UNITED NATIONS ENVIRONMENT PROGRAMME
INTERNATIONAL LABOUR ORGANISATION
WORLD HEALTH ORGANIZATION
INTERNATIONAL PROGRAMME ON CHEMICAL SAFETY
GUIDELINES FOR POISON CONTROL
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.
Guidelines for poison control
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
Guidelines for poison control
1.Poisoning - prevention & control 2.Poison control centres
3.Guidelines
ISBN 92 4 154487 2 (NLM Classification: QV 600)
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Contents
Preface
Acknowledgements
Introduction
I. Policy overview
1. Poison information centres: their role in the prevention and
management of poisoning
History
Functions
Benefits
Conclusions and recommendations
II. Technical guidance
2. Information services
Organization and operation
Location, facilities, and equipment
Staff
Financial aspects
Research
3. Clinical services
Introduction
Clinical toxicology units
Staff
Recommendations
4. Analytical toxicology and other laboratory services
Introduction
Functions of an analytical toxicology service
Location, facilities, and equipment
Staff
5. Toxicovigilance and prevention of poisoning
Introduction
Toxicovigilance and prevention programmes
Recommendations
6. Response to major emergencies involving chemicals
Introduction
Information
Treatment
Contingency planning
Education and training
Follow-up studies
Financial support
Collaboration between centres
7. Antidotes and their availability
Introduction
Scientific aspects
Technical aspects
Economic aspects
Registration and administrative requirements
Considerations of time and geography
Special problems of developing countries
Antidotes for veterinary use
Improving availability
8. Model formats for collecting, storing, and reporting data
Substance records
Product records
Communications records
Annual reports
9. Library requirements for poison information centres
Books
Journals
Publications of international organizations
Computerized databases
Educational material
Annexes
1. Summary description of the IPCS INTOX Package
2. Classified lists of antidotes and other agents
3. Example of a substance record: chemical
4. INTOX product record
5. INTOX communication record and miniform
6. Proposed format for a poison centre annual report
7. Environmental Health Criteria series
Preface
The International Programme on Chemical Safety (IPCS) was
established in 1980 as a collaborative programme of the International
Labour Organisation (ILO), the United Nations Environment Programme
(UNEP), and the World Health Organization (WHO) in order to provide
assessments of the risks to human health and the environment posed by
chemicals, so that all countries throughout the world might develop
their own chemical safety measures. The IPCS provides guidance on the
use of such assessments and seeks to strengthen the capacity of each
country to prevent and treat the harmful effects of chemicals and to
manage emergencies involving chemicals. In its different activities,
the IPCS collaborates with various international organizations and
professional bodies. Its work on prevention and treatment of poisoning
is undertaken in collaboration with the World Federation of
Associations of Clinical Toxicology Centres and Poison Control
Centres1 and its member associations. The aims of the European
Commission (EC) in the field of poison control are similar to those of
the IPCS and many activities are undertaken jointly by the two bodies.
Poisoning by chemicals is a significant risk in all countries
where substantial quantities and increasing numbers of chemicals are
being used in the development process. Some countries already have
well established facilities for the prevention and control of
poisoning, many wish to establish or strengthen such facilities, and
others have not yet fully recognized the extent of the risk.
The need for advice on poison control, particularly with a view
to encouraging countries to establish poison information centres, was
recognized at a joint meeting of the World Federation, the IPCS, and
the EC, held at WHO headquarters, Geneva, from 6 to 9 October 1985. At
this meeting it was recommended that guidelines be prepared on poison
control and particularly on the role of poison information centres. It
was also recommended inter alia that antidotes and other substances
used in the treatment of poisoning should be evaluated, comparable
information needed for diagnosis and treatment of poisoning collected
and recorded in a standardized manner, toxicovigilance and poison
prevention programmes developed, mechanisms for exchanging experience
of dealing with major chemical accidents established, and specialized
training in poison control encouraged.
A consultation of experts from poison information centres, from
developed and developing countries, was held in London, England, from
24 to 25 February 1986, to advise on the structure and content of the
proposed guidelines on poison control. It was agreed that the
guidelines would be in two parts, the first concerned with national
policy, and the second with technical aspects of establishing and
running the various elements of a poison control programme. A drafting
1 Hereafter referred to simply as the World Federation.
group was established and charged with the preparation of the
guidelines. This group met twice - from 25 to 26 November 1986 in
Brussels, Belgium, and from 16 to 20 February 1987 in London, England
- and concentrated on the drafting of the policy overview.
The initial draft was examined by an extended editorial group,
meeting from 9 to 14 November 1987 in Salvador, Bahia, Brazil, during
the Fifth Congress of the Brazilian Society of Toxicology. Work on the
drafting of Part II was also initiated at that time.
Additional contributions were made by a number of experts,
acknowledged below. Besides the extensive experience of poison control
published in the literature, the results of the following activities
were used in assembling material: the Joint IPCS/EC/World Federation
survey on poison control centres and related toxicological services;1
the Joint IPCS/EC Project on Antidotes; the IPCS Poisons Information
Package project - IPCS INTOX - being undertaken jointly with the
Canadian Centre for Occupational Health and Safety (CCOHS) and the
Centre de Toxicologie du Québec (CTQ), with financial assistance from
the International Development and Research Centre of Canada (IDRC);
the joint WHO (EURO)/IPCS/EC meetings held in Munich, 16 to 20
December 1985, on public health response to acute poisonings2 and in
Munster, 8 to 12 December 1986, on prevention of acute chemical
poisonings;3 and the IPCS seminar on training for poison control
programmes in developing countries,4 held in London in February 1987.
Subsequently, a complete draft text was circulated for comment to
members of the World Federation and selected IPCS focal points in
various countries. The text was examined at a joint IPCS/EC
secretariat meeting with the General Assembly of the World Federation,
held at WHO headquarters in Geneva, 31 October to 2 November 1988; it
was the opinion of the meeting that the guidelines reflected
experience in Europe and North America, but should be tested in a
number of other regions of the world before being finalized and
published.
The guidelines were first presented at the Joint IPCS/WHO/World
Federation Workshop on Prevention and Management of Poisoning by Toxic
Substances, held in Kuala Lumpur, Malaysia, 29 November to 2 December
1989, in which representatives from 27 countries took part. They were
also presented and discussed at two regional IPCS workshops on
development of poison control programmes, held in Montevideo, Uruguay,
in March 1991 and February 1992, organized by the Centro de
Información y Asesoriamento Toxicológico and with partial financial
support from the International Union of Toxicology (IUTOX). The
guidelines were further used as the basis for national workshops on
poison control held in Ciloto, Indonesia, in November 1992, Bangkok,
Thailand, in November 1992, and New Delhi, India, in December 1992.
Due account having been taken of experience of their use in
different parts of the world, the guidelines are now issued as a WHO
publication to encourage their wide distribution and use throughout
the world.
Attention is drawn to the report5 of the United Nations
Conference on Environment and Development (UNCED), held in Rio de
Janeiro, Brazil, in June 1992, in Agenda 21, Chapter 19, of which all
countries are called upon to promote the establishment and
strengthening of poison control centres to ensure prompt and adequate
diagnosis and treatment of poisoning, including networks of centres
for chemical emergency response.
Following the recommendations of UNCED in relation to sound
management of chemicals, an Intergovernmental Forum on Chemical Safety
(IFCS) was established in April 1994. One of the priority activities
recommended to all governments by IFCS is the establishment of poison
centres with related clinical and analytical facilities and the
promotion of harmonized systems for recording data in different
countries. These guidelines provide policy and technical advice to
those responsible for setting up poison centres and related
facilities, and give recommended approaches for harmonized data
recording among countries.
1 Report of the survey of poison control centres and related
toxicological services 1984-1986. Journal de toxicologie
clinique et expérimentale, 1988, 8(5):313-371.
2 Public health response to acute poisonings: poison control
programmes: report on a joint working group, Munich, 16-20
December, 1985. Copenhagen, World Health Organization Regional
Office for Europe, 1986 (Environmental Health Series, No. 11).
3 Prevention of acute chemical poisonings: high-risk circumstances:
report on a joint WHO/IPCS/CEC meeting. Copenhagen, World
Health Organization Regional Office for Europe, 1987
(Environmental Health Series, No. 28).
4 Report of IPCS Seminar on Training for Poison Control Programmes
in Developing Countries. Geneva, World Health Organization,
1987 (unpublished document ICS/87.33, available on request from
Programme for the Promotion of Chemical Safety, World Health
Organization, 1211 Geneva 27, Switzerland).
5 Adopted by the United Nations General Assembly at its 47th
Session in New York, in December 1992, Resolution GA47/719.
Acknowledgements
The following are the members of the drafting group and experts
who prepared specific sections of these guidelines:
Dr B. Fahim, Director, Poison Control Centre, Ain Shams University,
Cairo, Egypt
Dr R. Flanagan, Toxicology Laboratory, Medical Toxicology Unit, Guy's
and St Thomas's Hospital Trust, London, England
Dr M. Govaerts, formerly Director, Belgian Poisons Centre, Brussels,
Belgium
Dr J.A. Haines, IPCS Secretariat, World Health Organization, Geneva,
Switzerland (Chairman of the drafting group)
Dr V. Murray, Honorary Consultant, Medical Toxicology Unit, Guy's and
St Thomas's Hospital Trust, London, England (Rapporteur of the
drafting group)
Dr H. Persson, Director, Swedish National Poisons Information Centre,
Karolinska Hospital, Stockholm, Sweden
Dr J. Pronczuk de Garbino, IPCS Secretariat, World Health
Organization, Geneva, Switzerland
Dr E. Wickstrom, Director, Poisons Information Centre, Oslo, Norway
Ms H. Wiseman, Medical Toxicology Unit, Guy's and St Thomas's Hospital
Trust, London, England
The following experts took part in consultations and review
working groups for the guidelines:
Dr A. Berlin, Secretariat, Directorate General V, European Commission,
Luxembourg
Dr I.R. Edwards, Director, WHO Collaborating Centre for International
Drug Monitoring, Uppsala, Sweden, formerly Director, National
Toxicology Group, University of Otago, Dunedin, New Zealand
Dr N. Fernicola, Toxicology Consultant, Pan American Health
Organization, Bogota, Colombia
Dr E. Fournier, formerly Director, Toxicology Service, Fernand Widal
Hospital, Paris, France
Dr J. Garbino, formerly Assistant, Intensive Care Unit, Hospital de
Clínicas Dr Manuel Quintela, Montevideo, Uruguay
Dr A.N.P. van Heijst, formerly Director, Dutch Poisons Control Centre,
Utrecht, Netherlands
Dr J. Indulski, formerly Director, Nofer's Institute of Occupational
Medicine, Lodz, Poland
Dr A. Jaeger, Director, Poisons Centre, Strasbourg, France
Dr J.P. Lorent, Swiss Toxicological Information Centre, Zurich,
Switzerland
Dr S. Magalini, Director, Poisons Centre, Rome, Italy
Dr F. Oehme, Veterinary College, University of Kansas, Manhattan, KS,
USA, formerly President, World Federation of Associations of Clinical
Toxicology Centres and Poison Control Centres
Dr M. Repetto, Director, National Toxicology Institute, Seville, Spain
Dr L. Roche, Lyon, France, formerly Secretary General, World
Federation of Associations of Clinical Toxicology Centres and Poison
Control Centres
Dr B. Rumack, formerly Director, Rocky Mountain Drug and Poisons
Information Center, Denver, CO, USA
Dr N.N. Sabapathy, formerly Zeneca Agrochemicals, Hazelmere, England
Dr S. Shabeer Hussain, Director, National Poison Control Centre,
Karachi, Pakistan
Dr W.A. Temple, Director, National Toxicology Group, University of
Otago, Dunedin, New Zealand
Dr M. Thoman, Associate Editor, Veterinary and Human Toxicology, Des
Moines, IA, USA
Dr M.T. van der Venne, Directorate General V, European Commission,
Luxembourg
Dr C. Vigneaux, Anti-Poisons Centre, Lyon, France
Dr J. Vilska, Director, Poison Information Centre, Helsinki, Finland
Dr G. Volans, Director, Medical Toxicology Unit, Guy's and St Thomas's
Hospital Trust, London, England
Dr R. Wennig, Director, National Health Laboratory, Luxembourg
Introduction
The massive expansion in the availability and use of chemicals,
including pharmaceuticals, during the past few decades has led to
increasing awareness - on the part not only of the medical profession
but also of the public and various authorities - of the risks to human
health posed by exposure to those chemicals. Moreover, each country
has a variety of natural toxins to which its population may be
exposed. Authorities need only to consult local hospital accident and
emergency departments for confirmation that toxic risks exist in every
country and, in many cases, are increasing.
Tens of thousands of man-made chemicals are currently in common
use throughout the world, and between one and two thousand new
chemicals appear on the market each year. In industrialized countries,
there may be at least one million commercial products that are
mixtures of chemicals, and the formulation of up to one-third of these
may change every year. A similar situation exists in the rapidly
industrializing developing countries. Even in the least developed
regions, there is growing use of agrochemicals such as pesticides and
fertilizers, of basic industrial chemicals, particularly in small-
scale rural cottage industries, and of household and other commercial
products, as well as pharmaceuticals.
Every individual is exposed to toxic chemicals, usually in
minute, subtoxic doses, through environmental and food contamination.
In some instances, people may be subjected to massive, or even fatal,
exposure through a chemical disaster or in a single accidental or
intentional poisoning. Between these two extremes there exists a wide
range of intensity of exposure, which may result in various acute and
chronic toxic effects. Such effects clearly lie in the public health
domain, particularly in cases of chemical contamination of the
environment that may result in exposure of an unsuspecting public. The
situation is similar to, but subtler than, exposure to infectious
diseases: although chemicals may be absorbed in small quantities, they
do not induce pathological signs until toxic concentrations are
reached in the tissues of exposed individuals.
The global incidence of poisoning is not known. It may be
speculated that up to half a million people die each year as a result
of various kinds of poisoning, including poisoning by natural toxins.
WHO conservatively estimates that the incidence of pesticide
poisoning, which is high in developing countries, has doubled during
the past 10 years; however, the number of cases that occur each year
throughout the world, and the severity of cases that are reported, are
unknown. It was estimated in 1982 that, while developing countries
accounted for only 15% of the worldwide use of pesticides, over 50% of
cases of pesticide poisoning occurred in these countries and, being
due mainly to misuse of the chemicals, were largely avoidable. The
worldwide frequency of major incidents involving chemicals, i.e.
incidents that could cause multiple deaths, has been rising during the
past two decades. There is growing concern about the possible health
consequences of chronic exposure to naturally occurring toxic
substances and to man-made chemicals and waste. In addition,
poisonings of domestic animals are a cause for concern in certain
countries, because of their economic impact on animal husbandry.
The principal toxic risks that exist in any country may be
readily identified by surveys of hospital accident and emergency
wards, forensic departments, and rural hospitals in agricultural
areas. The growing incidence of poisoning from accidental exposures to
chemicals, and recent examples of acute poisoning in local populations
as a result of industrial and transport accidents involving chemicals
have highlighted the importance of countries having special programmes
for poison control and, in particular, the facilities for diagnosis,
treatment, and prevention of poisoning.
Although the risks of poisoning by chemicals are not yet
universally recognized, some countries have already established poison
control programmes that provide the framework for both prevention and
management of poisoning. These newly emerging programmes are important
elements of chemical safety. Such programmes will vary in their
structure according to local circumstances, but they all need clear
direction and coordination in order to ensure the efficient use of
resources, appropriate patient care, and effective preventive
measures. There is a wide variety of starting points for any country
wishing to initiate a poison control programme, and it is essential to
identify the existing capabilities and facilities on which a programme
may be built. The main elements of such programmes are identification
of the toxic hazards existing locally (in order to establish
preventive measures), diagnosis of poisoning, and treatment of
poisoned patients.
These guidelines are intended to help countries that wish to
establish or strengthen facilities for the prevention and management
of poisoning. They are concerned with the identification of relevant
existing facilities, of needs, of potential resources (including human
resources), and of other bodies whose collaboration is essential to
the implementation of successful poison control. Based on the
experience of established poison information centres throughout the
world, the guidelines provide advice rather than a unique model, and
should be adapted in accordance with the socioeconomic and cultural
conditions prevailing in each country.
Part I is written primarily for the administrator and decision-
maker; it provides a policy overview of the problems of poisoning and
the types of programmes and facilities that will be effective in
preventing and dealing with them. Particular emphasis is given to the
key role to be played by poison information centres.
Part II provides technical guidance for those with direct
responsibility for the establishment and operation of specific poison
control facilities and covers the following topics:
* information services
* clinical services (including lists of antidotes and other agents
used in the treatment of poisoning)
* analytical toxicology services
* toxicovigilance and prevention of poisoning
* response to major emergencies involving chemicals
* antidotes and their availability
* standardized formats for the collection and storage of essential
data by poison information centres
* documentary and library support for poison information centres.
I. Policy overview
1. Poison information centres: their role in the prevention and
management of poisoning
History
Recognition of the problem of poisoning and of the need for
specialized facilities to deal with it, as well as the existence of a
number of health care professionals concerned with human toxicology,
has invariably been the primary prerequisite for the establishment of
poison information centres. The first centres were instituted in North
America and Europe during the 1950s. Since then, numerous others have
been created, principally in industrialized countries. The early
poison information centres originated in a wide variety of fields,
including paediatrics, intensive care, forensic medicine, occupational
health, pharmacy, and pharmacology. To some extent, the original
character of many centres has been maintained, and there is thus
considerable heterogeneity in their structure and organization.
A global study undertaken during the period 1984-1986 indicated
that, while most developed countries had well established facilities
for poison control, this was rarely the case in developing
countries.1 Furthermore, in industrialized countries, there may be a
number of institutions that provide different types of information on
toxic chemicals. It must be remembered, however, that each ministry or
agency in a developed country may have its own information services
for its specialized needs, but that, in a developing country, the
poison information centre - where it exists - may be the only source
of information on toxic chemicals available 24 hours a day. Centres in
developing countries may therefore have to provide a much broader
toxicological information service than their counterparts in some
developed countries.
Poisoning of animals may have important economic consequences,
and special veterinary poison information centres have been
established in some countries, including Australia, France, and the
USA. In most countries, however, many poison information centres may
deal with toxicological problems that affect both animals and humans.
Poison information centres may operate effectively with various
types of organizational structure. The majority depend on a hospital
administration and are, to some extent, connected with a university
and with the country's public health service at national or regional
level. Close association with units that treat poisoned patients and
with analytical laboratories is essential to most centres, although
the way in which this is organized depends on local conditions. Many
1 Report of the survey of poison control centres and related
toxicological services 1984-1986. Journal de toxicologie clinique
et expérimentale, 1988, 8(5):313-371.
centres are multifunctional, providing an information service,
clinical unit, and analytical laboratory. Most are at least partially
supported by public funding, and operate as independent foundations
with their own governing bodies on which various public authorities
are represented. It is thus impossible to specify a single
organizational model for a poison information centre.
Functions
The poison information centre is a specialized unit providing
information on poisoning, in principle to the whole community. Its
main functions are provision of toxicological information and advice,
management of poisoning cases, provision of laboratory analytical
services, toxicovigilance activities, research, and education and
training in the prevention and treatment of poisoning. As part of its
role in toxicovigilance, the centre advises on and is actively
involved in the development, implementation, and evaluation of
measures for the prevention of poisoning. In association with other
responsible bodies, it also plays an important role in developing
contingency plans for, and responding to, chemical disasters, in
monitoring the adverse effects of drugs, and in handling problems of
substance abuse. In fulfilling its role and functions, each centre
needs to cooperate not only with similar organizations, but also with
other institutions concerned with prevention of and response to
poisoning.
Provision of information and advice
The main function of a poison information centre is to provide
information and advice concerning the diagnosis, prognosis, treatment,
and prevention of poisoning, as well as about the toxicity of
chemicals and the risks they pose. As already mentioned, centres in
some countries may be required to provide a very broad range of
information on toxic chemicals, including data on risks to the
environment and on safe levels in food and environmental media as well
as in the workplace. The information should be available to all who
may benefit from it, such as medical and other professional personnel,
other concerned groups, various authorities, the media, and the
public.
Access to the information service is normally by telephone,
especially in an emergency, but there are several other communication
channels, including computer networks, written responses to enquiries,
and publications. Where telephone services are inadequate, the centre
can act through direct consultation with those who visit in person and
by providing written material on specific topics.
If it is to be reliable, the advice should be based on the
continuous, systematic collection and evaluation of data by the staff
of the centre, backed by local experience. All information and advice
should be adapted to the specific circumstances of the suspected
poisoning, i.e. whether exposure to the poison is acute or chronic,
and the condition of the patient involved, taking into consideration
the type of enquiry and the enquirer's technical understanding of the
poisoning. While many routine enquiries may be answered by suitably
trained nurses, pharmacists, or other specialists, supervision by a
physician trained in medical toxicology is essential.
The information service must be available 24 hours a day, seven
days a week, throughout the year. Section 2 provides further details
of the role of centres in providing information.
Patient management
While a poison information centre may have its own clinical
toxicology unit or treatment facilities, poisoned patients may, be
cared for at any of a variety of medical facilities: the centre will
always provide information to a much larger area than that covered by
a specific clinical toxicology unit. Many different categories of
medical and paramedical personnel may be involved in the diagnosis and
treatment of poisoning. Poisoning incidents frequently occur in the
home, at work, or in rural areas and usually at some distance from
medical facilities. The first person in contact with an individual who
has been, or is suspected to be, poisoned may have little or no
medical training.
Appropriate information has therefore to be made available to
ensure an adequate response in every situation. It is necessary to
confirm whether poisoning has actually occurred, to ensure that the
proper first-aid measures can be taken, and to assess what type of
treatment, if any, is required. The centre exists to provide such
information, giving advice on the different aspects of diagnosis and
treatment that is appropriate to the enquirer's level of
understanding.
It is essential for poison information centres to be closely
connected with facilities that provide care for poisoned patients and
for the medical staff at each centre to be involved in the treatment
of poisoning. This close association between poison information
services and poison treatment services facilitates the necessary
updating and expansion of information on the diagnosis and treatment
of local poisoning cases, encourages detailed follow-up of patients,
and stimulates essential research on human toxicology and patient
management.
It is highly desirable that each country or major population area
should have at least one clinical toxicology service dedicated
exclusively to the management of poisoning cases and located in a
hospital that can provide a wide range of services, including
intensive care. Clinical toxicology services fulfil a specialized
medical function in the management and treatment of poisoning, helping
to improve the identification of toxins and evaluation of their
effects, to elucidate the mechanisms and kinetics of different kinds
of toxic action, and to assess new diagnostic and therapeutic
techniques. They also play an important role in evaluating the
clinical efficacy of antidotes. Clinical facilities are described in
more detail in Section 3.
Rapid transport of severely poisoned persons to treatment
facilities, or of doctors to patients who cannot be moved may be
required. It is essential for poison information centres to be aware
of the availability of ambulances - and possibly helicopters and
aeroplanes - for transporting patients who need intensive care. Some
ambulances and other means of transport may be specially equipped for
transporting critically ill patients to the appropriate hospital
facilities. In emergencies, coordination with the traffic police
authorities may also be needed to help speed the transport of poisoned
patients. Rapid delivery of antidotes and of samples for laboratory
analysis must also be ensured, and could be coordinated by poison
information centres.
Laboratory services
A laboratory service for toxicological analyses and biomedical
investigations is essential for the diagnosis, assessment, and
treatment of certain types of poisoning. It is especially important
for clinical units treating poisoned patients: without analytical
data, many toxicological problems cannot be accurately assessed. The
data are required primarily to assist diagnosis and to back up
decisions on the use of various therapeutic procedures to support
prognosis. The laboratory service can also determine the kinetics of
the toxin, particularly its absorption, distribution, metabolism, and
elimination. Analytical facilities are also essential for research and
for monitoring populations at risk from exposure to toxic chemicals. A
laboratory service of the type outlined will permit the
identification, characterization, and quantification of toxic
substances in both biological and non-biological samples, i.e. in body
fluids such as blood and urine, and in hair and nails, and in scene
residues, as well as of both natural toxins and substances suspected
of being poisonous.
If adequate general laboratory facilities already exist, it is
possible to give general guidelines for the development of a service,
although the requirements for particular analyses will vary with local
circumstances. Two levels of operation may be envisaged. The first
would offer a relatively restricted but more widely distributed
service based mainly on simple spot tests, immunoassays, and thin-
layer chromatography. Field tested techniques for use at this first
level are detailed in an IPCS manual.1 The second level would support
the first but be more advanced, offering a full range of analyses
using a wide variety of techniques. Laboratories operating at this
1 Flanagan RJ et al. Basic analytical toxicology. Geneva, World
Health Organization, 1995.
level would be capable of acting as reference laboratories, confirming
the results of screening tests and engaging in quality control and
method development. Links should be developed between laboratories in
such areas as training, research, and quality assurance.
The analyses to be developed should be selected according to
proven clinical need and should:
* be backed up by a supply of appropriate pure reference compounds;
* be backed up by an adequate supply of consumables, such as
reagents, and by satisfactory arrangements for maintenance; and
* use practical analytical techniques that can provide results
within a reasonable time.
It may be economical and advisable for the laboratory to
undertake other related work, such as the provision of services for
monitoring therapeutic drug use, dealing with occupational chemical
exposure, and screening for drug abuse, since these services require
similar skills and can be undertaken with the same or similar
equipment.
Adequate safety precautions must be taken to protect the
laboratory staff from health risks, such as hepatitis and human
immunodeficiency virus (HIV) infection, associated with handling
biological samples.
A laboratory should have adequate staff and equipment to carry
out the analyses that are essential in cases of poisoning within the
country or region. Thus, an analytical toxicology service will need at
least one trained analyst and one assistant, but larger numbers of
personnel will be needed as the range of techniques in use and the
number of analyses being performed increases. Analyses that are
directly concerned with the treatment of poisoned patients should be
available 24 hours a day.
Siting the laboratory in the same place as the poison information
centre and treatment service has marked advantages as regards
interdisciplinary collaboration. Many countries lack adequate
toxicological laboratory facilities; in such cases it may be necessary
to combine the services providing clinical analytical toxicology with
those used in forensic medicine, occupational toxicology, monitoring
of therapeutic drug use, food contaminants or substance abuse, and
veterinary toxicology. Laboratory services are described in more
detail in Section 4.
Teaching and training
The experience gained in a poison information centre can be an
important source of human and animal toxicological data. The
application and communication of this knowledge are vital for
improving the prevention and management of poisoning. Centres thus
have educational responsibilities that extend to the training of
medical practitioners and other professional health workers likely to
encounter cases of poisoning, and to communication with the local
population and the mass media. Later sections of these guidelines
include advice on the training needs of centres as well as on their
teaching and training functions.
Toxicovigilance
Toxicovigilance is an essential function of poison information
centres. It is the active process of identifying and evaluating the
toxic risks existing in a community, and evaluating the measures taken
to reduce or eliminate them. Analysis of enquiries received by centres
permits the identification of those circumstances, populations, and
possible toxic agents most likely to be involved, as well as the
detection of hidden dangers. The role of a centre in toxicovigilance
is to alert the appropriate health and other authorities so that the
necessary preventive and regulatory measures may be taken. For
example, the centre may record a large number of cases of poisoning by
a specific product newly introduced to the local market; cases
occurring in a particular population group (e.g. analgesic poisoning
in children); or cases occurring in particular circumstances (e.g.
carbon monoxide poisoning from faulty heating stoves) or at particular
times of the year (e.g. mushroom poisoning in the autumn or snake
bites in the summer). Only now is the unique role of poison
information centres in toxicovigilance being widely recognized. This
role enables them to make a major contribution to the prevention of
poisoning through their collaboration with the health and other
appropriate authorities. Section 5 gives further details on this
aspect of their work.
Prevention
Drawing on its observations and experience, a poison information
centre can contribute to the prevention of poisoning by:
* alerting responsible authorities to circumstances where the risk
of poisoning is high so that appropriate preventive measures may
be taken, including: drawing the attention of various users of
toxic chemicals to the risks involved, introducing codes of
practice or legislation to control the labelling of toxic
products or special packaging to reduce the risk of exposure to
toxic substances, and modification or withdrawal of products from
the market;
* encouraging manufacturers to employ less toxic formulations and
to improve the packaging and labelling of their products;
* informing the general public, as well as special groups at risk,
about recognized or emerging risks to the community posed by the
use, transport, storage, and disposal of specific chemicals and
natural toxins, and giving guidance on how to avoid exposure to,
or accidents with, these substances; means such as brochures,
leaflets, posters, educational programmes, and campaigns in the
media may be employed, but should not arouse unjustified false
anxieties and should take due account of local psychosocial and
cultural circumstances;
* giving special warnings to professional health care workers
concerning specific toxic risks.
The role of poison information centres in prevention of poisoning
is described further in Section 5.
Drug information and pharmacovigilance
The medical profession must have access to advice on the
therapeutic and adverse effects of pharmaceutical agents; some
countries have drug information centres that provide this specialized
information. Poison information centres are automatically concerned
with problems of adverse drug reactions and side-effects, and may be
contacted by physicians and the public for advice on both drug
overdoses and the adverse effects of therapeutic doses. Enquiries may
also relate to contraindications, for instance whether a drug should
be prescribed in pregnancy or to a patient with a history of hepatic
or renal disease. Poison information centres thus have the
responsibility of contributing to pharmacovigilance in collaboration
with other institutions established for that purpose. In a developing
country, a combined drug and poison information service may be a
logical use of resources.
Substances of abuse
All poison information centres receive enquiries about substances
of abuse, including substances of natural origin such as cocaine,
chemicals with a specific use such as solvents, pharmaceutical agents
such as amfetamines, and illicit drugs designed for abuse. There are
also increasing demands on analytical laboratories to identify
substances of abuse. As many as 10% of patients seen at clinical
toxicology facilities may be people poisoned by such substances; in
some cases a mixture of substances may be involved, and in others the
effects of one substance may be masked by those of another.
It is part of the task of a poison information centre to provide
information relating to substances of abuse and, when necessary, to be
able to refer enquiries or patients to institutions or authorities
dealing with other aspects of substance abuse. Centres must know how
to recognize the signs and symptoms of substance abuse, how to treat
an overdose in an emergency, and how to deal with withdrawal
syndromes. They must know what facilities are available for patients
needing rehabilitation and for those who wish to give up substance
abuse. Advice must be available for the families and friends of
substance abusers on how to identify signs of intoxication and the
substances involved.
Environmental toxicology
There is growing anxiety among the general public about the
possible deleterious effects on health of toxic chemicals found in
food, in consumer goods such as cosmetics, and in the environment
(air, water, and soil). People are uncertain about whether pollution
is giving rise to chronic poisoning among those exposed to it, whether
the effects are cumulative, and whether there are long-term sequelae.
Furthermore, the harmful effects on non-human species, and whether
they may be acute or chronic, are of growing concern to both the
scientific community and the public. Poison information centres,
particularly in countries where there is no other readily accessible
source of information on toxic chemicals, are being asked to provide
information on the effects of environmental contaminants, on the risks
associated with toxic wastes, and on safe levels of chemicals in the
environment and in food and other consumer goods.
Poison information centres could play an important role in
quantifying the relationship between exposure to toxic chemicals and
observed clinical features of poisoning, including long-term sequelae.
They should work closely with the medical profession, particularly
general practitioners and occupational health physicians, hospital
outpatient departments and pre- and postnatal clinics, who may be well
placed to observe the possible clinical features and sequelae of
exposure to chemicals. Medical practitioners must also be provided
with data on the possible effects of exposure to environmental
contaminants, and information on the types of biological and other
samples that should be collected and analysed. Mechanisms for the
systematic collection, validation, and follow-up of data should be
established; it is also essential that the data are comparable, both
nationally and internationally, so that they may be used for the
benefit of all.
Contingency planning for chemical incidents and disasters
Poison information centres can contribute to the handling of
major chemical incidents and disasters by providing appropriate
information in the event of an emergency and by taking an active part
in contingency planning and in education and training. They should
also take part in epidemiological follow-up studies and other research
initiatives, where appropriate, collaborating and acting in concert
with other bodies involved in accident prevention and control. A
national or regional poison information centre can serve to centralize
and coordinate such activities. The role of centres in responding to
chemical incidents and disasters is further described in Section 6.
Cooperation and interrelationships
To provide an effective information service and help in the
prevention and management of the deleterious effects of toxic
chemicals on human health and the environment, it is essential for
centres to cooperate closely with a wide range of partners,
particularly medical experts. Relationships should be fostered with
other professional and social institutions that can contribute to the
effective provision of information by poison information centres. For
example, specialists in fields such as botany and zoology can assist
in the rapid identification of toxic plants or animal species.
Cooperation must also be established with industrial and commercial
enterprises that manufacture, import, or handle chemicals, various
research institutions, and consumer organizations and trade unions.
Contacts are needed with ministries of health and the full range
of health services and institutions, including different hospital
departments, general practitioners, paediatricians, pharmacists,
coroners and medico-legal experts, occupational physicians,
epidemiologists, experts in information technology, scientific
societies, and local and central health authorities. It is also
important for poison information centres to cooperate with other
government bodies, such as ministries of agriculture, the environment,
labour, industry, trade, and transport, and with consumer protection
agencies.
Good relationships with newspapers, radio, and television are
valuable, since the media have a key role in bringing information to
the public. The publishing or broadcasting of educational messages on
the prevention of poisoning can form part of a general process of
health education; poison information centres should provide the media
with appropriate information and material. In the event of a major
chemical incident the media have an even more significant part to
play: they must be kept fully and properly briefed by poison
information centres and the emergency services so that all essential
information can be given to the public without causing undue panic and
alarm. In either role, the media have a responsibility to check the
accuracy of the information they disseminate, so that any tendency to
speculate or exaggerate is avoided. Regular contact between the media
and poison information centres will lay the foundation for mutual
confidence in the relationships.
Of equal importance is contact between the poison information
centres themselves, both nationally and internationally. This may be
established directly or through national and regional scientific and
professional associations, as well as through the World Federation.
Other means of contact include national and international congresses
and meetings. Important areas for international collaboration are:
exchange of case data and product and substance data in comparable
formats, evaluation of antidotes, quality control, training, response
to major accidents, and research.
Benefits
The service provided by poison information centres offers
considerable direct health benefits by reducing morbidity and
mortality from poisoning and enabling the community to make
significant savings in health care costs. Cases of exposure to
chemicals that carry no toxic risk can be rapidly identified, and
unnecessary medical care and transport are thus avoided. Mild
poisoning cases that can be treated by first-aid measures alone or by
non-hospital medical personnel are quickly recognized, and physicians
can be provided with advice on the management of moderately severe
cases that can be treated in general health facilities. Severe
poisoning cases, which may need very special facilities and equipment
for treatment, are sent directly to hospitals where these facilities
are available, thus avoiding delays and wastage of resources at
general treatment facilities. Specific antidotes, therapeutic agents,
and medical equipment can be made more easily available through
coordination of stocks, so reducing costs and saving lives. Centres
can also help to prevent the unnecessary use of special antidotes and
of sophisticated and expensive treatments.
Access to information and advice at poison information centres
stimulates the interest of local communities and makes them more
committed to the prevention of poisoning. Centres help promote
awareness of special requirements concerning the control and
regulation of chemicals, including the labelling and packaging of
products. Through active observation and evaluation of toxic risks and
phenomena in the community, they are in a position to recognize
sudden, unexpected rises in the incidence of poisoning and to alert
authorities capable of taking the necessary action. Particular
occupational settings may be involved, as well as the community in
general. Indirectly, through improved prevention, the cost of
poisoning to the whole community is reduced. Advice provided by
centres in the event of major chemical disasters will help to minimize
the effects on human health, maximize the effective use of limited
medical resources, and prevent a recurrence of similar accidents. The
education and training provided by poison information centres enable
professional health workers and the general public to recognize and
avoid the dangers of poisoning and to take effective action when
poisoning incidents occur.
The case data collected by centres provide an epidemiological
basis for local toxicovigilance and contribute to the international
fund of knowledge about human toxicology and management of poisoned
patients. Through its contacts with centres in other countries and
regions, a poison information centre may obtain information, notably
on antidotes, that has already been evaluated, thus enabling it to
respond to emergencies and other needs in a cost-effective manner. It
may also identify toxic risks evaluated elsewhere, so that timely
preventive action may be taken.
Conclusions and recommendations
In accordance with WHO's definition of health and its goal of
"Health for All by the Year 2000", everyone should have access to
relevant information on how to prevent and deal with poisoning. Poison
information centres provide such information and are an essential part
of a country's capacity for ensuring the safety of chemical
substances. Moreover, the United Nations, through its Conference on
Environment and Development, has called upon all countries to promote
the establishment of poison information centres with related chemical
and analytical facilities to ensure prompt and adequate diagnosis and
treatment of poisoning, including networks of centres for chemical
emergency response.
Establishing a poison information centre
A poison information service should be available in every
country, irrespective of its size or population. Ideally, there
should be one national centre with, if necessary, a series of regional
satellite centres. In a large country, or one with a large population
or several different language groups, a number of regional centres may
be needed, with close collaboration between them. Generally speaking,
a poison information centre should serve a population of 5-10 million,
but a proliferation of centres should be avoided. Depending on the
availability of other services that provide information on toxic
chemicals, a poison information centre may have to advise on a wide
range of problems, and its associated facilities, e.g. laboratory
services, may have to be multifunctional.
Location
When a poison information centre is established, especially in a
developing country, existing medical facilities should be surveyed to
determine where the centre can best be located and operate most
effectively, bearing in mind that it is essential for a centre to have
a number of health care professionals interested in human toxicology.
Where feasible, the centre should be located at a leading hospital
with emergency and intensive care services, as well as a medical
library and a laboratory. If possible it should be linked directly
with a hospital department where poisoned patients are treated: this
may make it easier to recruit staff who already have experience and
interest in the problems of poisoning. The laboratory facilities of
such a hospital can usually be expanded to allow toxicological
analysis to be undertaken and appropriate quality control to be
exercised. Location at a university teaching hospital or in a
toxicological or public health institution may also have advantages.
Whatever the location chosen, it should be the aim of the facility to
operate 24 hours a day all year round.
Potential for development
A poison information centre needs certain minimum facilities and
resources to function optimally, but a modest establishment that can
be expanded in the future is preferable to no service at all.
Initially, it may be impossible for the centre's own staff to provide
a round-the-clock service, and arrangements may have to be made for an
existing service, such as a hospital emergency ward, to help out at
certain times. The aim, however, should be to provide a 24-hours-a-
day, 7-days-a-week information service throughout the year, with
continuous access to a physician trained in toxicology, and to achieve
this as quickly as possible. The treatment and laboratory facilities
at a hospital may be further developed to deal with poisoning cases.
The information section of the centre should work closely with the
clinicians and laboratory specialists but should remain an independent
unit since it will serve a much larger community than the hospital -
possibly the whole country.
Staff
A poison information centre needs a multidisciplinary team of
poison information specialists1 led by physicians with toxicological
experience. The team may include physicians, nurses, analysts,
pharmacists, veterinarians, and other scientists representing a wide
variety of disciplines including biology, chemistry, medicine, and
pharmacology. This team needs the support of documentalists and such
experts in information science and informatics as the circumstances
and functions of the centre may warrant. A poison information
specialist helps to prepare and provide expert information and advice
on preventing and dealing with poisoning. While the scientific or
technical background of this specialist may vary, the work demands
appropriate training, which in some countries carries a certificate or
other qualification. A poison information specialist should work under
the supervision of a medical toxicologist. Those members of the team
who answer enquiries must have adequate knowledge of toxicology and
related scientific disciplines and should also be in regular contact
with analytical and treatment facilities. The medical members of the
team should themselves treat poisoned patients.
1 The term "poison information specialist" is used in these
guidelines to include all personnel at poison information centres
who are involved in providing the poison information service.
Medical personnel from emergency, intensive care, and treatment
units may work part-time in the information unit, thus adding to their
experience. There is growing recognition of the need for centres to
have access to expert psychiatric advice, which is especially helpful
in dealing with attempted suicide, the psychopathic use of poisons,
and substance abuse, and in the management of some poisoned patients.
Psychiatry may also provide guidance on dealing with emergency
situations without causing panic, e.g. in the event of a major
chemical disaster.
Good administration is of course essential. In some established
centres, an administrative director is responsible for all
administrative matters including funding, which allows the medical
director to concentrate on the scientific supervision of the centre.
Some form of administrative assistance is required at all centres, as
well as adequate secretarial support.
Numbers of staff in the various categories must be sufficient to
provide an adequate, continuous service at all times. While the
enquiry load may vary according to the time of day, it would be
desirable always to have a minimum of two poison information
specialists on duty to answer calls. To provide continuous medical
advice throughout the year, at least three trained physicians are
needed.
Since highly experienced staff are essential, independent
official recognition of the professional status of poison centre staff
is desirable. Pay, working conditions, and incentives must be
sufficiently attractive to keep staff turnover to a minimum. Further
advice on staff requirements is provided in Section 2.
Equipment and facilities
If a poison information centre is to function effectively,
certain basic equipment is essential, including suitable office
furniture and facilities for the storage of confidential data.
Specific areas should be set aside for answering telephone enquiries,
consultation with patients, preparation of documents, staff meetings,
and secretarial and administrative work. Staff on duty should have
comfortable, suitably furnished rest areas. Additional desk space is
needed at centres using computer equipment and on-line databases, and
air-conditioning and humidity control may also be necessary. Centres
themselves should be secure.
Equipment and facilities for the information service are
described in detail in Section 2; equipment for treatment units is
described in Section 3 and equipment for laboratory services in
Section 4.
Poison information centres should have their own libraries and
facilities for handling and reproducing documents. Reserved telephone
lines are essential, and other means of national and international
communication are highly desirable, such as telex, short-wave radio,
and - in particular - fax. A fax machine is a recognized means of
communicating information rapidly among centres and hospitals,
particularly during emergencies, and should therefore be regarded as
essential. Growing use is now being made of electronic mail for
communication among poison control centres and other partners in
poison control.
A list of handbooks and journals that are more or less essential
for the information unit of a centre is given in Section 9, although
each centre should add to and adapt this list in developing its own
documentation and ensure that it is updated periodically.
Legal status and financing
Poison information centres should be officially recognized by
government authorities. They should have independent status,
stability, and neutrality to enable them to carry out their functions
effectively. A centre may have a governing body, including
representatives of various government and other authorities, to
provide policy guidance and assist in fund-raising. This body should
not, however, interfere with the daily operation of a centre or
compromise its independence. The legal status of a centre should
enable it to maintain the confidentiality of the data it handles. Its
main source of financial support, which is a government
responsibility, should respect its independent and neutral status.
Information should be provided free of charge to enquirers,
particularly in emergencies, although charges may be levied in certain
circumstances.
Twinning arrangements
Twinning arrangements between centres in developing and developed
countries can be very valuable, permitting exchanges of documentation,
including case data on unusual types of poisoning, exchanges of staff
for teaching and training, and the provision of antidotes, especially
in emergencies. As a means of technical cooperation between developing
countries, twinning should also be encouraged between new and
established centres in these countries. For effective twinning it is
important that centres have facilities for rapid communication
(telephone, telex, and fax), and that arrangements are made to enable
the rapid importation of antidotes and other essential supplies in
times of emergency, without bureaucratic hindrance.
Action by national and local authorities
The prevention and control of poisoning could be made more
effective through a number of appropriate actions by national and
local authorities, where these have not yet been taken. These measures
include:
* official recognition by government authorities of the role of
poison information centres in carrying out toxicovigilance and of
their contribution to prevention through the provision of
information services, together with adequate financial support
for the centres providing these services;
* ensuring that the community has ready access to the services
provided by poison information centres;
* establishment of channels of communication providing prompt
access for poison information centres to organizations (including
the media) that can be alerted, outside normal working hours if
necessary, to toxic hazards and advised on appropriate ways of
dealing with them;
* ensuring that centres have access to adequate information on the
composition of commercial and other products on the local market,
on the understanding that the confidentiality of the information
will be respected;
* ensuring that the information on patients gathered by a poison
information centre remains confidential at all times;
* establishment of clinical toxicology services wherever needed;
* establishment of services for toxicological analysis wherever
needed;
* provision of educational facilities and courses in toxicology,
and establishment of certificates or other appropriate
qualifications for information specialists at poison information
centres, as well as for nursing and paramedical staff working in
treatment units and analysts in toxicological laboratories;
* official recognition of medical toxicology as a discipline in its
own right, and encouragement of academic institutions to develop
the discipline by providing appropriate teaching units or
departments;
* promotion of national and international exchanges of staff and
experts;
* facilitating the exchange of biological and other samples for
analysis, and the import and export of equipment and chemical
reagents;
* provision of antidotes and essential supplies for the treatment
of poisoned patients, and arrangements for their rapid
importation in the event of an emergency;
* provision of transport facilities for patients where existing
facilities are inadequate;
* improvement of the communications infrastructure in countries
where it is inadequate; and
* establishment of mechanisms and facilities for the systematic
recording and long term follow-up of patients exposed to toxic
chemicals.
Action at the international level
Cooperation at the international level between poison information
centres, their national and regional associations, relevant
professional bodies, governments, and international organizations in
the following areas could do much to improve the prevention and
control of poisoning:
* improving international communication and exchange of information
and experience in the field of poison control, as well as
exchange of personnel, particularly for purposes of education and
training;
* harmonizing definitions of and criteria for clinical signs,
symptoms, and sequelae of poisoning, including severity grading;
* establishing comparability between methods of collecting,
storing, transporting, and analysing biological and other
samples, and monitoring exposure to toxic chemicals and relating
these to observed features of toxicity and sequelae;
* establishing internationally agreed mechanisms for the
collection, validation, and analysis of data relating to exposure
to toxic chemicals and observed features of poisoning, including
long-term sequelae;
* undertaking collaborative research projects using agreed
protocols, e.g. for evaluating new antidotes, elucidating the
mechanisms of poisoning, and improving treatment regimens;
* establishing channels of communication between countries whereby
antidotes, other therapeutic agents, and medical equipment can be
made rapidly available on request in the event of a chemical
incident or emergency, and samples for analysis can be imported
and exported as necessary;
* establishing channels of communication between countries for
rapid access to information about chemical incidents or
emergencies that may be of value in deciding whether a toxic
alert should be called.
II. Technical guidance
2. Information services
Organization and operation
The roles and functions of a poison information centre are
briefly described in Section I of these guidelines. This section aims
to provide more detailed guidance, principally on the establishment
and operation of new centres, but also on the improvement of existing
centres. It is additionally concerned with the location, facilities,
and equipment of such centres and their staffing. Certain financial
aspects are also considered.
The effective functioning of a poison information centre depends
on the availability of an adequate volume of evaluated data to furnish
a basis for the advice given. Two categories of data are collected:
those derived from various external sources, including other centres,
as well as scientific journals, textbooks, reports, and data sheets;
and those obtained in the course of the centre's information work and
its follow-up of reported poisoning cases.
It is essential for centres to have data on local commercial
products, including pharmaceuticals, as well as on natural toxins
produced by local poisonous plants and poisonous and venomous animals.
Centres may be expected to identify tablets, capsules, plants, fungi,
and insects and other animals. Each centre uses data culled from the
various sources in compiling its own documentation for use by the
staff of the centre. This documentation enables staff to provide
information that is appropriate for the particular enquirer and
adapted to local and national conditions. It is thus unique to the
centre and essential for the information service that the centre
provides.
Centres should establish a mechanism for obtaining access to
adequate data on commercial products from manufacturers and importers;
such data should be regularly updated and its confidentiality
protected. A system of rapid access to data on foreign products is
also essential. Information on the composition, packaging, and form of
each product must be available and sufficiently detailed to allow the
product to be identified, its toxicity evaluated, and its long-term
effects assessed.
The documentation prepared by the centre itself on aspects of
poisoning by chemicals and products, including evaluation of toxicity,
symptoms, and treatment, is of particular importance. Past experience
of poisoning cases involving specific chemicals and products plays an
important role in this. Data on clinical cases, covering circumstances
of poisoning, relevant medical histories, and the full evolution of
each case, should be included in this documentation. Data on enquiries
to the centre, as well as clinical data, should be systematically
collected: they provide unique toxicological information that can be
extremely valuable in diagnosis and treatment. To be of maximum value,
case data must be fully recorded and followed up. Exchanges of such
data between poison information centres, both nationally and
internationally, could greatly enhance the effectiveness of the
services they provide. A standard format for reporting case data and a
mechanism for their collection and analysis are essential (see
Annex 5).
Centres should also collect (and regularly update) information on
health and other relevant resources and facilities in the region or
country. This information should cover services that provide diagnosis
and treatment, including specialized treatment facilities, such as
dialysis units, hyperbaric oxygen chambers, and clinical toxicology
services; analytical facilities and the types of analyses they
provide; facilities for emergency transport of patients; antidotes and
their availability; and other medical and non-medical services with
related areas of responsibility.
A poison information centre should have its own library, which
could be associated with a university or medical library. Certain
books and publications should be accessible at all times at the centre
itself; others could be kept at a local medical library but must be
immediately accessible. Section 9 lists a selection of the books and
journals that may provide library support for a poison information
centre.
Poison information centres would benefit greatly from more
efficient collection, storage, retrieval, and analysis of the data
they require. Computerization is one tool for this purpose, and most
established centres have their own computers. The IPCS has developed a
computerized information package, known as IPCS INTOX, to help centres
in developing their own poison information systems. A summary
description of the package is given in Annex 1.
Planning a poison information centre
Identification of the principal toxic risks in the local
community helps in determining the activities on which the efforts of
a poison information centre should initially be concentrated (e.g.
poisoning by pesticides). Available facilities should be reviewed to
allow the selection of locations that best meet the criteria outlined
in these guidelines. However, it must be stressed that primary
prerequisites for the success of a centre are enthusiasm and interest
in human toxicology on the part of a group of health care
professionals who recognize the problem of poisoning in their country
and are committed to dealing with it.
During the planning of a poison information centre, the following
questions should be carefully considered:
* To whom will the service be offered initially, e.g. the medical
profession only, the public, veterinarians? Will it be a
24-hours-a-day service from the outset? How will it be expanded
subsequently? How will its existence be advertised to the user
population?
* What are the initial and subsequent staffing requirements? How
will the centre contact and recruit the necessary expertise?
* Are the telephone and other communication systems adequate?
* How will the centre collect the full range of data needed to
operate the information service?
* How will the reliability, accuracy, and usefulness of the data be
evaluated?
* How will the data be compiled, recorded, and stored for rapid
retrieval?
* How will the data be managed and updated? Who will have access to
what type of data, and who will have the authority to modify data
files?
Before a centre becomes operational it is also necessary to:
* obtain certain essential literature (see section 9);
* provide basic training for the staff who will work in the centre
* print forms (in the local language) for collecting information
on local commercial products and for recording enquiries to the
centre, with provision for follow-up of calls and cases (see
Section 8); and
* on the basis of local information, begin compiling files on the
chemicals used in local commercial products, including
pharmaceuticals, on local natural toxins, and on relevant medical
and analytical services available in the country (see below and
Section 8).
Operating a poison information centre
Once a poison information centre becomes operational, i.e. is
able to offer an emergency response service, it should function around
the clock. In the initial period, before the centre is fully staffed,
the service may, at certain times, rely on the assistance of
established emergency or intensive care services.
For ethical and commercial reasons, much of the information
handled by poison information centres, notably that relating to
manufactured products and to patients, must be considered as
confidential. Responsibility for the correct handling of such
information rests essentially with the medical director and eventually
with the other staff of the centre, particularly the information
specialists who need the information on an emergency basis.
Rapid identification of the poisons or types of poison involved
in an emergency is one of a centre's main tasks. The constitution,
origin, uses, and toxicity of the pharmaceuticals, chemicals, plants,
or animals involved need to be identified immediately to permit the
appropriate action to be taken.
Information on commercial products
Most existing poison information centres began by organizing card
indexes of basic information on each of the toxic substances or
natural toxins used or occurring in the area or country concerned.
Although this type of information can now be stored in rapidly
accessible computer files, the use of card indexes may still be
recommended in a newly established centre for the initial
identification of poisons. A computerized system can be added later,
and the card index system should therefore contain as much information
as is needed, recorded in such a way that it can later be transferred
to a computerized system. The recommended format for collecting and
storing information on commercial products for use in the IPCS INTOX
Package is given in Annex 4.
The card index or computer file should contain entries on all
commercial products, such as pharmaceuticals, household products, and
pesticides, commonly used in the country concerned. Although files
from other (e.g. neighbouring) countries may be useful, every poison
information centre will have to organize and maintain its own files.
Information for these may be extracted from local pharmacopoeias and
government registries, or obtained from pharmaceutical firms,
manufacturers of household products, importers of chemicals, etc.
A similar card index or computerized file system should be
organized for natural toxins, poisonous plants, and poisonous and
venomous animals.
Information on enquiries
Systematically collected data on enquiries form an essential part
of the database at a centre. They must cover not merely the enquiries
that pertain to clinical cases but every kind of enquiry received at
the centre, including toxicological consultations registered by the
clinical services.
Standardized recording of enquiries, including those relating to
clinical cases, will allow the centre to:
* maintain its own clinical and other data registry
* implement toxicovigilance activities
* support epidemiological and statistical studies
* perform self-audit and continuously evaluate the quality and
efficiency of its services
* back up its clinical and legal responsibilities
* validate new techniques of patient management
* provide data for scientific reports
* exchange information with other poison information centres
* contribute to the fund of knowledge on human toxicology.
Computer facilities for recording data on enquiries and cases
offer enormous advantages, and the IPCS INTOX package provides a
framework for this purpose. Further work is needed on, inter alia,
the classification of agents involved in poisoning, the
standardization of analytical data, and the harmonization of severity
grading of case data; much is being done at present by IPCS in
collaboration with poison centres and experienced toxicologists. The
format used in the IPCS INTOX Package for recording communications is
given in Annex 5.
All poison information centres should prepare annual reports of
their activities; a suggested layout for an annual report for a poison
information centre is given in Annex 6. This layout provides a
comprehensive format, which should be adapted to local circumstances.
Location, facilities, and equipment
Location
General criteria for the location of a poison information centre
are given in Section 1 of these guidelines, but the final choice of
location will depend on local circumstances. Certain conditions,
however, should be respected, namely that:
* the centre is regarded as neutral and independent, and security
for all the information stored at the centre is ensured;
* there is rapid and ready communication with other organizations
concerned with poisoning, particularly clinical and analytical
services;
* access to the centre within the building in which it is located
is easy, but restricted for unauthorized persons; and
* the centre is centrally situated within the geographical and
demographic area it serves.
The poison information centre should ideally be located within,
or closely associated with, a hospital. Location within a hospital has
the advantage of providing ready access to a network of medical
disciplines that will support and enhance the work of the centre,
enabling staff to deepen their knowledge of the clinical aspects of
poisoning. If also located within a university, the centre will have
easier access to, among other things, libraries, research facilities,
and educational activities. Location within a public health institute
or ministry permits more activities relating to prevention of
poisoning and a closer relationship with decision-making authorities,
but it is still essential for the medical staff of a centre to be
involved in the care of poisoned patients, and for the information
service to operate round the clock.
To some extent, the location may also be determined by the number
of enquiries received. For example, if more than 5000 emergencies are
registered each year, a full-time staff will be required to provide a
24-hours-a-day service, and the centre should then be an independent
facility, though preferably situated in a hospital. However, some
centres are run effectively from other locations. If fewer than 5000
calls are received annually, outside support may be required to
maintain a 24-hour service. In this case also, the centre may be
located in a hospital but should be situated where regular hospital
staff, notably from emergency and intensive care wards, are available
to assist in maintaining the service.
Facilities
A poison information centre should be accommodated in suitable
rooms or working areas, equipped with basic furniture (desks, tables,
chairs) and such other facilities as are essential for its principal
functions. Additionally it should have immediate access to the
relevant literature and other sources of information.
The rooms should be large enough to permit the efficient storage
and retrieval of documents and the holding of necessary meetings. One
room should be allocated to the "answering" service and should contain
the telephones assigned to it, plus the basic files, protocols, and
books needed by the information specialists and physicians on duty. An
area should be set aside as a library where scientific work can be
undertaken. Another area is required for working groups and staff or
other meetings; this should be at least large enough to allow the
assembly of all the staff of the centre, together with a number of
advisers or visitors.
Staff on duty should have a private area providing the basic
facilities for personal hygiene and rest. Food and drink should also
be available, as well as vehicle parking space outside the building.
The medical director should have an office or suitable private
area for specific work, interviews, and consultations; similar
facilities should be available to other staff receiving patients. A
separate area should also be assigned for administrative and
secretarial work. As a centre develops new functions, additional space
may be required and the location should therefore allow for this
future expansion. Experience has demonstrated that, as more
information is gathered and new activities or responsibilities
assumed, bigger working areas rapidly become necessary.
Furniture
The minimum furniture needed for a new centre consists of desks
and chairs, a large work table, lockable filing cabinets, and
bookshelves. As the service develops and the working area grows,
further appropriate office and library furniture should be provided.
When the service starts functioning on a round-the-clock basis, the
medical toxicologists and information specialists on duty must have a
private area with suitable furniture and an adequate degree of
comfort. It may also be necessary to provide a bed for rest between
duty periods. Optimally, there could be specially designed work
stations incorporating computer terminals where appropriate.
Equipment
It is particularly important that a poison information centre
should have equipment for fast and reliable communication, and for the
storage and retrieval of information.
Communication with enquirers must be through reliable telephones
reserved for the purpose and covering the whole area served by the
centre. Two telephones are a minimum. In some countries the poison
information centre is automatically connected with the emergency
telephone services, and all calls concerned with toxicological
emergencies are directed straight to the centre. The emergency number
of the centre should be easy to remember and accessible from all
telephones in the region served by the centre. In developing regions
of the world, the radio telephone can be useful in reaching distant
areas and remote populations. Other rapid methods of communication
include the telex and, for documents, the fax, now considered a "must"
at most centres. Electronic mailing systems (e-mail) are now being
established at some centres. Fast and reliable communication will be
valuable not only for the information service but also for the
necessary contacts with other centres and access to international
databanks. These systems must be well maintained and financially
supported by the appropriate authorities or government ministry. The
importance of worldwide communication networks for toxicology has been
recognized: ideally, the centre should be equipped with the most
practical advanced communication system appropriate to the country and
to the centre's functions.
The storage of case records, files, and documentation requires,
at the least, sufficient bookshelves and filing cabinets to permit
systematic collection and easy retrieval. A lockable section should be
available for confidential data.
With the development of the service, additional space, furniture,
and storage facilities should be made available for the growing
collection of books, published material, and files. If circumstances
permit, automated systems may replace manual storage, retrieval, and
processing systems, and computers must consequently be recognized as
important items of equipment for a poison information centre. A
microfiche system may also be a useful means of storing documentation.
A poison centre often has to stock antidotes and other substances
used in the treatment of poisonings and therefore requires a
refrigerator; a lockable cabinet for storing pharmaceutical agents
should be provided.
From the outset, a centre should be adequately equipped with
typewriters, a word processor with a good quality printer, and
photocopying equipment or other suitable means of reproducing
documents. The role of a centre in education and training may require
it to have its own slide, overhead, and video projection equipment.
Staff
A poison information centre should be headed by a director
experienced in toxicology and have sufficient personnel to perform the
duties of the centre on a 24-hours-a-day, 7-days-a-week basis. The
director is wholly responsible for the operation of the centre and
should ideally be employed on a full-time basis. He or she should have
personal leadership qualities, together with the ability to supervise
other staff and maintain good relations with colleagues and other
collaborators in the poison control programme. The director should
also be able to promote research, raise funds, and undertake the
further development of the information service. The medical functions
of the centre must be the responsibility of a medical toxicologist. It
may also be desirable to have an administrative director responsible
for the financial, administrative, and other non-medical aspects of
the centre. In addition, full-time - and possibly also part-time -
medical toxicologists, poison information specialists, and
administrative and support staff are required. Ultimately, centres
also need advisers in various medical and non-medical fields, few of
whom would normally be on the staff of the centre at the outset. The
work of the centre may eventually call for the services of a number of
full-time or part-time experts in particular fields such as psychiatry
and veterinary medicine.
In Part I of these guidelines it was pointed out that a fully
operational centre, providing a round-the-clock service and adequate
medical advice, requires a minimum of three full-time medical
toxicologists (or the part-time equivalent) and a sufficient number of
poison information specialists to ensure at least one person being on
duty at any given time. The frequency of enquiries is likely to vary
during the course of the day, and it may be necessary to have
additional staff on duty at certain times. In this respect, patterns
vary throughout the world, and it is up to the individual centre to
ensure that its service is adequate for local needs. In practice, at
least 6-8 dedicated, trained, full-time poison information specialists
are required: this allows for coverage of staff absences for illness,
holidays, and professional training.
The medical toxicologist
Medical toxicology is the discipline concerned with the harmful
effects of chemicals, including natural substances, on humans,
although its scope is broader than simply the clinical aspects of the
subject. A medical toxicologist is a qualified physician with several
years' experience in the treatment of cases of poisoning and a
grounding in such areas as emergency medicine, paediatrics, public
health, internal medicine, intensive care, and forensic medicine.
Clinical experience in occupational diseases and in diseases caused by
pollutants and other chemicals of environmental origin is particularly
relevant. Experience in clinical toxicology is essential, and
experience in toxicological research is also valuable.
The medical toxicologist may provide expert advice to national
decision-making bodies, and is often responsible for training at
hospitals and medical faculties, and takes part in the
multidisciplinary teaching of toxicology at university level. He or
she must keep abreast of the latest developments in all areas of the
discipline, including analytical and experimental toxicology.
In the specific field of information, the medical toxicologist
must be able to organize and compile a comprehensive dossier on
poisons and their effects, based on the available material and
personal experience, to train junior toxicologists and the centre's
information specialists in collecting and interpreting data, and to
give appropriate information in response to enquiries.
It is particularly important for medical toxicologists to
undertake the systematic collection and evaluation of clinical
observations, as these constitute a major source of information for
the poison information centre.
The medical director of a poison information centre should be the
most experienced of its medical toxicologists and the best equipped to
take responsibility for medical decisions, treatment protocols, and
the promotion of research.
The poison information specialist
For the purpose of these guidelines, the personnel directly in
charge of the round-the-clock response to enquiries are termed poison
information specialists. They must be appropriately trained and able
to carry out the basic functions of a poison centre, with the support
of a medical toxicologist, preferably a clinician treating poison
victims. They should be able to give information to all types of
enquirer on the basis of duly evaluated data available at the centre
and in accordance with agreed patient management protocols. In cases
where information is not available at the centre, they should know how
it may be obtained. They must also know when to consult a medical
toxicologist or adviser in a special area and should be able to record
details of enquiries, cases, or consultations, using a standardized
method. In many situations, poison information specialists will help
evaluate the data used at the centre. With additional qualifications
or experience in information management and computing, they can play a
useful role in the organization and management of records kept at the
centre.
Poison information specialists may be drawn from many different
disciplines, including various branches of medicine, pharmacy,
nursing, chemistry, biology, and veterinary science. In each case,
training for the specialized work of a poison information centre is
essential and should be a continuing process so that they all remain
abreast of new developments in toxicology. Information specialists
should have the opportunity to participate in appropriate scientific
meetings in their own countries and elsewhere. Training should lead to
an officially recognized certificate or other qualification: there is
a need for universally recognized qualifications in this field.
All members of the information team should take part in the
different activities of the centre, e.g. answering enquiries,
preparing documentation and reports, operating computer programs, and
making regular searches of the literature. Regular discussions among
the team on interesting cases and various toxicological problems
should be encouraged as a means of making each member aware of new
developments and promoting a harmonized approach to poisoning and
patient management. Periodic meetings among poison information centres
within a country, or from the various countries of a region, should
also be encouraged in order to discuss similar topics.
Veterinary expertise
The widespread use of veterinary drugs and the addition of
chemicals to animal feedstuffs, unless carried out under veterinary
supervision, can lead to contamination of human food. The effects of
toxic substances on animals are often unique, and their diagnosis and
appropriate management require the expertise of trained veterinarians.
Furthermore, cases of exposure of animals to environmental chemicals
may provide early warning of the potential exposure of humans. It
would be highly desirable for poison information centres to have
access to specialist veterinary knowledge in order to be able to
recognize and respond to problems of animal poisoning as well as to
advise on the risks of human exposure to drugs used for animals.
Administrative and support staff
A centre should have at least one secretary and, if possible,
clerical staff to assist in the establishment, maintenance, and
updating of the information system. Provision should be made for the
maintenance and cleaning of equipment and facilities at the centre;
this is often the responsibility of the administration of the building
where the centre is located.
The administrative staff of a poison information centre should be
qualified to manage and supervise its financial resources, equipment
needs, and operational requirements, as well as dealing with routine
personnel matters. Ideally, there should be a senior administrator or
administrative director in charge of all these activities, with
suitable support staff and clearly defined responsibilities that do
not overlap with those of the medical director.
If a centre has its own library it will require a librarian or an
information specialist/documentalist, or both.
Advisers in special areas
When a poison information centre is being established, a variety
of specialist help and advice is essential. This may be medical or
non-medical and may come from independent experts or from
representatives of specialized organizations and local agencies. As
the centre acquires more experience and the scope and volume of its
work expand, it may become necessary to employ extra staff with some
of the various kinds of expertise indicated below, on a part-time or
full-time basis.
Specialists collaborating with the centre should be able to
provide, whenever necessary, specific information on subjects within
their recognized fields of expertise. The toxicology-related areas
where the information might be needed will depend on local
circumstances. Advice from the medical profession may be required in
such areas as public health, psychiatry, occupational medicine,
paediatrics, nephrology, teratology, anaesthesiology, veterinary
medicine, pharmacy, epidemiology, and environmental health.
Consultation with representatives of medical associations and
government or local medical organizations may be of value whenever
specific problems arise. In non-medical areas, advice might be needed
from specialists in agronomy, botany, zoology, herpetology,
entomology, mycology, ecology, statistics, computer sciences,
industry, engineering, law, and information technology and other areas
of information management.
A close relationship should be established, once those
specialists able and willing to collaborate with the centre have been
identified. An agreement should be made as to what is expected of the
specialists, and how and when advice is to be provided to the centre.
No special training is required for these collaborators, but they
should be introduced to the work of the centre and the way it
functions. Periodic joint scientific meetings and activities may be
very helpful in cementing the relationships between the centre and its
special advisers, who may also help in training the staff of the
centre in their specific areas of competence.
Development of human resources
The evolution of the poison information centre will depend on
local circumstances, needs, and resources. Ideally, there should be
career opportunities for all the staff of a centre, each of whom
should have the chance of additional training and advancement within
his or her own area of competence. Contacts with other agencies
dealing with various aspects of the prevention and treatment of
poisoning should be stimulated both within the country and abroad.
Where appropriate, professional staff should be encouraged to
undertake relevant research and contribute to the literature.
Financial aspects
Since poison information centres can be considered as part of the
public health service, government resources are the most appropriate
source of financial support. However, each centre must remain neutral,
independent, and preferably autonomous in order to carry out its
functions effectively, and these conditions must be respected,
whatever the principal source of financing.
Governments should recognize the cost-effectiveness of the
service provided by poison information centres to the community, and
therefore make every effort to sustain their financial support. It may
be difficult for a centre to produce direct evidence of its cost-
effectiveness, but it should be stressed that:
* it discourages the excessive use of medical resources
* it reduces the adverse effects of poisoning on health, as well as
mortality from poisoning
* it helps to reduce the risks of occupational poisoning.
Other sources of funding may be acceptable, if they are available
and if the autonomy of the centre is guaranteed. Social groups in the
community, fund-raising campaigns, philanthropic groups, and
associations of industry and commerce may all be sources of support.
Funds for specific projects received from national and international
organizations concerned with chemical safety may be very useful for
investigating areas of joint interest. Private funding initiatives
have proved to be effective in many countries and should not be
discouraged, particularly in the case of new services.
It is an important principle that information should be provided
free of charge, at least in an emergency. However, some payment to the
centre may be appropriate when special reports or expertise are
requested by private institutions or individuals.
Although the bulk of a centre's budget will be devoted to
salaries, it should be remembered that adequate funding for the
maintenance of up-to-date information is essential. Significant
portions of the budget should also be devoted to the operation and
maintenance of equipment, for example the telephones, telex, fax,
photocopying, and computer systems, as well as to the development of
appropriate educational material.
Research
Poison information centres are important sources of information
on human toxicology; in particular, they may be able to signal the
approach of new toxicological hazards. They also have enormous scope
for broadening the scientific database on human toxicology through
regional and international cooperation. Their research function should
be recognized and encouraged by the relevant authorities.
3. Clinical services
Introduction
Cases of poisoning may be treated in many places, e.g. at the
scene of the accident, during transport, in a hospital. The type of
care that can be given will depend on whoever makes the initial
contact with the patient and in what circumstances. Certain members of
the community, such as firemen, policemen, and teachers, may
frequently be the first to be faced with poisoning cases. In rural
areas, nurses and primary health care workers, and even agronomists
and veterinarians, may have to deal with poisoned persons. They all
need at least some basic training in first aid as well as in
decontamination and measures for their own protection. An IPCS
handbook on this first level of response to poisoning is in
preparation.1
1 Management of poisoning. A handbook for health care workers.
Geneva, World Health Organization (in preparation).
General practitioners or family doctors are often the first
medically qualified persons consulted. They must be able to give
appropriate initial treatment and may need to contact their local
poison information centre. Most patients with serious poisoning, if
they survive, will sooner or later reach a hospital, ideally one with
a wide range of medical facilities, including intensive care. In some
places, specialized treatment services have been established offering
the best possible conditions for the management of poisoning. These
services also have the advantage of ready access to a wide range of
related medical facilities.
Most cases of poisoning, however, will be treated through a
country's normal health service facilities, usually at a general
hospital, far from a poison information centre and without access to a
specialized clinical toxicology unit. According to patients' needs,
treatment may be given by different services within the hospital,
including the following:
* Emergency services. In practice, emergency services receive a
relatively high number of poisoning cases, as they function on a
round-the-clock basis and are provided with trained personnel and
basic equipment for decontamination and life-support measures.
* Intensive care units. Intensive care units are usually well
provided with highly specialized personnel and equipment for
resuscitation, life-support measures, and care of critical
poisoning cases.
* General medical units. Basic medical care of non-critical
poisoning cases can be provided within general medical units in
which staff have received some training in, or information on,
clinical toxicology and which are in close contact with poison
information centres.
* Specialized services. Specialized services offer the advantage of
well trained medical staff and appropriate equipment for the
management of poisoning cases in which specific organs or
physiological functions are affected; they include nephrology,
gastroenterology, neurology, cardiology, and haematology
services.
* Paediatric departments. Poisoned children are frequently treated
in paediatric departments.
To be able to treat poisoned patients, general hospitals need
equipment for:
* gastrointestinal, cutaneous, and ocular decontamination (e.g.
equipment for gastric lavage)
* immediate, and often longer-term, life-support measures (e.g.
endotracheal intubation, assisted and controlled ventilation,
parenteral fluid therapy, pharmacological treatment, cardiac
pacing, defibrillation)
* continuous cardiac and circulatory monitoring (through ECGs,
blood pressure measurements, etc.) and monitoring of other vital
functions
* X-ray examinations
* initial and repeated general biomedical laboratory analyses (e.g.
acid-base balance, blood gases, electrolytes, blood glucose,
liver and kidney function, and coagulation)
* initial and repeated specific toxicological analyses of body
fluids such as blood, urine, and stomach contents (the choice of
analyses will vary according to local patterns of poisoning)
* haemodialysis, peritoneal dialysis, haemoperfusion
* administration of appropriate antidotes (some of which may be
specific to local needs and all of which should be stored in
accordance with WHO recommendations1.
In an emergency, it is essential that the relevant medical
personnel at general hospitals and other health service facilities
where poisoning cases are treated have rapid access to toxicological
information and experience. Here, the poison information centre plays
a key role through its telephone advice service. Ideally, centres
should circulate information to general hospitals and other health
service facilities on a regular basis. This information should be
adapted to suit local needs and should include general advice on the
diagnosis and management of poisoning cases commonly expected to be
treated at the particular hospital or facility, as well as information
on new developments in patient management and on new types of
poisoning.
The information flow should be a two-way process. General
hospitals and health science facilities should be encouraged to
maintain close contact with national and regional poison information
centres and to furnish these centres with regular reports on cases of
poisoning, particularly the more unusual ones. Such reporting helps to
maintain an up-to-date national database on poisoning and is important
for toxicovigilance.
1 The International Pharmacopoeia, Third edition. Vol. 2, Quality
specifications. Geneva, World Health Organization, 1981.
The training of medical personnel in relevant aspects of
toxicology for their work in managing poisoned patients is another
important task for the poison information centre. For this purpose, it
is essential that the centre itself is closely involved in the
management of poisoning cases.
Some countries have found it valuable to have one or more
specialized clinical toxicology units where the most important cases
of poisoning in a region are treated. In some cases an intensive care
unit is associated with, or forms part of, a clinical toxicology unit.
The latter would normally be associated with a national or regional
poison information centre.
Clinical toxicology units
Roles and functions
While general clinical wards and various specialized services
that treat both poison victims and other types of patient are
potential participants in poison control programmes, clinical
toxicology units deal exclusively with the management of poisoning.
These independent specialized units may have three principal functions
besides patient management, namely toxicovigilance, education, and
research. Locating a poison information service and analytical
facilities in the same department or building as a clinical toxicology
unit is an advantage and may be of benefit to patients. However, where
there is no common location, highly reliable communications between
the unit, the information service, and the laboratory are essential in
order to establish a partnership between them in the diagnosis and
management of poisoning.
Ideally, a specialized clinical toxicology unit should be part of
national or regional medical facilities for the management and
treatment of poisoning. It provides for:
* optimal treatment of poisoned patients
* identification of the effects of chemicals and natural toxins on
health
* evaluation of the cause-effect relationship in a case of
poisoning
* assessment of new developments in clinical and analytical methods
of diagnosis and in treatment
* development of specific therapeutic management
* appropriate follow-up and surveillance of cases for
identification and assessment of sequelae, and
* study of the circumstances of the poisoning and predisposing
factors (data can then be used for planning preventive action).
Clinical toxicology units should record data on poisoning cases
and toxicological consultations in a standardized format, preferably
compatible with that used by poison information centres. Full case
data, including follow-up, should be recorded.
Location and facilities
The minimum requirements for setting up a clinical unit for the
treatment of acute poisoning are:1
* availability of methods, equipment, and areas for the
resuscitation, decontamination, and initial management of
poisoning cases
* good communication links with a poison information centre
* well established protocols for the treatment of common cases of
acute poisoning
* availability of antidotes for immediate use, in quantities
appropriate to the frequency of the main forms of poisoning (see
Section 7)
* laboratory facilities for standard biological analyses and for
toxicological screening (see Section 4)
* availability of emergency transport for patients
* an emergency plan for dealing with disasters and major chemical
accidents.
1 See also Table 1.
Table 1
Facilities for clinical toxicology
Minimal facilities Optimal facilities
Location Emergency department; internal Separate specialized unit within a
medicine ward; or intensive care multifunctional poison centre, or
unit with ready access to a poison closely associated with such a centre
information centre with two-way links
Equipment for:
Resuscitation Devices for: suction; airway control; Additionally: mechanical ventilator;
and IV administrations ECG; oscilloscope; defibrillator;
pacemakers; haemodynamic
monitoring equipment
Decontamination Separate area for decontamination, Additionally: facilities for dialysis
with gastric lavage equipment, and haemoperfusion
shower, and facilities for skin and
eye washing
Diagnosis and EEG; fibroscopic devices, e.g.
prognosis oesophagoscope, bronchoscope
Antidotes and other Selection made from the list in Full selection, including agents still
agents Annex 2, according to local needs under development
Laboratory:
Biological Blood typing; cross-matching; blood Comprehensive analysis of blood,
gases; pH; electrolytes; standard urine, and other body fluids;
uring analysis; cerebrospinal fluid functional studies
analysis
Table 1 (contd.)
Facilities for clinical toxicology
Minimal facilities Optimal facilities
Toxicological Screening test equipment for thin- Equipment for more specific
layer chromatography quantitative and qualitative analyses,
including those for toxicokinetic
and various research studies (see
Section 4)
Other facilities Normal facilities for transport of Transport facilities (e.g. ambulances,
patients aircraft) equipped with life-saving
systems
Access to a specialized centre, e.g.
for psychiatric and social rehabilitation
Personnel Emergency room physicians and Clinical toxicologists; anaesthetist;
intensive care physicians, available paediatrician; psychiatrist; social
24 hours a day worker
To function to the best advantage, a clinical toxicology service
should be located as a separate department within an advanced
multifunctional hospital and within or next to the poison information
centre, preferably on the ground floor in order to facilitate rapid
access. It should have:
* full facilities for prolonged life support, stabilization of
vital signs, and correction of acid-base and fluid and
electrolyte abnormalities (see Table 1)
* equipment for decontamination and the elimination of poisons,
including dialysis and haemoperfusion
* the appropriate range of antidotes and medicaments used in the
treatment of poisoning (see Section 7)
* protocols for the assessment and management of poisoning cases
* access to an analytical laboratory with appropriate equipment for
qualitative and quantitative biological and toxicological assays
on a round-the-clock basis (see Section 4)
* protocols for recommended analytical tests, including collection
of specimens and interpretation of results (see Section 4)
* established systems for the collection and analysis of data on
all clinical cases for epidemiological records, toxicovigilance
assessment, and preventive action
* psychiatric rehabilitation and social assistance services.
There should be sufficient space for all levels of patient care,
and for the activities of the staff on duty, including administration,
small conferences, education activities, and storage of clinical
records.
Consideration should also be given to such practical matters as a
comfortable rest area, personal hygiene facilities, parking space, and
the provision of food and beverages round the clock for duty staff.
Staff
Initially, the staff may consist of emergency-room physicians to
provide resuscitation and first aid, plus paediatricians,
anaesthetists, and intensive-care staff to look after severely
poisoned patients. However, in developing countries or in newly
established clinical units, there may be a shortage of sufficiently
well qualified medical personnel, in which case medical officers or
adequately trained paramedical personnel have an important part to
play in the initial evaluation, transfer, and referral of poisoning
cases. They should be capable, for example, of recognizing a case of,
poisoning, of identifying the main toxic syndromes (e.g.
anticholinergic, cholinergic, opioid), and especially of recognizing
situations that require the immediate application of life-saving
measures.
Ideally, therefore, the staff should consist of:
* The medical director of the clinical toxicology service, who
should be qualified to:
- organize the care of poisoned patients, both directly and
through case consultation
- implement, review, and update protocols for the evaluation
and treatment of poisoning cases
- supervise staff performance
- promote toxicological research
- identify those programmes or agencies that might provide
funding for research or the further development of the
service.
* Trained specialist(s) in clinical toxicology with practical
experience and, ideally, with a professional qualification.
* Physician(s) with competence in the care of critically ill
patients.
* Psychiatrist(s).
* Advisers from other medical disciplines, e.g. pharmacology, and
from non-medical areas of interest.
* Social workers.
* Supporting paramedical staff (e.g. nurses, medical officers).
* Administrative staff and record-keepers.
Training
While the need for clinical toxicology services is becoming
increasingly obvious, the growing demand for adequate, trained
personnel is not being met. Physicians from countries with no
appropriate facilities should be sent for training in toxicology to
established centres where poisoned patients are treated. The objective
in each case should be for the trainee to obtain experience of every
aspect of the work of a centre, so as to be able to initiate or
develop poison control activities in his or her own country. It is
important for trainees to know the problems and special "risk
profiles" associated with poisoning in their own countries before
starting their courses.
Physicians from developing countries where facilities for
training in some aspects of clinical toxicology are available could be
trained in their own countries if appropriate programmes were
organized, with visiting experts invited to teach those subjects for
which training facil