and the heart.

 

How poisonous they are

 

Acute and chronic poisoning may cause serious illness and death.

The effect of a dose of ethanol depends on how much alcohol a person

regularly drinks. Someone who does not usually drink much alcohol may

be badly affected by an amount that would have very little effect on a

person who regularly drinks large amounts. Children may get severe

poisoning after drinking just a mouthful of aftershave, mouthwash or

perfume. Isopropanol is more poisonous than ethanol. Serious poisoning

can be caused by using isopropanol as rubbing alcohol, if large

amounts are rubbed on the skin and absorbed into the body.

 

Signs and symptoms

 

Acute poisoning

 

*    If swallowed:

 

–    the patient’s clothes and breath may smell of alcohol; patients

who have swallowed isopropanol smell of acetone (a strong sweet

smell),

 

–    slurred speech,

 

–    difficulty in performing simple tasks,

 

–    staggering walk,

 

–    nausea, vomiting, and abdominal pain which are more severe after

swallowing isopropanol,

 

–    drowsiness,

 

–    blurred or double vision,

 

–    unconsciousness,

 

–    fits,

 

–    low blood pressure,

 

–    low body temperature,

 

–    shallow breathing.

 

*    If spilt on the skin or breathed in:

 

For isopropanol: the same effects as if swallowed.

 

Chronic ethanol poisoning

 

Long-term abuse of alcohol results in:

 

–    weight loss,

 

–    loss of appetite,

 

–    diarrhoea caused by damage to the liver and gut,

 

–    pale skin due to anaemia,

 

–    memory loss, tremor, loss of mental abilities.

 

What to do

 

Acute poisoning

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes and keep the patient warm.

 

Take the patient to hospital as soon as possible if:

 

–    the patient is a child,

 

–    the patient has severe poisoning,

 

–    the patient has swallowed isopropanol.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if it happened less than one

hour ago and if the patient is fully awake and breathing normally, and

has not had fits, make the patient vomit, unless he or she has already

vomited a lot.

 

Chronic poisoning

 

Take the patient to see a doctor.

 

Information for doctors outside hospital

 

As well as the effects listed above, the blood glucose may be low

(more commonly in children than in adults), and there may be metabolic

acidosis and electrolyte imbalance. Do a full medical examination to

exclude other causes of the patient’s condition, such as head injury.

 

Ensure the airway is clear and the patient remains in the

recovery position. Monitor breathing, blood pressure, pulse, and blood

glucose. Supportive care, including oxygen and ventilation, should be

given as needed:

 

*    Fluid and electrolyte balance should be corrected.

 

*    Hypoglycaemia should be treated with oral or intravenous

glucose.

 

Ethylene glycol and methanol

 

Chemicals covered in this section

 

Ethylene glycol and methanol (also called methyl alcohol, wood

alcohol and wood spirit).

 

Uses

 

Ethylene glycol is used in antifreeze and has many uses in

industry.

 

Methanol is used in antifreeze for radiators, air brakes, petrol

and diesel oil; in windscreen washing fluid; as fuel for small

engines, picnic stoves and soldering torches; and in some inks, dyes,

resins, adhesives, paint removers and varnish removers. It is widely

used in industry and as a laboratory chemical.

 

Small amounts of methanol are present in preparations of ethanol

meant for commercial, medical or industrial uses, for example,

denatured alcohol, surgical spirit and methylated spirit.

 

*    Antifreezes may contain methanol, isopropanol or ethylene glycol.

Some products contain more than one of these chemicals. The

concentrations vary.

 

*    Cleaners for car windscreens contain either isopropanol or

methanol.

 

How they cause harm

 

Ethylene glycol and methanol are poisonous if swallowed, and most

poisonings happen in this way. Methanol is also poisonous if breathed

in or absorbed through the skin. People who work with methanol may be

poisoned by breathing in the fumes. Ethylene glycol affects the brain

and the kidneys. Methanol affects the brain and the eyes and can cause

blindness.

 

How poisonous they are

 

If swallowed, just a few mouthfuls may cause death, although

people with severe poisoning may recover if treated in hospital

without delay. Severe poisoning may result in permanent brain damage.

Methanol spilt on the skin may cause severe poisoning if large amounts

are absorbed.

 

Special dangers

 

Methanol poisoning is often caused by drinking methylated spirit

or denatured alcohol because it is cheaper, or more easily available

than alcoholic drink. Sometimes methanol poisoning is caused by

contaminated alcoholic drink and may affect many people at the same

time.

 

Antifreeze and windscreen washing liquid may be swallowed by

mistake if they are kept in drink bottles, instead of their original

containers.

 

Signs and symptoms

 

Ethylene glycol

 

*    If swallowed

 

At first:

 

–    vomiting,

 

–    headache,

 

–    the patient appears to be drunk, but the breath does not smell of

alcohol.

 

After 24-72 hours:

 

–    fast breathing,

 

–    fast pulse,

 

–    low blood pressure,

 

–    lung oedema,

 

–    unconsciousness,

 

–    fits.

 

Death may occur within 24 hours. If the patient survives more

than 24 hours, there may be kidney damage and the patient may stop

passing urine.

 

*    In the eyes:

 

–    irritation and redness.

 

Methanol

 

*    If swallowed

 

At first:

 

–    mild drunkenness and drowsiness.

 

After 8-36 hours:

 

–    headache,

 

–    belly pain, vomiting and diarrhoea,

 

–    fast breathing,

 

–    drowsiness,

 

–    pale, cold and clammy skin,

 

–    large pupils which do not change size if a light is shone in the

eyes,

 

–    patient sees flashing lights or complains that things look

blurred or that he or she is blind,

 

–    unconsciousness,

 

–    fits,

 

–    lung oedema,

 

–    slow pulse,

 

–    low blood pressure.

 

*    On the skin:

 

–    irritation and redness,

 

–    if large areas of skin are covered, or exposure lasts a long

time, effects are the same as if swallowed.

 

*    In the eyes:

 

–    irritation and redness.

 

*    If breathed in:

 

–    coughing and sneezing,

 

–    shortness of breath,

 

–    the same signs and symptoms as if swallowed.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as soon as possible.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water. Take the

patient to hospital if pain or irritation continues.

 

On the skin

 

Remove contaminated clothing, shoes, socks and jewellery. Wash

the skin well with soap and cold water, if possible using running

water. Take the patient to hospital as soon as possible if methanol

has been spilt on a large area of skin.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if it happened less than one

hour ago and the patient is fully awake and breathing normally, has

not had fits and has not already vomited a lot:

 

*    Make the patient vomit.

 

*    Give ethanol to drink if the patient has signs of serious

poisoning. Ethanol is an antidote to ethylene glycol and methanol

poisoning. Give 150 ml of any strong alcoholic drink, like rum,

whisky or gin (25 ml for a child). Dilute the alcohol in fruit

juice and give small swallows over 10-15 minutes. If the patient

shows signs of low blood sugar (dizziness, confusion, pale sweaty

skin, rapid pulse, shallow breathing, drowsiness) give fruit

juice or sugar.

 

If the patient stops passing urine, treat as recommended in

chapter nine. If the patient has signs of lung oedema, treat as

recommended in chapter nine.

 

Information for doctors outside hospital

 

As well as the effects listed above ethylene glycol may cause

severe metabolic acidosis, electrolyte imbalance, disturbed heart

rhythm, and kidney failure. Methanol tends to cause severe metabolic

acidosis with hyperventilation; blindness is common in severe cases.

 

Monitor breathing, blood pressure, pulse, and fluid and

electrolyte balance. Supportive care, including oxygen and mechanical

ventilation, should be given as needed:

 

*    Fluid and electrolyte balance should be corrected.

 

*    For repeated fits diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

The antidote is ethanol. It should be given as soon as possible,

preferably by intravenous infusion. A poisons centre can tell you what

dose to give. Blood sugar should be measured frequently while ethanol

is being given, as it may cause hypoglycaemia, especially in children.

Haemodialysis may be necessary if the patient has severe poisoning or

has taken a large amount.

 

Glue

 

Products covered in this section

 

This section covers glues that contain cyanoacrylate and glues

that are water-based, sometimes called gums or pastes. For glues and

adhesives that contain benzene, toluene, trichloroethylene or xylene

see Part Two (Benzene, etc.)

 

Uses

 

These glues are widely used in the home and in craft and hobby

activities. Cyanoacrylate glues also have many industrial uses.

 

How they cause harm

 

Water-based glues may be mildly irritant to the gut.

 

How poisonous they are

 

They are not poisonous if swallowed. Cyanoacrylate glue becomes

solid as soon as it gets into the mouth and does not dissolve. These

glues do not produce poisonous vapours.

 

Special dangers

 

Cyanoacrylate glues harden very quickly and it is difficult to

separate surfaces that are stuck together with them. People may glue

their fingers or eyelids together by mistake.

 

Signs and symptoms

 

If cyanoacrylate glue is swallowed there are no signs or

symptoms. The glue may stick to the teeth or the inside of the mouth.

 

If water-based glue is swallowed it may cause nausea and

vomiting.

 

For cyanoacrylate glue on the skin or in the eyes

 

The glue does not irritate or burn the skin. However if fingers

or eyelids are stuck together, there is a risk of injury if you try to

force them apart. Glue may damage the surface of the eye, but does not

cause chemical burns.

 

What to do

 

Cyanoacrylate glue

 

In the mouth

 

There is no need to remove glue from the teeth or the inside of

the mouth. It will come off by itself in a few days.

 

On the skin

 

There is no need to remove glue from the skin unless the fingers

are stuck together or stuck to something else. Soak affected parts in

warm soapy water and use a thin, blunt object, like the handle of a

spoon, to gently push the fingers apart. Do not force them apart

because the skin may tear.

 

In the eye

 

If the eyelids are stuck together do not force them apart. Cover

the eye with a gauze patch. The eyelids will come apart within 2-3

days.

 

Water-based glue

 

If swallowed

 

Give water to drink. There is no need to take the patient to

hospital.

 

Lead

 

Chemicals covered in this section

 

This section covers metallic lead, inorganic lead salts and

organic lead compounds such as tetraethyl lead.

 

Uses

 

Lead is used in storage batteries, solder, electric cable

insulations, paints, pottery and ceramic glazes. Tetraethyl lead is

often added to petrol.

 

Some traditional and folk remedies contain lead. Black eye make-

up (called  tiro, surma or  kohl) may contain lead.

 

Lead has been used for water-supply pipes, in house-paints and in

pottery, which may be used for eating, drinking or cooking. These uses

are known to have caused poisoning and are now banned in many

countries. However, lead paints and water-pipes may still be found in

old houses.

 

How it causes harm

 

Lead affects the nervous system, kidneys, reproductive system and

blood. Inorganic lead builds up in bone, tissue, and blood. Organic

lead is broken down by the liver, but the products damage the brain

and nervous system.

 

Children are more likely to get lead poisoning than adults

because the body absorbs lead more easily in childhood and is less

able to get rid of it.

 

Poisoning is usually a result of chronic exposure from repeatedly

breathing in or swallowing low doses. However, a single acute exposure

can cause poisoning, for example, if a lead object is swallowed and

stays in the gut for several days, if lead bullets are left in the

body, or if a large amount of organic lead is swallowed. Skin contact

with cold metallic lead will not cause lead poisoning, but organic

lead compounds are absorbed through the skin.

 

How poisonous it is

 

Lead is very poisonous. A single exposure rarely causes

poisoning, but repeated exposures can result in permanent brain damage

or death.

 

Special dangers

 

Work that is likely to create lead dust or fumes includes lead

smelting and refining, lead-battery making and breaking, welding,

heat-stripping or sanding where lead paints have been used. There is a

danger of breathing in lead unless adequate precautions are taken to

ensure ventilation and use of protective clothing and respirators.

There is a danger of swallowing lead if people eat, drink or smoke in

areas where there are lead fumes or dust. People may also be poisoned

by eating and drinking from lead-glazed pottery. “Sniffing” petrol

that contains lead may also result in lead poisoning. Most childhood

poisoning is caused by eating paint or dust containing lead, or by

using black eye make-up.

 

Symptoms and signs

 

If swallowed or breathed in, usually after repeated exposures

 

In children:

 

–    irritability, memory loss, clumsiness and low intelligence (these

may occur with no other symptoms),

 

–    pale skin due to anaemia,

 

–    loss of appetite, headache, and tiredness,

 

–    vomiting and colicky belly pain,

 

–    metallic taste in the mouth.

 

With higher concentrations a life-threatening illness may

develop:

 

–    persistent forceful vomiting,

 

–    uncoordinated movements,

 

–    periods of unconsciousness,

 

–    fits.

 

Brain damage is usually permanent.

 

In adults:

 

–    colicky belly pain and constipation,

 

–    pain in the joints, headache and weakness,

 

–    wrist drop or foot drop,

 

–    blue line on the gums,

 

–    personality changes, poor memory and slow reactions,

 

–    difficulty in coordinating movement.

 

Lead from petrol (tetraethyl lead) may also cause:

 

–    insomnia, vivid dreams,

 

–    mental disturbances,

 

–    hallucinations,

 

–    fits.

 

What to do

 

For a child with life-threatening poisoning

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

For acute poisoning from swallowing lead salts or compounds

(but not metallic lead): if the patient is fully awake and not

vomiting, give activated charcoal and water to drink.

 

If the patient has swallowed a metallic lead object or pieces of

lead-based paint: give a laxative (magnesium sulfate by mouth) and

check whether the object is passed in the faeces.

 

For a patient with signs and symptoms of chronic lead poisoning

but no acute sickness

 

Take the patient to a doctor as soon as possible. Treatment with

an antidote may be needed.

 

In all cases of lead poisoning

 

Always identify the source of lead and make sure there is no risk

that the patient will be re-exposed.

 

Information for doctors outside hospital

 

As well as the effects listed above, lead may cause cerebral

oedema, anaemia and peripheral neuropathy. The life-threatening

effects are due to an acute encephalopathy.

 

Acute encephalopathy should be treated promptly. Supportive care

should be given as needed:

 

*    Give fluids to keep a good urine flow, but be careful not to give

too much.

 

*    Monitor kidney function.

 

*    For repeated fits diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

There are several antidotes which may be of use: dimercaprol,

sodium calcium edetate, penicillamine, succimer (DMSA; 2,3-

dimercaptosuccinic acid) and DMPS (dimercaptopropane sulfonate). The

decision to use an antidote, the choice of antidote, and the dose will

depend on the symptoms and signs, and the concentration of lead in the

body. Discuss with a poisons centre which antidote to use and how much

to give.

 

If the patient has swallowed a metallic lead object or pieces of

lead-based paint, use X-rays to check if they are still in the gut.

Give magnesium sulfate to move the objects quickly through. Lead

bullets should be removed if possible.

 

Petroleum distillates

 

Chemicals covered in this section

 

This section covers a large group of chemicals made from

petroleum. Petroleum distillates are complex mixtures of aromatic and

aliphatic hydrocarbons.

 

They may be liquids that flow easily, spread across a surface

very rapidly, and evaporate readily at room temperature, such as:

 

–    diesel oil,

 

–    fuel oil,

 

–    kerosene (also called paraffin oil),

 

–    mineral seal oil,

 

–    mineral spirit (also called white spirit, turpentine substitute,

petroleum spirit),

 

–    petrol (also called gasoline),

 

–    petroleum ether,

 

–    petroleum naphtha.

 

Some other hydrocarbons are liquids that flow slowly, such as:

 

–    lubricating oil,

 

–    asphalt,

 

–    tar,

 

–    petrolatum.

 

Soft paraffin is semi-solid and paraffin wax is solid.

 

Uses and abuses

 

Kerosene is used as fuel for stoves and lamps. Solid firelighters

are soaked in kerosene. Mineral spirits are used as paint thinners,

paint removers and paintbrush cleaners. Mineral seal oil is used in

furniture polish. There are petroleum distillates in some shoe

polishes, window cleaners, furniture polishes, paints, pesticides, and

degreasers.

 

*    Floor and car polishes: most contain petroleum wax and water, but

some contain a large amount of liquid petroleum distillates.

 

*    House paint and varnishes contain petroleum distillates, but

some, such as emulsion paints, contain only small amounts.

 

*    Metal cleaners and polishes may contain petroleum distillates,

sometimes with small amounts of ammonia or acid (not enough to

cause burns). Some are solutions made with water rather than

petroleum distillates.

 

*    Window cleaners usually contain petroleum distillates but some

kinds contain only water and detergents (see Soap and

detergents).

 

Petrol (gasoline) and petroleum ethers are sometimes abused by

breathing in the vapour (solvent sniffing). White spirit and paraffin

do not give off enough vapour to be abused in this way.

 

How they cause harm

 

Liquid petroleum distillates irritate and inflame body tissues.

Those that spread quickly across a surface can enter the air passages

when they are swallowed, or during vomiting, and inflame and damage

lung tissues. This is particularly likely to happen if mineral spirit,

kerosene, mineral seal oil or petroleum naphtha is swallowed.

Swallowing or breathing in petroleum distillates may affect the brain.

These chemicals are irritant to skin and eyes.

 

Abuse of petrol affects the brain and may affect the heart.

Chronic abuse may damage the liver and kidneys and cause permanent

brain damage. Abuse of petrol containing tetraethyl lead as an

antiknock agent may cause lead poisoning.

 

How poisonous they are

 

Even very small amounts of those liquid petroleum distillates

that flow easily, sometimes as little as one or two mouthfuls, can

cause severe lung oedema. The risk from slow-flowing liquids is not so

great. The brain is not usually affected unless a large amount has

been swallowed or breathed in.

 

Special dangers

 

Kerosene fuel, polishes, paint thinners and paint-brush cleaners

are commonly found in the home and are common causes of childhood

poisoning. While in use they may be left in open containers in places

where children can easily reach them. There is a risk of swallowing

small amounts of petrol when siphoning fuel from car fuel tanks.

Petrol vapour is heavier than air and collects in pits or cellars.

Someone who goes into a pit or cellar that is full of petrol vapour

may die from lack of oxygen.

 

Signs and symptoms

 

Acute exposure

 

*    If liquid is swallowed:

 

–    coughing and choking almost immediately,

 

–    vomiting,

 

–    sore throat and a burning feeling in the mouth.

 

From large amounts there may also be:

 

–    weakness, dizziness and headache,

 

–    drowsiness,

 

–    unconsciousness,

 

–    slow shallow breathing,

 

–    fits.

 

After 6-24 hours:

 

–    wheezing and fast breathing,

 

–    lung oedema.

 

Death may be due to lung oedema or to infection in the damaged

lung.

 

*    If vapour is breathed in:

 

–    dizziness and headache,

 

–    other effects as when a large amount of liquid is swallowed, but

usually without lung oedema; breathing in a large amount, as in

abuse, may cause sudden death.

 

*    On the skin:

 

–    redness,

 

–    blistering and pain, if in contact with skin for a long time, for

instance if wet clothes are worn for several hours.

 

*    In the eyes:

 

–    mild irritation.

 

Chronic exposure

 

Repeated abuse may result in:

 

–    loss of appetite,

 

–    loss of weight,

 

–    muscle weakness,

 

–    mental changes,

 

–    sleeplessness, irritability, restlessness,

 

–    fits.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water. Take the

patient to hospital if irritation is severe.

 

On the skin

 

Immediately remove contaminated clothing, shoes, socks and

jewellery. Wash the skin well with soap and cold water for 15 minutes,

if possible using running water. Take the patient to hospital if

irritation is severe or there are burns.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if the patient is awake and can

swallow, give water to drink. Do not make the patient vomit, because

liquid might get into the lungs as the patient vomits. Do not give

activated charcoal, because it does not bind petroleum distillates.

 

For lung oedema, treat as recommended in chapter five.

 

Information for doctors outside hospital

 

Monitor breathing. If the patient is coughing or wheezing, the

chemical has probably entered the lungs. A chest X-ray will help

confirm chemical pneumonitis. If possible, repeat lung function tests

(such as peak flow or similar tests) every 2-4 hours.

 

Supportive care, including oxygen and mechanical ventilation,

should be given as needed. For repeated fits diazepam should be given

by intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Patients who stay free of symptoms for 12 hours can be sent home.

 

Phosgene

 

Phosgene is a colourless gas that smells like mouldy hay.

 

Uses

 

Phosgene is used in the manufacture of resins, dyes, and

pesticides, and has been used as a chemical weapon. It is produced

when chemicals containing chlorine are heated or burn, such as in a

fire.

 

How it causes harm

 

It damages the lungs, liver and kidneys. It dissolves slowly in

water to produce hydrochloric acid, which irritates the eyes, throat

and lungs. Because it dissolves only slowly, low concentrations may

not have any effect at first and people may not be aware that they are

breathing poison. It does not affect the skin.

 

How poisonous it is

 

Large doses may cause death.

 

Signs and symptoms

 

*    If breathed in:

 

–    irritation and watering of eyes,

 

–    coughing, choking,

 

–    tightness in chest,

 

–    nausea, vomiting, retching.

 

After a delay of up to 24 hours:

 

–    rapid, shallow breathing,

 

–    painful cough,

 

–    frothy white or yellowish sputum,

 

–    low blood pressure,

 

–    fast pulse.

 

The patient may die within 48 hours.

 

What to do

 

Move the patient away from the gas or smoke. Wear breathing

equipment and protective clothing as needed to protect yourself.

 

Give first aid. If the patient has stopped breathing open the

airway, wipe chemical off the patient’s lips, then give mouth-to-mouth

respiration.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm and quiet.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the patient has signs of lung oedema, treat as recommended

in chapter nine.

 

Information for doctors outside hospital

 

Supportive care, including oxygen, should be given as needed. The

patient may need mechanical ventilation. There is no antidote.

 

The patient should be observed for at least 12-24 hours because

lung oedema may be delayed.

 

Soap and detergents

 

Chemicals covered in this section

 

Soap is a natural product made from animal or vegetable fats or

oils. Deter-gents are synthetic chemicals. They are more effective

cleaning agents than soap and do not cause scum in hard water. There

are three groups: nonionic, anionic and cationic. It is important to

be able to distinguish the cationic detergents from other kinds,

because they are more harmful.

 

The most common cationic detergents are benzalkonium, cetrimide,

cetylpyridinium and dequalinium. They are sometimes called quaternary

ammonium compounds.

 

Detergent products usually also contain other chemicals such as

phosphates, carbonates and silicates to improve the cleaning action,

bleaches, perfumes, chemicals to kill bacteria, and stain removers.

 

Uses

 

Anionic detergents are used in most household products for

washing dishes, clothes, or hair or for general household cleaning.

Nonionic detergents are used in low-lather laundry products.

 

Cationic detergents are used as antiseptics and disinfectants in

the home, in the food and dairy industries, in health centres and in

hospitals.

 

Soap is usually sold in solid blocks or bars, liquids or flakes

for washing the skin or washing fabrics.

 

How they cause harm

 

Most household products containing anionic or nonionic detergents

are mild irritants. Detergents for use in automatic dishwashers are

corrosive, and so are many products used in hospitals, agriculture or

industry. Cationic detergents may burn the inside of the mouth and

throat and are also poisonous when swallowed, affecting the muscles.

 

Some shampoos for killing lice or other insects contain

insecticides. If the shampoo is not used in the right way, people may

be poisoned by the insecticide.

 

How poisonous they are

 

Household detergents do not usually cause harm if swallowed in

small amounts, except for automatic dishwasher detergents which can

cause burns. Cationic detergents may cause serious poisoning that may

result in death.

 

Signs and symptoms

 

*    If swallowed

 

Soap, nonionic and anionic detergents:

 

–    soreness in the mouth,

 

–    swelling of lips and tongue if a block of soap is sucked,

 

–    vomiting and diarrhoea.

 

Cationic detergents:

 

–    burns in the mouth, throat and gullet,

 

–    vomiting and diarrhoea,

 

–    muscle weakness,

 

–    the patient cannot breathe,

 

–    unconsciousness,

 

–    fits,

 

–    low blood pressure,

 

–    lung oedema.

 

*    On the skin

 

Repeated contact may make skin dry and cracked.

 

*    In the eyes

 

Cationic detergents may cause serious burns.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital at once in any of the following

circumstances:

 

*    The patient has swallowed a product containing cationic

detergent.

 

*    The patient vomits for a long time or has other signs or symptoms

of poisoning.

 

*    The patient has burns in the mouth.

 

If the patient does not need to go to hospital, give milk to

drink.

 

In the eyes

 

Gently brush or dab away any liquid or powder from the face then

wash the eyes for at least 15-20 minutes with water. Check that there

are no solid bits of chemical on the lashes or eyebrows or in the

folds of skin round the eyes. Take the patient to hospital if pain or

irritation continues.

 

On the skin

 

Remove contaminated clothing, shoes, socks and jewellery. Wash

the skin well with cold water, if possible using running water.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if the patient is awake, give a

cup of water to drink. Do not try to make the patient vomit, because

the vomit may burn the throat.

 

If there are signs of lung oedema, treat as recommended in

chapter nine.

 

 

Information for doctors outside hospital

 

Monitor breathing, pulse, blood pressure, and fluid and

electrolyte balance. Supportive care, including oxygen and

ventilation, should be given as needed. For repeated fits diazepam

should be given by intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Tobacco products

 

This section covers cigarettes, cigars, and pipe and chewing

tobacco made from cultivated tobacco  (Nicotiana tabacum). In some

societies other leaves may be smoked or chewed with tobacco, and other

plants may be added to tobacco to flavour cigarettes. Tobacco contains

nicotine.

 

How they cause harm

 

Nicotine affects the brain and nervous system.

 

How poisonous they are

 

Nicotine is very poisonous. Serious poisoning from swallowing

cigarettes is uncommon although two cigarettes made from cultivated

tobacco contain enough nicotine to cause severe poisoning in small

children. Even a cigarette end may cause poisoning.

 

Special dangers

 

Products like cigarettes, cigarette ends and loose tobacco are

often left within easy reach of children.

 

Signs and symptoms

 

*    If swallowed:

 

–    vomiting,

 

–    agitation,

 

–    diarrhoea,

 

–    wet mouth, sweating and pallor,

 

–    weakness,

 

–    pupils may be wide or very small,

 

–    fast pulse at first, becoming slow or irregular later,

 

–    a short period of unconsciousness,

 

–    jerking limbs,

 

–    fits.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes and keep the patient warm and quiet.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the patient is fully awake, breathing normally and not

vomiting, give activated charcoal and water to drink. Do not make the

patient vomit.

 

Children who swallow more than one cigarette or a similar amount

of loose tobacco should be taken to a doctor and watched for several

hours.

 

Volatile oils

 

Chemicals covered in this section

 

This section covers a group of chemicals that evaporate at room

temperature. Sometimes they are called essential oils because they are

made from the essences or perfume oils of plants. Camphor, clove oil,

eucalyptus oil, pine oil, and turpentine oil are some common volatile

oils.

 

Note: turpentine oil is made from pine wood and is not the same

chemical as turpentine substitute, which is a petroleum distillate.

 

Uses

 

Camphor, eucalyptus oil, menthol and turpentine oil are used in

liniments for rubbing on the skin to treat muscle pains; eucalyptus

oil, camphor and menthol are also used in preparations for rubbing on

the chest, and preparations meant to be breathed in. Camphor has been

used as nose drops or sprays for treating colds, but this is not

recommended.

 

These oils also have many non-medical uses. Turpentine oil is

used as a paintbrush cleaner. Camphor, in the form of crystals,

tablets or balls, is used to keep moths away. However, moth repellents

may be made of naphthalene or  para-dichlorobenzene rather than

camphor (see Air-fresheners, deodorant blocks and moth-balls.)

 

Products containing camphor

 

*    Camphorated oil, camphor liniment: camphor, 200 g/kg (20%) in

oil.

 

*    Compound camphor liniment, ammoniated camphor liniment: camphor,

125 g/l (12.5%) in strong ammonia solution (300 ml/l).

 

*    Camphor spirit: camphor, 100 g/l (10%) in alcohol.

 

Perfume oils are used in cosmetics and toiletries such as perfume

and aftershave (see Ethanol and isopropanol), air-fresheners (see Air-

fresheners, deodorant blocks and moth-balls), and other household

products. Pine oil is used in disinfectants (see Disinfectants and

antiseptics). However these products contain only small amounts of

volatile oils, and if they are swallowed harmful effects are usually

due to other chemicals rather than the volatile oils.

 

How they cause harm

 

Volatile oils are mildly irritant to the skin. Poisoning is

usually caused by swallowing the liquid, but in some cases it may be

caused by skin contact or breathing in the vapour. Volatile oils are

irritant to the gut, may cause lung oedema, and may affect the brain

and kidneys.

 

How poisonous they are

 

They may cause serious poisoning and even death. Children have

died after swallowing just a few mouthfuls of turpentine oil,

eucalyptus oil or camphor-containing products. Liniments and paint-

brush cleaners containing turpentine have caused serious poisoning in

young children.

 

Large amounts of camphor liniment, spirits or oil rubbed on the

skin may cause severe poisoning. Camphor nose drops can cause

poisoning in infants.

 

Special dangers

 

Camphorated oil is sometimes swallowed in mistake for castor oil.

Household products and medications containing essential oils are often

stored where children can easily get hold of them.

 

Signs and symptoms

 

*    If swallowed

 

The patient may have symptoms within a few minutes of swallowing

the oil:

 

–    breath smells of the oil,

 

–    burning feeling in mouth, throat and belly,

 

–    nausea, vomiting and diarrhoea,

 

–    anxiety, excitement and hallucinations,

 

–    dizziness,

 

–    twitching,

 

–    fits, which may happen suddenly, without warning, within 5

minutes of swallowing the oil,

 

–    unconsciousness,

 

–    slow, shallow breathing.

 

Death may occur early during fits. If not the patient may

develop:

 

–    signs of lung oedema,

 

–    signs of kidney failure, and may pass less urine than

normal.

 

*    In the eyes:

 

–    irritation and redness, but serious injury is unlikely.

 

*    On the skin:

 

–    redness and irritation,

 

–    large amounts rubbed on the skin may cause effects similar to

those of swallowing.

 

What to do

 

Give first aid. If breathing stops, open the airway, wash

chemical off the patient’s lips, then give mouth-to-mouth or

mouth-to-nose respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes and keep the patient warm and quiet.

 

If the patient has a fit, treat as recommended in chapter five.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with water.

 

On the skin

 

Immediately remove contaminated clothing, shoes, socks and

jewellery. Wash the skin thoroughly with soap and cold water, if

possible using running water. Rinse for at least 15 minutes.

 

Take the patient to hospital as soon as possible if any amount

has been swallowed, or if there is continuing pain or irritation in

the eye, or burns or signs of poisoning following skin contact.

 

What to do if there is a delay in getting to hospital

 

If the chemical was swallowed: if the patient is fully awake

and breathing normally, has not had muscle twitching or fits, and is

not vomiting, give activated charcoal and water to drink. Do not make

the patient vomit because liquid or vapour might get into the lungs

causing lung oedema, and vomiting might set off a fit.

 

If the patient has signs of lung oedema, treat as recommended

in chapter nine.

 

After 24 hours, if the patient is passing urine as often as

usual, give 3-4 litres of water to drink each day for the next 5 days.

 

If the patient has signs of kidney failure, treat as recommended

in chapter nine.

 

 

Information for doctors outside hospital

 

As well as the effects listed above there may be liver and kidney

damage. Monitor pulse, breathing, blood pressure, and liver and kidney

function. Supportive care, including oxygen and ventilation, should be

given as needed. For repeated fits diazepam should be given by

intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Products that are not usually harmful

 

The following would not be expected to cause any ill-effects:

 

*    Ink: ball-point pens, felt-tip pens, and fountain pens contain so

little ink that there is not enough to cause poisoning if it is

sucked from a pen. Some inks may cause soreness in the mouth.

Large amounts of ink swallowed from a bottle could be irritant,

but serious poisoning has not been reported.

 

*    Pencils and wax crayons: “lead” pencil is not lead but graphite,

which is harmless.

 

*    Silica-gel drying crystals used to keep things dry by absorbing

moisture.

 

*    Thermometers: if the end is bitten off a glass thermometer and

the contents swallowed the small amount of liquid will not cause

poisoning. Metallic mercury will pass through the body unchanged.

The broken glass may cause injury.

 

What to do

 

Give a cup of water. There is no need to do anything else.

 

If the patient has bitten a thermometer, check that there is no

broken glass inside the mouth.

 

Medicines

 

Acetylsalicylic acid, choline salicylate, methyl salicylate,

salicylic acid

 

Medicines covered in this section

 

This section covers acetylsalicylic acid (aspirin), choline

salicylate, methyl salicylate (oil of wintergreen) and salicylic acid.

All these medicines are known as salicylates.

 

Uses

 

Acetylsalicylic acid is widely used to treat pain, fever,

influenza, and inflammation of bones and muscles such as arthritis. It

is usually given by mouth as tablets. Pain killers and medicines for

treating colds may also contain paracetamol, caffeine, meprobamate or

opiates. Aspirin should not be given to children under 12 years old.

 

Choline salicylate gel or liquid is rubbed onto children’s gums

to treat teething pain.

 

Methyl salicylate is made into liniments and ointments that are

put on the skin to treat pain in the bones and rheumatism.

 

Salicylic acid is used in powders, lotions or ointments to treat

skin diseases. It is also used for removing warts.

 

How they cause harm

 

Salicylates make breathing faster and deeper, and upset the

balance of chemicals and water in the body. The change in the balance

of chemicals affects the brain and the heart.

 

How poisonous they are

 

Salicylates are very poisonous if large amounts are taken. More

than 300 mg/kg of body weight is likely to cause serious poisoning and

over 500 mg/kg may cause death. Children and old people may be

poisoned if given repeated high doses for 24 hours or more. Methyl

salicylate liniments are very dangerous because they are usually

strong solutions. One millilitre may contain more than 4 times as much

salicylate as one 300 mg tablet of aspirin, and children have died

after drinking only a teaspoonful. Salicylates are absorbed into the

body when ointments, lotions or gels are put on skin and gums, and can

cause poisoning if too much is used.

 

Special dangers

 

Aspirin is widely used, many people keep it at home, and it is a

common cause of acute poisoning in small children. Poisoning in

children may not be recognized when aspirin is given to treat feverish

illness because the symptoms of poisoning (fever and sweating) are

like the effects of the illness.

 

Signs and symptoms

 

Effects may be delayed for 12 hours or more, because aspirin

tablets dissolve very slowly in the stomach.

 

Mild poisoning:

 

–    belly pain, nausea and vomiting,

 

–    dizziness,

 

–    ringing in the ears and deafness,

 

–    fast breathing.

 

Moderate poisoning:

 

–    fast breathing,

 

–    confusion and restlessness,

 

–    fever and sweating,

 

–    dry tongue.

 

Severe poisoning:

 

–    drowsiness or unconsciousness,

 

–    fits,

 

–    shallow, fast breathing,

 

–    signs of lung oedema,

 

–    signs of kidney damage,

 

–    heart and breathing may stop.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the patient has fever, sponge the body with cool water.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the medicine was swallowed: if it happened less than 12

hours ago, and if the patient is fully awake and breathing normally

and has not had fits:

 

*    Make the patient vomit unless he or she has already vomited a

lot.

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until vomiting has stopped.

 

Give repeated doses of activated charcoal: for adults, 50 g every

2-4 hours; for children, 10-15 g every 2-4 hours. With each dose of

charcoal give sodium sulfate or magnesium sulfate, 30 g for adults,

250 mg/kg of body weight for children, until the stools look black.

 

If the patient has signs of lung oedema, treat as recommended

in chapter nine.

 

Information for doctors outside hospital

 

The effect on the respiratory centre results in a respiratory

alkalosis (except in children), dehydration and a fall in plasma

potassium concentration. A mild acidosis also develops. Blood glucose

may be low or high. Urine may be alkaline at first but soon becomes

acid.

 

Monitor fluid and electrolyte balance, blood glucose and urine

pH. Supportive care should be given as needed:

 

*    Fluid and electrolyte balance should be corrected, particularly

potassium; this may be all that is needed to treat mild

poisoning.

 

*    For repeated fits, diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

*    Pulmonary oedema should be treated with oxygen and mechanical

ventilation.

 

Plasma salicylate concentrations are valuable in assessing the

severity of poisoning after single doses. Plasma salicylate should be

measured every two hours as long as the plasma concentration is

rising. Generally patients with plasma salicylate concentrations of

between 350 and 600 mg/l (250-450 mg/l in children and old people) six

hours after taking an overdose have only mild poisoning; patients with

concentrations of 600-800 mg/l (450-700 mg/l in children and old

people) have moderate poisoning; patients with concentrations of above

800 mg/l (700 mg/l in children and old people) have severe poisoning.

 

To speed up the clearance of aspirin from the body, give repeated

doses of activated charcoal, as described above. Other ways to remove

salicylates from the body are:

 

–    by making the urine alkaline (pH 7.5-8.5) by giving sodium

hydrogen carbonate (sodium bicarbonate),

 

–    haemodialysis, which is more useful in serious poisoning

(salicylate level over 800 mg/l) because it improves the balance

of fluid and electrolytes.

 

Amfetamine-like medicines, atropine-like medicines,

antihistamines, cocaine, ephedrine, and pseudoephedrine

 

Medicines covered in this section

 

Amfetamine and medicines like amfetamine, such as:

 

amfepramone (diethylpropion)      methylphenidate

 

amfetamine                        pemoline

 

dexamfetamine                     phenmetrazine

 

fenfluramine                      phentermine

 

metamfetamine

 

Atropine and medicines like atropine, such as:

 

atropine                          homatropine

 

belladonna                        procyclidine

 

benzatropine                      scopolamine (hyoscine)

 

dicycloverine (dicyclomine)

 

Examples of antihistamines:

 

chlorphenamine                    pheniramine

 

cyclizine                         promethazine

 

dimenhydrinate                    triprolidine

 

diphenhydramine

 

The word “antihistamine” describes what these medicines do – they

act against histamine. Histamine is a chemical made in the body that

produces allergic effects such as rashes, itching and hay fever, when

the body is in contact with some chemical substances. Antihistamines

stop these effects.

 

Cocaine, ephedrine and pseudoephedrine do not belong to any of

the above groups, but are included in the same section because the

first aid treatment of poisoning with them is similar.

 

Uses and abuses

 

Amfetamine-like medicines

 

Amfetamine-like medicines are used to treat some kinds of mental

disorder. They are used by some doctors to help overweight people to

lose weight. They may be misused by people who want to keep alert and

active for a long time, or abused because they make people feel good

or “high”. Long-term misuse or abuse of amfetamines can lead to

dependence.

 

Amfetamines are given by mouth as capsules or tablets, some of

which are called “sustained-release preparations”, which means that

their effects last for many hours. People who abuse amfetamines may

swallow tablets, sniff powder, or use injections.

 

Atropine-like medicines

 

Atropine, homatropine and hyoscine are put into the eye, as drops

or ointment, during eye examination or to treat some eye conditions.

Atropine, belladonna and hyoscine are sometimes given by mouth or by

injection to treat stomach problems. Atropine is given by injection to

treat poisoning with organophosphorus and carbamate insecticides.

Benzatropine is given by mouth or by injection to treat Parkinson

disease. Dicycloverine is used to treat stomach ulcers. Procyclidine

is given by mouth or injection to treat Parkinson disease. Scopolamine

and hyoscine are given by mouth to prevent travel sickness.

 

Antihistamines

 

These are used to treat allergy, travel sickness and cough. They

are given by mouth as tablets, capsules and liquid, and by injection.

They are also used in ointments for stings, sunburn, and skin rash.

 

Cocaine

 

Cocaine is used as a local anaesthetic on the skin. It is made

from dried leaves of the coca plant,  Erythroxylon coca, or can be

made from chemicals. It is abused because it makes people feel good,

“high” and self-confident. Drug abusers usually take the drug as a

powder which they sniff (snort) or smoke. Sometimes it is injected. In

some countries people chew coca leaves.

 

Ephedrine and pseudoephedrine

 

These are used to treat coughs, colds and asthma. They are given

by mouth as tablets and liquids. Many products contain pseudoephedrine

mixed with other medicines. Ephedrine nose drops are given to clear a

blocked nose.

 

How they cause harm

 

All these medicines excite the brain, although antihistamines

sometimes have the opposite effect and slow down the brain. They also

have other effects:

 

*    Amfetamine-like medicines, cocaine, ephedrine and pseudoephedrine

affect the nerves that control the heart.

 

*    Antihistamines affect the nerves that control the heart, gut and

bladder. They sometimes slow down the brain causing drowsiness

and unconsciousness.

 

*    Atropine-like medicines affect the nerves that control the heart,

eyes, gut and bladder. They make the skin and mouth dry, and

cause fever, wide pupils, fast heart-beat and fast breathing.

 

*    Cocaine affects the nerves that control breathing.

 

These effects occur when any of these medicines are swallowed or

injected. General systemic effects can also occur when atropine-like

medicines are put into the eye, and when amfetamine, cocaine and

ephedrine are in contact with the inside of the nose. Antihistamines

do not cause systemic effects if put on the skin.

 

How poisonous they are

 

All these medicines can cause serious illness and death if too

much is taken or if they are abused, especially if they are injected,

smoked or sniffed. The poisonous doses of amfetamines and ephedrine

 

are only slightly larger than the doses used for treatment. Repeated

use or abuse of amfetamines can cause tolerance, so that a dose which

produces effects of poisoning in a person who has never taken

amfetamines will not have any effects on a person who regularly takes

them. Children are more likely than adults to get serious poisoning

from antihistamines, atropine-like medicines, ephedrine and

pseudoephedrine.

 

Special dangers

 

Medicines containing antihistamines, for treating colds and

coughs, are often kept in the home, in places where children can

easily get hold of them. These medicines are usually liquids that are

sweet or taste of fruit, they taste good to children and are easy to

swallow. Travel sickness tablets are often mistaken for sweets by

children.

 

Drug smugglers who swallow large amounts of cocaine in sealed

bags get severe poisoning if the bags burst inside the body.

 

Signs and symptoms

 

Amfetamine-like medicines

 

When amfetamines are taken by mouth, effects begin within 30-60

minutes and last for 4-6 hours. If large amounts are taken, or if

sustained-release preparations are taken, the effects may last much

longer. When amfetamines are injected, effects begin within seconds:

 

–    restlessness and sleeplessness,

 

–    trembling,

 

–    dry mouth,

 

–    nausea, vomiting and belly pain,

 

–    flushing and sweating,

 

–    wide pupils,

 

–    confusion and panic,

 

–    hallucinations,

 

–    high blood pressure at first,

 

–    fast breathing and chest pain,

 

–    irregular pulse,

 

–    fits,

 

–    fever (temperature measured in the rectum may be higher than

40°C),

 

–    unconsciousness,

 

–    low blood pressure in severe poisoning.

 

Antihistamines

 

The usual effects are:

 

–    drowsiness,

 

–    dry mouth,

 

–    headache,

 

–    nausea,

 

–    fast pulse,

 

–    the patient cannot pass urine, – drowsiness and confusion,

 

–    hallucinations,

 

–    unconsciousness,

 

–    shallow breathing.

 

Some people, especially children, may have different signs and

symptoms:

 

–    wide pupils,

 

–    shaking,

 

–    excitement,

 

–    high temperature and warm skin,

 

–    fits.

 

Atropine-like medicines

 

Effects are:

 

–    red, dry skin,

 

–    wide pupils,

 

–    blurred vision,

 

–    dry mouth and thirst,

 

–    confusion and hallucinations,

 

–    excitement and aggression,

 

–    fast pulse,

 

–    the patient cannot pass urine,

–    unconsciousness,

 

–    fever,

 

–    fits.

 

Cocaine

 

Effects are:

 

–    fast, irregular pulse,

 

–    fast, deep breathing,

 

–    excitement, restlessness and anxiety,

 

–    hallucinations,

 

–    shaking, twitching,

 

–    high blood pressure at first, low blood pressure later,

 

–    fits,

 

–    raised temperature,

 

–    fast, shallow breathing, which may stop completely,

 

–    unconsciousness,

 

–    paralysis of muscles.

 

When cocaine is injected, the patient may die within a few

minutes.

 

Ephedrine and pseudoephedrine

 

Effects are:

 

–    nausea and vomiting,

 

–    headache and irritability,

 

–    hallucinations,

 

–    fever,

 

–    fast pulse,

 

–    wide pupils,

 

–    blurred vision,

 

–    high blood pressure,

 

–    breathing in gasps,

 

–    muscle spasms and fits,

 

–    unconsciousness.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position, and check breathing every 10 minutes.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the patient has fever, sponge the body with cool water.

 

A patient who is anxious, confused, very restless, or aggressive,

or who has hallucinations, should be kept in a quiet, dimly lit place

and protected from injury. Stay calm and quiet yourself to reassure

the patient.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the substance was swallowed: if it was taken less than 4

hours ago (6 hours for atropine, 12 hours for sustained-release

amfetamines) and if the patient is fully awake and breathing normally,

and has not had fits:

 

*    Make the patient vomit unless he or she has already vomited a

lot. This should be done even if the patient has taken medicine

to stop travel sickness, because these medicines do not usually

stop vomiting caused by ipecacuanha or touching the throat. If

you give the patient ipecacuanha but this does not cause

vomiting, do not give another dose.

 

*    If the patient is fully awake give repeated doses of activated

charcoal and water to drink. If you have made the patient vomit,

wait until vomiting has stopped.

 

Dose: adults, 50 g every 2-4 hours; children, 10-30 g every 2-4

hours. With each dose of charcoal give sodium sulfate or magnesium

sulfate, 30 g to adults, 250 mg/kg of body weight to children, until

the stools look black.

 

Information for doctors outside hospital

 

As well as the effects listed above, all of these medicines may

cause heart rhythm disturbances in overdose.

 

Monitor breathing and blood pressure. Supportive care, including

oxygen and mechanical ventilation, should be given as needed:

 

*    For low blood pressure, intravenous fluids should be given but

fluid output must be monitored carefully because there is a

possibility of kidney failure.

 

*    For repeated fits, diazepam should be given by intravenous

injection, but there is a danger that diazepam might affect

breathing.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Do not use chlorpromazine to treat agitated patients who are

poisoned by amfetamine or atropine.

 

Amfetamine and cocaine

 

If the rectal temperature rises above 40°C cover the patient with

a cold wet sheet and blow air onto the patient with a fan, until the

temperature falls to 39°C. Measure temperature, pulse and breathing

every 10-15 minutes.

 

If fits do not stop after the patient has been given diazepam, it

may be necessary to paralyse the patient with pancuronium and give

mechanical ventilation. High blood pressure does not usually last a

long time, so there is no need to use medicine to treat it.

 

Atropine and antihistamines

 

It may be necessary to catheterize a patient who cannot pass

urine. Physostigmine given intravenously may be useful in life-

threatening atropine poisoning but may itself have life-threatening

side-effects, so it should only be given in hospital with the patient

on a heart monitor.

 

Aminophylline and theophylline

 

Uses

 

These medicines are used to treat asthma. They are given by mouth

as tablets, capsules, or liquids, and may also be given by injection.

In some countries aminophylline may be available as suppositories to

be given by rectum. Some tablets are “sustained-release” preparations;

this means that the effects of the medicine last a long time and fewer

doses are needed per day compared with ordinary tablets.

 

How they cause harm

 

Aminophylline and theophylline upset the balance of chemicals in

the body and this affects the heart and causes fits.

 

How poisonous they are

 

Poisoning may be caused by a single overdose, or by repeatedly

taking too large a dose of prescribed medicine for more than 24 hours.

Amounts only a little larger than the therapeutic dose may cause

poisoning. Serious poisoning may cause death. Elderly people and

patients with asthma are particularly at risk.

 

Signs and symptoms

 

Effects may be delayed for 12 hours or more if sustained-release

preparations have been taken:

 

–    nausea and vomiting,

 

–    fast pulse,

 

–    restlessness, headache and sleeplessness,

 

–    hallucinations,

 

–    fast breathing,

 

–    unconsciousness in some cases,

 

–    vomiting blood,

 

–    fits, which may occur suddenly,

 

–    low blood pressure,

 

–    irregular pulse.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm.

 

If the patient is fully awake and breathing normally, has not had

fits, and is not vomiting, give 50-100 g (10-15 g for children) of

activated charcoal and water to drink.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the patient has hallucinations, keep the patient in a quiet,

dimly lit room, and protect from injury. Stay calm and quiet yourself

to reassure the patient.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the patient is fully awake, give repeated doses of activated

charcoal and water to drink (adults, 50 g every 2-4 hours; children,

10-15 g every 2-4 hours). With each dose of charcoal give sodium

sulfate or magnesium sulfate, 30 g for adults, 250 mg/kg of body

weight for children, until the stools look black.

 

Keep the patient in bed. If possible raise the foot of the bed so

that the patient’s feet are higher than the head. This will help blood

to reach the brain if the blood pressure is low.

 

Information for doctors outside hospital

 

As well as the effects listed above, there may be a low serum

potassium concentration, metabolic acidosis, respiratory alkalosis,

and serious disorders of heart rhythm (supraventricular or ventricular

arrhythmias).

 

Monitor breathing, pulse, blood pressure and serum electrolytes.

In moderate to severe poisoning, acid-base balance should be

monitored. Supportive care, including oxygen and mechanical

ventilation, should be given as needed:

 

*    Correct fluid and electrolyte balance, particularly potassium.

 

*    Treat low blood pressure with intravenous fluids.

 

*    For repeated fits, diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

If the patient is vomiting and unable to take activated charcoal,

metoclopramide should be given intravenously to stop the vomiting.

 

Dose of metoclopramide to be given intravenously over 1-2

minutes:

 

child up to 3 years (up to 14 kg): 1 mg

 

child 3-5 years (15-19 kg): 2 mg

 

child 5-9 years (20-29 kg): 2.5 mg

 

children over 9 years and young adults (30-60 kg): 5 mg

 

adults: 10-50 mg.

 

Charcoal haemoperfusion or haemodialysis may be indicated in

severe poisoning.

 

Measurement of serum theophylline concentration may be helpful in

showing how severe the poisoning is. Patients with signs and symptoms

of poisoning usually have plasma theophylline concentrations of

25 mg/l or more, and in severe poisoning, plasma concentrations are

usually above 50 mg/l. However, some patients with low plasma

concentrations may have severe poisoning, especially if toxicity is

chronic, and some patients with high plasma concentrations may be free

of severe effects. It is therefore important that treatment should be

based on the clinical condition as well as the plasma drug

concentration. Measurements should be repeated at regular intervals if

possible.

 

Amitriptyline-like medicines, chloroquine, quinidine,

and quinine

 

Medicines covered in this section

 

This section covers amitriptyline and similar medicines (also

called tricyclic antidepressants), chloroquine, quinidine and quinine.

 

These are examples of amitriptyline-like medicines:

 

clomipramine        imipramine

 

desipramine         nortriptyline

 

dosulepin           protriptyline

 

doxepin             trimipramine

 

Uses

 

Medicines in the amitriptyline group are given to patients who

are depressed, to make them feel happier. They are given by mouth as

liquids, tablets or capsules; some of these are “sustained-release”

preparations, which means that their effects last for many hours.

 

Chloroquine is used to prevent and treat malaria and to treat

amoebic liver disease and some kinds of arthritis. It is given by

mouth as tablets or syrup, or by injection.

 

Quinidine is used to treat heart disease. It is given by mouth as

tablets or by injection.

 

Quinine is used to treat malaria and is sometimes given to people

who get cramp during the night. It is given by mouth as tablets or by

intravenous infusion. It is sometimes misused to cause abortions.

 

How they cause harm

 

All these medicines affect the heart and the brain. Overdose can

cause serious heart rhythm disturbances and low blood pressure. In

addition:

 

–    amitriptyline-like medicines affect the nerves controlling the

heart, gut and bladder, in the same way as atropine-like

medicines;

 

–    chloroquine affects the eyes;

 

–    quinine affects muscles, the eyes, and the ears.

 

How poisonous they are

 

All these medicines can cause serious poisoning and death if too

much is taken. For many of these medicines, the dose that causes

poisoning is often only slightly bigger than the dose used to treat

illness.

 

Special dangers

 

Depressed people may try to kill themselves by taking too much

medicine. They may be careless with their medicines and leave them

where children can easily find them. People who take quinine for night

cramps sometimes leave their tablets on a bedside table where children

can easily reach them.

 

Women misusing quinine to cause abortion may take a dose that

causes serious poisoning.

 

Signs and symptoms

 

Amitriptyline-like medicines

 

Effects are:

 

–    dry mouth,

 

–    medium size or wide pupils,

 

–    blurred vision,

 

–    fast or irregular pulse,

 

–    the patient may not be able to pass urine,

 

–    hallucinations and confusion,

 

–    unconsciousness,

 

–    shallow breathing,

 

–    fits,

 

–    low blood pressure,

 

–    heart and breathing may stop, causing sudden death.

 

Chloroquine

 

Within 1-3 hours:

 

–    vomiting and diarrhoea,

 

–    headache and dizziness,

 

–    drowsiness within 10-30 minutes, then excitement,

 

–    unconsciousness (sometimes),

 

–    fits,

 

–    low blood pressure,

 

–    shallow, fast breathing,

 

–    irregular pulse,

 

–    heart and breathing may stop, causing death.

 

The patient may be very ill within 1 hour and may die within 2-3

hours of taking the medicine. Patients who survive for 48 hours

usually recover completely. Patients who become blind after taking one

large dose always recover their sight.

 

Quinidine

 

Effects may begin within 2-4 hours:

 

–    nausea and vomiting,

 

–    irregular pulse,

 

–    low blood pressure,

 

–    unconsciousness,

 

–    fits,

 

–    shallow breathing,

 

–    heart and breathing may stop, causing death.

 

Patients who survive for 48 hours usually recover.

 

Quinine

 

Effects are:

 

–    nausea and vomiting,

 

–    ringing sound in the ears, deafness,

 

–    large pupils,

 

–    blurred vision,

 

–    disturbed colour vision,

 

–    blindness, partial or complete, within 30 minutes or after many

hours,

 

–    dizziness,

 

–    headache,

 

–    fever,

 

–    excitement and confusion,

 

–    rapid, shallow breathing,

 

–    fast pulse,

 

–    fits,

 

–    low blood pressure,

 

–    unconsciousness,

 

–    heart and breathing may stop.

 

If the patient does not die within a few hours there may be signs

of kidney failure after a few days. Sight may return after 14-24 hours

or after several weeks, but may never be as good as it was before.

Sometimes blindness is permanent. Hearing usually returns quickly and

completely.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops. It

may be necessary to continue heart massage for a long time. Some

patients with amitriptyline poisoning have needed heart massage for

over an hour before the heart started beating by itself.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes and

keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the patient has hallucinations or is confused, keep him or her

in a quiet, dimly lit place, protected from injury. Stay calm and

quiet yourself to reassure the patient.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the patient is fully awake and breathing normally, and is not

vomiting:

 

*     For amitriptyline: if the medicine was swallowed less than 12

hours ago, give activated charcoal and water to drink and a dose

of sodium sulfate or magnesium sulfate.

 

*     For chloroquine, quinidine and quinine: give repeated doses of

charcoal for 24 hours (adults, 50 g every 2-4 hours; children,

10-30 g every 2-4 hours). With each dose of charcoal give sodium

sulfate or magnesium sulfate, 30 g to adults, 250 mg/kg of body

weight to children, until the stools look black.

 

Keep the patient in bed. If possible raise the foot of the bed so

that the patient’s feet are higher than the head. This will help blood

to reach the brain if the blood pressure is low.

 

Information for doctors outside hospital

 

Monitor breathing, pulse, blood pressure, fluids and

electrolytes, blood glucose and kidney function. Supportive care,

including oxygen and mechanical ventilation, should be given as

needed:

 

*    Low blood pressure should be treated with intravenous fluids;

keep the patient lying with the feet higher than the head.

Isoprenaline, dopamine or norepinephrine (noradrenaline) can be

used if needed.

 

*    For repeated fits diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

*    Fluid and electrolyte balance should be corrected.

 

Chloroquine

 

Serum potassium concentration may be low, but potassium chloride

infusion should only be given if the plasma potassium concentration

can be measured frequently during the infusion. The plasma potassium

may rise suddenly and become dangerously high.

 

Diazepam may protect the heart from the effects of chloroquine,

but may depress breathing and should only be given if it is possible

to ventilate the patient.

 

Dose: 0.5 mg/kg of body weight, given by intravenous injection.

 

If poisoning is severe, diazepam can be given by continuous

intravenous infusion for 24-48 hours.

 

Dose: 5-10 mg per hour for adults; 0.25-0.4 mg/kg of body weight per

hour for children.

 

Quinine

 

The patient’s eyes should be examined frequently. Look for pallor

of the optic disc, contraction of retinal blood vessels, retinal

oedema and constricted visual fields.

 

Barbiturates, chlorpromazine-like medicines, diazepam-like

medicines and meprobamate

 

Medicines covered in this section

 

This section covers barbiturates, chlorpromazine-like medicines

(also called phenothiazines), diazepam-like medicines (also called

benzodiazepines), haloperidol and meprobamate.

 

Examples of barbiturates:

 

amobarbital         phenobarbital

 

barbital            secobarbital

 

pentobarbital

 

Examples of chlorpromazine-like medicines (phenothiazines):

 

chlorprothixene     prochlorperazine

 

fluphenazine        thioridazine

 

perphenazine        trifluoperazine

 

Examples of diazepam-like medicines (benzodiazepines):

 

chlordiazepoxide    nitrazepam

 

chlorazepate        oxazepam

 

lorazepam

 

Uses and abuse

 

Phenobarbital is given for epilepsy (fits); it can make fits

happen less often or stop them altogether. The other barbiturates are

used to help people sleep. They are supplied as tablets or capsules.

Barbiturates may be abused and some abusers become dependent on them.

Some abusers mix the powder from inside the capsules with water, or

crush tablets in water, and inject themselves with the solution.

 

Chlorpromazine-like medicines and haloperidol are used to calm

violent people, and to help people with mental disorders behave

normally. Chlorpromazine is also used to stop vomiting. They are given

by mouth as tablets or liquid, or by injection.

 

Diazepam and some similar medicines are given to anxious people

to make them feel calm. Some, such as nitrazepam, are given to help

people sleep. Diazepam is also used to stop fits. The medicines are

given by mouth as tablets, capsules or liquid, or by injection.

 

Meprobamate is given to anxious people to help them sleep. It is

given by mouth as tablets.

 

How they cause harm

 

All these medicines slow down the brain, and big doses cause

unconsciousness and may make breathing shallow. Chlorpromazine-like

medicines and haloperidol can also cause fits, restlessness and

strange movements the patient cannot control. The heartbeat may be

irregular and blood pressure may be low.

 

How poisonous they are

 

Barbiturates, chlorpromazine-like medicines, and meprobamate are

very poisonous and overdose may cause death. Long-term treatment with

phenobarbital for weeks or months may cause chronic poisoning because

the medicine builds up in the body.

 

Diazepam-like medicines and haloperidol do not usually cause

severe poisoning, and unconscious patients normally recover completely

if given medical care. However, people may get serious poisoning if

they take diazepam-like medicines with other medicines that slow down

the brain.

 

People are more likely to get serious poisoning if they take any

of these medicines with alcohol.

 

Signs and symptoms

 

Barbiturates

 

*    Acute poisoning:

 

–    drowsiness,

 

–    unconsciousness which may last for many days,

 

–    low temperature,

 

–    low blood pressure,

 

–    shallow breathing,

 

–    skin blisters between the fingers, or on the body, knees or

ankles,

 

–    no bowel sounds – this means that the gut has stopped working and

that poisoning is very serious.

 

The patient may die because heart and breathing stop. Patients

who are unconscious for a long time may die from lung oedema.

 

*    Chronic poisoning:

 

–    drowsiness,

 

–    the patient cannot walk properly,

 

–    slurred speech.

 

Chlorpromazine-like medicines and haloperidol

 

Effects are:

 

–    drowsiness,

 

–    unconsciousness,

 

–    low blood pressure,

 

–    low temperature,

 

–    fast pulse which may also be irregular,

 

–    rigid, stiff limbs,

 

–    abnormal eye movements and grimaces,

 

–    restlessness and fits,

 

–    shallow breathing.

 

Diazepam-like medicines

 

Effects are:

 

–    staggering walk,

 

–    slurred speech,

 

–    drowsiness,

 

–    unconsciousness (but the patient is usually rousable),

 

–    shallow breathing (rare).

 

Meprobamate

 

Effects are:

 

–    weakness and confusion,

 

–    low blood pressure,

 

–    low temperature,

 

–    drowsiness,

 

–    unconsciousness,

 

–    shallow breathing.

 

Patients who are unconscious for a long time may die from lung

oedema.

 

What to do

 

Acute poisoning

 

Give first aid. If breathing stops open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm.

 

For chlorpromazine-like medicines and haloperidol: if the

patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the medicine was swallowed: if it happened less than 4 hours

ago, and if the patient is fully awake and breathing normally, and has

not had fits:

 

*    Make the patient vomit.

 

*    When the patient has stopped vomiting give activated charcoal and

water to drink. Give sodium sulfate or magnesium sulfate with the

charcoal.

 

For phenobarbital: repeat the dose of charcoal every 4 hours

(adults, 50 g; children, 10-15 g). With each dose of charcoal give

sodium sulfate or magnesium sulfate, 30 g for adults, 250 mg/kg of

body weight for children, until the stools look black.

 

If the patient is an epileptic taking phenobarbital regularly,

wait for 48 hours after the patient has woken up, before you start

giving doses of phenobarbital again.

 

Chronic poisoning

 

A patient who has signs of chronic poisoning after taking

prescribed doses of phenobarbital should go back to the doctor who

prescribed the medicine. If the patient cannot get to the doctor

straight away, he or she should stop taking the medicine for 48 hours

then take half the usual dose each day.

 

Information for doctors outside hospital

 

Monitor breathing, pulse, blood pressure, fluids and

electrolytes, and kidney function. Supportive care should be given as

needed:

 

–    oxygen and mechanical ventilation

 

–    intravenous fluids for low blood pressure.

 

Barbiturates and meprobamate

 

For severe poisoning charcoal haemoperfusion may be useful.

 

Chlorpromazine-like medicines and haloperidol

 

Treat low blood pressure by keeping the patient lying with the

head lower than the feet. This will help blood to reach the brain. Do

not give epinephrine or dopamine. For repeated fits, give diazepam by

intravenous injection, but note that there is a risk that diazepam

might affect breathing.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Carbamazepine, phenytoin and valproic acid

 

Medicines covered in this section

 

This section covers carbamazepine, phenytoin and valproic acid

(sodium valproate). Other medicines used to treat fits are not

included because the treatment for poisoning is different.

 

Uses

 

These medicines are given to patients who have epilepsy (fits);

they can make the fits happen less often or stop them. Carbamazepine

is also used to treat some kinds of very painful headache, and some

illnesses affecting the mind. It is given by mouth as tablets or

syrup. Phenytoin is also used in hospital to treat fits due to

poisoning and irregular heart rhythms. It is given by mouth as

 

capsules, tablets or liquid or by intravenous injection. Valproic acid

is given by mouth as capsules, tablets, or liquid.

 

How they cause harm

 

These medicines affect the brain. Carbamazepine also affects

breathing, heart, and muscles.

 

How poisonous they are

 

Carbamazepine and valproic acid may cause serious poisoning, but

most patients recover if treated in hospital, and deaths are rare.

Phenytoin rarely causes serious poisoning. People on long-term

treatment with carbamazepine and phenytoin may get chronic poisoning

even though they are taking the dose prescribed by the doctor.

 

Signs and symptoms

 

Carbamazepine

 

*    Acute poisoning

 

Signs of poisoning may be delayed because it takes several hours

for tablets to dissolve in the gut, and for the medicine to reach

the bloodstream:

 

–    aggressive or violent behaviour,

 

–    dry mouth,

 

–    dizziness and unsteadiness,

 

–    drowsiness,

 

–    wide pupils,

 

–    blurred vision,

 

–    nausea, vomiting and diarrhoea,

 

–    trembling, jerking movements the patient cannot control,

 

–    fast or slow or irregular pulse,

 

–    unconsciousness,

 

–    low or high blood pressure,

 

–    shallow, irregular breathing,

 

–    the patient passes very little urine or none at all,

 

–    low temperature.

 

*    Chronic poisoning:

 

–    dizziness and unsteadiness,

 

–    blurred vision.

 

Phenytoin

 

*    Acute poisoning:

 

–    nausea and vomiting,

 

–    drowsiness,

 

–    the patient cannot walk properly,

 

–    slurred speech,

 

–    the eyes move from side to side,

 

–    blurred vision,

 

–    the hand shakes when the patient reaches out to touch something,

 

–    unconsciousness.

 

The effects may last for 48-72 hours.

 

*    Chronic poisoning:

 

–    the patient cannot walk properly,

 

–    slurred speech,

 

–    blurred vision.

 

Valproic acid

 

*    Acute poisoning:

 

–    confusion,

 

–    restlessness,

 

–    drowsiness and unconsciousness,

 

–    shallow breathing,

 

–    low blood pressure.

 

What to do

 

Acute poisoning

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes, and keep the patient warm.

 

For carbamazepine: if the patient has a fit, treat as

recommended in chapter five. If the patient is aggressive, keep him

or her in a quiet, dimly lit place and protect from injury. Stay calm

and quiet yourself to reassure the patient.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the medicine was swallowed: if it happened less than 4 hours

ago (12 hours for carbamazepine), and if the patient is fully awake

and breathing normally, and has not had fits:

 

*    Make the patient vomit, unless the patient has already vomited a

lot.

 

*    When the patient has stopped vomiting give activated charcoal and

water to drink.

 

For carbamazepine, give repeated doses of activated charcoal:

adults, 50 g every 2-4 hours; children 10-15 g every 2-4 hours. With

each dose of charcoal give sodium sulfate or magnesium sulfate, 30 g

for adults, 250 mg/kg of body weight for children, until the stools

look black. If the patient has low blood pressure raise the foot of

the bed so that the patient’s feet are higher than the head. This will

help blood to reach the brain.

 

If the patient has epilepsy and is being treated with any of

these medicines, wait for 48 hours after the patient wakes up and can

talk normally before starting to give the medicine again.

 

Chronic poisoning

 

If an epileptic patient on long-term treatment has poisoning from

the dose prescribed by the doctor, tell the patient to go back to the

doctor who prescribed the medicine. If there is a delay in seeing the

doctor, the patient should stop taking the medicine for 48 hours, then

take half the usual dose each day until he or she sees the doctor.

 

Information for doctors outside hospital

 

Monitor breathing, pulse, blood pressure, fluids and

electrolytes, and kidney function. Supportive care, including oxygen

and mechanical ventilation, should be given as needed:

 

*    Intravenous fluids should be given for low blood pressure but

urine output must be measured, as there is a danger of giving the

patient too much fluid if the kidneys are not making enough

urine. Dopamine or norepinephrine (noradrenaline) can be used if

needed.

 

*    For repeated fits due to carbamazepine, give diazepam by

intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Charcoal haemoperfusion may be useful in carbamazepine poisoning

if a severely ill patient is not responding to medical care. It is not

useful for treatment of poisoning with phenytoin or valproic acid.

Neither haemodialysis nor forced diuresis is useful for treating

poisoning with any of these medicines.

 

Chlorpropamide-like medicines and insulin

 

Medicines covered in this section

 

This section covers chlorpropamide and similar medicines (also

called sulfonylureas), and insulin. Examples of medicines like

chlorpropamide are glibenclamide, tolazamide and tolbutamide.

 

Uses

 

These medicines are used to treat diabetics who have too much

sugar in their blood. Insulin is given by injection, but

chlorpropamide, glibenclamide, tolazamide and tolbutamide are given by

mouth as tablets.

 

How they cause harm

 

These medicines reduce the amount of sugar in the blood. Sugar is

the body’s source of energy and if the amount of sugar falls too low

the body cannot work properly, the patient becomes unconscious, the

brain may be damaged, and the patient may die.

 

How poisonous they are

 

Poisoning may cause permanent brain damage and death. Poisoning

is more likely to be serious if alcohol is taken as well. Insulin is

not poisonous when taken by mouth, because it is destroyed in the gut.

 

Signs and symptoms

 

If insulin is injected, or if chlorpropamide, glibenclamide,

tolazamide and tolbutamide are swallowed, the effects are the same

whether the patient is diabetic or not:

 

–    anxiety, confusion and abnormal behaviour,

 

–    shaking,

 

–    sweating without fever,

 

–    fast pulse,

 

–    blurred vision,

 

–    drowsiness,

 

–    unconsciousness,

 

–    fits.

 

What to do

 

If the patient has injected insulin or has swallowed

chlorpropamide, glibenclamide, tolazamide or tolbutamide, give first

aid. If breathing stops, open the airway and give mouth-to-mouth

respiration. If the patient is unconscious or drowsy, lay him or her

on one side in the recovery position. Check breathing every 10

minutes, and keep the patient warm.

 

If the patient is awake and able to swallow, give something sweet

to eat or drink, such as a sugary drink, glucose solution, very sweet

tea, fruit juice, honey, sugar cubes, chocolate or other sweet food.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

If the patient has swallowed insulin there is no need to do

anything.

 

Information for doctors outside hospital

 

Take a blood sample to test blood sugar level with test strips

and glucometer. Give glucose immediately.

 

For a conscious patient:

 

Give 10-20 g of glucose orally in a solution, or give any of the

high carbohydrate foods listed above.

 

For an unconscious patient:

 

Give glucose solution by intravenous injection (adults, 50%

glucose, 50 ml; children, 25% glucose, 2-4 ml/kg of body weight).

 

If the patient does not recover, give another dose. As soon as

possible, and even if the patient recovers consciousness, the patient

should be given a continuous intravenous infusion of 10% glucose.

Monitor blood glucose levels every 15-30 minutes during treatment; aim

to keep the blood glucose concentration within the range 5-10 mmol/l

(about 90-180 mg/dl).

 

Note that a patient may have a dangerously low blood glucose

concentration but have no symptoms. On the other hand, a patient may

stay unconscious even after the blood glucose concentration has

returned to normal.

 

If the patient has been unconscious for some time, the response

to treatment may be slow. In severe poisoning from chlorpropamide,

glibenclamide, tolazamide, tolbutamide, or long-acting insulin,

treatment may need to be continued for several days.

 

Monitor breathing, pulse, blood pressure, fluid and electrolytes,

and liver and kidney function. Supportive care should be given as

needed:

 

*    For low blood pressure keep the patient lying with the head lower

than the feet. Intravenous fluids should be given but care must

be taken to avoid fluid overload. If needed, dopamine or

norepinephrine (noradrenaline) can be used.

 

*    For repeated fits give diazepam by intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Colchicine

 

The medicine covered in this section

 

This section covers colchicine and the plants that contain it:

 

*     Colchicum autumnale (autumn crocus): a bulb that produces

crocus-like flowers with white or light violet petals. It is

found in Europe and north America.

 

*   Gloriosa superba (glory lily): a climbing plant with a tuberous

root and yellow, dark orange or scarlet flowers. It is found in

tropical Africa, India, Malaysia, Myanmar and Sri Lanka.

 

Colchicine is found in all parts of the plants but the roots are

most poisonous.

 

Medicine is made from the root and seeds of  Colchicum

autumnale.

 

Uses

 

Colchicine is used to treat gout and familial Mediterranean

fever. It is given by mouth as tablets, or by injection.

 

How it causes harm

 

It affects the gut, muscles, nerves, blood and liver.

 

How poisonous it is

 

Colchicine poisoning is uncommon, but may cause serious illness

and death. Poisoning is more often caused by taking the medicine than

by eating plants. The poison is not destroyed if the plant is cooked.

 

Special dangers

 

In some countries  Gloriosa is eaten by people who want to kill

themselves and is sometimes used to cause abortions. It may be

mistaken for a sweet potato plant because it often grows near sweet

potatoes and looks very like them.

 

Signs and symptoms

 

Effects may start after 2 hours or be delayed for up to 12 hours:

 

–    burning throat and skin,

 

–    nausea, vomiting, belly pain and severe diarrhoea, making the

patient very dehydrated,

 

–    shallow breathing,

 

–    low blood pressure,

 

–    confusion,

 

–    unconsciousness,

 

–    fits,

 

–    the patient passes very little urine, and it may be dark or

blood-stained,

 

–    bleeding from wounds and gums, with blood taking longer than

usual to clot (this may occur within a few hours or after 3-4

days).

 

The patient may die within 2-3 days because of the effects on

breathing and the heart. If the patient survives, after 10-12 days the

hair may begin to fall out and may not start to grow again for about a

month.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes, and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the patient has severe vomiting or diarrhoea, give several

sips of water every few minutes to replace water lost from the body.

 

If the medicine was swallowed less than four hours ago (or if the

plant was swallowed less than 24 hours ago), and if the patient is

fully awake, breathing normally, has not had fits and is not vomiting:

 

*    Give activated charcoal and water to drink. Give one dose every

4-6 hours (adults, 50 g; children, 10-15 g). If the patient does

not have diarrhoea, with each dose of charcoal give sodium

sulfate or magnesium sulfate, 30 g for adults, 250 mg/kg of body

weight for children, until the stools look black.

 

Information for doctors outside hospital

 

As well as the effects listed above, colchicine may cause

electrolyte imbalance, liver damage, bone marrow depression with

leukocytosis and leukopenia, blood clotting disorders and peripheral

neuropathy. Kidney failure may occur as a complication.

 

Monitor breathing, pulse, blood pressure. Supportive care,

including oxygen and mechanical ventilation, should be given as

needed:

 

*    Fluid and electrolyte balance should be corrected.

 

*    Low blood pressure should be treated with intravenous fluids;

dopamine or dobutamine can be given if blood pressure does not

respond to fluids.

 

*    Morphine should be given for severe belly pain.

 

*    For repeated fits, diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Antibiotics should be given to prevent infection with Gram-

positive, Gram-negative and anaerobic bacteria.

 

Haemodialysis may be needed to treat kidney failure but will not

remove the poison.

 

Dapsone

 

Uses

 

Dapsone is used to treat leprosy, infectious skin diseases and

malaria. It is given by mouth as tablets.

 

How it causes harm

 

It affects the blood cells so that the blood cannot carry the

normal amount of oxygen. This may mean that the brain does not get

enough oxygen to work properly.

 

How poisonous it is

 

Large single doses may cause severe poisoning and sometimes

death. Sometimes patients get signs and symptoms of poisoning after

being treated for several weeks with dapsone.

 

Signs and symptoms

 

Signs may be delayed for up to 24 hours after a single dose:

 

–    blue colour to skin and lips,

 

–    restlessness,

 

–    drowsiness,

 

–    nausea, vomiting and severe belly pain,

 

–    fast pulse,

 

–    low blood pressure,

 

–    fast breathing,

 

–    dizziness,

 

–    hallucinations,

 

–    unconsciousness,

 

–    fits.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes, and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

A patient who has hallucinations should be kept in a quiet, dimly

lit room and protected from injury. Stay calm and quiet yourself to

reassure the patient.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the patient is awake and breathing normally and has not had

fits:

 

*    Make the patient vomit, unless the medicine was swallowed more

than four hours ago or the patient has vomited a lot already.

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until vomiting has stopped. Give repeated

doses every 2-4 hours for up to 3 days (adults, 50 g; children

10-15 g). With each dose of charcoal give sodium sulfate or

magnesium sulfate, 30 g for adults, 250 mg/kg of body weight for

children, until the stools look black.

 

Keep the patient in bed. If possible raise the foot of the bed so

that the patient’s feet are higher than the head. This will help blood

to reach the brain if the blood pressure is low.

 

Information for doctors outside hospital

 

Monitor breathing, blood pressure, and pulse. Supportive care

should be given as needed. For repeated fits, diazepam should be given

by intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours;

 

Children: 200-300 µg/kg of body weight.

 

Repeated doses of activated charcoal, in the doses given above,

reduce the time taken for dapsone to leave the body.

 

For cyanosis

 

There is no specific treatment for cyanosis that can be given

outside hospital. Oxygen is not useful for treating cyanosis due to

dapsone.

 

Cyanosis in dapsone poisoning may have several causes.

Methaemoglobinaemia is one cause. Methylthioninium chloride (methylene

blue) may be of use in treating cyanosis caused by methaemoglobin, but

the dose depends on the concentration of methaemoglobin so it should

only be given in hospital where methaemoglobin can be measured.

Methylthioninium chloride will not treat cyanosis from other causes.

Patients have survived severe poisoning without methylthioninium

chloride treatment.

 

Dose: Adults and children: 1-2 mg/kg of body weight, given

intravenously over 5-10 minutes. The dose may have to be repeated over

several days (to a maximum of 7 mg/kg of body weight) as dapsone is

excreted slowly.

 

Dapsone poisoning is worse in patients who are deficient in

glucose-6-phosphate dehydrogenase.

 

Digitalis, digitoxin and digoxin

 

Medicines covered in this section

 

Digitalis, digoxin and digitoxin are prepared from the foxglove

plant  Digitalis purpurea.

 

Uses

 

These medicines are used to treat heart disease. Digoxin is given

by mouth as tablets or liquid, or intravenously by injection or

infusion.

 

How they cause harm

 

These medicines affect the heart.

 

How poisonous they are

 

These medicines can cause serious poisoning and death,

particularly in old people with heart disease who have been taking

them for some time. Serious poisoning is uncommon in children.

Patients on long-term treatment with these medicines sometimes get

mild poisoning from the prescribed doses. The leaves, roots and seeds

of the foxglove plant are poisonous.

 

Special dangers

 

These medicines are often prescribed for old people, who may

forget to lock their tablets away when children visit.

 

Signs and symptoms

 

Acute poisoning

 

Effects are:

 

–    nausea, vomiting, and sometimes diarrhoea,

 

–    pulse may be fast, slow or irregular,

 

–    drowsiness and confusion,

 

–    low blood pressure.

 

The effect on the heart may be delayed for up to 6 hours.

 

Chronic poisoning

 

Long-term treatment may result in:

 

–    feeling ill,

 

–    tiredness and weakness,

 

–    loss of appetite,

 

–    nausea and vomiting,

 

–    headache,

 

–    confusion and hallucinations.

 

What to do

 

Acute poisoning

 

Give first aid. Give heart massage and mouth-to-mouth respiration

if the heart stops. If the patient is unconscious or drowsy, lay the

patient on one side in the recovery position. Check breathing every 10

minutes, and keep the patient warm.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the medicine was swallowed: if it happened less than four

hours ago, and if the patient is fully awake and breathing normally:

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until vomiting has stopped.

 

Give repeated doses of activated charcoal and water to drink

(adults, 50 g every 2-4 hours; children 10-15 g every 2-4 hours). With

each dose of charcoal give sodium sulfate or magnesium sulfate, 30 g

for adults, 250 mg/kg of body weight for children, until the stools

look black.

 

Keep the patient lying down with the feet higher than the head.

This will help blood to reach the brain if the blood pressure is low.

 

Chronic poisoning

 

Patients with chronic poisoning should be taken to hospital.

 

Information for doctors outside hospital

 

As well as the effects listed above, there may be changes in

heart rhythm (commonly bradycardia, heart block or tachydysrhythmias)

and electrolyte imbalance. In acute poisoning, plasma potassium

concentration may be higher than normal, while the plasma magnesium

concentration may be lower than normal.

 

Monitor heart rhythm, breathing, blood pressure, and electrolytes

(magnesium, sodium, calcium and potassium). Supportive care should be

given as needed and fluid and electrolyte balance should be corrected.

 

Glyceryl trinitrate, hydralazine, and propranolol-like medicines

 

Medicines covered in this section

 

This section covers glyceryl trinitrate, hydralazine, and

propranolol and similar medicines. Propranolol and similar medicines

are called beta-adrenoceptor blocking agents, or beta-blockers.

 

Examples of propranolol-like medicines: atenolol and oxprenolol.

 

Glyceryl trinitrate is also called nitroglycerin or glycerol

trinitrate.

 

Uses

 

Glyceryl trinitrate is used to treat heart disease. It may be

given as tablets that are put under the tongue and dissolved in the

mouth, as tablets that are swallowed whole, by injection or by

intravenous infusion.

 

When given as tablets that dissolve in the mouth, the medicine

starts working within a few minutes and the effects last for less than

30 minutes. These tablets are taken by people with heart disease, to

treat sudden chest pain.

 

The tablets that are meant to be swallowed whole are sustained-

release tablets; these have effects lasting for many hours. They are

taken to prevent chest pain.

 

Hydralazine is used to treat high blood pressure. It is given as

tablets by mouth, by injection or by intravenous infusion.

 

Propranolol-like medicines are used to treat high blood pressure

and heart disorders. They are given by mouth as tablets or capsules

(some of which are sustained-release preparations and have an effect

lasting many hours), or by injection.

 

How they cause harm

 

The main effects of poisoning with all the medicines covered in

this section are low blood pressure and changes in heart rate.

Glyceryl trinitrate and hydralazine make the muscles in the walls of

the blood vessels relax, so that the blood pressure falls.

Propranolol-like medicines cause low blood pressure by affecting the

nerves that control the heart rate and blood vessels. They also affect

breathing and the brain.

 

How poisonous they are

 

Serious poisoning with glyceryl trinitrate is rare. Large doses

of propranolol-like medicines may cause serious poisoning and death.

 

Special dangers

 

Some people with heart disease take glyceryl trinitrate when they

have a sudden attack of chest pain. They need to be able to get their

tablets quickly and often keep them where children can easily get hold

of them too.

 

Signs and symptoms

 

Glyceryl trinitrate

 

Effects usually start within 30 minutes and last for less than an

hour if the short-acting tablets have been taken, or for several hours

if the sustained-release tablets have been taken:

 

–    throbbing headache,

 

–    warm face,

 

–    dizziness,

 

–    palpitations,

 

–    low blood pressure.

 

Hydralazine

 

Effects are:

 

–    warm skin,

 

–    nausea and vomiting,

 

–    headache,

 

–    fast, irregular pulse,

 

–    low blood pressure.

 

Propranolol-like medicines

 

Effects usually start very soon but may last for a day or more:

 

–    slow pulse,

 

–    nausea and vomiting,

 

–    hallucinations,

 

–    drowsiness,

 

–    low blood pressure,

 

–    fits,

 

–    unconsciousness,

 

–    the heart and breathing may stop completely.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm.

 

For propranolol-like medicines: if the patient has a fit, treat

as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

Glyceryl trinitrate passes out of the stomach very quickly so it

is no use making the patient vomit or giving activated charcoal unless

the patient has taken sustained-release tablets.

 

If sustained-release glyceryl trinitrate tablets, hydralazine or

propranolol-like medicines were swallowed: if it happened less than

four hours ago, and if the patient is fully awake and breathing

normally, and has not had fits:

 

*    Make the patient vomit, unless he or she has already vomited a

lot.

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until vomiting has stopped. Give sodium

sulfate or magnesium sulfate with the charcoal.

 

Keep the patient in bed. If possible raise the foot of the bed so

that the patient’s feet are higher than his head. This will help blood

to reach the brain if the blood pressure is low.

 

Information for doctors outside hospital

 

Monitor breathing, pulse, blood pressure, fluids and

electrolytes, and kidney function.

 

Supportive care, including oxygen and mechanical ventilation,

should be given as needed:

 

*    Give intravenous fluids for low blood pressure.

 

*    For repeated fits give diazepam by intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Hydralazine

 

If blood pressure does not return to normal with intravenous

fluids, dopamine or norepinephrine (noradrenaline) can be used.

 

Propranolol-like medicines

 

If blood pressure does not return to normal with intravenous

fluids, intravenous isoprenaline should be used. Large doses may be

needed to raise the blood pressure. Blood pressure should be monitored

 

carefully, since isoprenaline may make blood pressure lower in some

cases.

 

Dose: Adults: 5-50 µg/minute.

 

Children: 0.02 µg/kg of body weight per minute to a maximum of

0.5 µg/kg of body weight per minute.

 

Monitor blood glucose. Intravenous glucose should be given if

blood glucose is low.

 

For bronchospasm, intravenous salbutamol or aminophylline should

be given.

 

Ibuprofen

 

Uses

 

Ibuprofen is used as a pain killer. It is given by mouth as

tablets or liquid. It is also made as an ointment to be rubbed on the

skin.

 

How poisonous it is

 

It does not usually cause serious poisoning even in very large

amounts.

 

Signs and symptoms

 

Effects are:

 

–    nausea, vomiting and abdominal pain,

 

–    headache,

 

–    dizziness,

 

–    shaking,

 

–    drowsiness,

 

–    unconsciousness after a large overdose.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes, and keep the patient warm.

 

If the patient is awake, give activated charcoal with water to

drink.

 

If the patient has taken a large amount or is very sick take the

patient to hospital as quickly as possible.

 

Information for doctors outside hospital

 

Very rarely, kidney failure may occur after acute overdose. Give

plenty of fluids so that the patient does not become dehydrated.

 

Iron-containing medicines

 

Medicines covered in this section

 

This section covers iron salts such as ferric ammonium citrate,

ferrous fumarate, ferrous gluconate, and ferrous sulfate.

 

Uses

 

Medicines containing iron are used to treat anaemia (thin blood)

that is caused by not having enough iron in the diet, or by losing too

much iron from the body, as in hookworm infestation. Iron salts are

given by mouth as tablets or liquid. Some vitamin tablets contain

small amounts of iron.

 

How they cause harm

 

Iron salts damage the gut, the liver, the brain, the blood

vessels and the blood.

 

How poisonous they are

 

Poisoning may cause death. More than 20 mg/kg of body weight of

elemental iron may cause poisoning. It takes only a very few tablets

of preparations containing 60 mg of elemental iron per tablet to

poison a young child.

 

Special dangers

 

Iron tablets are often found in homes with young children because

they are given to pregnant women. Iron tablets are often brightly

coloured and shiny and look like sweets.

 

Signs and symptoms

 

Within 6 hours of the overdose:

 

–    vomiting, belly pain and diarrhoea; vomit and stools may be

coloured black by the iron, or may be dark because they contain

blood,

 

–    drowsiness and unconsciousness,

 

–    fits.

 

The patient usually improves after 6-24 hours, then either

recovers or deteriorates.

 

From 12 to 48 hours:

 

–    low blood pressure,

 

–    unconsciousness,

 

–    fits,

 

–    yellow skin, caused by liver damage,

 

–    lung oedema,

 

–    low output of urine and signs of kidney damage.

 

Patients may die from liver failure.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes, and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the patient vomits for a long time, give frequent drinks to

replace water lost from the body.

 

If the medicine was swallowed less than 12 hours ago, and if the

patient is fully awake and breathing normally, and has not had fits,

make the patient vomit unless he or she has vomited a lot already. Do

not give activated charcoal because it does not bind iron.

 

Keep the patient in bed. If possible raise the foot of the bed so

that the patient’s feet are higher than the head.

 

If the patient passes very little urine, treat as recommended

in chapter nine.

 

If the patient looks yellow and has signs of liver damage, treat

as recommended in chapter nine.

 

If the patient has signs of lung oedema, treat as recommended

in chapter nine.

 

Information for doctors outside hospital

 

As well as the effects listed above, there may be hyperglycaemia

at first and hypoglycaemia later. In severe poisoning there may be a

metabolic acidosis, gastrointestinal haemorrhage, shock and

cardiovascular collapse.

 

Monitor blood pressure, fluid and electrolyte balance, white

blood cell count, blood glucose, and liver and kidney function.

Supportive care, including oxygen and mechanical ventilation, should

be given as needed:

 

*    Fluid and electrolyte balance should be corrected.

 

*    For repeated fits, diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Patients who do not have signs or symptoms of poisoning within 6

hours do not need any treatment.

 

The antidote is deferoxamine. It can be given intramuscularly or

intravenously, but it is better to give deferoxamine by intravenous

infusion if possible. Rapid intravenous bolus injection may cause

hypotension or an anaphylactoid reaction. Local pain may occur at

intramuscular injection sites, and large intramuscular injections may

cause hypotension.

 

Deferoxamine should be given to all patients with signs and

symptoms of severe poisoning such as shock, unconsciousness,

convulsions, severe vomiting or acidosis, or a serum iron

concentration greater than 5 mg/l.

 

It may be useful to give deferoxamine to patients with signs and

symptoms of mild to moderate poisoning. However, it is best to discuss

such cases with a poisons centre because it is difficult to interpret

serum iron concentrations, especially if a sustained-release

preparation was taken.

 

Dose by slow intravenous infusion:

 

adults and children: 15 mg/kg of body weight per hour (do not

give more than 80 mg/kg of body weight in 24 hours).

 

Dose by intramuscular injection:

 

adults and children: 1-2 g intramuscularly every 3-12 hours.

 

Do not give more than 6 g in 24 hours.

 

Kidney failure should be treated with haemodialysis.

 

Patients with corrosive damage to the gut may develop strictures

after 2-6 weeks.

 

Isocarboxazid, phenelzine and tranylcypromine

 

Medicines covered in this section

 

This section covers isocarboxazid, phenelzine and

tranylcypromine. They are called monoamine oxidase inhibitors (MAOIs).

 

Uses

 

These medicines are antidepressants; they are given to people who

are depressed to make them feel happier. They are given by mouth as

tablets or capsules.

 

How they cause harm

 

These medicines affect the brain and the nerves that control the

heart and muscles.

 

How poisonous they are

 

They are very poisonous and may cause death if too large a dose

is taken.

 

Special dangers

 

Depressed patients may try to kill themselves by taking too much

of their medicine. Depressed people are often careless with their

medicines and leave them where children can easily find them.

 

When these medicines are taken with alcohol, certain foods (like

cheese, chocolate, large amounts of coffee, broad beans, and pickled

herring) or certain medicines, they cause severe illness. People on

long-term treatment with monoamine oxidase inhibitors should have been

told which foods and drinks they must not have, and that they must

check with a doctor before they take any other medicines.

 

Signs and symptoms

 

The effects of a single large dose may be delayed for 12-24

hours:

 

–    excitement and irritability,

 

–    sweating, warm skin,

 

–    fast, irregular pulse,

 

–    fast breathing,

 

–    stiff muscles, stiff neck and back, the patient cannot open the

mouth, and cannot breathe easily,

 

–    shaking of the body and limbs,

 

–    low blood pressure or high blood pressure,

 

–    fits,

 

–    high temperature,

 

–    wide pupils which do not get smaller in the light,

 

–    unconsciousness,

 

–    breathing or the heart may suddenly stop, causing death.

 

If a patient taking these medicines also takes the wrong food or

medicine, the effects are:

 

–    throbbing headache,

 

–    very high blood pressure,

 

–    vomiting,

 

–    fits,

 

–    unconsciousness.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the patient has warm skin and stiff muscles, keep the patient

cool and sponge with tepid water; however this may not bring the

temperature down.

 

A patient who is very excited should be kept in a quiet, dimly

lit place. Stay calm and quiet yourself to reassure the patient.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the medicine was swallowed less than two hours ago, and if the

patient is fully awake, breathing normally, and has not had fits:

 

*    Make the patient vomit, unless he or she has already vomited a

lot.

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until vomiting has stopped.

 

Information for doctors outside hospital

 

Secondary complications include haemolysis, breakdown of the

muscles (rhabdomyolysis), kidney failure and lung oedema.

 

Monitor breathing, pulse and blood pressure for at least 24

hours. Supportive care, including oxygen and mechanical ventilation

should be given as needed:

 

*    Low blood pressure should be treated with intravenous fluids.

 

*    For repeated fits, diazepam should be given by intravenous

injection; this may not always stop the fits.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Rigid muscles may make the body temperature rise and may make it

hard for the patient to breathe. To make the muscles relax, dantrolene

may be given at a dose of 1 mg/kg of body weight by rapid intravenous

injection. This can be repeated as needed up to a total dose of

10 mg/kg. If the patient has a very high temperature (above 39°C) the

best way to lower the temperature is to give pancuronium to paralyse

the muscles, but this can only be done if the patient can be

ventilated.

 

Isoniazid

 

Uses

 

Isoniazid is used to treat tuberculosis. It is given by mouth as

tablets or liquid, or by injection. Some medicines are a mixture of

isoniazid with rifampicin, or isoniazid with pyridoxine.

 

How it causes harm

 

It affects the brain, causing fits.

 

How poisonous it is

 

It can cause serious poisoning and death.

 

Signs and symptoms

 

Within 30 minutes to 3 hours:

 

–    nausea, vomiting and belly pain,

 

–    large pupils, blurred vision,

 

–    slurred speech and dizziness,

 

–    fever,

 

–    fits,

 

–    unconsciousness,

 

–    fast pulse,

 

–    patient passes less urine, and there may be blood in the urine,

 

–    low blood pressure,

 

–    shallow breathing.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes, and keep the patient cool.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the patient has a fever, sponge the body with cool water.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If isoniazid was swallowed less than four hours ago, and if the

patient is fully awake and breathing normally, and is not vomiting,

give activated charcoal and water to drink.

 

The patient should not be made to vomit because this may cause a

fit and the patient might choke.

 

If the patient stops passing urine, treat as recommended in

chapter nine.

 

Information for doctors outside hospital

 

Complications of severe poisoning include lactic acidosis,

ketoacidosis, high blood glucose, raised white blood cell count and

kidney failure.

 

Monitor pulse, breathing, blood pressure, liver and kidney

function, blood glucose and serum electrolytes. Potassium

concentration may be lower or higher than normal. Supportive care,

including oxygen and mechanical ventilation, should be given as

needed:

 

*    Low blood pressure should be treated with intravenous fluids.

 

*    Fluid and electrolyte balance should be corrected.

 

*    For repeated fits, give intravenous diazepam.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Diazepam may not control fits until pyridoxine has been given.

The two medicines should not be given in the same infusion because

diazepam has a low solubility and may precipitate rapidly.

 

Dose of pyridoxine: adults: give 5 g intravenously over 5

minutes. If the patient has severe symptoms with fits, acidosis and

unconsciousness, the dose may be repeated every 30 minutes as needed,

until fits have stopped or the patient is awake. Note that large doses

may be neurotoxic.

 

Lithium carbonate

 

Uses

 

Lithium carbonate is used to treat mental disorders. It is given

by mouth as tablets. Some tablets are sustained-release preparations.

This means that the effects of the medicine last a long time and fewer

doses are needed per day compared with ordinary tablets.

 

How it causes harm

 

Lithium affects the brain, kidneys and heart.

 

How poisonous it is

 

Poisoning may be caused by amounts only a little larger than a

therapeutic dose. People on long-term lithium treatment may get

chronic poisoning. Patients usually recover from acute or chronic

poisoning if treated in hospital.

 

Special dangers

 

Many other medicines interact with lithium. Patients on long-term

treatment with lithium should check with their doctor before they take

other medicines.

 

Signs and symptoms

 

After acute overdose, symptoms may be delayed for 12 hours or

more. Effects are:

 

–    nausea, vomiting and diarrhoea,

 

–    thirst,

 

–    some patients pass more urine than normal,

 

–    confusion,

 

–    dizziness,

 

–    drowsiness,

 

–    shaking,

 

–    unconsciousness,

 

–    fits,

 

–    low blood pressure.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes, and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If more than the prescribed dose was taken less than 12 hours

ago, and if the patient is fully awake, breathing normally, and has

not had fits:

 

*    Make the patient vomit unless he or she has vomited a lot

already.

 

*    Give frequent drinks of water to replace water passed out in the

urine.

 

Do not give activated charcoal because it does not bind lithium.

 

Information for doctors outside hospital

 

The plasma concentration of sodium may fall and in severe

poisoning the concentration of potassium may rise. In unconscious

patients there may be changes in heart rhythm. Fluid and electrolyte

balance should be measured every 6-12 hours so that any imbalance or

dehydration can be corrected. Severe poisoning may lead to kidney

failure.

 

For repeated fits, diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Haemodialysis may be useful in removing lithium from the body in

cases of severe poisoning.

 

Magnesium hydroxide, magnesium sulfate, phenolphthalein and senna

 

Uses

 

These medicines are all laxatives (also called cathartics or

purgatives). They are given to people who cannot pass stools easily,

 

or who pass hard stools. These medicines are usually taken by mouth.

Some products are made as tablets, capsules or liquids, some as

granules or powders that have to be mixed with water, and some are put

in biscuits or bars of chocolate.

 

How they cause harm

 

Poisoning causes diarrhoea so that the patient loses too much

water from the body.

 

How poisonous they are

 

Large amounts of laxatives can cause serious poisoning and death,

but children who take a few tablets in mistake for sweets do not

usually get serious poisoning.

 

Special dangers

 

Some laxative tablets look and taste like sweets or chocolate and

children may eat them by mistake.

 

Signs and symptoms

 

Effects are:

 

–    diarrhoea, vomiting and belly pain,

 

–    pink urine if phenolphthalein has been taken,

 

–    blood in stools,

 

–    low blood pressure,

 

–    fast pulse,

 

–    unconsciousness.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes, and keep the patient warm.

 

If the patient is conscious and alert, give drinks to replace the

water lost in the vomit and stools.

 

It is not necessary to make the patient vomit.

 

Information for doctors outside hospital

 

Monitor fluid and electrolyte balance, particularly serum

potassium. Supportive care should be given as needed:

 

*    Fluid and electrolyte balance should be corrected.

 

*    Intravenous fluids should be given for severe dehydration.

 

*    Potassium chloride should be given if serum potassium

concentration is low.

 

Opiates

 

Medicines covered in this section

 

Opiates (also called opioids or narcotics) are a group of

medicines that have similar effects to morphine. Examples of opiates

are:

 

codeine                  methadone

 

dextromethorphan         morphine

 

dextropropoxyphene       opium

 

diamorphine/heroin       pentazocine

 

dihydrocodeine           pethidine

 

diphenoxylate            pholcodine

 

loperamide

 

Uses and abuse

 

Opiates are used to treat pain, cough and diarrhoea. Some

preparations contain mixtures of opiates and other medicines. Codeine,

dextropropoxyphene, diamorphine, dihydrocodeine, methadone, morphine,

pentazocine, and pethidine are used to treat pain. Some preparations

contain acetylsalicylic acid (aspirin) or paracetamol as well as an

opiate. Codeine, dextromethorphan, methadone and pholcodine are used

in cough syrups and linctuses. Codeine, diphenoxylate, loperamide and

morphine are used to treat diarrhoea. Preparations of diphenoxylate

with atropine are widely available.

 

Opiates are abused because they make people feel relaxed.

 

How they cause  harm

 

Opiates affect the brain so that the patient becomes deeply

unconscious; breathing becomes slower and may stop suddenly.

 

When diphenoxylate is taken together with atropine, it may be

many hours before the opiate affects breathing. Atropine slows down

the absorption of the opiate from the gut into the blood.

 

How poisonous they are

 

Poisonous amounts of opiates can cause death within an hour

particularly if taken with alcohol or other substances that slow down

the brain.

 

Special dangers

 

People treated with opiates may become dependent on them. People

taking opiates for a long time may need to take larger doses to get

the same effects, and may take a fatal dose by mistake.

 

Diphenoxylate with atropine can cause serious poisoning if given

to young children to treat diarrhoea. Diphenoxylate with atropine is

specially dangerous if more than the therapeutic dose is taken,

because atropine delays the effect of the opiate for many hours,

sometimes up to 30 hours after the dose. If patients with suspected

poisoning are sent home too soon, before the opiate has started to

take effect, they may stop breathing and die before there is time to

get them back to hospital.

 

Signs and symptoms

 

Effects are:

 

–    very small pupils,

 

–    drowsiness then unconsciousness,

 

–    slow breathing,

 

–    twitching or fits (from codeine, dextropropoxyphene, pethidine),

 

–    low body temperature,

 

–    low blood pressure (sometimes),

 

–    lung oedema,

 

–    the patient may suddenly stop breathing and die very quickly,

within minutes of an injection into a vein or within 1-4 hours of

taking opiate by mouth. Patients who are unconscious for a long

time may die from pneumonia.

 

Patients who are dependent on opiates may have needle marks.

 

When diphenoxylate is taken together with atropine, it may be

many hours before the opiate affects breathing. Atropine slows down

the absorption of the opiate from the gut into the blood.

 

How poisonous they are

 

Poisonous amounts of opiates can cause death within an hour

particularly if taken with alcohol or other substances that slow down

the brain.

 

Special dangers

 

People treated with opiates may become dependent on them. People

taking opiates for a long time may need to take larger doses to get

the same effects, and may take a fatal dose by mistake.

 

Diphenoxylate with atropine can cause serious poisoning if given

to young children to treat diarrhoea. Diphenoxylate with atropine is

specially dangerous if more than the therapeutic dose is taken,

because atropine delays the effect of the opiate for many hours,

sometimes up to 30 hours after the dose. If patients with suspected

poisoning are sent home too soon, before the opiate has started to

take effect, they may stop breathing and die before there is time to

get them back to hospital.

 

Signs and symptoms

 

Effects are:

 

–    very small pupils,

 

–    drowsiness then unconsciousness,

 

–    slow breathing,

 

–    twitching or fits (from codeine, dextropropoxyphene, pethidine),

 

–    low body temperature,

 

–    low blood pressure (sometimes),

 

–    lung oedema,

 

–    the patient may suddenly stop breathing and die very quickly,

within minutes of an injection into a vein or within 1-4 hours of

taking opiate by mouth. Patients who are unconscious for a long

time may die from pneumonia.

 

Patients who are dependent on opiates may have needle marks.

 

Diphenoxylate with atropine

 

Soon after the overdose:

 

–    warm face,

 

–    fast pulse,

 

–    temperature higher than normal,

 

–    hallucinations.

 

Within 2-3 hours, or as long as 30 hours after the overdose:

 

–    small pupils,

 

–    drowsiness then unconsciousness,

 

–    slow pulse,

 

–    slow breathing, which may stop altogether.

 

The patient may begin to recover, but become ill again many hours

later.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

The antidote is naloxone. Naloxone should be given if the patient

is taking fewer than 10 breaths per minute.

 

Dose: 1 ml (0.4 mg) by intramuscular injection, for adults and

children. If the patient does not wake up and begin to breathe

normally after 2-3 minutes, give another injection. Up to four doses

can be given if the patient still does not recover.

 

Keep watching breathing closely. If breathing again becomes slow,

give more naloxone until breathing is normal. Several doses may be

needed.

 

 

If there is no effect after four doses of naloxone:

 

–    the patient may have taken other drugs with opiates;

 

–    the patient may not have taken opiates; something else may have

made the patient unconscious, such as a head injury;

 

–    the poisoning may be so bad that the patient has brain damage;

 

–    the patient may have been unconscious for a long time and be very

cold.

 

For diphenoxylate with atropine: if the patient has fever,

sponge the body with cool water. If the patient has hallucinations,

keep him or her in a quiet, dimly lit place, and protect from injury.

Stay calm and quiet yourself to reassure the patient.

 

Take the patient to hospital as quickly as possible. A patient

who has taken diphenoxylate together with atropine may be in danger

even if there are no signs or symptoms.

 

Drug dependence should be treated in hospital.

 

What to do if there is a delay in getting to hospital

 

If the medicine was swallowed: if it happened less than 4 hours

ago, and if the patient is fully awake, breathing normally, and has

not had fits:

 

*    Make the patient vomit, unless the patient has

already vomited a lot.

 

*    Give activated charcoal and water to drink. If you have made the

patient vomit, wait until vomiting has stopped; give sodium

sulfate or magnesium sulfate with the charcoal.

 

If you think the patient is dependent on drugs, ask someone to

stay and help you because he or she may be violent on waking up.

 

Information for doctors outside hospital

 

As well as the effects listed above, the patient may have low

blood glucose, and there may be breakdown of the muscles

(rhabdomyolysis) leading to kidney failure.

 

Monitor breathing, pulse, blood pressure, fluid and electrolyte

balance, and blood glucose. A patient given an opiate for diarrhoea

may be dehydrated. Supportive care, including oxygen and mechanical

ventilation, should be given as needed:

 

*    Intravenous fluids should be given for low blood pressure.

 

*    Fluid and electrolyte balance should be corrected.

 

Antidote: Naloxone can be given intramuscularly, as described in the

text, or intravenously.  For adults, the dose of naloxone given

intravenously is 0.4-2 mg. If there is no response give repeated doses

of 2 mg every 2-3 minutes until the patient responds or until 10 mg

have been given. If the patient responds, start a continuous

intravenous infusion at a rate of 0.4-0.8 mg per hour. Assess the

patient’s condition after 10 hours. The infusion may need to be

continued for up to 48 hours.  For children, give 0.01 mg/kg of body

weight every 2-3 minutes to a maximum of 0.1 mg/kg of body weight.

 

A patient who has taken diphenoxylate with atropine should be

watched for at least 24-36 hours in case he or she becomes

unconscious.

 

Oral contraceptives

 

Medicines covered in this section

 

This section covers oral contraceptives containing an estrogen or

a progestogen or both.

 

Examples of estrogens: ethinylestradiol, mestranol.

 

Examples of progestogens: etynodiol, gestodene, levonorgestrel,

lynestrenol, medroxyprogesterone, megestrol, norethisterone,

noretynodrel, norgestrel.

 

Uses

 

These medicines are used for family planning. They are taken by

women to stop them having babies. They are given by mouth as tablets.

 

How poisonous they are

 

Single large doses are not harmful, and children do not usually

have any symptoms even when they have taken 20 or 30 tablets.

 

Special dangers

 

Women often keep oral contraceptives in places where children can

easily reach them.

 

Signs and symptoms

 

Effects are:

 

–    nausea and vomiting,

 

–    girls over 4 years of age may have bleeding like a monthly

period.

 

What to do

 

There is no need to do anything. If the patient is a small girl,

warn the girl and her parents that she may bleed but that it will soon

stop.

 

Paracetamol

 

Uses

 

Paracetamol (also known as acetaminophen) is widely used to treat

pain, colds and influenza. It is given by mouth as tablets, capsules

or liquid. Some medicines contain a mixture of paracetamol with

acetylsalicylic acid (aspirin), antihistamines, barbiturates, or

opiates.

 

How it causes harm

 

Large doses of paracetamol damage the liver and kidneys.

 

How poisonous it is

 

A dose of 150 mg/kg of body weight may cause liver damage.

Children rarely get serious poisoning after swallowing paracetamol.

 

Special dangers

 

Many people keep paracetamol at home, often in places where

children can easily find it.

 

Signs and symptoms

 

For the first 24 hours, the patient may not have any signs of

poisoning, or there may be:

 

–    nausea,

 

–    vomiting,

 

–    belly pain.

 

After 24-48 hours:

 

–    pain on the right side of the belly.

 

After 2-6 days:

 

–    yellow colour to skin and whites of eyes, showing that the liver

is damaged,

 

–    vomiting as a result of liver damage,

 

–    fast, irregular pulse,

 

–    confusion,

 

–    unconsciousness.

 

The patient may die as a result of liver damage.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes, and keep the patient warm.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the paracetamol was swallowed less than 15 hours ago and the

patient is fully awake and breathing normally, give methionine as an

antidote (dose given below).

 

Do not give activated charcoal because this will bind methionine

and stop it working as an antidote.

 

Dose of methionine:

 

adults: 2.5 g by mouth, every 4 hours for 4 doses.

 

children: 1 g by mouth, every 4 hours for 4 doses.

 

The first dose of methionine should not be given more than 15

hours after the paracetamol was taken. If the patient vomits within 1

hour of taking methionine, repeat the dose once.

 

If the patient has signs of liver damage, treat as recommended

in chapter nine.

 

Information for doctors outside hospital

 

Monitor fluid, electrolytes, blood glucose, and liver and kidney

function. Supportive care should be given as needed and fluid and

electrolyte balance should be corrected.

 

Antidotes. These are most effective if given within 8-10 hours, and

are probably not effective later than 24 hours after the patient took

the paracetamol. If it is likely that the patient has taken a

poisonous dose, start giving an antidote at once. If possible discuss

this with a poisons centre first. Doses given here are only a guide.

Do not give activated charcoal if giving antidote by mouth.

 

Methionine may be given if it is less than 15 hours since the

paracetamol was swallowed and if the patient can be given medicine by

mouth. Doses are given in the main text.

 

Acetylcysteine may be used if the paracetamol was swallowed less

than 24 hours ago. It can be given intravenously or by mouth. When

given by mouth it may cause nausea and vomiting. Intravenous

acetylcysteine may cause nausea, flushing, skin reactions and, rarely,

angio-oedema, wheezing, and respiratory distress. If serious reactions

occur, stop the infusion, give antihistamine then either restart the

infusion or give methionine instead.

 

Dose for adults and children:

 

–    150 mg/kg of body weight in 200 ml of 5% dextrose, by slow

intravenous infusion over 15 minutes;  then

 

–    50 mg/kg of body weight by intravenous infusion in 500 ml of 5%

dextrose over 4 hours;  then

 

–    100 mg/kg of body weight in 1000 ml of 5% dextrose over 16 hours.

 

This gives a total dose of 300 mg/kg of body weight, given over

20 hours 15 minutes.

 

If you do not have a preparation of acetylcysteine that can be

given intravenously, preparations meant for treating chronic asthma

can be given by mouth.

 

These are usually 10% or 20% solutions of acetylcysteine. They

should be diluted immediately before use with fruit juice, soft drink

or water to make a 5% solution.

 

Dose of 5% acetylcysteine solution, given as a drink: a total dose

of 1330 mg of acetylcysteine per kg of body weight should be given

over 72 hours as follows:

 

–    140 mg/kg of body weight at first;  then

 

–    70 mg/kg of body weight every 4 hours, 17 times (over 68 hours).

 

If the patient vomits less than one hour after a dose it should

be repeated.

 

The plasma paracetamol concentration, measured at least 4 hours

after a single overdose, shows the likelihood of liver damage and the

need for an antidote. The result should be discussed with a poisons

centre if possible. If the plasma paracetamol concentration is low,

stop giving the antidote. Plasma concentrations are unreliable if the

patient has taken more than one large dose. All such patients should

be given acetylcysteine.

 

Penicillin and tetracycline antibiotics

 

Medicines covered in this section

 

This section covers penicillin and tetracycline and similar

antibiotics.

 

Examples of medicines similar to penicillin: amoxicillin,

ampicillin, benzyl-penicillin, and cloxacillin.

 

Examples of medicines similar to tetracycline: doxycycline,

oxytetracycline.

 

Uses

 

These medicines are given to treat infections. They are given by

mouth as tablets, capsules or liquid, by injection or by intravenous

infusion.

 

How poisonous they are

 

Single large doses of these medicines taken by mouth are not

poisonous, but some people are allergic to penicillin-like medicines.

After one dose they may get a mild allergic reaction, like a rash, or

a severe reaction that may cause death.

 

Special dangers

 

Some liquid antibiotic medicines have a sweet or fruity taste and

children may think they are soft drinks.

 

Signs and symptoms

 

If the patient is not allergic:

 

–    nausea, vomiting and diarrhoea.

 

If the patient is allergic:

 

–    itching and rash,

 

–    difficulty in swallowing,

 

–    swelling round the eyes,

 

–    wheezing, gasping for air and difficulty in breathing,

 

–    weakness and dizziness,

 

–    cold, sweaty skin,

 

–    chest pain,

 

–    fast, weak pulse,

 

–    low blood pressure,

 

–    unconsciousness.

 

What to do

 

No treatment is needed unless the patient has an allergic

reaction.

 

If the patient has an allergic reaction

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

Put the patient flat on his or her back, with the head turned to

one side, and the legs raised higher than the head (by resting the

feet on a box, for example). This will help the blood to reach the

brain and lessen the danger of vomit blocking the airway. Check

breathing every 10 minutes, and keep the patient warm.

 

Take the patient to hospital as quickly as possible.

 

Information for doctors outside hospital

 

If the patient has a severe allergic (anaphylactic) reaction:

 

*    Give oxygen by face-mask in as high a concentration as possible.

Insert an airway if the patient is unconscious.

 

*    Give epinephrine (adrenaline) by intramuscular injection as soon

as possible, unless there is a strong central pulse and the

general condition is good. Any delay may be fatal.

 

Age                 Dose of epinephrine (1 in 1000, 1 mg/ml)

 

Under 1 year                    0.05 ml

 

1 year                          0.1 ml

 

2 years                         0.2 ml

 

3-4 years                       0.3 ml

 

5 years                         0.4 ml

 

6-12 years                      0.5 ml

 

Adult                           0.5-1 ml

 

These doses may be repeated every 10 minutes until blood pressure

and pulse improve. Doses should be reduced for underweight children.

 

It is useful to give antihistamines, such as chlorphenamine or

promethazine, by slow intravenous injection after the epinephrine, to

treat skin rash, itching or swelling and prevent relapse.

 

If the patient does not get better, supportive care should be

given as needed:

 

–    oxygen and mechanical ventilation,

 

–    intravenous fluids,

 

–    inhaled salbutamol or intravenous theophylline may be useful for

asthma or wheezing.

 

Proguanil

 

Uses

 

Proguanil is used to prevent and treat malaria. It is given by

mouth as a tablet.

 

How poisonous it is

 

It does not cause serious poisoning, even when quite large

overdoses are taken.

 

Signs and symptoms

 

Effects are:

 

–    nausea, vomiting and diarrhoea,

 

–    blood in the urine.

 

What to do

 

If the patient has vomiting and diarrhoea, give frequent drinks

of water to replace water lost from the body. There is no need to make

the patient vomit.

 

Rifampicin

 

Uses

 

Rifampicin is used to treat tuberculosis and other diseases

caused by bacteria. It is used with dapsone to treat leprosy. It is

given by mouth as tablets, capsules or liquid or by intravenous

infusion.

 

How it causes harm

 

It affects the blood, liver and kidneys.

 

How poisonous it is

 

Poisoning from taking a single large dose can result in death,

but most patients recover if they are given treatment. Some people on

long-term treatment may develop chronic poisoning. Poisoning is more

severe in people who frequently drink large amounts of alcohol or have

liver disease.

 

Signs and symptoms

 

Acute poisoning

 

Effects are:

 

–    orange-red colour in the skin, urine, faeces, sweat and tears;

the red colour can be removed from the skin by washing,

 

–    warm skin, itching, sweating and swelling of the face,

 

–    nausea, vomiting and belly pain,

 

–    lethargy and unconsciousness,

 

–    after 6-10 hours, the whites of the eyes become yellow,

 

–    fits.

 

Death may occur suddenly.

 

Chronic poisoning

 

Effects are:

 

–    nausea, vomiting, constipation or diarrhoea, and belly pain,

 

–    skin rash, itching and warm skin,

 

–    influenza-like symptoms,

 

–    signs of liver and kidney damage.

 

What to do

 

Acute poisoning

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes, and keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If rifampicin was swallowed less than 4 hours ago, and if the

patient is fully awake and breathing normally:

 

*    Make the patient vomit unless he or she has vomited a

lot already.

 

*    Give activated charcoal mixed with water to drink. If

you have made the patient vomit, wait until vomiting has stopped.

 

Give repeated doses of activated charcoal and water every 2-4

hours for 24 hours (adults, 50 g per dose; children, 10-15 g per

dose). With each dose of charcoal give sodium sulfate or magnesium

sulfate, 30 g for adults, 250 mg/kg of body weight for children, until

the stools look black.

 

Chronic poisoning

 

If the patient has signs of liver damage, treat as recommended in chapter nine.

If there are signs of kidney damage, treat as recommended in chapter nine.

 

Information for doctors outside hospital

 

Acute poisoning

 

Monitor pulse, breathing, blood pressure and kidney function.

Supportive care, including oxygen and mechanical ventilation, should

be given as needed. For repeated fits, diazepam should be given by

intravenous injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Chronic poisoning

 

Chronic poisoning may cause blood disorders such as

thrombocytopenia, eosinophilia, leukopenia, and haemolytic anaemia.

Complete blood counts and platelet counts should be done. Liver

function should be monitored.

 

Salbutamol

 

Uses

 

Salbutamol is used to treat asthma. It is given by mouth as

tablets, intravenously by injection or infusion, or as preparations,

such as sprays or aerosols, that can be breathed in.

 

How it causes harm

 

It affects the nerves that control the heart and breathing.

 

How poisonous it is

 

Salbutamol does not usually cause serious poisoning.

 

Special dangers

 

Salbutamol is commonly prescribed for children with asthma, and

is often kept where children can easily find it. Young teenagers

sometimes abuse salbutamol because it causes feelings of excitement.

They spray the aerosol into their mouths.

 

Signs and symptoms

 

Effects are:

 

–    excitement and agitation,

 

–    hallucinations,

 

–    fast pulse,

 

–    palpitations,

 

–    shaking,

 

–    fits,

 

–    lung oedema.

 

What to do

 

Give first aid. For fast pulse or palpitations, make the patient

rest until the pulse is normal again.

 

Information for doctors outside hospital

 

Serious complications include low plasma potassium concentration,

heart rhythm disorders including ventricular tachyarrhythmias, high

blood glucose and lactic acidosis.

 

Monitor pulse and blood pressure, fluid and electrolyte balance,

and blood glucose. Supportive care should be given as needed: fluid

and electrolyte balance should be corrected, particularly plasma

potassium.

 

There should not be any need to treat tachycardia. Severe

arrhythmias can be treated with a small dose of propranolol by slow

intravenous injection (adult dose 1-2 mg). Do not give propranolol to

an asthmatic patient because it may cause an asthmatic attack.

 

Plants, animals and natural toxins

 

Plants that contain atropine

 

Plants covered in this section

 

All the plants in this section contain atropine. The most common

are  Atropa belladonna (commonly called deadly nightshade or

enchanter’s nightshade),  Datura stramonium (commonly called thorn

apple, jimson weed or angel’s trumpet), and  Hyoscyamus niger

(commonly called henbane).

 

Atropa belladonna is a shrub with bell-shaped purple or red flowers

and purple or black berries, found in Europe, north Africa and west

Asia.  Datura stramonium is a herb that grows 1-1.5 m high, with

funnel-shaped white or mauve flowers. The fruits are prickly or spiny

capsules containing several black seeds. The plant has an unpleasant

smell. It is native to north America but is found throughout the

world.  Hyoscyamus niger is a herb with yellow flowers, some with

purple markings, and has an unpleasant smell. It is found in north and

south America, Europe, India, and western Asia.

 

Uses and abuse

 

Datura stramonium is used in folk medicine to prevent or treat

asthma.  Atropa belladonna and  Datura are abused for their

hallucinogenic effects. The seeds of  Datura are most commonly used.

Sometimes the leaves are infused in water to make a drink, or made

into cigarettes and smoked. In some countries these plants are used to

cause abortion.

 

How they cause harm

 

They excite the brain and affect the nerves that control the

heart, eyes, gut and bladder. They make the skin and mouth dry, and

cause fever, wide pupils, fast heartbeat and fast breathing.

 

How poisonous they are

 

All parts of these plants are poisonous if eaten, even when cooked

or boiled, because the poison is not destroyed by heat.  Atropa

and Hyoscyamus both contain sap that is irritant to the skin and

eyes. The sap of  Atropa may cause poisoning if it gets in the eye.

 

The amount of atropine that causes poisoning varies. Most people

recover from poisoning within 24 hours, but poisoning may be severe,

especially in old people and young children.

 

Special dangers

 

There is a danger of poisoning when these plants are abused for

their hallucinogenic effects. Children may eat the berries of  Atropa

and the flowers and seeds of  Datura. Some cases of poisoning have

occurred as a result of  Datura being mistaken for an edible plant

such as spinach, and berries of  Atropa for edible fruit.

 

Signs and symptoms

 

*    If swallowed:

 

–    red, dry skin,

 

–    wide pupils,

 

–    blurred vision,

 

–    dry mouth and thirst,

 

–    confusion and hallucinations,

 

–    excitement and aggression,

 

–    fast pulse,

 

–    the patient cannot pass urine,

 

–    unconsciousness,

 

–    fever,

 

–    fits (rarely).

 

*    On the skin  (Atropa belladonna and  Hyoscyamus niger):

 

–    redness and irritation,

 

–    blistering.

 

*    In the eyes:

 

–    same effects as if swallowed.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes.

 

If the patient has a fit, treat as recommended in chapter five.

 

If the patient has fever, sponge the body with cool water.

 

A patient who is confused, very restless or aggressive, or who

has hallucinations, should be kept in a quiet, dimly lit place and

protected from injury. Stay calm and quiet yourself to reassure the

patient.

 

Take the patient to hospital as quickly as possible.

 

On the skin

 

Atropa belladonna and  Hyoscyamus niger

 

As soon as possible wash exposed skin with soap and water and a

soft sponge. Relieve itching and inflammation with cold compresses.

Tell the patient not to scratch the skin.

 

If the patient has a mild skin reaction (redness, dry rash) apply

hydrocortisone cream. If the rash is oozing or if there are blisters

do not use hydrocortisone cream. Take the patient to hospital.

 

In the eyes

 

Wash the eyes for at least 15-20 minutes with running water. Take

the patient to hospital.

 

What to do if there is a delay in getting to hospital

 

If the patient swallowed one of these plants less than 6 hours

ago, is fully awake and breathing normally, and has not had fits:

 

*    Make the patient vomit unless he or she has already

vomited a lot.

 

*    Give activated charcoal and water to drink. If you

have made the patient vomit, wait until vomiting has stopped.

Give repeated doses of activated charcoal every 4 hours (adults

50 g, children 10-30 g). With each dose of charcoal give sodium

sulfate or magnesium sulfate, 30 g for adults, 250 mg/kg of body

weight for children, until the stools look black.

 

Information for doctors outside hospital

 

As well as the effects listed above, there may be heart rhythm

disturbances.

 

Monitor breathing and blood pressure. Supportive care, including

oxygen and ventilation, should be given as needed. For repeated fits,

diazepam should be given by intravenous injection, but there is a risk

that diazepam might affect breathing.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Do not use chlorpromazine to treat agitated patients.

 

Physostigmine may be useful in life-threatening poisoning but may

itself have life-threatening side-effects, so it should only be given

in hospital with the patient on a heart monitor.

 

Cannabis

 

The substance covered in this section

 

Cannabis, also known as marijuana, Indian hemp, hashish, ganja,

pot, dope and grass, is made from the Indian hemp plant  Cannabis

sativa.

 

Uses and abuse

 

Cannabis is often abused and, in some countries, is used almost

as much as alcohol or tobacco. It makes people feel relaxed and makes

colours and sounds seem brighter and louder. The dried plant is made

into cigarettes or put in a pipe and smoked. Sometimes it is taken

with food. Some people inject it.

 

How it causes harm

 

Cannabis affects the brain.

 

How poisonous it is

 

It does not cause much harm to adults, unless it is injected.

Children are likely to get signs of poisoning but usually recover.

 

Signs and symptoms

 

Effects start within 10 minutes of smoking the drug and last for

about 2-3 hours. When the drug is eaten the effects start within 30-60

minutes and last for 2-5 hours. The effects are:

 

–    usually a feeling of well-being, happiness and sleepiness, but

high doses may cause fear, panic and confusion,

 

–    fast pulse,

 

–    the person cannot balance when standing up,

 

–    hallucinations,

 

–    drowsiness,

 

–    slurred speech,

 

–    coughing if the drug is breathed in, as when smoking cigarettes.

 

If the drug is injected it may cause more serious problems:

 

–    severe headache,

 

–    dizziness,

 

–    irregular breathing,

 

–    fever,

 

–    low blood pressure,

 

–    unconsciousness.

 

What to do

 

Give first aid. If the patient is unconscious or drowsy, lay him

or her on one side in the recovery position. Check breathing every 10

minutes.

 

A patient who is anxious or confused should be kept in a quiet,

warm room.

 

If the cannabis was swallowed: there is no need to make the patient

vomit. If the patient is fully awake, breathing normally, and not

vomiting, give activated charcoal and water to drink.

 

A patient who has injected cannabis should be taken to hospital

as quickly as possible.

 

Information for doctors outside hospital

 

If the patient is hallucinating or violent, give chlorpromazine,

50-100 mg (adult dose), intramuscularly.

 

If cannabis has been injected

 

Monitor breathing, pulse, blood pressure, temperature. Supportive

care, including oxygen and mechanical ventilation, should be given as

needed:

 

*    Low blood pressure should be treated by keeping the patient lying

with the feet higher than the head; intravenous fluids can be

given.

 

Irritant plants

 

Plants covered in this section

 

The plants covered in this section cause skin reactions. Some are

poisonous if swallowed.

 

The cashew nut tree  (Anacardium occidentale) is found in most

tropical countries. The nut shell, but not the kernel, contains an

irritant brown, oily juice. Roasting the shell destroys these

chemicals.

 

Dumb-cane ( Dieffenbachia species) has a thick, fleshy stem and

oval or lance-shaped green leaves, often with yellow or white

markings. It grows wild in tropical areas but is a common houseplant

in many countries.

 

The spurges ( Euphorbia species) are a large group of plants

ranging from trees to herbs.

 

Poison ivy,  Rhus radicans (Toxicodendron radicans), and poison

oak,  Rhus toxicodendron (Toxicodendron toxicarium), grow wild mainly

in northern America and northern Mexico. They are sometimes found in

other countries as garden plants. Poison ivy is a climbing plant and

may be found clinging to trees or houses. Poison oak is a shrub-like

plant, forming a bush or small tree. The plants have white flowers and

green berries, and green leaves that turn red, yellow, violet or

orange in autumn. African poison ivy  (Smodingium argutum) contains

poison similar to that of the American species.

 

The mango  (Mangifera indica) is a large tree with green to

yellow-red fruit, found in east Asia, Myanmar, some parts of India,

and Central America.

 

The common stinging nettle,  Urtica dioica, is an annual or

perennial herb that grows as a weed on wasteland in temperate areas.

 

How they cause harm

 

The sap of spurge plants irritates the skin and affects the brain

if swallowed. Sap from cut leaves or stems of dumb-cane causes severe

irritation of the lips and inside of the mouth and throat, and can

affect the heart and muscles if swallowed. Skin reactions to the

common stinging nettle are caused by brushing against stinging hairs

on the stem and leaves that release irritant chemicals. This plant is

not poisonous if swallowed.

 

Cashew nut shells, mango leaves, stems and fruit skins, African

poison ivy, poison ivy, and poison oak cause intense allergic skin

reactions in sensitive individuals. Allergic reactions to African

poison ivy, poison ivy and poison oak can be caused by contact with

bruised or broken plant tissue, wood sap, sawdust or smoke from

 

burning plants. Contaminated fingers or clothing may spread the rash

over the body.

 

How poisonous they are

 

Stinging nettles and spurges usually produce only mild skin

reactions. Dumb-cane may be dangerous if swelling blocks the airway.

The severity of the skin reactions to cashew nut shells, mango,

African poison ivy, poison ivy and poison oak depends on the

sensitivity of the individual; people vary greatly in their

sensitivity. People rarely swallow enough of any of these plants to

get systemic poisoning.

 

Signs and symptoms

 

Dumb-cane

 

*    If swallowed:

 

–    swollen lips, mouth and tongue which may make it difficult to

talk, swallow or breathe,

 

–    severe burning pain inside the mouth,

 

–    rarely, slow heart rate and muscle cramps.

 

*    In the eyes:

 

–    intense pain that is worse in bright light,

 

–    redness and watering,

 

–    injury to the surface of the eye.

 

*    On the skin (contact with sap):

 

–    irritation, burning and redness,

 

–    blistering.

 

Poison ivy, poison oak, cashew nut shells and parts of the mango tree

 

*    If swallowed:

 

–    flushed face,

 

–    burning and itching of the lips and mouth,

 

–    drowsiness,

 

–    severe vomiting and diarrhoea,

 

–    fever.

 

*    On the skin

 

The effects usually occur within 24-48 hours but may appear

sooner or be delayed for 1-2 weeks:

 

–    intense itching, burning, redness,

 

–    blisters,

 

–    swelling of face and eyelids,

 

–    oozing rash with crusting and scaling.

 

*    In the eyes:

 

–    pain that is worse in bright light,

 

–    redness, watering and swelling of the eyelids.

 

Spurges

 

*    If swallowed:

 

–    burning pain and redness in the mouth and throat,

 

–    vomiting and diarrhoea,

 

–    rarely, fits and unconsciousness.

 

*    In the eyes:

 

–    burning pain,

 

–    blurred vision,

 

–    watering.

 

*    On the skin (within 24 hours):

 

–    painful rash,

 

–    itching and burning,

 

–    blisters.

 

Stinging nettle

 

*    On the skin:

 

–    immediate stinging, itching and burning,

 

–    redness and rash within an hour of contact.

 

What to do

 

If swallowed

 

If the patient can swallow, give cold drinks or ice to relieve

pain. Do not make the patient sick. If there is severe swelling of the

tongue or throat or difficulty in breathing, take the patient to

hospital.

 

On the skin

 

As soon as possible wash exposed skin with soap and water and a

soft sponge. The poisons from poison ivy and similar plants are

absorbed through the skin within 15 minutes; after that washing will

not remove them.

 

Relieve itching and inflammation with cold compresses. Tell the

patient not to scratch the skin.

 

If the patient has a mild skin reaction (redness, dry rash) apply

hydrocortisone cream.

 

If the rash is oozing or if there are blisters do not use

hydrocortisone cream. Take the patient to hospital.

 

In the eye

 

As soon as possible wash the eye for at least 15-20 minutes with

running water. If this does not relieve symptoms take the patient to

hospital.

 

Information for doctors outside hospital

 

Supportive care should be given as needed. Give an antihistamine

such as diphenhydramine, by mouth or by intramuscular injection, to

relieve itching.

 

For moderate to severe dermatitis from poison ivy give systemic

corticosteroids such as prednisone.

 

Oleanders

 

Plants covered in this section

 

This section covers the common oleander,  Nerium oleander, and

the yellow oleander,  Thevetia peruviana.

 

Nerium oleander is an evergreen shrub with clusters of white,

pink, dark red, orange or yellow flowers with a sweet smell. It is

found in China, India and places with Mediterranean climates, and is

 

grown as a garden plant. All parts of the plant are poisonous and

crushed leaves and stems are irritant to the skin.

 

Thevetia peruviana is a small ornamental tree with bright

yellow flowers and fleshy round fruits which are green when unripe and

black when ripe, and which contain a nut. The plant has milky white

sap. It grows wild in Central and South America, and in gardens in

tropical and subtropical regions.

 

How it causes harm

 

Both plants contain poisons that affect the heart in a similar

way to digitalis. The poisons are found in all parts of the plants.

 

How poisonous they are

 

Serious poisonings and deaths have been reported in children and

adults from eating the fruit of  Thevetia. Nerium oleander is also

reported to have caused deaths.

 

Special dangers

 

The bright flowers of both plants and the green fruit of

Thevetia are attractive to children. In Sri Lanka, the seeds of

Thevetia are eaten by people who want to kill themselves, and in

Bengal they are used to cause abortions.

 

Signs and symptoms

 

Effects are:

 

–    numbness or burning pain in the mouth,

 

–    nausea and vomiting, which may be severe,

 

–    diarrhoea,

 

–    belly pain,

 

–    pulse may be fast, slow or irregular,

 

–    drowsiness,

 

–    unconsciousness,

 

–    possibly fits.

 

The effect on the heart may result in death.

 

What to do

 

Give first aid. If breathing stops open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the plant was swallowed less than 4 hours ago, and if the

patient is fully awake and breathing normally, has not had fits, and

is not already vomiting:

 

*    Make the patient vomit.

 

*    When the patient has stopped vomiting, give activated charcoal

and water to drink. Give sodium sulfate or magnesium sulfate with

the charcoal.

 

Information for doctors outside hospital

 

As well as the effects listed above there may be changes in heart

rhythm, including bradycardia, heart block, ventricular tachycardia

and ventricular fibrillation. Heart rhythm may be disturbed for up to

5 days. Plasma potassium concentration may be raised.

 

Monitor breathing, pulse, blood pressure, fluids and

electrolytes. Give supportive care as needed.

 

Ornamental beans

 

Plants covered in this section

 

This section covers the bean-shaped seeds of  Ricinus communis

(castor oil bean) and  Abrus precatorius (jequirity bean).

 

Abrus precatorius is a climbing plant with clusters of small

pink flowers. The fruit is a flat pod containing 3-5 small seeds,

which are shiny red with a black patch. It grows in countries with

subtropical or tropical climates such as south China, India,

Philippines, Sri Lanka, Thailand, and tropical Africa.

 

Ricinus communis is a large non-woody plant, growing up to 3

metres high, with large palm-like leaves and round, prickly fruits.

The bean-shaped seeds are usually mottled pink and grey. The plant is

common in the tropics where it is grown as a crop and is also found

scattered on farmland and roadsides.

 

Uses

 

The beans of both these plants are made into necklaces and

rosaries, and children may be given seeds to use in handicrafts and as

an aid to counting. However, these uses are not recommended. Castor

 

oil beans are used to make castor oil. Castor oil that has been

treated to destroy the poison is used as a laxative.

 

How they cause harm

 

They contain poisons that damage the blood cells, the gut and the

kidneys.

 

How poisonous they are

 

The beans can cause death if they are chewed, but because the

outer shell is very hard, poisoning does not occur if the beans are

swallowed whole. Contact with the eyes may cause irritation and

blindness, and skin contact may result in a rash.

 

Special dangers

 

Children have been poisoned by chewing and eating beans from

necklaces. The brightly coloured seeds of the jequirity bean are

especially attractive to children.

 

Signs and symptoms

 

*    If swallowed

 

Effects are delayed for 2 hours or up to 2 days:

 

–    burning pain in the mouth and throat,

 

–    severe vomiting,

 

–    belly pain,

 

–    diarrhoea with blood,

 

–    dehydration,

 

–    drowsiness,

 

–    fits,

 

–    the patient passes blood-stained urine, in smaller volumes than

normal.

 

Death may occur up to 14 days later.

 

*    In the eyes:

 

–    reddening and swelling,

 

–    sometimes blindness.

 

*    On the skin:

 

–    redness,

 

–    rash.

 

What to do

 

Take any bits of seed out of the mouth. If the patient has a fit,

treat as recommended in chapter five.

 

In the eyes

 

For eye contact with  Abrus seeds: wash the eye for at least

15-20 minutes with running water.

 

On the skin

 

Wash the skin thoroughly with soap and water.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the poison was swallowed: if it happened less than 4 hours ago,

and if the patient is fully awake and breathing normally, has not had

fits, and is not already vomiting:

 

*    Make the patient vomit.

 

*    When the patient has stopped vomiting, give activated charcoal

and water to drink. Give sodium sulfate or magnesium sulfate with

the charcoal.

 

Information for doctors outside hospital

 

The poisons in  Abrus precatorius and  Ricinus communis cause

haemorrhage and oedema in the gut; secondary complications include

cerebral oedema and irregular heart rhythm.

 

Monitor breathing, pulse, blood pressure, fluids and

electrolytes, and kidney function. Give supportive care as needed.

Give analgesics for pain. There is no antidote.

 

For repeated fits, diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Peritoneal dialysis or haemodialysis may be needed for treatment

of kidney failure.

 

Mushrooms

 

Plants covered in this section

 

This section covers  Amanita species, including  Amanita

muscaria, A. pantherina (the panther),  A. phalloides (death cap),

1. verna (destroying angel) and A. virosa, and species of

Clitocybe, Coprinus (common ink cap),  Cortinarius, Inocybe,

Lepiota, Psilocybe semilanceata (liberty cap) and  Psilocybe

cubensis (magic mushroom).

 

How they cause harm

 

1. muscaria and A. pantherina cause hallucinations and sleep

or unconsciousness;  A. phalloides, A. virosa, A. verna, Cortinarius

speciosissimus and Lepiota species contain poisons that damage

cells;  Clitocybe and  Inocybe species contain a poison that causes

sweating and affects the gut;  Coprinus atramentarius only causes

poisoning when alcohol is taken as well.  Psilocybe semilanceata and

1. cubensis cause hallucinations without sleep.

 

How poisonous they are

 

Most mushrooms cause only mild to moderate poisoning but some

kinds can cause severe poisoning and death. Mushrooms that contain

cell-damaging poisons are highly poisonous and may cause death. Many

people have died after eating  Amanita phalloides.

 

Special dangers

 

Identification of mushrooms is very difficult. It is often

difficult to distinguish poisonous mushrooms from non-poisonous ones

and most poisonings happen when poisonous kinds are eaten by mistake.

Cooking may destroy the poison in some cases, but many kinds,

including  Amanita species, are poisonous even after cooking.

 

Signs and symptoms

 

1. muscaria and A. pantherina

 

Within 30 minutes to 2 hours:

 

–    dizziness,

 

–    incoordination,

 

–    staggering,

 

–    muscle jerking or tremors,

 

–    agitation, anxiety, euphoria or depression,

 

–    hallucinations,

 

–    deep sleep or unconsciousness.

 

1. phalloides, A. virosa, A. verna, and Lepiota species

 

Effects may be delayed for 6-14 hours and sometimes for as long

as 24 hours:

 

–    belly pain, nausea, severe vomiting, intense thirst, and

diarrhoea, lasting about 2-3 days.

 

After 3-4 days:

 

–    jaundice,

 

–    fits,

 

–    unconsciousness,

 

–    signs of kidney damage.

 

Death may occur within 6-16 days as a result of liver and kidney

failure.

 

Clitocybe and  Inocybe species

 

Effects may occur within a few minutes or be delayed a few hours:

 

–    sweating,

 

–    wet mouth and wet eyes,

 

–    belly pain, nausea, vomiting and diarrhoea,

 

–    blurred vision,

 

–    muscle weakness.

 

Effects may last for up to 24 hours.

 

Coprinus atramentarius

 

If alcohol is taken at the same time or within a few hours or

days:

 

–    a metallic taste in the mouth,

 

–    red face and neck,

 

–    palpitations and chest pain,

 

–    headache,

 

–    dizziness,

 

–    sweating,

 

–    nausea, vomiting, and diarrhoea.

 

Cortinarius speciosissimus

 

Effects may be delayed 36-48 hours:

 

–    nausea, vomiting, diarrhoea,

 

–    muscle aches and back pain,

 

–    headache,

 

–    chills.

 

After 2-17 days:

 

–    the patient stops passing urine,

 

–    signs of kidney failure.

 

Psilocybe semilanceata and  P. cubensis

 

Within 30 minutes to 2 hours:

 

–    laughing,

 

–    muscle weakness,

 

–    drowsiness,

 

–    hallucinations, increased perception of colour,

 

–    anxiety,

 

–    nausea.

 

The effects last several hours.

 

More serious poisoning may occur in small children, producing

fits and unconsciousness.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm.

 

If the patient has a fit treat as recommended in chapter five.

 

If the patient has hallucinations or is very agitated, keep him

or her in a quiet, dimly lit place, protected from injury. Stay calm

and quiet yourself to reassure the patient.

 

Take the patient to hospital as quickly as possible.

 

What to do if there is a delay in getting to hospital

 

If the mushroom was eaten less than 4 hours ago, and if the

patient is fully awake, breathing normally, has not had fits, and is

not already vomiting:

 

*    Make the patient vomit.

 

*    When the patient has stopped vomiting give activated charcoal and

water to drink. Give sodium sulfate or magnesium sulfate with the

charcoal.

 

If the patient has signs of liver damage, treat as recommended

in chapter nine. If the patient has signs of kidney damage, treat as

recommended in chapter nine.

 

Information for doctors outside hospital

 

Monitor breathing, heart, blood pressure, fluids and

electrolytes. Supportive care, including oxygen and mechanical

ventilation, should be given as needed:

 

*    Fluid and electrolyte balance should be corrected.

 

*    For repeated fits, diazepam should be given by intravenous

injection.

 

Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,

repeated if necessary after 30-60 minutes; this may be followed by

intravenous infusion to a maximum of 3 mg/kg of body weight over 24

hours.

 

Children: 200-300 µg/kg of body weight.

 

Amanita spp. and  Lepiota spp.: monitor liver and kidney

function. Liver failure is reversible but the risk of fatal

complications is high.

 

Clitocybe and  Inocybe species: severe poisoning should be

treated with atropine to clear secretions.

 

Cortinarius, Amanita spp.,  Lepiota spp.: monitor kidney

function. Haemodialysis may be needed to treat kidney failure.

 

Psilocybe spp.: for severe agitation give diazepam or

chlorpromazine.

 

Snakes

 

Snakes covered in this section

 

This section covers:

 

*     Elapid snakes: coral snakes ( Micrurus species) found in South,

Central and North America; cobras ( Naja species) found in

Africa and Asia; kraits ( Bungarus species) found in Asia; and

mambas ( Dendroaspis species) found in Africa.

 

*     Viperid snakes: lance-headed vipers ( Bothrops species) found in

Central and South America; green pit vipers  (Trimeresurus

species) found in Asia; puff adders ( Bitis species) found in

Africa; saw-scaled vipers ( Echis species) found in Africa, Asia

and the Eastern Mediterranean; true vipers  (Vipera species)

found in Africa, Asia and Europe; rattlesnakes ( Crotalus

species) found in North, Central and South America; moccasins

( Agkistrodon species) found in North America; and pit vipers

( Agkistrodon or  Calloselasma species) found in Asia.

 

*     Hydrophid snakes: sea snakes.

 

How they cause harm

 

Elapid snakes

 

The venoms affect the nervous system causing paralysis. Venoms

from African and some Asian cobras can cause marked swelling,

blistering and damage to the skin near the bite. Venoms from kraits,

mambas, coral snakes and other cobras cause swelling but no local skin

damage.

 

Viperid snakes

 

The venoms affect the blood, the heart, and the circulation.

Usually venoms also cause severe damage to the skin and muscle near

the bite.

 

Hydrophid snakes

 

The venoms affect the nervous system and cause paralysis.

 

How poisonous they are

 

Many venomous snakes can cause death. However, many people

survive bites even from very poisonous snakes, because snakes

sometimes bite without injecting venom or inject too little venom to

cause serious envenomation. For example, although the carpet viper

(Echis carinatus) probably bites and kills more people than any

other species of snake, in the Benue Valley of northeastern Nigeria

88% of people survive after being bitten, and in northern Ghana 72% of

people survive.1

 

Special dangers

 

It is dangerous to disturb or handle any snake. In areas where

snakes live, it is dangerous to walk through tall grass, forests,

jungles, or deep sand, or to climb rocks and trees, especially at

night; people should wear boots, socks and long trousers to protect

themselves. Farmers, plantation workers, herders, hunters and fishers

in rural areas of the tropics are particularly at risk, as well as

children. Some snakes, such as Asiatic kraits and African cobras, may

enter dwellings at night and bite people while they are asleep.

 

Signs and symptoms

 

Elapid snakes

 

*    Local effects

 

From kraits, mambas, coral snakes and some cobras:

 

–    mild pain,

 

–    little or no swelling or damage to the skin near the bite.

 

From African spitting cobras and some Asian cobras:

 

–    severe pain,

 

–    blisters,

 

–    large areas of skin destroyed near the bite.

 

__________

 

1    Warrell DA. Injuries, envenoming, poisoning, and allergic

reactions caused by animals. In: Weatherall D J, Ledingham JGG,

Warrell DA, eds,  Oxford textbook of medicine, 3rd ed. Oxford,

Oxford University Press, 1996:1127.

 

*    Early signs of poisoning, within 15 minutes after the bite or

delayed for up to 10 hours:

 

–    paralysis of the muscles in the face, lips, tongue and throat,

causing slurred speech, drooping eyelids, difficulty in

swallowing,

 

–    muscle weakness,

 

–    lips and tongue blue or pale,

 

–    headache,

 

–    cold skin,

 

–    vomiting,

 

–    blurred vision,

 

–    numbness round the mouth,

 

–    dizziness.

 

*    Later:

 

–    paralysis of neck muscles and limbs,

 

–    paralysis of muscles used in breathing, so that breathing is slow

and difficult,

 

–    low blood pressure,

 

–    slow pulse,

 

–    unconsciousness.

 

Death may occur within 24 hours.

 

With some snakes it may be difficult to know whether the bite has

injected venom if there is no damage to skin near the bite and the

symptoms and signs are delayed for up to 12 hours.

 

*    Venom in the eye (from spitting cobras):

 

–    intense pain,

 

–    spasms of the eyelids,

 

–    swelling round the eye,

 

–    damage to the surface of the eye.

 

Viperids

 

*    Local effects, within 15 minutes or after several hours:

 

–    swelling near the bite that spreads quickly to the whole limb,

 

–    pain near the bite.

 

*    Early signs of poisoning, within 5 minutes or after several

hours:

 

–    vomiting,

 

–    sweating,

 

–    colic,

 

–    diarrhoea,

 

–    bleeding from gums, cuts and wounds made by the snake’s fangs,

 

–    nose bleeds,

 

–    blood in vomit, urine and stools.

 

Episodes of vomiting and diarrhoea last only a short time and may

be repeated.

 

*    Over the next few days:

 

–    bruising, blistering and tissue damage; this is particularly

severe with rattlesnakes,  Bothrops, Asian pit vipers and the

African giant viper  (Bitis),

 

–    kidney damage,

 

–    lung oedema,

 

–    sometimes low blood pressure and fast pulse (some North American

rattlesnakes and vipers).

 

With a few species:

 

–    paralysis (South American rattlesnakes),.

 

–    twitching of the face, head, neck or limbs.

 

Hydrophids

 

*    Early signs of poisoning:

 

–    headache,

 

–    tongue feels thick,

 

–    sweating,

 

–    vomiting.

 

*    After about 30 minutes to several hours:

 

–    general aching and stiffness,

 

–    spasm of jaw muscles,

 

–    muscle paralysis,

 

–    dark brown urine, kidney failure,

 

–    heart stops beating.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm.

 

Take off the patient’s rings, bracelets, anklets and shoes as

soon as possible.

 

Clean the wound, but leave blisters alone. Do not cover the

wound.

 

Tell the patient to keep the limb still and lower than the heart.

A splint and a sling may help to keep the limb still, but do not use a

tight bandage.

 

For elapid snakes that do not cause tissue damage (coral snakes,

kraits, mambas, some cobras  but not some Asian cobras or vipers)

 

Apply a broad, firm bandage over the bite site, then bind as much

of the bitten limb as possible over the patient’s clothing. The

bandage should be firm but not tight. You should still be able to feel

the pulse in the lower part of the limb. Severe pain in the bandaged

limb may mean that the bandage is too tight. Put a splint on the limb

so that the patient cannot bend it. Do not take the bandage off until

the patient is in hospital.

 

The wound may become infected. Find out if the patient has been

immunized against tetanus and give tetanus toxoid if appropriate.

 

Paracetamol may be given for pain, but aspirin should not be

given because it may make the patient bleed.

 

Venom in the eye (from spitting snakes)

 

Wash the eyes with water.

 

Information for doctors outside hospital

 

If the limb has been bandaged do not take off the bandage before

the patient gets to a hospital where antivenom is available. When the

bandage is removed, venom may spread through the body very rapidly.

 

Antivenom should only be given in a hospital or medical centre

where resuscitation can be given if the patient has an allergic

reaction.

 

When available, antivenom should only be used if there are signs

of systemic envenoming.

 

Monitor breathing, heart, blood pressure, fluids and electrolytes

and kidney function. Supportive care, including oxygen and mechanical

ventilation, should be given as needed. Low blood pressure should be

treated with intravenous fluids.

 

Do not give unnecessary injections because of the risk of

bleeding if the blood is not able to clot.

 

For kidney failure dialysis may be needed, preferably

haemodialysis, but even peritoneal dialysis is useful.

 

Local tissue injury

 

Leave the wound open. Blisters usually heal in about 2 weeks

without infection. Usually there is no need for surgery, and

unnecessary surgery could cause complications or permanent damage to

the bitten limb.

 

Infection of the wound

 

Treat as for any other local infection. Use antibiotics if

needed.

 

Spiders

 

Spiders covered in this section

 

This section covers species of  Latrodectus, including

Latrodectus mactans mactans, the black widow spider, found in

temperate and tropical regions worldwide;  Loxosceles, the brown or

violin spiders, found in Central and South America, North Africa, and

the Mediterranean area; and  Phoneutria including  Phoneutria

nigriventer, the banana spider, found in Central and South America.

 

How they cause harm

 

Venom from  Latrodectus and  Phoneutria spiders affects the

nervous system but does not cause local tissue damage. The main effect

of  Loxosceles spider venom is local tissue damage but general

envenoming may develop.

 

How poisonous they are

 

Some spider bites have caused death, but this is unusual. Most

bites are painless or cause only mild poisoning, except black widow

spider bites which are very painful.

 

Special dangers

 

Some poisonous spiders live in or near to houses and huts and may

get inside clothing, shoes and beds.

 

Signs and symptoms

 

Latrodectus and  Phoneutria species

 

Effects are:

 

–    intense pain affecting the whole body,

 

–    nausea and vomiting,

 

–    sweating,

 

–    abdominal cramps, painful muscle spasms and tremors,

 

–    chest pain or tightness, difficulty in breathing,

 

–    fast pulse,

 

–    high blood pressure,

 

–    restlessness and irritability,

 

–    spasms of face and jaw with swollen eyelids and sweating.

 

Loxosceles species

 

Effects:

 

–    burning pain, swelling near the bite.

 

Within 24-48 hours:

 

–    fever,

 

–    chills,

 

–    nausea and vomiting,

 

–    muscle pain,

 

–    unconsciousness,

 

–    fits,

 

–    blood in urine.

 

Death may occur within a few days but most patients survive.

 

A blue scab which turns black forms at the bite site and drops

off after a few weeks leaving an ulcer. This may spread over the

bitten limb and take 6-8 weeks to heal.

 

What to do

 

Give first aid. Take off the patient’s rings, bracelets, anklets

and shoes as soon as possible. Keep the patient calm and still. Lay

him or her on one side in the recovery position. Check breathing every

10 minutes, and keep the patient warm.

 

Clean the wound, but leave blisters alone. Do not cover the

wound.

 

Tell the patient to keep the limb still and lower than the heart.

A splint and a sling may help to keep the limb still.

 

There is no effective treatment for pain. Neither paracetamol nor

aspirin should be given.

 

The wound may become infected. Find out if the patient has been

immunized against tetanus and give tetanus toxoid if appropriate.

 

Information for doctors outside hospital

 

Antivenom is available for some spiders:  Latrodectus

(worldwide),  Loxosceles (South America),  Phoneutria (South

America). It may cause an allergic reaction and should be given only

in a hospital or medical centre where resuscitation can be given.

 

Local injury

 

The wound should be treated open as for a burn. Antivenom may be

useful to treat local tissue injury by  Loxosceles, even when there

are no signs of general poisoning.

 

Venomous fish

 

Fish covered in this section

 

This section covers fish with spines, many of which live in the

Indo-Pacific seas and other tropical areas, but some of which live in

temperate waters. They include Rajiformes (stingrays and mantas),

Scorpaenidae (scorpionfish, stonefish and lionfish), Siluroidei

(catfish), Squaliformes (sharks and dogfish), and Trachinidae

(weevers).

 

How they cause harm

 

Venomous fishes inject venom through their spines. The venom

causes intense pain near the bite and affects the muscles.

 

How poisonous they are

 

Fish stings may cause death but this is rare. Stonefish are the

most poisonous. Deaths have happened when people have lain or fallen

on a fish and a spine has punctured the chest or belly. Venom from

dead fish is still poisonous for up to 24 hours after the fish has

died.

 

Special dangers

 

These fish generally live in shallow water near the shore, or

near reefs, and lie hidden in sand or among rocks. People may be stung

on the soles of the feet when wading near the shore or near coral

reefs. Fishermen may be stung when handling fish.

 

Signs and symptoms

 

Effects are:

 

–    immediate sharp pain which may last 24 hours,

 

–    swelling of the stung limb.

 

Rajiformes and Scorpaenidae:

 

–    nausea and vomiting,

 

–    low blood pressure,

 

–     fits.

 

What to do

 

If the patient is stung while he or she is in the water, rescue

him or her from the water.

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. If the patient is unconscious or drowsy,

lay him or her on one side in the recovery position. Check breathing

every 10 minutes, and keep the patient warm.

 

Soak the wounded part of the body at once in a bowl or bath of

water as hot as the patient can safely bear (about 50°C), for not more

than 30 minutes.

 

Clean the wound and remove any broken spines.

 

Lacerated wounds from stingrays may become infected. Find out if

the patient has been immunized against tetanus and give tetanus toxoid

if appropriate.

 

Information for doctors outside hospital

 

Local anaesthetics or painkillers, even morphine, are usually

ineffective.

 

Antivenom is available for stonefish stings (Australia-Pacific).

It may cause an allergic reaction and should be given only in a

hospital where resuscitation can be given, and only if the patient is

very badly affected.

 

Poisoning from eating seafood

 

Poisoning covered in this section

 

This section covers the following:

 

*    Ciguatoxin poisoning from tropical reef fish such as barracuda,

grouper, red snapper and amber jack, found in the Caribbean and

Pacific.

 

*    Poisoning from shellfish (mussels, clams, oysters, cockles, and

scallops) contaminated by feeding on poisonous dinoflagellates.

This is called paralytic shellfish poisoning because the poison

affects the nervous system.

 

*    Tetrodotoxin poisoning from porcupine fish, puffer fish and sun

fish.

 

*    Scombrotoxin poisoning from fish that have begun to spoil: fresh

or canned scombroid fish such as tuna, bonito, skipjack,

mackerel, and canned fish of other types, such as sardines and

pilchards. The poison is made by bacteria.

 

How they cause harm

 

Ciguatoxin, tetrodotoxin and poisons from shellfish affect the

gut and the nervous system. Tetrodotoxin and the poison from shellfish

paralyse muscles, including the muscles that are used in breathing.

Scombrotoxin causes an allergic type of reaction.

 

How poisonous they are

 

The most dangerous is tetrodotoxin, which often causes death.

People are more likely to survive poisoning from ciguatera fish and

contaminated shellfish, although death may sometimes occur.

Scombrotoxin poisoning rarely causes death.

 

Shellfish are most poisonous at times of year when the

dinoflagellates on which they feed multiply and form “red tides”.

 

Special dangers

 

Poisonous fish usually look no different from fish that are good

to eat. Cooking does not destroy the poison.

 

Signs and symptoms

 

Ciguatoxin poisoning

 

Within 1-6 hours after eating fish containing ciguatoxin:

 

–    watery diarrhoea,

 

–    vomiting,

 

–    abdominal cramps.

 

Within 12 hours:

 

–    headache,

 

–    numbness and tingling of lips, mouth and limbs,

 

–    trembling,

 

–    aching muscles,

 

–    weakness and dizziness,

 

–    itching (may be delayed more than 30 hours),

 

–    reversal of hot and cold sensations, so that cold objects feel

hot.

 

Less commonly:

 

–    low blood pressure,

 

–    slow heart rate,

 

–    shallow breathing,

 

–    fits.

 

Paralytic shellfish poisoning

 

Within 30 minutes:

 

–    nausea,

 

–    vomiting,

 

–    headache,

 

–    numbness and tingling of the lips and mouth, spreading to the

legs, arms and the whole body,

 

–    muscle paralysis, causing blurred vision, difficulty in

swallowing, weakness and dizziness,

 

–    aching muscles,

 

–    reversal of hot and cold sensations, so that cold objects feel

hot.

 

Less commonly:

 

–    low blood pressure,

 

–    paralysis of muscles used in breathing, so that the patient is

unable to breathe,

 

–    death.

 

Tetrodotoxin poisoning

 

Effects are similar to those of paralytic shellfish poisoning.

Within 10-45 minutes muscles become weak, then paralysed. The muscles

used in breathing are affected, so that the patient is unable to

breathe and dies.

 

Scombrotoxin poisoning

 

Within a few minutes to a few hours:

 

–    headache,

 

–    red itching skin over the face and body,

 

–    nausea, belly pain and diarrhoea.

 

Rarely:

 

–    skin rash,

 

–    breathlessness and wheezing.

 

What to do

 

Give first aid. If breathing stops, open the airway and give

mouth-to-mouth respiration. Give heart massage if the heart stops.

 

If the patient is unconscious or drowsy, lay him or her on one

side in the recovery position. Check breathing every 10 minutes, and

keep the patient warm.

 

If the patient has a fit, treat as recommended in chapter five.

 

Take the patient to hospital as quickly as possible.

 

Information for doctors outside hospital

 

Monitor breathing, heart, blood pressure, fluids and

electrolytes. Supportive care, including oxygen and mechanical

ventilation, should be given as needed. Low blood pressure should be

treated with intravenous fluids.

 

Antihistamine can be given for scombrotoxin poisoning.

 

 

Word list1

 

absorption  The movement of a chemical through gut, skin or lungs,

into the bloodstream.

 

abuse  Misuse or excessive use of a drug or other chemical

substance to change mood or behaviour, or to avoid withdrawal

syndrome.

 

acute exposure  A single contact with a poison, lasting for

seconds, minutes or hours, or several exposures over about a day or

less.

 

acute poisoning  The effects occurring within a few hours

or at most a few days after a single dose of a chemical, or several

exposures over about a day or less.

 

acid  A chemical that combines with an alkali to form a

salt, and turns blue litmus paper red.

 

agitation  Restless movement of the body caused by distress, anxiety

or by a problem in the brain.

 

alkali  A substance that neutralizes an acid to form a salt,

and turns pink litmus paper blue.

 

allergy  Special sensitivity of a person to such things as plants

and plant products, insect bites and animal hair.

 

anaesthetic, general A medication that produces

unconsciousness.

 

anaesthetic, local  A substance that causes loss of feeling,

especially of pain, when put on the skin or injected.

 

anaemia  A condition in which the concentration of the

oxygen-carrying part of the blood, the haemoglobin, is below

normal. The symptoms of severe anaemia may include tiredness, pale

skin and, sometimes, difficulty in breathing.

 

antidote  A chemical that lessens, or counteracts, the

harmful effect of a poison.

 

antiseptic  A liquid that stops some germs (bacteria)

growing. Usually used to clean skin.

 

__________

 

1    The definitions given here refer to the use of terms in this

book; they are not necessarily applicable in other contexts.

 

antivenom  A medicine that acts against poison or venom

from an animal such as a snake, fish, insect, or spider.

 

asthma  A condition in which a person has attacks of difficult

breathing. The person wheezes when breathing out, and may not be

able to get enough air.

 

bacterium (plural  bacteria)  A scientific name for a kind of

microorganism, which may cause disease.

 

blister  A bubble just under the surface of the skin filled

with watery liquid; caused by burning or rubbing.

 

blood  vessel  A tube that carries blood inside the body.

Vessels carrying blood away from the heart are called arteries.

They have a pulse. Vessels that carry blood back to the heart are

called veins. They do not have a pulse.

 

caustic  Describes chemicals that burn or corrode living

things.

 

chronic exposure  A contact with a poison that lasts for

many days, months or years. It may be continuous or broken by

periods when there is no contact.

 

chronic poisoning  The effects developing slowly as a

result of continuous or repeated exposure over a long time to small

doses of poison.

 

concentrate  A product with a high concentration of

chemicals, which is meant to be diluted for use. Many pesticides

are sold as concentrates.

 

concentration  The proportion of an ingredient in a

mixture.

 

contamination  The soiling of an object or substance by

covering or mixing it with an unwanted substance. For example, the

soiling of clothing or skin with insecticide.

 

corrosive  Describes a substance that destroys living

tissues on contact, by direct chemical action.

 

dehydration  Excessive loss of water from the body.

 

delirium  A state of mental confusion and semi-consciousness.

 

dermatitis  Inflammation of the skin. May be caused by contact

with a substance to which the skin is sensitive, such as cosmetics

or certain plants.

 

detergent  A chemical cleaning agent; sometimes used instead

of soap.

 

diabetes  A disease in which a person has too much sugar in the

blood. Some diabetic people need special medicine such as insulin.

 

dilute  To make a chemical solution less concentrated, usually by

adding water. Pesticides are often sold as concentrates which have

to be diluted by adding water.

 

disinfectant  A cleaning agent that stops some germs (bacteria)

growing.

 

dissolve  The action of a solid when it is mixed with a liquid so

that it disappears and forms a solution.

 

distillate  A substance that is separated from a mixture, usually by

heating the mixture to a particular temperature, and collecting the

vapour as it cools and turns to liquid. The different components of

the mixture will turn to vapour at different temperatures.

Petroleum distillate is the mixture produced by this method from

petroleum.

 

dose  The amount of a chemical substance that gets into the body at

one time.

 

envenomation  The injection of venom into the body.

 

epilepsy  A condition that causes fits. It is caused by problems in

the brain.

 

exposure  Contact with a chemical. The chemical may or may not enter

the body.

 

euphoria  A feeling of great elation.

 

evaporate  To change from a liquid or solid to a vapour.

 

faeces  Stools; the waste from the body that passes out in a “bowel

movement”.

 

fertilizer  A product, usually added to soil, containing chemicals

essential for plant growth.

 

fever  A body temperature that is higher than normal.

 

first aid  The immediate treatment of poisoning or injury.

 

fit  Jerking movements that a person cannot control; also called

seizures or convulsions. A fit happens when there is a problem in

the brain.

 

germ  A very small, living organism; a microorganism or microbe;

usually refers to microorganisms that cause sickness or disease if

they get inside the body.

 

gut  The tube that goes between the stomach and the anus. Also

called

the intestines.

 

hallucination  Something a person sees, hears or smells which seems

real to them, but which does not exist; caused by a disturbance in

the brain.

 

hallucinogenic  Producing hallucinations.

 

hydrocarbon  One of a group of chemical compounds made up of only

hydrogen and carbon, found naturally in petroleum.

 

infection  A sickness caused by germs.

 

inflammation  Tissue response to injury, characterized by local

redness, swelling, pain and increased temperature.

 

ingestion  Taking into the body. Usually used to mean taking in

through the mouth and swallowing.

 

inhalation  Breathing into the lungs through the mouth and nose.

 

intramuscular injection  An injection into a muscle, usually in the

arm or buttock.

 

intravenous injection  An injection into a vein. A vein is a blood

vessel that carries blood towards the heart.

 

irritant  Describes chemicals that cause inflammation following

immediate, prolonged or repeated contact with skin or other

tissues.

 

jaundice  A yellow colour in the eyes and skin caused by liver

damage. The liver may be damaged by poison, by infection or by

problems in the blood.

 

kidney  One of two large bean-shaped organs in the lower back; they

take waste out of the blood and make urine.

 

lacerate  To tear the skin and muscle making a wound with jagged

edges.

 

laxative  A medicine that makes a person pass faeces. Laxatives are

sometimes given to people who have swallowed poison to make the

poison move through the gut, and leave the body quickly.

 

liver  A large organ under the lower right ribs. Many poisons are

changed into non-poisonous chemicals by the liver.

 

local effect  An effect limited to the part of the body in contact

with a chemical.

 

lukewarm  Slightly warm; blood-warm; neither hot nor cold.

 

lung oedema  A condition in which fluid fills the lungs and the

patient is unable to breathe.

 

medicine  A substance used to maintain, improve or restore health.

 

metabolite  A chemical substance produced by chemical reactions

inside the body.

 

nausea  A feeling of a need to vomit.

 

nervous system  The brain, spinal cord and nerves.

 

oedema  Accumulation of fluid in tissue as a result of injury,

inflammation or allergy.

 

paralysis  Loss of movement in the muscles.

 

pesticide  A chemical for killing or controlling pests such as

insects or weeds.

 

poison  Any substance that causes harm if it gets into the body.

 

poisonous  dose  A dose that causes poisoning.

 

prescription  A written instruction from a doctor to the health

professional who dispenses medicines, with details of the name of

the medicine to be dispensed, the dose to be taken, how often it

should be taken and other instructions as needed.

 

protective clothing  Clothes that protect people from exposure to

chemicals, usually by covering skin. Some protective clothing also

includes masks to cover the mouth and nose to stop chemical being

breathed in, or goggles to protect the eyes.

 

pulse  The pulse is a wave of pressure in the arteries (blood

vessels) each time the heart beats and pushes out blood. You can

feel the pulse wherever an artery is close to the surface of the

body.

 

pupil  The black centre of the eye. It gets small in bright light

and wide in the dark. Medicines and poisons can make the pupil

change size.

 

rectum  The last part of the gut.

 

rehydration  Giving of water, or other liquids, to a person who has

lost a lot of water in diarrhoea, vomit or sweat. Special

rehydration drinks can be made with packets of oral rehydration

salts.

 

respirator  Equipment that prevents the wearer from breathing in

dangerous chemicals. It may cover half the face, including the

mouth and nose, or be full-faced, covering nose, mouth and eyes. It

should only be used by people who have been trained to use and

maintain it correctly.

 

rodenticide  A poison for killing rodents, such as rats and mice.

 

route  Way, path. Route of exposure is the way a poison gets into

the body.

 

saliva  Spittle; spit; the liquid inside the mouth.

 

signs  Effects you can see, feel, hear or measure, such as fever,

fast pulse, noisy breathing.

 

solution  A solid stirred into a liquid so that you cannot see it,

or two liquids mixed together to look like one.

 

solvent  A liquid in which one or more chemical substances will

dissolve (disappear when stirred) to form a solution. Many liquids

are solvents: for example, water is a solvent for salt; kerosene

and similar chemicals are solvents for some pesticides.

 

spasm  A sudden, violent and painful, involuntary contraction of a

muscle or group of muscles.

 

stethoscope  An instrument used to listen to noises inside the body,

such as the noise made by the heart beating or by air moving in the

lungs.

 

sustained release  Describes a medicine that breaks down slowly in

the body, so that it takes many hours for all the medicine to pass

into the bloodstream. The medicine goes on working for many hours

after it is swallowed.

 

symptoms  Effects that a person feels or senses, such as nausea,

pain, or thirst.

 

systemic effects/systemic poisoning  Effects of a poison on the

body as a whole. Systemic effects only occur if a poisonous

substance is absorbed and distributed to sites distant from the

entry point.

 

target organ  The organs most affected by a particular poison.

 

 

temperature  A measure of the heat of a person’s body. You can find

out a person’s temperature by feeling the skin, or by using a

thermometer.

 

tetanus  Lockjaw; a disease caused when germs that live in the

faeces of people or animals get into the body through a wound.

Tetanus causes very stiff muscles and fits.

 

thermometer  An instrument used to measure how hot, or cold, a

person’s body is.

 

threshold dose  The smallest amount that causes poisoning.

 

toxin  Poison made by a living creature, plant or microorganism.

 

tremor  Trembling or quivering.

 

ulcer  An open sore resulting from destruction of the skin or mucous

membrane, such as caused by a corrosive chemical.

 

unconsciousness  A state in which a person does not respond to

outside stimuli such as noise or pain. It is caused by disturbance

of, or damage to, part of the brain.

 

vapour  The gas produced by a substance when it boils. Vapour is

also present above the surface of a liquid at temperatures below

its boiling-point.

 

venom  The poisonous fluid produced by animals such as snakes,

spiders and fish, and injected into prey by a bite or sting or

through spines which puncture the skin.

 

womb  The place inside a woman’s belly where a baby grows when she

is pregnant.

 

 

 

 

 

 

The following information has been extracted from our CHEMINFO database, which also contains hazard control and regulatory information. [More about…] [Sample Record]

 

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SECTION 1. CHEMICAL IDENTIFICATION

 

CHEMINFO Record Number:           10

CCOHS Chemical Name:   Calcium hydroxide

Synonyms:

Calcium dihydroxide

Calcium hydrate

Agricultural lime

Biocalc

Calvital

Caustic lime

Hydrated lime

Lime hydrate

Lime water

Slaked lime

Hydroxyde de calcium

Chemical Name French:    Hydroxyde de calcium

Chemical Name Spanish:   Hidróxido de calcio

CAS Registry Number:      1305-62-0

Other CAS Registry Number(s):      1333-29-5 7719-01-9

RTECS Number(s):           EW2800000

EU EINECS/ELINCS Number:         215-137-3

Chemical Family: Calcium and compounds / inorganic calcium compound / alkaline earth metal hydroxide

Molecular Formula:          Ca-H2-O2

Structural Formula:          Ca(OH)2

 

SECTION 2. DESCRIPTION

 

Appearance and Odour:

White crystals or soft powder or granules; impure material has gray or buff colour; odourless; readily absorbs carbon dioxide from the air to form calcium carbonate.(12,14,15)

Odour Threshold:

Odourless.(15)

Warning Properties:

POOR – odourless

Composition/Purity:

Commercial material has 95% purity or more. May contain magnesium hydroxide, magnesium oxide, silicon dioxide, calcium carbonate, etc. in trace amounts.

Uses and Occurrences:

Manufacture of mortar, plaster, cement and other building and paving materials; lubricants; drilling fluids; petrochemicals; fireproofing coatings; pesticides; pigments; and water-based paints; buffer and neutralizing agent; recovery of ammonia from ammonium chloride in Solvay process; caustizing soda; used in nonferrous metallurgy (used for extraction of gold and silver, recovery of nickel, tungsten, uranium, magnesia and magnesium metal; alumina production); in the iron and steel industry; water and sewage treatment; used to neutralize acid wastes; to precipitate metals from industrial effluents; flue gas desulfurization; soil conditioner; sugar refining; chemical intermediate for calcium hypochlorite, bleaching powder and calcium salts; water softening agent, food additive, component of dental cement, accelerator for low grade rubber compounds; in SBR rubber vulcanization; manufacture of paper pulp; dehairing hides.(12,13,14)

 

SECTION 3. HAZARDS IDENTIFICATION

 

 

 

EMERGENCY OVERVIEW:

White, odourless crystals or soft powder or granules; impure material has gray or buff colour. Does not burn. Can decompose at high temperatures forming irritating calcium oxide. Very irritating to the respiratory tract. CORROSIVE. Causes severe skin and eye burns. May cause blindness and permanent scarring.

 

 

 

 

POTENTIAL HEALTH EFFECTS

 

Effects of Short-Term (Acute) Exposure

 

Inhalation:

Dusts or mists of concentrated solutions are likely to be very irritating to the nose, throat and upper respiratory tract, based on information for calcium oxide (calcium oxide reacts with moisture to form calcium hydroxide).

Skin Contact:

Many cases of chemical burns to the skin have been reported after exposure to wet (calcium oxide-containing) cement for as little as half an hour.(1,2,3,4,5) The calcium oxide in the cement reacts with water forming calcium hydroxide. Often, no pain is experienced immediately, so the exposure (skin contact) is allowed to continue.

Eye Contact:

Many case reports have been written about severe chemical burns of the eye cause by calcium oxide or calcium hydroxide, commonly known as “lime burns”. These burns are reportedly caused most commonly by a splash of a thick, moist, pasty material (plaster, mortar or cement), less commonly by a splash of milky fluid, and rarely by a clear solution of calcium hydroxide. Solid particles react with moisture in the eye to form clumps of moist compound which are difficult to remove, resulting in a similar effect. In severe cases, the injury may be permanent and blindness may result.(6,7)

Ingestion:

Calcium hydroxide is low in oral toxicity, based on animal information. Effects could include severe pain and burning of the mouth, throat and esophagus, stomach cramps, vomiting and diarrhea. Ingestion is not a typical route of occupational exposure.

Effects of Long-Term (Chronic) Exposure

 

There is no relevant animal or human information available.

Carcinogenicity:

There is no human or animal information available.

The International Agency for Research on Cancer (IARC) has not evaluated the carcinogenicity of this chemical.

The American Conference of Governmental Industrial Hygienists (ACGIH) has not assigned a carcinogenicity designation to this chemical.

The US National Toxicology Program (NTP) has not listed this chemical in its report on carcinogens.

Teratogenicity and Embryotoxicity:

There is no human or animal information available.

Reproductive Toxicity:

There is no human or animal information available.

Mutagenicity:

There is no information available.

Toxicologically Synergistic Materials:

There is no information available.

Potential for Accumulation:

Does not accumulate in the body. Calcium ions are normally found in the body. About one third of ingested calcium ion is absorbed. Calcium ion is excreted mainly in the feces and the urine.

 

SECTION 4. FIRST AID MEASURES

 

 

 

Inhalation:

Remove source of contamination or have victim move to fresh air. Obtain medical advice.

Skin Contact:

Avoid direct contact. Wear chemical protective clothing, if necessary. As quickly as possible, remove contaminated clothing, shoes and leather goods (e.g. watchbands, belts). Quickly and gently blot or brush away excess chemical. Immediately flush with lukewarm, gently flowing water for at least 60 minutes. DO NOT INTERRUPT FLUSHING. If necessary, and it can be done safely, continue flushing during transport to emergency care facility. Quickly transport victim to an emergency care facility. Completely decontaminate clothing, shoes and leather goods before re-use or discard.

Eye Contact:

Avoid direct contact. Wear chemical protective gloves, if necessary. Quickly and gently blot or brush chemical off the face. Immediately flush the contaminated eye(s) with lukewarm, gently flowing water for at least 60 minutes, while holding the eyelid(s) open. If a contact lens is present, DO NOT delay irrigation or attempt to remove the lens until flushing is done. Neutral saline solution may be used as soon as it is available. DO NOT INTERRUPT FLUSHING. If necessary, continue flushing during transport to emergency care facility. Quickly transport victim to an emergency care facility.

Ingestion:

NEVER give anything by mouth if victim is rapidly losing consciousness, is unconscious or convulsing. Have victim rinse mouth thoroughly with water. DO NOT INDUCE VOMITING. If vomiting occurs naturally, have victim rinse mouth with water again. Quickly transport victim to an emergency care facility.

First Aid Comments:

Provide general supportive measures (comfort, warmth, rest).

Consult a doctor and/or the nearest Poison Control Centre for all exposures except minor instances of inhalation.

All first aid procedures should be periodically reviewed by a doctor familiar with the material and its conditions of use in the workplace.

 

 

 

 

SECTION 5. FIRE FIGHTING MEASURES

 

Flash Point:

Non-combustible (does not burn)

Lower Flammable (Explosive) Limit (LFL/LEL):

Not applicable

Upper Flammable (Explosive) Limit (UFL/UEL):

Not applicable

Autoignition (Ignition) Temperature:

Not applicable

Sensitivity to Mechanical Impact:

Probably not sensitive. Stable material.

Sensitivity to Static Charge:

Not applicable. Not combustible.

Combustion and Thermal Decomposition Products:

Calcium oxide fumes can be generated by thermal decomposition at elevated temperatures.

Fire Hazard Summary:

Calcium hydroxide will not burn or support combustion. During a fire corrosive fumes of calcium oxide may be given off. Closed containers may explode in the heat of a fire.

Extinguishing Media:

Calcium hydroxide does not burn. Use extinguishing media appropriate to the surrounding fire conditions. DO NOT use carbon dioxide as an extinguishing agent.

 

 

Fire Fighting Instructions:

Evacuate area and fight fire from a safe distance or a protected location. Approach fire from upwind. If possible, isolate materials not involved in the fire and protect personnel.

Move containers from fire area if it can be done without risk. Otherwise, use water in flooding quantities as a spray or fog to keep fire-exposed containers cool and absorb heat to help prevent rupture. Water spray may also be used to knock down irritating/toxic combustion products which may be produced in a fire. Apply water from as far a distance as possible.

At high temperatures, decomposition occurs giving off strong, corrosive fumes of calcium oxide. Do not enter without wearing specialized protective equipment suitable for the situation. Firefighter’s normal protective clothing (Bunker Gear) will not provide adequate protection. Chemical resistant clothing (e.g. chemical splash suit) and positive pressure self-contained breathing apparatus (MSHA/NIOSH approved or equivalent) may be necessary.

 

 

 

 

NATIONAL FIRE PROTECTION ASSOCIATION (NFPA) HAZARD IDENTIFICATION

 

NFPA – Comments:

NFPA has no listing for this chemical in Codes 49 or 325.

 

SECTION 9. PHYSICAL AND CHEMICAL PROPERTIES

 

Molecular Weight:            74.10

Conversion Factor:

Not applicable

Physical State:    Solid

Melting Point:      Not applicable (decomposes).

Boiling Point:      Not applicable (decomposes).

Decomposition Temperature:         580 deg C (1076 deg F) (15)

Relative Density (Specific Gravity): 2.24 at 20 deg C (water = 1) (15)

Solubility in Water:          0.185 g/100 mL at 0 deg C; 0.071 g/100 mL at 100 deg C (14)

Solubility in Other Liquids: Soluble in acids, glycerol and ammonia salt solutions; insoluble in ethanol.(12,15)

Coefficient of Oil/Water Distribution (Partition Coefficient):     Not available

pH Value:           11.3 (0.01% at 25 deg C); 12.5 to 12.7 (saturated solution (0.18 g/100 mL) at 25 deg C) (14,15)

Vapour Density:   Not applicable

Vapour Pressure: Zero (does not form vapour)

Saturation Vapour Concentration:   Not applicable

Evaporation Rate:            Not applicable

 

SECTION 10. STABILITY AND REACTIVITY

 

Stability:

Normally stable. Absorbs carbon dioxide from the air to form calcium carbonate.(14,15)

Hazardous Polymerization:

Does not occur.

Incompatibility – Materials to Avoid:

NOTE: Chemical reactions that could result in a hazardous situation (e.g. generation of flammable or toxic chemicals, fire or detonation) are listed here. Many of these reactions can be done safely if specific control measures (e.g. cooling of the reaction) are in place. Although not intended to be complete, an overview of important reactions involving common chemicals is provided to assist in the development of safe work practices.

 

 

STRONG ACIDS (e.g. sulfuric acid) – may react violently.(16)

MALEIC ANHYDRIDE – may react explosively with decomposition.(17)

NITROALKANES (e.g. nitromethane, nitroethane, nitropropane) – react to form explosive salts.(17)

PHOSPHORUS – yields phosphines which may ignite spontaneously in air.(17)

Hazardous Decomposition Products:

Calcium carbonate.

Conditions to Avoid:

High temperatures, generation of dust .

Corrosivity to Metals:

Corrosive to aluminum.(18) Not corrosive to certain grades of stainless steel (302, 304, 316, 410, 430) at room temperature and to nickel-chromium-molybdenum alloy.(15,18)

Stability and Reactivity Comments:

Calcium hydroxide reacts readily with carbon dioxide in air to form calcium carbonate.(14,15) Attacks some metals.(19)

 

SECTION 11. TOXICOLOGICAL INFORMATION

 

LD50 (oral, rat): 7340 mg/kg (8)

LD50 (oral, mouse): 7300 mg/kg (9, unconfirmed)

Eye Irritation:

Application of 10 mg (0.01 g) of solid calcium hydroxide caused severe irritation or corrosion in rabbits in a modified Draize test. Healing did not occur within 21 days.(10) Injury to the corneas of rabbits resulted from exposure to a paste of calcium hydroxide for 1 minute, followed by cleaning and rinsing with a physiological salt solution. This injury reached a maximum at 24 hours after exposure and the eye had not returned to normal after 3 months.(11) Further details on this study are not available.

Effects of Long-Term (Chronic) Exposure:

Ingestion:

Male rats were given tap water containing 50 or 350 mg/L. At 2 months, the rats were restless, aggressive and had reduced food intake. At 3 months, there was a decrease in body weight and a decrease in certain blood components (for example, red blood cells, hemoglobin).(11) Further details on this study were not available. Its relevance to occupational exposures is questionable.

 

SECTION 16. OTHER INFORMATION

 

Selected Bibliography:

(1) Vickers, H.R., et al. Cement burns. Contact Dermatitis. Vol. 2 (1976). p. 73-78

(2) Buckley, D.B. Skin burns due to wet cement. Contact Dermatitis. Vol. 8, no. 6 (1982). p. 407-409.

(3) Tosti, A., et al. Skin burns due to transit-mixed Portland cement. Contact Dermatitis. Vol. 21, no. 1 (1989). p. 58

(4) Hannuksela, M., et al. Caustic ulcers caused by cement. British Journal of Dermatology. Vol. 95 (1976). p. 547-549.

(5) Flowers, M.W. Burn hazard with cement. British Medical Journal. Vol. 1, no. 6122. (May, 1978). p. 1250.

(6) Grant, W.M., et al. Toxicology of the eye. 4th edition. Charles C. Thomas, 1993. p. 298-302

(7) McLaughlin, R.S. Chemical burns of the human cornea. American Journal of Ophthalmology. Vol. 20, no. 11 (November, 1946). p. 1355- 1362.

(8) Smyth Jr., H.F., et al. Range-finding toxicity data: list VII. American Industrial Hygiene Association Journal. Vol. 30, no. 5 (September-October, 1969). p. 470-476

(9) RTECS record for calcium hydroxide. Date of last update: 9504.

(10) Griffith, J.F., et al. Dose-response studies with chemical irritants in the Albino rabbit eye as a basis for selecting optimum testing conditions for predicting hazard to the human eye. Toxicology and Applied Pharmacology. Vol. 55 (1980). p. 501-513

(11) Pierce, J. O. Alkaline materials. In: Patty’s industrial hygiene and toxicology. 4th edition. Edited by G.D. Clayton, et al. Volume II, Part A. John Wiley and Sons, 1993. p. 762-764

(12) HSDB record for calcium hydroxide. Date of last revision: 96/03/21

(13) Petersen, R.L., et al. Calcium compounds: survey. In: Kirk-Othmer encyclopedia of chemical technology. 4th edition. Volume 4. John Wiley and Sons, 1992. p. 788-796

(14) Oates, T. Lime and limestone In: Ullmann’s encyclopedia of industrial chemistry. 5th completely revised edition. Volume A 15. VCH Verlagsgesellschaft, 1990. p. 334-345

(15) Environmental and technical information for problem spills: calcium oxide and hydroxide. Environmental Protection Service, Environment Canada, March, 1984

(16) The Sigma-Aldrich library of chemical safety data. Edition II. Volume 1. Sigma-Aldrich Corporation, 1988. p. 667B

(17) Fire protection guide to hazardous materials. 11th edition. National Fire Protection Association, 1994. NFPA 491

(18) Corrosion data survey: metals section. 6th edition. National Association of Corrosion Engineers, 1985. p. 30-1 to 31-1

(19) NIOSH pocket guide to chemical hazards. National Institute for Occupational Safety and Health, June 1994. p. 46-47

(20) Forsberg, K., et al. Quick selection guide to chemical protective clothing. 4th ed. Van Nostrand Reinhold, 2002

(21) Occupational Safety and Health Administration (OSHA). Metal and Metalloid Particulates in Workplace Atmospheres. In: OSHA Analytical Methods Manual. Revision Date: Oct. 31, 2001. Available at: <www.osha-slc.gov/dts/sltc/methods/toc.html>

(22) National Institute for Occupational Safety and Health (NIOSH). Calcium and compounds as Ca. In: NIOSH Manual of Analytical Methods (NMAM(R)). 4th ed. Edited by M.E. Cassinelli, et al. DHHS (NIOSH) Publication 94-113. Aug. 1994. Available at: <www.cdc.gov/niosh/nmam/nmammenu.html>

Information on chemicals reviewed in the CHEMINFO database is drawn from a number of publicly available sources. A list of general references used to compile CHEMINFO records is available in the database Help.

 

Review/Preparation Date: 1996-11-08

 

Revision Indicators:

Resistance of material       1998-05-01

Bibliography        1998-05-01

PEL-TWA final     2003-12-04

PEL final comments          2003-12-04

PEL-TWA transitional         2003-12-04

PEL transitional comments 2003-12-04

Resistance of materials for PPE       2004-04-05

Bibliography        2004-04-05

Bibliography        2005-03-09

Sampling/analysis            2005-03-09

Sampling/analysis            2005-03-28

 

 

The following information has been extracted from our CHEMINFO database, which also contains hazard control and regulatory information. [More about…] [Sample Record]

 

Access the complete CHEMINFO database by contacting CCOHS Client Services.

 

 

 

SECTION 1. CHEMICAL IDENTIFICATION

 

CHEMINFO Record Number:           77

CCOHS Chemical Name:   Hydrogen peroxide solutions less than 8%

Synonyms:

Dihydrogen dioxide

Hydrogen dioxide

Hydroperoxide

Peroxide

Hydrogen peroxide

Chemical Name French:    Peroxyde d’hydrogène

Chemical Name Spanish:   Peróxido de hidrógeno

Trade Name(s):

Albone

Kastone

Perone

Tysul

CAS Registry Number:      7722-84-1

RTECS Number(s):           MX0887000

EU EINECS/ELINCS Number:         231-765-0

Chemical Family: Inorganic peroxide / hydrogen oxide / hydrogen peroxide

Molecular Formula:          H2-O2

Structural Formula:          H-O-O-H

 

SECTION 2. DESCRIPTION

 

Appearance and Odour:

Colourless liquid; odourless or having an odour resembling ozone (18); vapour is not irritating except at high concentrations.

Odour Threshold:

Not available

Warning Properties:

Insufficient information for evaluation.

Composition/Purity:

All information given is for hydrogen peroxide solutions in water because this is the only form in which hydrogen peroxide is commercially available. Hydrogen peroxide is available in grades ranging from 3 to 90 wt.%. The most common industrial grades are 35, 50, and 70 wt.%. Less concentrated solutions, such as 3-6%, are obtained by dilution of more concentrated ones, such as 35%, with water, usually with the addition of extra stabilizer.(4,19) Commercial solutions almost always contain very small amounts of impurities, such as iron or copper, which can cause decomposition. Therefore, stabilizers are often added to prevent decomposition into oxygen and water. Common stabilizers include sodium pyrophosphate and sodium stannate trihydrate, phosphoric or other mineral acids and organic stabilizers such as 8- hydroxyquinoline, pyridine carboxylic acids, tartaric and benzoic acids, acetanilide and acetophenetidin.(4,19,20)

Uses and Occurrences:

Hydrogen peroxide solutions of less than 8% are used in pharmaceutical preparations such as mouth wash, dentifrices, and sanitary lotions; as a disinfectant for cleansing wounds and ulcers; in ear drops; in cosmetic preparations such as hair bleaches, skin care and nail hardeners; for bleaching delicate fabrics; and for artificially aging wines and liquors.(4,18)

 

SECTION 3. HAZARDS IDENTIFICATION

 

 

 

EMERGENCY OVERVIEW:

Clear, colourless liquid. Will not burn. Essentially non-toxic following short-term exposure. Solutions of greater than 5% may cause eye irritation.

 

 

 

 

POTENTIAL HEALTH EFFECTS

 

Effects of Short-Term (Acute) Exposure

 

Inhalation:

Hydrogen peroxide does not readily form a vapour at room temperature. If heated or misted, it is irritating to the nose, throat and respiratory tract, based on limited human and animal information.

Throat irritation has been reported in employees exposed to aerosol concentrations of 12 to 41 mg/m3.(1) No effect on airways resistance was observed in volunteers exposed to 0.3 mg/m3 of hydrogen peroxide aerosol for 5 minutes.(2) In volunteers exposed to the aerosol for 4 hours, the threshold for respiratory tract irritation was 10 mg/m3.(3)

Skin Contact:

Hydrogen peroxide solutions of less than 8% are not irritating, based on animal information. Whitening or bleaching of the skin has been observed in humans.(4,5,6)

Eye Contact:

Hydrogen peroxide solutions of 5% are minimally irritating based on animal information. No reliable information was located for solutions greater than 5% and less than 8%, but this concentration range may be irritating to the eyes. In humans, application of 1-3% solutions has caused severe pain which soon subsided. Use of contact lenses which had been soaked in 3% hydrogen peroxide produced immediate pain, tearing and spasm of the eyelids in one case, but not another. Permanent damage did not result.(7, unconfirmed)

Ingestion:

Case reports of non-occupational ingestion of hydrogen peroxide describe symptoms such as sharp pains in the abdomen, foaming at the mouth, vomiting, temporary unconsciousness and fever. Sensory and motor impairment have also been described. Hydrogen peroxide reacts in the stomach releasing large amounts of oxygen.(4,5) Ingestion is not a typical route of occupational exposure.

Effects of Long-Term (Chronic) Exposure

 

INHALATION EXPOSURE: No firm conclusions can be drawn from one case report. This report described reversible lung disease in an employee exposed to 12 to 41 mg/m3 of hydrogen peroxide aerosols for 1 year. This individual was also a heavy smoker which may have contributed to him developing lung disease. Six other employees similarly exposed did not show evidence of lung disease. All 7 employees reported eye and throat irritation and gradual bleaching of their hair since the machine which generated hydrogen peroxide was in use.(1)

 

SKIN SENSITIZATION: There is one occupational case report of a hairdresser who developed an intensely itchy rash. She later tested positive to a 3% solution of hydrogen peroxide, as well as nickel sulfate and 4-aminophenol. She had no previous history of allergies. This authors indicate that 156 other hairdressers tested negative to 3% hydrogen peroxide.(8) Negative results were also reported for hydrogen peroxide in another study of employees exposed to several chemicals in a hydrogen peroxide production unit.(9)

Carcinogenicity:

In a limited human population study, there was no indication of an increased risk of cancer due to hydrogen peroxide exposure. This study is limited by the small number of people studied and possibly low exposure levels.(34) Animal studies have shown that long-term oral administration of 0.1-0.15% hydrogen peroxide causes an inflammatory response in the gastro-duodenal tissue of mice. This inflammatory response may progress to carcinogenic changes.(4,10) The International Agency for Research on Cancer (IARC) has concluded that there is inadequate evidence for the carcinogenicity of hydrogen peroxide to humans. There is limited evidence of the carcinogenicity of hydrogen peroxide in experimental animals.(34).

The International Agency for Research on Cancer (IARC) has concluded that this chemical is not classifiable as to its carcinogenicity to humans (Group 3).

The American Conference of Governmental Industrial Hygienists (ACGIH) has designated this chemical as an animal carcinogen (A3).

The US National Toxicology Program (NTP) has not listed this chemical in its report on carcinogens.

Teratogenicity and Embryotoxicity:

There is no human information available. No conclusions can be drawn based on the limited animal information available.

Reproductive Toxicity:

There is no human information available. No conclusions can be drawn based on the limited animal information available.

Mutagenicity:

It is not possible to conclude that hydrogen peroxide is mutagenic. Positive results have been obtained in cultured humans cells.(34) Negative results have been obtained in relevant studies using live animals. Positive results have been obtained in short-term mutagenicity tests.

Toxicologically Synergistic Materials:

Increased airways resistance was observed in volunteers exposed to hydrogen peroxide and sulfur dioxide aerosols at the same time.(2) Exposure to hydrogen peroxide increased the toxicity of ozone in animals.(11)

Potential for Accumulation:

Some hydrogen peroxide undergoes decomposition to oxygen and water when in contact with mammalian tissues, such as skin and the tongue, before absorption. In the body, hydrogen peroxide is readily metabolized to oxygen and water, by one route, or to water alone by another. It does not accumulate in the body.(4)

 

SECTION 4. FIRST AID MEASURES

 

 

 

Inhalation:

If symptoms are experienced, remove source of contamination or have victim move to fresh air and obtain medical advice.

Skin Contact:

As quickly as possible, flush with lukewarm, gently flowing water for at least 5 minutes or until the chemical is removed. If irritation persists, obtain medical advice immediately. Completely decontaminate clothing before re-use or discard.

Eye Contact:

Immediately flush the contaminated eye(s) with lukewarm, gently flowing water for 15-20 minutes, while holding the eyelid(s) open. If a contact lens is present, DO NOT delay irrigation or attempt to remove the lens until flushing is done. If irritation persists, obtain medical attention.

Ingestion:

If irritation or discomfort occur, obtain medical advice immediately.

First Aid Comments:

All first aid procedures should be periodically reviewed by a doctor familiar with the material and its condition of use in the workplace.

 

 

 

 

SECTION 5. FIRE FIGHTING MEASURES

 

Flash Point:

Does not burn

Lower Flammable (Explosive) Limit (LFL/LEL):

Not applicable

Upper Flammable (Explosive) Limit (UFL/UEL):

Not applicable

Autoignition (Ignition) Temperature:

Not applicable

Sensitivity to Mechanical Impact:

Very dilute hydrogen peroxide solutions are not shock sensitive.

Sensitivity to Static Charge:

Not sensitive

Combustion and Thermal Decomposition Products:

Molecular oxygen

Fire Hazard Summary:

Does not burn. Hydrogen peroxide (solutions less than 8%) is a very weak oxidizing agent. In a fire, it may release oxygen which can increase the burning rate of flammable materials.(19-22)

Extinguishing Media:

Hydrogen peroxide does not burn. Use large quantities of water as fog to fight fires in which this material is involved.(23) Some chemical extinguishing agents may accelerate decomposition. Carbon dioxide or other extinguishing agents that smother flames are not effective in extinguishing fires involving oxidizers.(22)

 

 

Fire Fighting Instructions:

Evacuate area and fight fire from a safe distance or a protected explosion-resistant location or maximum possible distance. Approach fire from upwind to avoid hazardous vapours and decomposition products.

Move containers from the fire area if this can be done without risk. Explosive decomposition may occur under fire conditions. Use extreme caution since heat may cause rupture of containers and release large amounts of oxygen. Otherwise, apply water from as far a distance as possible, in flooding quantities as a spray or fog to keep fire-exposed containers or equipment cool and absorb heat, until well after the fire is out.

Remove all flammable and combustible materials from the vicinity, especially oil and grease. Do not direct water directly on leak as this may cause leak to increase. Stay away from ends of tanks, but realize that shrapnel may travel in any direction. Withdraw immediately in case of rising sound from venting safety device or any discolouration of tanks due to fire. In an advanced or massive fire, the area should be evacuated; use unmanned hoseholders or monitor nozzles.

Firefighters may enter the area if positive pressure self-contained breathing apparatus (MSHA/NIOSH approved or equivalent) and full Bunker Gear is worn.

 

 

 

 

NATIONAL FIRE PROTECTION ASSOCIATION (NFPA) HAZARD IDENTIFICATION

 

NFPA – Comments:

NFPA has no listing for this chemical in Codes 49 or 325.

 

SECTION 9. PHYSICAL AND CHEMICAL PROPERTIES

 

Molecular Weight:            34.02

Conversion Factor:

1 ppm = 1.39 mg/m3; 1 mg/m3 = 0.72 ppm at 25 deg C (calculated)

Physical State:    Liquid

Melting Point:      No information available

Boiling Point:      No specific information available; probably close to 100 deg C (212 deg F)

Relative Density (Specific Gravity): No specific information available; probably close to 1 at 20-25 deg C (water = 1)

Solubility in Water:          Soluble in all proportions.(4,19,20)

Solubility in Other Liquids: Soluble in all proportions in many polar solvents, e.g. low molecular weight alcohols, glycols and ketones; insoluble in petroleum ether.(4,20,24)

Coefficient of Oil/Water Distribution (Partition Coefficient):     Log P(oct) = -0.70 to -1.33 (estimated) (25)

pH Value:           Very slightly acid to litmus paper.

Acidity:  Weak acid; pKa = 11.75 at 20 deg C (Ka = 1.78 X 10(-12) at 20 deg C).(19,20)

Viscosity-Dynamic:           Approximately 1 mPa.s (1 centipoise) at 20 deg C.(4)

Surface Tension:  Approximately 73 mN/m (73 dynes/cm) at 20 deg C.(4)

Vapour Density:   1.2 (air = 1)

Vapour Pressure: Not available

Saturation Vapour Concentration:   Not available

Evaporation Rate:            Not available

 

SECTION 10. STABILITY AND REACTIVITY

 

Stability:

Solutions which are completely free of contamination are relatively stable. Alkaline solutions are less stable than acidic ones (the optimum pH is 3.5-4.5). It can decompose in sunlight. Hydrogen peroxide can liberate oxygen, water and heat.(4,19)

Hazardous Polymerization:

Does not occur

Incompatibility – Materials to Avoid:

NOTE: Chemical reactions that could result in a hazardous situation (e.g. generation of flammable or toxic chemicals, fire or detonation) are listed here. Many of these reactions can be done safely if specific control measures (e.g. cooling of the reaction) are in place. Although not intended to be complete, an overview of important reactions involving common chemicals is provided to assist in the development of safe work practices.

 

 

Dilute hydrogen peroxide solutions (less than 8%) are incompatible with reducing agents, including organic matter and oxidizable substances, alkalies, iodides, permanganates and other stronger oxidizing agents (e.g. nitric acid, perchloric acid). Its decomposition is increased by contact with powdered metals or their salts (e.g. iron, copper).(18)

More concentrated hydrogen peroxide solutions (30% or greater) are strong oxidizing agents and are capable of reacting explosively with many substances. For a review of the many substances with which hydrogen peroxide can react, consult references 23, 26 and 27.

Hazardous Decomposition Products:

Oxygen

Conditions to Avoid:

Temperatures greater than 100 deg C, depletion of stabilizers, pH greater than 4.5.

Corrosivity to Metals:

Hydrogen peroxide solutions less than 8% are corrosive (corrosion rate greater than 1.27 mm/year) to carbon steel (types 1010 and 1020), ductile cast iron, copper, nickel-copper alloy, brass, cartridge brass, naval brass, bronze, aluminum bronze, naval bronze, silicon bronze, and lead at room temperature.(28,35,36) Hydrogen peroxide solutions attack types 1010 and 1020 carbon steel at any concentration and temperature.(35) Hydrogen peroxide solutions less than 8% are not corrosive (corrosion rate less than 0.5 mm/year) to stainless steel (e.g. types 304, 316, 403, 410, 430, Carpenter 20Cb-3), aluminum (99.5%), certain aluminum alloys (types 1060, 3003, 5052, 6063, Cast B-356 and aluminum-magnesium alloys), nickel, the nickel-base alloys, Monel, Hastelloy C, Inconel and Incoloy, tantalum, titanium and zirconium.(35,36,37) Both stainless steel and aluminum surfaces must be passivated (formation of a protective film by chemical treatment) before use.(19,20)

Stability and Reactivity Comments:

The degree of hazard associated with hydrogen peroxide depends on concentration. It may attack some forms of plastics, rubber, or coatings.(30)

 

SECTION 11. TOXICOLOGICAL INFORMATION

 

LC50 (rat): 2000 mg/m3 (4-hour exposure; whole body exposure) (concentration not specified) (3)

NOTE: This value is not considered reliable since a whole body exposure was used and the study was poorly reported.

LD50 (oral, male rat): 1517 mg/kg (9.6% solution) (4,12)

Eye Irritation:

Hydrogen peroxide solutions of 5% have caused minimal irritation. No reliable information was located for solutions of greater than 5 and less than 8%.

Application of 0.1 mL of a 5% solution caused minimal irritation in washed and unwashed eyes (maximum score 3/110) in rabbits.(13) Repeated instillation of a drop of a 1% solution caused severe irritation and clouding of the cornea.(4, unconfirmed) Other unpublished studies have shown no effects following application of a 3% solution.(4, unconfirmed) A drop of 5-30% solution caused severe damage, which was persistent when concentrations were greater than 10%. Even a 5% solution resulted in severe irritation, which only improved partially over 4-5 months.(7, unconfirmed)

Skin Irritation:

Hydrogen peroxide solutions of less than 8% are not irritating.

In unpublished studies, application of a 3, 6 or 8% hydrogen peroxide solution, under a cover to intact skin for 24 hours, caused no irritation in rabbits (all scores for erythema and edema were 0/4).(4, unconfirmed)

Effects of Short-Term (Acute) Exposure:

Inhalation:

Interpretation of the available inhalation exposure information is complicated because the form of hydrogen peroxide (vapour or aerosol) is not always specified. In general, studies have shown that airborne hydrogen peroxide is irritating to the respiratory tract. Symptoms have included nose irritation and discharge, fluid accumulation in the lungs and necrosis of bronchial tissue. Deaths have been reported.(4,14,15)

Ingestion:

Male mice showed a decrease in body weight and died within 2 weeks when their drinking water contained greater than 1% hydrogen peroxide. Significant decreases in body weight gain were observed after administration of 0.6% but not 0.3% for 3 weeks.(4,5) In another study, decreased fluid intake and body weight were observed in male rats exposed to 0.45% for 3 weeks.(16)

Effects of Long-Term (Chronic) Exposure:

Inhalation:

There is no specific information available for vapours or aerosols generated from solutions of less than 20%. A study which examined rats exposed to 67 ppm (93 mg/m3) of an aerosol/vapour mixture generated from 90% hydrogen peroxide over a 7 week period showed irritation of the respiratory tract and lung congestion in all animals. In the same study, two dogs were exposed to 7 ppm (10 mg/m3) of an aerosol/vapour mixture generated from 90% hydrogen peroxide for 6 months. There were no signs of toxicity by 14 weeks except for bleaching and loss of hair. Autopsy showed signs of lung irritation, as well as loss of hair and thickening of the skin.(14)

Ingestion:

Several studies have investigated the effects of long-term oral administration of hydrogen peroxide. In general, decreases in body weight gain and biochemical changes have been observed with exposure to lower doses or with exposures of longer durations. Deaths have occurred in animals exposed to doses of 1.5% and higher for 8 weeks or longer. Liver damage and thickening of the stomach wall has been observed in mice administered 0.15% hydrogen peroxide (approximately 230 mg/kg/day) in their drinking water for 16 weeks. This study continued for 35 weeks during which harmful changes in the kidneys, gastrointestinal tract and spleen were also observed.(4,5)

Skin Sensitization:

Negative results were obtained in guinea pigs exposed to 3 or 6% solutions.(4, unconfirmed)

Carcinogenicity:

The International Agency for Research on Cancer (IARC) has concluded that there is limited evidence of the carcinogenicity of hydrogen peroxide in experimental animals.(5,34) The American Conference of Governmental Industrial Hygienists (ACGIH) has designated hydrogen peroxide as an A3 (animal carcinogen).

Several studies have shown that long-term oral administration of 0.1-0.15% hydrogen peroxide causes an inflammatory response in the gastro-duodenal tissue of mice. This inflammatory response may progress to carcinogenic changes. In rats, hydrogen peroxide only induced benign tumours, not malignant tumours, even at nearly lethal concentrations (1-1.5%).(4,10) No neoplasms were observed in hamsters administered 0.75% hydrogen peroxide in dentrifice 5 times/week for 20 weeks. This study is limited by its short duration and the unknown effect of using dentrifice as the vehicle.(34) Hydrogen peroxide did not act as a tumour promoter when administered to rats or hamsters with a known carcinogen.(10,34)

Teratogenicity, Embryotoxicity and/or Fetotoxicity:

No conclusions can be drawn based on the available information.

One historical study which lacks details reported that normal litters were born to 3 female rats exposed to 0.45% in drinking water for 5 months and then mated with unexposed males.(16) No conclusions can be drawn from another poorly conducted study (4, unconfirmed).

Reproductive Toxicity:

No conclusions can be drawn based on the limited information available.

Male mice were given 0.33% or 1.0% hydrogen peroxide solutions in place of drinking water. The mice were mated after days 7 and 28 or day 21 of exposure. No significant effects on fertility were observed. The concentration, morphology and motility of sperm of mice and rabbits receiving hydrogen peroxide in their drinking water over 3 and 6 weeks remained normal.(17) This study is limited by the small number of animals used and the fact that a control group was not used. Rats were orally administered doses of up to 50 mg/kg orally for 6 months. At the high dose, altered fertility cycles were observed in the females and decreased sperm mobility in males. Treated animals were mated. High dose females produced fewer litters.(4, unconfirmed) There is insufficient information available to evaluate this report.

Mutagenicity:

Negative results have been obtained in most studies using live animals. However, positive results have been obtained in host-mediated assays. In these studies, mutagenicity was observed in bacteria and tumour cells injected into live animals.(4,5,34)

Positive results were obtained in cultured mammalian cells, including human cells, and in bacteria and yeast.(4,5,34)

Negative results were obtained in fruit flies.(4,5,34)

 

SECTION 16. OTHER INFORMATION

 

Selected Bibliography:

(1) Kaelin, R.M.. Diffuse interstitial lung disease associated with hydrogen peroxide inhalation in a dairy worker. American Review of Respiratory Diseases. Vol. 137, no. 5 (May 1988). p. 1233-1235

(2) Toyama, T., et al. Synergistic response to hydrogen peroxide aerosols and sulfur dioxide to pulmonary airway resistance. Industrial Health. Vol. 2 (1964). p. 35-45

(3) Kondrashov, V.A. Comparative toxicity of hydrogen peroxide vapour on inhalation and dermal exposure. [English translation]. Gigiena Truda i Professionalnye Zabolevaniya. Vol. 21, no. 10 (1977). p. 22-25. (HSE Translation No. 14391A)

(4) Hydrogen peroxide CAS No. 7722-84-1. Joint assessment of commodity chemicals no. 22. European Centre for Ecotoxicology and Toxicology of Chemicals (ECETOC), Sept. 1992

(5) International Agency for Research on Cancer (IARC). Hydrogen peroxide. In: IARC monographs on the evaluation of the carcinogenic risk of chemicals to humans. Vol. 36. Allyl compounds, aldehydes, epoxides and peroxides. World Health Organization, Feb. 1985. p. 285-314

(6) Goette, D.K., et al. Skin blanching induced by hydrogen peroxide. Case reports. Southern Medical Journal. Vol. 70, no. 5 (May 1977). p. 620-622

(7) Grant, W.M., et al. Toxicology of the Eye. 4th ed. Charles C. Thomas, 1993. p. 791-797

(8) Aguirre, A., et al. Positive patch tests to hydrogen peroxide in 2 cases. Contact Dermatitis. Vol. 30, no. 2 (Feb. 1994). p. 113

(9) Barsotti, M., et al. Symptoms of bronchial asthma and eczema in workers assigned to hydrogen peroxide production units. English summary. Medicina del Lavoro. Vol. 42, no. 2 (1951). p. 68

(10) Takahashi, M., et al. Effects of ethanol, potassium metabisulfite, formaldehyde and hydrogen peroxide on gastric carcinogenesis in rats after initiation with N-methyl-N’-nitro-N-nitrosoguanidine. Japanese Journal of Cancer Research. Vol. 77, no. 2 (Feb. 1986). p. 118-124

(11) Svirbely, J.L., et al. Enhanced toxicity of ozone-hydrogen peroxide mixture. American Industrial Hygiene Association Journal. Vol. 22, no. 1 (Feb. 1961). p. 21-26

(12) RTECS database record for hydrogen peroxide, 8% to 20%. Last updated: 1997/10

(13) Weiner, M., et al. Eye irritation studies on three concentrations of hydrogen peroxide. Journal of the American College of Toxicology. Part B (1990). p. 49-50

(14) Oberst, F.W., et al. Inhalation toxicity of ninety percent hydrogen peroxide vapor. A.M.A. Archives of Industrial Hygiene and Occupational Medicine. Vol. 10 (Oct. 1954). p. 319-327

(15) Punte, C.L., et al. The inhalation toxicity of aerosols of 90% hydrogen peroxide. Medical Laboratories Research Report No. 189. Chemical Corps Medical Laboratories. Army Chemical Center, Maryland, May 1953. (NIOSHTIC Control Number: 00068230)

(16) Hankin, L. Hydrogen peroxide ingestion and the growth of rats. Nature. No. 4647 (Nov. 22, 1958). p. 1453

(17) Wales, R.G., et al. The spermicidal activity of hydrogen peroxide in vitro and in vivo. Journal of Endocrinology. Vol. 18 (1959). p. 236-244

(18) Reynolds, J.E.F., ed. Martindale; the extra pharmacopoeia. 29th ed. The Pharmaceutical Press, 1989. p. 1578-1579

(19) Eul, W.E., et al. Hydrogen peroxide. In: Kirk-Othmer encyclopedia of chemical technology. John Wiley and Sons, 2005. Available at: <www.mrw.interscience.wiley.com/kirk/kirk_search_fs.html> {Subscription required}

(20) Goor, G., et al. Hydrogen Peroxide. In: Ullmann’s encyclopedia of industrial chemistry. 7th ed. John Wiley and Sons, 2005. Available at: <www.mrw.interscience.wiley.com/ueic/ueic_search_fs.html> {Subscription required}

(21) Chemical safety sheets: working safely with hazardous chemicals. Kluwer Academic Publishers, 1991

(22) NFPA 430. Code for the storage of liquid and solid oxidizers. 1995 ed. National Protection Association, 1995. p. 430-1 to 430-16

(23) Fire protection guide to hazardous materials. 11th ed. National Fire Protection Association, 1994

(24) HSDB database record for hydrogen peroxide. Last revision date: 97/05/01

(25) Leo, A., et al. Partition coefficients and their uses. Chemical Reviews. Vol. 71, no. 6 (Dec. 1971). p. 555

(26) Urben, P.G., ed. Bretherick’s handbook of reactive chemical hazards. 5th ed. Vol. 1. Butterworth-Heinemann Ltd., 1995

(27) Sigma-Aldrich library of chemical safety data. Ed. II. Vol. 1. Sigma-Aldrich Corporation, 1988

(28) Corrosion data survey: metals section. 6th ed. National Association of Corrosion Engineers, 1985

(29) Merrifield, R. Fire and explosion hazards associated with the storage and handling of hydrogen peroxide. Specialist Inspector Report no. 19. Health and Safety Executive, Technology Division, Oct. 1988

(30) Emergency action guide for hydrogen peroxide. Association of American Railroads, Jan. 1990

(31) NIOSH pocket guide to chemical hazards. National Institute for Occupational Safety and Health, June 1997

(32) Forsberg, K., et al. Quick selection guide to chemical protective clothing. 4th ed. Van Nostrand Reinhold, 2002

(33) European Communities (EC). Commission Directive 2004/73/EC. Apr 29, 2004

(34) International Agency for Research on Cancer (IARC). IARC monographs on the evaluation of carcinogenic risks to humans. Vol. 71, parts 1, 2 and 3. Re-evaluation of some organic chemicals, hydrazine and hydrogen peroxide. IARC, 1999

(35) Pruett, K.M. Hydrogen peroxide. In: Chemical resistance guide to metals and alloys: a guide to chemical resistance of metals and alloys. Compass Publications, 1995. p. 170-181

(36) Schweitzer, P.A. Hydrogen peroxide. In: Corrosion resistance tables: metals, nonmetals, coatings, mortars, plastics, elastomers and linings, and fabrics. 4th ed. Part B, E-O Marcel Dekker, Inc., 1995. p. 1553-1556

(37) Hydrogen peroxide. In: Handbook of corrosion. 2nd ed. Edited by B.D. Craig, et al. ASM International, 1997. p. 468-470

Information on chemicals reviewed in the CHEMINFO database is drawn from a number of publicly available sources. A list of general references used to compile CHEMINFO records is available in the database Help.

 

Review/Preparation Date: 1998-05-05

 

Revision Indicators:

WHMIS (disclosure list)     1999-03-01

Carcinogenicity    1999-12-01

Mutagenicity        1999-12-01

ERPG     2001-03-01

PEL-TWA final     2003-12-19

PEL transitional comments 2003-12-19

Resistance of materials for PPE       2004-04-06

EU classification   2004-11-18

EU risks 2004-11-18

EU safety           2004-11-18

EU comments      2004-11-18

Toxicological info 2006-03-27

Short-term eye contact     2006-03-27

Emergency overview        2006-03-27

WHMIS health effects       2006-03-27

WHMIS proposed classification       2006-03-27

OSHA hazcom     2006-03-27

Corrosivity to metals        2006-04-04

WHMIS detailed classification         2006-04-04

Bibliography        2006-04-04

Eye/face protection          2006-04-04

Resistance of materials for PPE       2006-04-04

Skin protection    2006-04-04

Handling 2006-04-04

 

 

The following information has been extracted from our CHEMINFO database, which also contains hazard control and regulatory information. [More about…] [Sample Record]

 

Access the complete CHEMINFO database by contacting CCOHS Client Services.

 

SECTION 1. CHEMICAL IDENTIFICATION

 

CHEMINFO Record Number:           780

CCOHS Chemical Name:   Bisphenol A diglycidyl ether

Synonyms:

2,2-Bis(4-(2,3-epoxypropoxy)phenyl)-propane

2,2-Bis(4-hydroxyphenyl)propane diglycidyl ether

4,4′-Bis(2,3-epoxypropoxy)diphenyldimethylmethane

DGEBPA

4,4′-Isopropylidenebis(1-(2,3-epoxypropoxy)benzene)

4,4′-Isopropylidenediphenol diglycidyl ether

Bis(4-glycidyloxyphenyl)dimethylmethane

Bis(4-hydroxyphenyl)dimethylmethane diglycidyl ether

Diglycidyl bisphenol A ether

2,2′-[(1-Methylethylidene)bis(4,1-phenyleneoxymethylene)]bis[oxirane]

CAS Registry Number:      1675-54-3

RTECS Number(s):           TX3800000

EU EINECS/ELINCS Number:         216-823-5

Chemical Family: Aromatic glycidyl ether / aromatic diglycidyl ether / bisphenol A ether / epoxy resin / epichlorohydrin resin

Molecular Formula:          C21-H24-O4

Structural Formula:          H2C-(O)-CH-CH2-O-C6H4-C[(CH3)2]-C6H4-O-CH2-CH-(O)-CH2

 

SECTION 2. DESCRIPTION

 

Appearance and Odour:

Colourless, crystalline solid.(32)

Odour Threshold:

Not available

Warning Properties:

Information not available for evaluation

Composition/Purity:

Diglycidyl ether of bisphenol A (DGEBPA) is made by reacting epichlorohydrin and bisphenol A. DGEBPA is not generally produced as a pure monomer, but occurs as a component of a resin mixture containing varying amounts of the low molecular weight polymers (monomer, dimers, trimers and tetramers) (CAS 25068-38-6); as a homopolymer of DGEBPA (CAS 25085-99-8); or as a higher molecular weight polymer of DGEBPA (CAS 25036-25-3). It is unlikely that many commercial products are pure DGEBPA monomer (CAS 1675-54-3).(9,32-35) Nevertheless, some suppliers/manufacturers do use the monomer CAS Registry Number (1675-54-3) for products that are actually complex DGEBPA-based epoxy resin mixtures. Interpretation and evaluation of the information on DGEBPA and DGEBPA-based epoxy resins is complicated by the fact that these materials are complex mixtures; it is not always clear exactly which material is being studied; and the CAS Registry Numbers and names of the materials are, at times, used interchangeably. This CHEMINFO profile reviews information available for pure DGEBPA monomer (CAS 1675-54-3). For information on low molecular weight liquid DGEBPA-based epoxy resin mixtures (CAS 25068-38-6 or 25085-99-8), low molecular weight solid DGEBPA-based epoxy resin mixtures (CAS 25068-38-6 or 25085-99-8), or medium to high molecular weight solid DGEBPA-based epoxy resin mixtures (CAS 25036-25-3) refer to the relevant CHEMINFO reviews.

Uses and Occurrences:

Epoxy resins based on glycidyl ethers are used in protective coatings, including waterborne coatings, solventless coatings, high solids coatings and powder coatings, decorative and protective coatings for automobiles, coal tar pitch modified coatings, reinforced plastics, structural composites, including pipes, vessels, electrical, aerospace and sporting goods applications; electrical laminates, moulding components, bonding materials and adhesives, sealants, patching compounds, flooring, paving and aggregates, tins and closures, boats and ships, appliances, piping and miscellaneous metal decoration, fibre-reinforced laminates, encapsulants and grouting compounds, tooling, casting and moulding resins.(9,32)

 

SECTION 3. HAZARDS IDENTIFICATION

 

EMERGENCY OVERVIEW:

Colourless, crystalline solid. POTENTIAL COMBUSTIBLE DUST HAZARD. Powdered material may form explosive dust-air mixtures. SKIN SENSITIZER. May cause severe allergic skin reaction.

 

POTENTIAL HEALTH EFFECTS

 

Effects of Short-Term (Acute) Exposure

 

Inhalation:

For most workers, exposure to DGEBPA is probably not harmful following short-term exposure, based on animal information for DGEBPA and related compounds. High concentrations of DGEBPA dust may cause coughing and mild, temporary irritation. In very rare cases, DGEBPA may cause an allergic respiratory reaction like asthma, based on limited human information for low molecular weight DGEBPA-based epoxy resins which contain a high percentage of pure DGEBPA. Refer to “Effects of Long-term (Chronic) Exposure” for more information.

Skin Contact:

Pure DGEBPA is a mild skin irritant, based on animal information. DGEBPA is a well known skin sensitizer, based on animal and human information. It can cause a severe allergic skin reaction in sensitized individuals, even following very brief contact. Refer to “Effects of Long-term (Chronic) Exposure” for more information.

Animal toxicity information suggests that DGEBPA is not absorbed through the skin in harmful amounts.

Eye Contact:

Pure DGEBPA dust is a mild eye irritant, based on animal information for low molecular weight DGEBPA-based epoxy resins, which contain a large percentage of pure DGEBPA. Some tearing, blinking and mild, temporary pain may occur as the solid material is rinsed from the eye by tears.

Ingestion:

There is no human information available. Animal toxicity information suggests that pure DGEBPA would not cause significant harmful effects following ingestion. Ingestion is not a typical route of occupational exposure.

Effects of Long-Term (Chronic) Exposure

 

Respiratory Sensitization:

It is not possible to conclude that DGEBPA is a respiratory sensitizer, based on the available information.

In a very small number of cases (three people), low molecular weight DGEBPA-based epoxy resins have caused respiratory sensitization in humans occupationally exposed to these compounds.(4,17,57) Pure DGEBPA is normally a significant component of low molecular weight resins and may, therefore, also cause this effect. Sensitized people can experience symptoms of bronchial asthma such as wheezing, difficult breathing, sneezing and runny or blocked nose at low airborne concentrations that have no effect on unsensitized people.

Skin:

Repeated or prolonged contact may result in dermatitis (dry, red, cracked skin), based on animal information.

Skin Sensitization:

Repeated skin contact can cause allergic skin sensitization in some individuals. Once a person is sensitized to DGEBPA, contact with even a small amount causes outbreaks of dermatitis with symptoms such as skin redness, itching, rash and swelling. This reaction can spread from the point of contact (usually the hands or arms) to other parts of the body.

Numerous cases of allergic skin reactions have been reported in people occupationally exposed to DGEBPA-based epoxy resins (13-19,27,50-56) and in animal studies following exposure to pure DGEBPA and DGEBPA-based epoxy resins (1,2,12,21,22,26). Low molecular weight resins, which contain a high percentage of pure DGEBPA, appear to be the true sensitizers.

Endocrine System:

Firm conclusions cannot be drawn from one study that also involved exposure to organic solvents. In this study, 42 male epoxy sprayers who worked with hardening agents containing 10-30% DGEBPA for at least 3 hrs/day (duration unspecified) were compared to 82 unexposed controls. Exposure was to DGEBPA with mixed organic solvents including toluene, xylene, 2-ethoxyethanol, 2-butoxyethanol and methyl isobutyl ketone. Urinary concentrations of bisphenol A (a metabolite of DGEBPA) were increased and plasma FSH (Follicle Stimulating Hormone) concentrations were decreased, but still within the normal range. Plasma testosterone and LH (Luteinizing Hormone) levels were normal. The authors speculated that bisphenol A may interfere with pituitary FSH secretion, but the clinical importance of the reported findings remains unclear.(37)

OTHER EFFECTS: Skin irritation and rashes, muscle and joint disorders and central nervous system and respiratory disturbances have been reported in workers exposed to DGEBPA-based epoxy resins, as well as several other potentially harmful chemicals.(10,11,27,28) It is not possible to say that DGEBPA alone caused any of these effects because of the exposures to other potentially harmful chemicals at the same time.

Carcinogenicity:

There is no human information available. The International Agency for Research on Cancer (IARC) has determined that there is limited evidence for the carcinogenicity of DGEBPA in experimental animals.(9,43)

The International Agency for Research on Cancer (IARC) has concluded that this chemical is not classifiable as to its carcinogenicity to humans (Group 3).

The American Conference of Governmental Industrial Hygienists (ACGIH) has no listing for this chemical.

The US National Toxicology Program (NTP) has not listed this chemical in its report on carcinogens.

Teratogenicity and Embryotoxicity:

There is no human information available. No significant effects have been observed in animal studies following oral or skin exposure, even in the presence of significant toxicity in the mothers.

Reproductive Toxicity:

There is no human information available. No reproductive effects were observed in one animal study following oral exposure to low molecular weight DGEBPA-based epoxy resins which contain a high percentage of pure DGEBPA.

Mutagenicity:

It is not possible to conclude that DGEBPA is mutagenic. Negative results were obtained in two studies of a small number of workers exposed to DGEBPA-based epoxy resins.(24,25) One other study cannot be evaluated because of insufficient information.(2) Positive results (DNA adducts) were obtained in a limited test using live mice. Positive results were also obtained in cultured mammalian cells. Positive and negative results were obtained in tests using bacteria.

Toxicologically Synergistic Ma