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,
Tokyo, Japan, and the Institute of Terrestrial Ecology, Monk's Wood,
United Kingdom
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
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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
A. 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.
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.
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.
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.
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
it. 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.
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.
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.
* 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
it. 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.
* 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.
* 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.
* 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.
* 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.
* 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.
* 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.
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.
* 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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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;
- 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
so. 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.