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    UNITED NATIONS ENVIRONMENT PROGRAMME
    INTERNATIONAL LABOUR ORGANISATION
    WORLD HEALTH ORGANIZATION


    INTERNATIONAL PROGRAMME ON CHEMICAL SAFETY



    MANAGEMENT OF POISONING





    A handbook for health care workers







        The issue of this document does not constitute formal publication.
    It should not be reviewed, abstracted, or quoted without the written
    permission of the Manager, International Programme on Chemical Safety,
    WHO, Geneva, Switzerland.

    This report contains the collective views of an international group of
    experts and does not necessarily represent the decisions or the stated
    policy of the United Nations Environment Programme, the International
    Labour Organisation, or the World Health Organization.


    Management of Poisoning





    First draft prepared at the National Institute of Health Sciences,
    Tokyo, Japan, and the Institute of Terrestrial Ecology, Monk's Wood,
    United Kingdom


    Published under the joint sponsorship of the United Nations
    Environment Programme, the International Labour Organisation, and the
    World Health Organization


    World Health Organization
    Geneva, 1997

         The International Programme on Chemical Safety (IPCS) is a joint
    venture of the United Nations Environment Programme, the International
    Labour Organisation, and the World Health Organization. The main
    objective of the IPCS is to carry out and disseminate evaluations of
    the effects of chemicals on human health and the quality of the
    environment. Supporting activities include the development of
    epidemiological, experimental laboratory, and risk-assessment methods
    that could produce internationally comparable results, and the
    development of manpower in the field of toxicology. Other activities
    carried out by the IPCS include the development of know-how for coping
    with chemical accidents, coordination of laboratory testing and
    epidemiological studies, and promotion of research on the mechanisms
    of the biological action of chemicals.

    WHO Library Cataloguing in Publication Data



    Henry J.A.
      Management of poisoning:  a handbook for health care workers /
      J.A. Henry Wiseman.

    1.Toxicology - handbooks  2.Poisons - handbooks  3.Poisoning -
    prevention & control  I.Wiseman, H.M.  II.International Programme on
    Chemical Safety  III.Title
    3. I.Series

    ISBN 92 4 154481 3  (NLM Classification: QV 600)
    ISSN 0250-863X

         The World Health Organization welcomes requests for permission to
    reproduce or translate its publications, in part or in full.
    Applications and enquiries should be addressed to the Office of
    Publications, World Health Organization, Geneva, Switzerland, which
    will be glad to provide the latest information on any changes made to
    the text, plans for new editions, and reprints and translations
    already available.

    (c) World Health Organization 1997

         Publications of the World Health Organization enjoy copyright
    protection in accordance with the provisions of Protocol 2 of the
    Universal Copyright Convention. All rights reserved. The designations
    employed and the presentation of the material in this publication do
    not imply the expression of any opinion whatsoever on the part of the
    Secretariat of the World Health Organization concerning the legal
    status of any country, territory, city or area or of its authorities,
    or concerning the delimitation of its frontiers or boundaries. The
    mention of specific companies or of certain manufacturers' products
    does not imply that they are endorsed or recommended by the World
    Health Organization in preference to others of a similar nature that
    are not mentioned. Errors and omissions excepted, the names of
    proprietary products are distinguished by initial capital letters.

    Contents

    Preface

    Acknowledgements

    Introduction
    How to use this book
    Poisons centres and poison control programmes

    Part 1. General information on poisons and poisoning

         1. Poisons and poisoning
              Objectives
              What is a poison?
              Exposure to a poison
              How poison gets into the body
              What happens when poison is inside the body The effects of
              poison
              When systemic effects happen

         2. How poisoning happens

              Objectives
              Accidental poisoning
              Self-poisoning
              Using poison to harm other people
              Poison in food or drink
              Medical poisoning
              Abuse of drugs, chemicals or plants
              The benefits and dangers of using chemicals

         3. How to prevent poisoning
              Objectives
              How you can help people make their homes,
                   workplaces, and the community safer
              What can be done to prevent poisoning?
              How to make homes safe
              How to prevent poisoning with pesticides

              What employers can do to prevent poisoning at work
              How to avoid snake bites
              How to prevent insect, spider and scorpion stings
                   and bites
              How to avoid eating poisonous plants, mushrooms
                   and fish
              How to avoid infection from food contaminated
                   with germs

         4. What to do in an emergency
              Objectives
              The dangers to look out for
              What to do in an emergency

         5. First aid
              Objectives
              Give first aid at once
              First aid for poisoning
              Using traditional medicines to treat
                   poisonous bites and stings

         6. Getting medical help
              Objectives
              If you can get to a hospital in less than two hours
              If you are a long way from a hospital
              If you cannot get medical help quickly
              Taking the patient to hospital
              What to do after you have read this chapter

         7. Examining the patient Objectives Symptoms and signs
              What the examination cannot tell you
              When the patient does not have any symptoms or signs
              How to examine a patient and find out the symptoms
                   and signs
              Patterns of symptoms and signs

         8. Finding out what happened
              Objectives
              Talking to people
              Look for the poison or other things that show you
                   what happened
              What to do next

         9. How to look after a poisoned patient outside hospital
              Objectives
              What to do when the patient has swallowed poison
              How to stop poison getting into the blood after it
                   has been swallowed
              Making the patient vomit
              Giving activated charcoal
              Giving a laxative
              How to look after a very sick patient

         10. Medicines and equipment
              How to care for medicines and first aid equipment
              Medicines
              First aid equipment

    Part 2. Information on specific poisons

         Introduction
              The information in each section

         Pesticides
              Aluminium phosphide and zinc phosphide
              Arsenic and arsenic-containing chemicals
              Chlorophenoxyacetate weedkillers
              Dinitro-o-cresol (DNOC), dinitrophenol, dinoseb and
                   pentachlorophenol
              Insect repellent
              Metaldehyde
              Organochlorine pesticides
              Organophosphorus and carbamate insecticides
              Paraquat
              Phenol and related substances
              Pyrethrins and pyrethroid insecticides
              Rat poisons
              Sodium chlorate
              Strychnine
              Thallium
              Warfarin and other pesticides that stop blood clotting

         Chemicals and chemical products used in the home and the
                   workplace
              Aerosol sprays
              Air-fresheners, deodorant blocks and moth-balls
              Benzene, tetrachloroethylene, toluene, trichloroethane,
                   trichloroethylene and xylene
              Borax, boric acid and sodium perborate
              Button batteries
              Carbon monoxide
              Carbon tetrachloride
              Caustic and corrosive chemicals
              Cosmetics and toiletties
              Cyanide
              Disinfectants and antiseptics
              Ethanol and isopropanol
              Ethylene glycol and methanol
              Glue
              Lead
              Petroleum distillates
              Phosgene
              Soap and detergents
              Tobacco products
              Volatile oils
              Products that are not usually harmful

         Medicines
              Acetylsalicylic acid, choline salicylate, methyl salicylate,
                   salicylic acid
              Amfetamine-like medicines, atropine-like medicines,
                   antihistamines, cocaine, ephedrine, and pseudoephedrine
              Aminophylline and theophylline
              Amitriptyline-like medicines, chloroquine,
                   quinidine and quinine
              Barbiturates, chlorpromazine-like medicines, diazepam-
                   like medicines and meprobamate
              Carbamazepine, phenytoin and valproic acid
              Chlorpropamide-like medicines and insulin
              Colchicine
              Dapsone
              Digitalis, digitoxin and digoxin
              Glyceryl trinitrate, hydralazine, and propranolol-like
                   medicines
              Ibuprofen
              Iron-containing medicines
              Isocarboxazid, phenelzine and tranylcypromine
              Isoniazid
              Lithium carbonate
              Magnesium hydroxide, magnesium sulfate,
                   phenolphthalein, and senna
              Opiates
              Oral contraceptives
              Paracetamol
              Penicillin and tetracycline antibiotics
              Proguanil
              Rifampicin
              Salbutamol

         Plants, animals and natural toxins
              Plants that contain atropine
              Cannabis
              Irritant plants
              Oleanders
              Ornamental beans
              Mushrooms
              Snakes
              Spiders
              Venomous fish
              Poisoning from eating seafood

    Word list

    Index
    
    Preface

         This handbook has two main aims: to give people living in rural
    places, far from medical help, information on what to do when someone
    is poisoned; and to suggest ways of preventing poisoning in the
    community.

         It is written for people with little or no medical training who
    are likely to be the first to come into contact with someone who has
    been poisoned, such as community health workers (CHWs), first-aiders,
    or professionals in other sectors working in rural communities. Some
    information has also been included for health workers with a knowledge
    of clinical medicine and diagnostic procedures, working in rural
    health stations and health centres where there may be some medical
    equipment and medicines available.

         The handbook is meant to be used as a practical reference book in
    an emergency. It can also be used by people who teach community health
    workers and others practical skills, such as mouth-to-mouth
    respiration and heart massage, that can only be learnt by practising
    under trained supervision. It may also be useful as a teaching aid for
    student doctors, nurses, and paramedical personnel.

         The book will be most useful if it is translated into local
    languages and adapted to local conditions, which may vary in terms of:
    the tasks authorized for CHWs, such as giving injections; the
    functions assigned to CHWs; the functions assigned to local health
    centres and doctors at rural hospitals; the availability of medicines;
    and the particular problems prevalent in the area.

         Only a small amount of information is given about chronic
    poisoning, which is often caused by using chemicals at work. Readers
    who wish to know more about chronic poisoning should find a book that
    deals with the health of people at work (occupational health).

    The intended readership

     Community health workers. CHWs can generally read, write, and do
    simple arithmetic, and have basic training in:

    - first aid,

    - taking body temperature,

    - counting the pulse,

    - dispensing medicines.

         CHWs may also be trained to give intramuscular and subcutaneous
    injections.

     First-aiders. First-aiders are trained to rescue people from danger,
    and to give immediate help to the victims of accidents until a trained
    health care worker can take charge. People who are likely to be the
    first on the scene of an accident, such as workers in factories or
    offices, firefighters, or policemen, are often trained in first aid.

     Professionals with no medical training. Many highly educated
    professional workers, such as teachers, agricultural advisors,
    pharmacists, scientists and technologists, know about the use and
    effects of chemicals. In communities where there are no doctors, they
    may be the only people who know about chemicals and poisons. They may
    be first on the scene of an accident or they may be called upon to
    help someone who is thought to have been poisoned. They need to know
    the first aid for poisoning due to pesticides, medicines, household
    products, and other substances. They should also be able to advise
    people on how to prevent poisoning.

         In some countries professional people with no medical training
    may attend courses run by poisons centres to learn basic first aid
    skills.

     Nurses, medical students and paramedical staff. The book may be
    useful as a handbook and training manual.

     Doctors. Some information has been included specifically for doctors
    working in rural health stations and health centres where there may be
    some medical equipment and medicines available. This information has
    been separated from the main text. It does not include details of
    medical treatment that can be given only in a hospital.

    Acknowledgements

         This handbook has been prepared on the recommendation of a group
    of experts convened by the International Programme on Chemical Safety
    (IPCS)1 in February 1987. A draft text was prepared by Dr J.A. Henry
    and Ms H.M. Wiseman, and commented on by a number of experts, in
    particular Dr E. Fogel de Korc (Montevideo, Uruguay), Dr G.R.
    Gardiner, Dr J. Jackson and Mr W. Tardoir (Brussels, Belgium), and
    colleagues from UNEP's International Register of Potentially Toxic
    Chemicals (IRPTC) and the Occupational Safety and Health Branch of
    ILO. An editorial group, convened by the IPCS to review the text,
    consisted of Dr J.-C. Berger (Luxembourg), Dr N. Besbelli (Ankara,
    Turkey), Professor M. Ellenhorn (Los Angeles, USA), Professor B. Fahim
    (Cairo, Egypt), Dr Sming Kaojarern (Bangkok, Thailand), Professor A.
    Furtado Rahde (Porto Alegre, Brazil), Dr N.N. Sabapathy (Fernhurst,
    England), Professor A.N.P. van Heijst (Utrecht, Netherlands), and Dr
    A. David (ILO). The text was tested at an IPCS Workshop, held in
    Harare, Zimbabwe, from 28 January to 1 February 1991, and subsequently
    in two training workshops in Zimbabwe. Parts of the text were also
    reviewed at an IPCS Workshop held in Dakar, Senegal, 24-27 January
    1995. For the IPCS, Dr J. Pronczuk de Garbino provided the editorial
    inputs and Dr J.A. Haines coordinated the work.

         The first aid manual of the Joint Voluntary Aid Societies in the
    United Kingdom, and publications of the Global Crop Protection
    Federation, were particularly useful as source materials for the first
    draft. The United Kingdom Department of Health, through its financial
    support to the IPCS, provided the resources for the drafting of the
    text and for the editorial group to meet. The illustrations were
    prepared by Picthall & Gunzi, London.
    __________

    1    The IPCS is a cooperative venture of the World Health
         Organization (WHO), the International Labour Organisation (ILO)
         and the United Nations Environment Programme (UNEP). WHO is the
         executing agency for the programme, which aims to provide the
         internationally evaluated scientific data basis for countries to
         develop their own chemical safety measures, and to strengthen
         national capabilities to prevent and treat harmful effects of
         chemicals and to manage chemical emergencies.

    Introduction

    How to use this book

         This book is in two parts. Part 1 gives general information on
    poisons and poisonings, how poisonings happen and how you can prevent
    them. It also gives guidance on how to deal with poisoning
    emergencies. Part 2 gives specific information on the effects of
    poisoning with various pesticides, medicines, household chemical
    products, and poisonous plants and animals, and guidance on what to do
    when you think someone has been poisoned. A word list and an index are
    also provided.

    To be ready for emergencies

    1.   Keep a first aid kit, like the one recommended in Chapter 10, in
         the house, in the community, or at work.

    2.   Study this book before it is needed, especially Part 1, Chapters
         4-9, which tell you what to do when someone is poisoned.

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

    To look up a chemical, plant or animal

         Use Part 2 when you see someone who is poisoned. Look in the
    index at the end of the book to find the medicine, chemical, plant or
    animal you think may have caused the poisoning.

    Information for doctors

         In Chapter 5, "First aid", and Chapter 9, "How to look after a
    poisoned patient outside hospital", and in Part 2, parts of the text
    are separated off by horizontal lines. This information is meant for
    doctors.

    If you do not understand the meaning of some of the words in this book

         Look for the word in the word list (medical words used in the
    boxes of information for doctors are not explained in the word list).

    Poisons centres and poison control programmes

         In many countries there are poisons centres which give advice
    about the treatment and prevention of poisoning. They have information
    about medicines, pesticides, poisonous plants, venomous animals, and
    household products, and chemicals used at work. The doctor in the
    poisons centre can tell you what to do when someone has swallowed or
    breathed in a chemical, spilt it on the skin, or splashed it in the
    eyes.

         Most poisons centres can be contacted at any time of day or night
    by telephone or, in some countries, by radio. They may have supplies
    of special antidotes (for example snake or spider antivenoms). Some
    poisons centres have hospital wards where they can treat poisoned
    patients.

         In many countries, other organizations work with poisons centres
    in a national poisons control programme to improve the treatment and
    prevention of poisoning. These organizations include:

    -    hospitals and other places where poisoned patients are treated;

    -    organizations that collect information on poisoning;

    -    organizations that make or use substances which might cause
         poisoning;

    -    government authorities that control the use of chemicals within
         the country;

    -    universities and colleges where doctors and other people are
         taught about poisoning.

         There is space in the back of this book where you can write the
    addresses of organizations in your country that might help you deal
    with cases of poisoning or give advice on how to prevent poisoning.

    PART 1

    General information on poison and poisoning

    CHAPTER 1

    Poisons and poisoning

    Objectives

    After studying this chapter you should:

    1.   Know what a poison is.

    2.   Understand what is meant by local poisoning and systemic
         poisoning. Understand all the ways poison can get into the body,
         and be able to recognize circumstances where poisoning might
         happen.

    3.   Understand what is meant by acute poisoning and chronic
         poisoning, and be able to explain to people that continued
         exposure to small amounts of poison for several days, weeks or
         months can be harmful, even if they do not immediately feel
         unwell.

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

    5.   Be able to explain to people why it is important to take care
         when handling dangerous chemicals and why it is important to wash
         chemicals off the skin as soon as possible.

    6.   Be able to explain how petroleum distillates, such as kerosene,
         cause harm if they are swallowed.

    7.   Understand why people who have swallowed poison may be helped if
         they are made to vomit or given activated charcoal.

    8.   Recognize that people are more likely to be harmed by poison if
         they are very old, very young or in poor health.

    9.   Know why a person who has been exposed to poison may appear to be
         unaffected by it, and why it is often a good plan to watch a
         person for 12-24 hours after they have been exposed to poison,
         even if they seem well.

    What is a poison?

         A poison is any substance that causes harm if it gets into the
    body. Harm can be mild (for example, headache or nausea) or severe
    (for example, fits or very high fever), and severely poisoned people
    may die.

         Almost any chemical can be a poison if there is enough in the
    body. Some chemicals are poisonous in very small amounts (for example,
    a spoonful by mouth or a tiny amount injected by a snakebite); others
    are only poisonous if a large amount is taken (several cupfuls, for
    example).

         The amount of a chemical substance that gets into the body at one
    time is called the dose. A dose that causes poisoning is a poisonous
    dose or toxic dose. The smallest amount that causes harm is the
    threshold dose. If the amount of a chemical substance that gets into
    the body is less than the threshold dose, the chemical will not cause
    poisoning and may even have good effects. For example, medicines have
    good effects if people take the right doses, but some can be poisonous
    if people take too much.

    Exposure to a poison

         When people are in contact with a poison they are said to be
    exposed to it. The effect of exposure depends partly on how long the
    contact lasts and how much poison gets into the body, and partly on
    how much poison the body can get rid of during this time.

         Exposure may happen only once or many times.

          Acute exposure is a single contact that lasts for seconds,
    minutes or hours, or several exposures over about a day or less.

          Chronic exposure is contact that lasts for many days, months or
    years. It may be continuous or broken by periods when there is no
    contact. Exposure that happens only at work, for example, is not
    continuous.

         Chronic exposure to small amounts of poison may not cause any
    signs or symptoms of poisoning at first. It may be many days or months
    before there is enough chemical inside the body to cause poisoning.
    For example, a person may use pesticide every day. Each day the person
    is exposed to only a small amount of pesticide, but the amount of
    pesticide in the body gradually builds up, until eventually, after
    many days, it adds up to a poisonous dose. Only then does the person
    begin to feel unwell.

    How poison gets into the body

         The way poison gets into the body is called the  route of
     exposure or the  route of absorption. The amount of poison that
    gets into the blood during a given time depends on the route.

     Through the mouth by swallowing (ingestion)

         Most poisoning happens this way. Small children often swallow
    poison accidentally, and adults who want to poison themselves may
    swallow poison. If people eat, drink or smoke after they have been 

    handling poisons, without first washing their hands, they may
    accidentally swallow some of the poison. This is a common cause of
    pesticide poisoning.

    FIGURE 1

         When poisons are swallowed they go to the stomach (Fig. 1). Some
    poisons can pass through the gut walls and into the blood vessels. The
    longer a poison stays in the gut the more will get into the blood and
    the worse the poisoning will be.

         If a person vomits soon after swallowing a poison, it may be
    expelled from the body before a poisonous dose gets into the blood.
    So, if the person does not vomit straight away, it is sometimes useful
    to make the person vomit. There are two other ways to stop poisons
    passing from the gut into the blood: (1) give activated charcoal
    because this binds some poisons so that they cannot pass through the
    gut walls; or (2) give laxatives to make the poison move through the
    gut and out of the body more quickly. The circumstances when it is
    useful to make a patient vomit or to give activated charcoal or
    laxatives, and the circumstances when these procedures may be
    dangerous, are described in Chapter 9.

         Poisons that do not pass through the gut walls do not get into
    the blood and so cannot affect other parts of the body. They move
    along the gut and leave the body in the faeces. For example, mercury
    metal cannot pass through the gut walls; if mercury from a thermometer
    is swallowed, it passes out of the body in the faeces and does not
    cause poisoning.

    FIGURE 2

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

         Poisons in the form of gas, vapour, dust, fumes, smoke or fine
    spray droplets may be breathed into the mouth and nose and go down the
    air passages into the lungs (Fig. 2). Only particles that are too
    small to be seen can pass into the lungs. Larger particles are trapped
    in the mouth, throat and nose and may be swallowed. A person may
    breathe in poison when working with a poisonous substance inside a
    building without fresh air, or when spraying pesticide without wearing
    adequate protection. Oil or gas heaters, cookers, and fires give off
    poisonous fumes which may reach dangerous concentrations if the smoke
    cannot get outside or if the room does not have a good supply of fresh
    air.

         Poison that gets into the lungs passes into the blood vessels
    very quickly because the air passages in the lungs have thin walls and
    a good blood supply.

     Through the skin by contact with liquids, sprays or mists

         People working with chemicals such as pesticides may be poisoned
    if the chemical is sprayed or splashed onto the skin, or if they wear
    clothes soaked with chemical.

         The skin is a barrier that protects the body from poisons.
    However, some poisons can pass through the skin (Fig. 3). They pass
    through warm, wet, sweaty skin more quickly than through cold, dry
    skin, and they pass through skin damaged by scratches or burns more
    quickly than through undamaged skin. A poison that damages the skin
    will pass through more quickly than one that does not damage the skin.
    It may be possible to wash poison off the skin before a poisonous dose
    gets into the body.

    FIGURE 3

     By injection through the skin

         Poisons can be injected through the skin from a syringe, or a
    pressure gun, or during tattooing, or by the bite or sting of a
    poisonous animal, insect, fish or snake. The injection may go directly
    into the blood vessels, or under the skin into muscle or fatty
    tissues. Poison injected into the blood has a very quick effect.
    Poison injected under the skin or into muscle has to pass through
    several layers of tissue before reaching the blood vessels, so it acts
    more slowly.

    What happens when poison is inside the body

     How poison is carried round the body

         Once a poison gets into the blood it is carried to the whole body
    as the blood is pumped round the body by the heart (Fig. 4).

     How poison is broken down by the body

         Some poisons are changed by the body into other chemicals. These
    are called metabolites, and may be less poisonous or more poisonous
    than the original substance. The metabolites are more easily passed
    out of the body than the original chemicals. These changes take place
    mostly in the liver.

    FIGURE 4

     How poison leaves the body

         Unchanged poisons or their metabolites usually leave the body in
    the urine, faeces or sweat, or in the air that a person breathes out.
    The movement of poison from the blood into urine takes place in the
    kidneys, and the movement of poison from blood into breathed-out air
    takes place in the lungs. Poison in the faeces may have passed down
    the gut without being absorbed into the blood or it may have been
    absorbed into the blood and then passed out into the gut again. Some
    poisons, like DDT, pass into body tissues and organs where they may
    stay for a long time.

    The effects of poison

         The effects of a chemical substance on the body may be described
    as either local or systemic.

         A local effect is limited to the part of the body in contact with
    the chemical: the skin, the eyes, the air passages or the gut.
    Examples of local effects are skin rashes, skin burns, watery eyes,
    and irritation of the throat causing coughing. Many poisons cause
    local effects, but there are also many poisons that do not. Further
    details about local effects are given below.

         A systemic effect is a more general effect that occurs when a
    poison is absorbed into the body.

         Some poisons cause both local effects and systemic effects. If
    someone has local effects from exposure to a chemical it is important
    to check whether they also have signs or symptoms of systemic
    poisoning.

     Local effects

    On the skin

         Chemicals that damage the skin cause reddening or a rash, pain,
    swelling, blisters or serious burns. The burns are like the burns
    caused by fire.

         An irritant chemical causes itching, a burning feeling, or pain
    when it first touches the skin, but does not cause burns if washed off
    straight away. However, if it is in contact with the skin for a long
    time, for example when people wear contaminated clothes for several
    hours, it might cause burns.

         Some irritant chemicals have no effect the first few times they
    touch the skin, but with continued contact they cause reddening or a
    rash. This might happen with repeated use of a household cleaner.

         Sometimes people become sensitive to a chemical after they have
    used it many times. They may have no effects at first but after a few
    weeks or months they get a rash every time they use it.

         A corrosive or  caustic chemical very quickly causes painful
    burns and destroys the skin. There may be blisters and the skin may
    turn grey-white or brown.

    On the eyes

         Irritant or corrosive chemicals can cause severe pain if they get
    into the eyes. They may very quickly burn the surface of the eye and
    cause scars or even blindness. The eyes will look red and watery. The
    person may not want to open the eyes and bright light will hurt.

    Inside the gut

         Irritant or corrosive chemicals may damage the mouth and throat
    or the inside of the gut. The person will have belly pain, vomiting
    and diarrhoea, and the vomit and faeces may contain blood. If the
    throat is burnt it may swell very quickly, so that the person cannot
    breathe.

    Inside the air passages and lungs

         Some gases and vapours can irritate the nose, throat and upper
    air passages and cause coughing and choking.

         Some gases and vapours damage the lungs in a way that causes them
    to fill with water. This may happen very soon after a person breathes
    in the substance, or it may happen up to 48 hours afterwards. A person
    with water in the lungs cannot breathe properly and may drown. He or
    she must be taken to a hospital as quickly as possible. Water in the
    lungs is called lung oedema.

         Some of the gases that cause lung oedema also irritate the nose,
    throat and upper air passages, and make people cough and choke. When
    people start to cough and choke, they will quickly move away from the
    gas into fresh air, if possible. This often means that they are not
    exposed to the gas for long enough to get poisoned.

         Some poisonous gases, such as carbon monoxide, have no effect on
    the nose and throat. Poisonous gases that do not cause coughing and
    choking are very dangerous because people may not know they are
    breathing poison.

         Petroleum distillate liquids, such as kerosene, may cause lung
    oedema when swallowed. When people swallow any liquid or solid, the
    air passage closes and keeps most of it out of the lung but small
    amounts of liquid may still get in. With most liquids this does not
    harm the lungs because the amount is too small, but even very small
    amounts of petroleum distillates can cause lung oedema.

         More importantly, when people are unconscious the air passage
    does not close, so there is nothing to stop food, drink or vomit
    getting into the lungs and blocking the air passages or causing lung
    oedema. That is why it is very dangerous to try to give any food,
    drink or medicine to unconscious people.

    At injection sites

         Irritant poisons that are injected into the skin, such as poisons
    from insect stings and snake bites, may cause pain and swelling where
    they are injected. People who accidentally inject themselves with
    veterinary products, when giving injections to animals or birds, may
    get local effects.

    Systemic effects

         There are many ways in which poisons can cause harm:

    *    By damaging organs such as the brain, nerves, heart, liver,
         lungs, kidneys, or skin. Most poisons have a greater effect on
         one or two organs than on other parts of the body. The organs
         that are most affected are called the target organs.

    *    By blocking messages between nerves.

    *    By stopping the body working properly, for example, by blocking
         energy supply or oxygen supply.

     Effects on unborn babies

         Some poisons can harm a baby inside the womb. This is most likely
    during the first three months of pregnancy when the nervous system and
    all the major organs begin to form. The parts of the baby usually
    affected are the bones, eyes, ears, mouth and brain. If the damage is
    very bad the baby will stop growing and die. Some poisonous chemicals
    may harm a baby in the womb without harming the mother. This is
    serious because there is nothing to warn the mother that her baby is
    in danger.

         If a mother drinks alcohol or smokes during pregnancy it may harm
    her baby. Medicines may also harm a baby in the womb. Pregnant women
    should never take medicines unless they are prescribed by a doctor.

    When systemic effects happen

         Systemic effects only happen when the amount of poison in the
    body is greater than the amount the body can get rid of, and the
    poison builds up and reaches the threshold level.

         Usually, when contact with a poison lasts only a short time
    (acute exposure), the effects happen soon after exposure and do not
    last very long. But, in some cases, the effects of a poison are not
    seen for several hours or even days after an acute exposure. When
    people have been exposed to a poison for a long time (chronic
    exposure), the effects may last for a long time.

         Sometimes a person may be exposed to a poison yet not seem to
    have any ill effects. This may be because the person has not been
    exposed for long enough to absorb a toxic dose. Or it may be that the
    person has absorbed a toxic dose but appears well because it is too
    soon to see any effects of poisoning.

         Sometimes it can be hard to know whether a person who has been
    exposed to a poison is going to develop any ill effects. Before you
    send a person home always check:

         -    how long ago the exposure to poison happened;

         -    how long it usually takes before the effects of the poison
              can be seen (check in Part 2 of this book or contact a
              poisons centre).

         When you suspect someone has been poisoned it is often a good
    idea to watch the person for 12-24 hours to see if any ill effects
    develop. In some cases you may need to watch them even longer than
    that.

         Exposure to a chemical does not affect everyone in exactly the
    same way. Some people may be more sensitive than others. For example,
    young children and old people are more likely to be severely poisoned
    than young adults; and people who are sick because they are not eating
    well, or because they drink a lot of alcohol or have a disease, are
    more likely to be severely poisoned than healthy people.

    CHAPTER 2

    How poisoning happens

    Objectives

         After studying this chapter you should be able to:

    1.   Recognize when there is a danger of poisoning from chemical
         products, medicines, carbon monoxide, pesticides, or contaminated
         food, at home or at work.

    2.   Explain to other people how poisoning happens so that they are
         aware of the dangers.

    3.   Warn people about the danger of taking a chemical product out of
         its original container and putting it in another one.

    4.   Explain to people why it is important to use a product in the way
         the manufacturers mean it to be used.

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

    6.   Discuss with people the usefulness and dangers of using
         chemicals.

         Some poisonings happen by accident but some happen when people
    try deliberately to harm themselves (self-poisoning) or others. There
    are other circumstances that may result in poisoning:

    -    eating food containing poison;

    -    taking, or being given, the wrong kind of medicine or the wrong
         dose;

    -    taking drugs because they change mood or behaviour, or using 
         plants or chemical products for this purpose.

    Accidental poisoning

         Accidental poisoning may happen when:

    -    young children or old people handle poisons not knowing what
         they are;

    -    people mistake poison for food or drink because it is not in 
         its original container;

    -    people misuse chemical products or medicines;

    -    people use or misuse pesticides;

    -    people work with chemicals;

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

     Poisoning in childhood

         Many poisoning accidents in the home happen to small children
    aged between 1 and 4 years. At this age children want to explore. They
    can crawl or walk round the house on their own and by the age of 2
    they can probably climb onto a chair to reach a high shelf. They can
    open drawers and cupboards, and they may be able to open screw-top
    bottles.

         They like to put things in their mouths but they are not old
    enough to understand that some things might be harmful. They seem to
    have a different sense of taste from adults, and often like to swallow
    things that to adults taste strange or bitter. They may swallow
    medicines that look like sweets or motor oil that looks like syrup. If
    they are thirsty they may swallow a liquid, such as a household
    cleaner, that looks like a soft drink or fruit juice.

         The chemical products most often swallowed by children are:

    -    household cleaners such as bleach, detergent and disinfectant;

    -    paraffin and kerosene used as household fuels;

    -    cosmetics;

    -    medicines;

    -    paint and products for household repairs;

    -    household pesticides.

         These chemicals are often used around the home. They are often
    kept in places where a small child can see and reach them, for
    example, on shelves or tables, or on the ground.

         Many accidents happen when people looking after young children
    are too busy to watch them all the time. They may be looking after a
    large family with several young children, or doing housework. If an
    open container is left within easy reach, it may take only a few
    seconds for a child to grab it and swallow the contents.

         It is especially dangerous if a child is left alone, or in the
    care of slightly older brothers or sisters, for several hours at a
    time.

     Poisoning in old age

         Old people may poison themselves accidentally. If they cannot see
    very well, they may pick up the wrong bottle and swallow a household
    cleaner, for example, instead of a drink or a medicine. Old people
    tend to be forgetful and confused. They may forget to take their
    medicine, or they may take too much and poison themselves because they
    cannot remember how much to take or when they took the last dose.

     Taking products out of their own containers

         Accidents can happen when someone takes a chemical product out of
    its container and puts it in another one. The new container does not
    have the right label so nobody else will know what is inside. Even the
    person who did it may forget. It is specially dangerous to pour any
    chemical or medicine into a drinking cup, or drink bottle, or any
    container where it might be mistaken for food or drink. Young children
    cannot tell the difference between harmful chemicals and food or
    drink, and even adults may drink from bottles without checking to see
    what is inside.

         That is why it is dangerous for shopkeepers to take chemicals
    from large containers and then sell them in smaller containers.

     Poisoning from misuse of chemical products or medicines

         Poisoning accidents can happen when safety warnings are ignored
    and chemicals are used in the wrong way. For example, there is usually
    a warning on a bleach container that bleach should not be mixed with
    any other cleaner. If people ignore the warning and use bleach with
    another household cleaner, they may be poisoned by the gases given
    off. Another example of misuse of a product is when insecticides that
    are meant to be used on plants or buildings are used to kill insects
    living on people, in their hair or on their bodies.

         Sometimes people poison themselves by misusing medicines. They
    may take more than the doctor prescribed because they think, wrongly,
    that a larger dose will make them better more quickly. Taking someone
    else's medicine is also a kind of misuse. People who take someone
    else's medicine may be harmed if they take the wrong dose or take a
    medicine that is not meant for treating their condition. Women who
    take medicine to try to end a pregnancy are misusing the medicine, and
    may poison themselves.

     Pesticide poisoning

         Pesticides are chemicals made to poison insects, weeds or other
    pests. Most pesticides are also poisonous or harmful to humans if they
    get on the skin, or if they are breathed into the lungs in the form of
    gases, fumes, dust or fine spray droplets, or if they are swallowed.

         These are some of the ways people may be poisoned:

    -    if they use pesticides in the wrong way; for example,
         children may be poisoned if pesticides are sprayed on their bed-
         clothes;

    -    if they do not use protective equipment; for example, they may
         splash pesticide on their clothes or skin, or may breathe in
         pesticide;

    -    if they eat, drink or smoke after working with pesticides, and
         have the chemicals on their hands - they should wash their hands
         first;

    -    if empty pesticide containers are used to store food or drink -
         it is impossible to wash all the pesticide out of an empty can,
         and some pesticide will get into the food or drink;

    -    if food containers or drink bottles are used to store pesticides
         - someone may mistake the contents for food or drink.

     Poisoning at work

         Many chemicals that are made, used, or stored in workplaces are
    poisonous. People who work with these chemicals need to know how to
    handle them safely to avoid being poisoned.

         Sometimes workers may not know that they are handling a poisonous
    chemical, or they may know that the chemical is poisonous but not have
    been told or shown how to handle it safely. They may not have read the
    label or the safety information. Sometimes they may know the dangers
    but be too lazy or careless to use safe methods.

         Accidents, fires or explosions at work may result in chemicals
    spilling or leaking out of their containers onto roads or into rivers,
    or vapours and gases being released into the air. Sometimes chemicals
    spread over a large area and poison many people.

         Chemical waste and empty chemical containers may be serious
    safety hazards if they are not dealt with in the right way.

     Carbon monoxide poisoning

         When oil, gas, wood, coal or other fuels burn they give off a gas
    called carbon monoxide, which can cause serious poisoning and often
    causes death. This can happen when fires, stoves, heaters, or ovens
    are used in rooms, huts or tents where there is no open window or
    chimney to let fresh air in and carbon monoxide out. Petrol engines
    also give off carbon monoxide, and people may be poisoned if they run
    a car engine inside a garage when the doors are shut.

    Self-poisoning

         People may try to harm themselves by deliberately taking poison -
    this is called self-poisoning. In some countries people take medicines
    to poison themselves, but people living in rural communities are more
    likely to take pesticides.

         People suffering from depression, serious illness, or alcohol
    dependence may try to kill themselves by taking poison. They may
    swallow large amounts of medicine, pesticide or other poisons. If they
    recover they might try to poison themselves again unless they receive
    appropriate treatment.

         Many young people who try to poison themselves are unhappy
    because of problems they do not know how to deal with, such as unhappy
    love affairs or arguments with boyfriends or girlfriends.

    Using poison to harm other people

         Sometimes people use poison to harm others. They may do it as a
    joke or they may want to frighten or even kill a person. If you have
    evidence that this is happening or has happened, tell the police.

    Poison in food or drink

         Food or drink can be contaminated by poison from microscopic
    organisms such as bacteria, viruses, or mould, or by chemical poisons.
    Some plants, mushrooms, animals or sea-creatures contain poisonous
    chemicals. Poisons made by plants, animals or microorganisms are
    called toxins.

     Poisons made by microscopic organisms

         Food may be contaminated by bacteria before or after cooking,
    during preparation or storage, by contact with hands that have not
    been thoroughly washed, or with contaminated surfaces, containers or
    kitchen utensils. It may also be contaminated by animals or insects,
    particularly flies. Heating food thoroughly destroys most - but not
    all - bacteria and bacterial toxins. However, if cooked food is kept
    warm or at room temperature for any length of time, any bacteria
    present will multiply and may cause disease.

         Moulds grow on foods that are damp or damaged by insects, and
    some moulds produce poisons. Moulds growing on nuts or grain that has
    been gathered and stored before it is dry may cause serious poisoning.
    Some ways of drying and preserving food do not stop moulds growing on
    the food.

         People can catch diseases from eating food infected with worms or
    other organisms, but this is not poisoning and is not dealt with in
    this book.

     Chemical poisons

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

    -    when people working with chemicals eat in the workplace or do not
         wash their hands before eating;

    -    when chemicals spill onto food as it is being moved from place to
         place, or when it is in a storeroom;

    -    when food or drink is stored or cooked in containers that are
         contaminated with chemicals;

    -    when people make flour from grain that has been treated with
         pesticide because it was meant to be used for seed or bait, not
         for food;

    -    when people brew their own alcoholic drinks and produce poisonous
         alcohols, such as methanol;

    -    when water supplies are polluted by accidental spills of
         chemicals, or by chemical waste from factories or waste dumps
         near watercourses.

     Poisonous plants, mushrooms, animals and sea-creatures

         Some plants, mushrooms, animals and sea-creatures contain toxins.
    Sometimes it is very hard to tell the difference between plants or
    fish that are good to eat and those that are poisonous.

    Medical poisoning

         Sometimes people are poisoned by medicines given to them by a
    doctor or another health care worker. They may be given the wrong
    medicine or be given the wrong dose of the right medicine. There are
    many reasons why this can happen. The doctor may not know the patient
    is allergic to a medicine, or may give the wrong dose because of a
    mistake in measuring it.

    Abuse of drugs, chemicals or plants

         People may take drugs to change their mood or behaviour, to feel
    relaxed, or to get more energy. This is called drug abuse because it
    is not a medical use of the drug. Some people abuse drugs such as
    heroin, cocaine or barbiturates. Drinking too much alcohol is an
    important kind of drug abuse.

         Other substances may produce some of the same effects. Some
    people breathe in chemicals such as glue, paint, nail varnish remover,
    cigarette lighter gas, petrol or dry-cleaning fluid. This is sometimes
    called solvent sniffing or solvent abuse. People may breathe fumes
    from a cloth soaked in liquid or put chemicals or glue into a plastic
    bag and breathe deeply from the bag.

         In many societies people use plants or fungi for their
    hallucinogenic, stimulant or relaxing effects. Some plants may be
    eaten raw, others are cooked, made into drinks, or smoked. Two plants
    commonly used in this way are tobacco and cannabis.

         Many of the drugs, chemicals and plants that are abused are
    poisonous if people take too much at one time or use them for many
    months or years. For example, alcohol causes liver damage, smoking
    causes lung cancer and cannabis can affect people's memory.

    The benefits and dangers of using chemicals

         All countries use a large number of different chemicals in
    agriculture, in industry, in medicines and in the home. There are many
    good reasons for using them. Pesticides and fertilizers have helped
    farmers grow more crops. Medicines can cure or prevent disease, and
    they can give people longer and more comfortable lives. Cleaning
    products have made household tasks easier.

         Useful chemicals can also be dangerous. People may have to use
    amounts that could be poisonous if they got into the body. Some
    chemicals can also cause harm if they get into the air people breathe,
    into the soil where people work or grow food and animals live, and
    into the rivers and streams that supply water for drinking, washing,
    or irrigating crops. The danger can be made smaller if chemicals are
    used safely, and efforts are made to prevent accidents, but the danger
    will never completely go away.

         Communities must decide whether the benefit of using the
    chemicals is large enough and the danger small enough for them to live
    with. There are many things to think about:

    *    How useful is the chemical?

    *    What kind of harm can the chemical cause?

    *    Will the chemical affect the environment?

    *    Can the chemical be handled safely?

    *    How many people will use the chemical, and how many people might
         be exposed to it because they work or live near the place it is
         made or used?

    *    Can a less poisonous chemical be used instead?

    *    How much money could be saved by using the chemical and how much
         would it cost to stop using it?

    CHAPTER 3

    How to prevent poisoning

    Objectives

         After studying this chapter you should be able to:

    1.   Discuss with people how to prevent poisoning.

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

         It is better, safer and cheaper to prevent poisoning than to cure
    it. Most poisonings can be prevented.

         Everyone - children, parents, farmers, schoolteachers, factory
    workers and health care workers - can do things to make their homes,
    their workplaces, and the community safer.

    How you can help people make their homes, workplaces, and
    the community safer

         There are three steps you should take:

    1.   First of all, find out about the poisonings that have happened in
         your community in the last few years. Find out how they happened,
         where they happened and what the poisons were. Think about why
         the poisonings happened.

    2.   Think about how poisonings that have happened in your community
         could have been prevented. This chapter lists many ways to
         prevent poisoning. Talk to your poisons centre about the
         poisonings in your community. The poisons centre may be able to
         suggest ways to prevent them.

    3.   Discuss with people how poisonings can be prevented. Share what
         you know with others and help them understand why poisonings
         happen and what can be done to stop them happening again.

         *    Talk with families and mother-and-child health groups about
              preventing poisoning at home. Talk about how to teach
              children, even at an early age, not to touch, eat or play
              with medicines or household chemicals.

         *    Talk to schoolteachers about how to teach children about the
              dangers of poisoning in their homes and the dangers from
              poisonous snakes, plants and animals. For example, teachers
              could ask the children to find out about accidents that have
              happened in the community and to suggest ways to prevent
              such accidents.

         *    Talk to community leaders or committees about the accidents
              that have happened. Discuss with them and the people what
              you think can be done to make your community safe.

         *    Make friendly visits to homes and workplaces from time to
              time, not to find fault, but to help people to see where
              there are dangers and how to make them safe.

         This chapter gives some "dos" and "do nots" to help you when you
    talk to people about how to prevent poisoning.

         The first time you read this chapter you may think "It is
    impossible for people in my community to do that. How can I tell
    people to wear boots to protect themselves from snake bites, when they
    cannot even afford shoes? How can I tell them to keep medicines in a
    locked cupboard, when we do not have cupboards in our homes?"

         The community should know the best ways of preventing poisoning
    and aim to use them. But when you talk to people about how to prevent
    poisoning, discuss how to adapt the advice to your local situation.
    There may be other ways that will work just as well. For example,
    people may tell you that there are other places in their homes that
    are as safe as locked cupboards. There may be a local carpenter who
    could make boxes or cupboards that lock, if the community wants them.

         Work towards your target in stages. For example, if people cannot
    afford boots, start by encouraging them to wear simple, locally made
    shoes or sandals.

    What can be done to prevent poisoning?

         It is important to handle all chemicals safely, not just the ones
    you know are poisons. Many chemicals that you might not think are
    poisonous could make someone ill or cause burns.

         It is very important to protect children, because they cannot
    protect themselves and they do not understand that some things can be
    poisonous.

         Many poisonings could be prevented if chemicals were kept safely,
    used safely and got rid of safely.

     Keep chemicals safely

    *    Do keep medicines, cleaners and pesticides where children cannot
         see or reach them (Fig. 5).

    *    Do not keep chemicals you no longer need.

    *    Do not put chemicals in containers that once contained food or
         drink; people may eat or drink the chemicals by mistake.

     Use chemicals safely

    *    Do use medicines, cleaners, pesticides and other chemicals in the
         right way, and use the right amount (not more or less). Read the
         label and follow carefully the instructions for use (Fig. 6). A
         person who cannot read it should find someone who can. It may be
         dangerous to use chemicals from unlabelled containers. Ask the
         supplier for another container with a label.

    FIGURE 5

    FIGURE 6

     Get rid of left-over chemicals and empty containers safely

    *    Do find out whether it is better to bury or burn the
         chemicals you want to get rid of. Choose a place to bury or burn
         chemical waste where there will be as little danger as possible
         to the people living nearby or to the environment (Fig. 7).

    *    Do find out from environmental health officers or community
         leaders the local arrangements for getting rid of chemical waste.
         Seek professional advice about how to get rid of large amounts of
         unwanted chemicals.

    *    Do not use empty bottles, cans or other containers that have 
         been used for storing chemicals to store or cook food or drink.
         Do not give them to children to play with.

    *    Do not leave left-over chemicals or empty containers where
         children might find them.

    *    Do not throw left-over chemicals or empty containers near a
         river, pond or spring. Chemicals might get into the water and
         poison fish, or poison people or animals that drink the water or
         wash in it. This may also happen if chemical waste is poured into
         drains that empty into waterways.

         The rest of this chapter gives more detailed guidelines on how to
    prevent the different types of poisoning described in Chapter 2.

    FIGURE 7

    How to make homes safe

     How to keep chemicals safely

    *    Do keep all household chemicals where children cannot see 
         them or reach them. Keep medicines, insecticides, weedkillers and
         rat poison in a locked cupboard or locked suitcase or in a high
         cupboard.

    *    Do keep household products, pesticides and medicines in their 
         own containers.

    *    Do keep caps and tops on bottles and keep them properly closed
         (Fig. 8). Keep boxes closed. A child who finds an open container
         may swallow the contents before anyone can stop him or her. A
         child may try to open a closed container, but this may take time
         and a young child will often find it difficult. An adult may see
         what is happening and stop the child before he or she can open
         the container.

    *    Do not keep household cleaners on the floor, under the 
         kitchen sink, or in low cupboards that a child can easily open
         (Fig. 9).

    *    Do not keep medicines, pesticides or household products 
         next to food or drink. A child may think they are something to
         eat or drink. Even an adult may swallow the contents of some
         containers without first checking what is inside. A chemical may
         spill onto food, and someone may be poisoned by eating the
         contaminated food.

    FIGURE 8

    FIGURE 9

    *    Do not keep medicines, pesticides or household products in
         drink bottles, cups or containers normally used for food or
         drink.

    *    Do not keep chemicals or empty containers you no longer need. For
         drink guidelines for getting rid of them safely, see chapter 3.

     How to use medicines and household products safely

    Medicines

    *    Do be sure to take or give the right dose of medicine. Find out
         the right dose by reading the label or asking a health care
         worker. Be very careful not to take or give too much. Too large a
         dose of medicine may make a person very sick. It is a mistake to
         think that if you take all the medicine at once you will get
         better more quickly.

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

    *    Do not take medicine or give medicine to others without taking
         advice from a doctor or health worker.

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

    *    Do not pretend to children that medicines are sweets. They cannot
         tell the difference and might later poison themselves if they
         think medicines are sweets.

    Household chemicals, such as cleaners or pesticides

    *    Do read the label. Make sure you know how to use the product and
         how much to use, and look for advice about how to use the product
         safely.

    *    Do hold on to a product while you are working with it. If you put
         it down, leave it where you can see it all the time. A child can
         quickly grab an open bottle and swallow the liquid, or spill it
         onto the skin or into the eyes.

    *    Do wipe up any of the chemical that gets spilt, and make sure the
         outside of the bottle or container is clean and dry.

    *    Do put chemicals away as soon as you have finished using them.
         While they are out of their usual storage place, children may get
         hold of them.

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

    *    Do not mix different cleaners or other products together.

    *    If the product has to be added to water before it is used, do not
         mix it in a container that is used for food and drink.

     Get rid of household products safely

    *    Do put lids on household rubbish bins so that children cannot
         take things out.

    *    Do use the local arrangements for getting rid of household
         rubbish. Do not leave rubbish lying around the house or dump it
         anywhere else.

    *    Do not puncture, heat or burn pressurized containers. If the
         community burns household rubbish, do not put pressurized
         containers into the fire. They should be buried instead.

     Other ways to prevent poisoning in the home

    *    Do keep the floors and walls clean. Fill holes or cracks so that
         there is nowhere for insects to live and no way snakes can get
         into the house.

    *    Do keep gas or liquid fuel heaters, stoves and ovens in good
         working order so that they do not produce dangerous amounts of
         carbon monoxide gas.

    *    Do keep chimneys or flues clear and open to the outside air so
         that fumes containing carbon monoxide gas from fires and stoves
         do not stay inside the house.

    *    Do not use heaters, stoves or ovens in rooms with no chimney,
         flue or open window to let in fresh air and let out the fumes
         containing carbon monoxide gas.

    How to prevent poisoning with pesticides

         Pesticides are very widely used and in some countries many people
    get sick or die because of poisoning with pesticides. Poisoning can be
    prevented if pesticides are used safely and proper precautions are
    taken.

         People working where pesticides are used or stored - on
    plantations, on farms, in factories or in shops - should know how to
    handle and use pesticides safely. Every member of the community needs
    to know about the hazards of using pesticides and how to avoid them.

         Most of these guidelines can be applied wherever chemicals of any
    kind are stored or used. If you want to know more about safety at work
    ask someone with expert knowledge about health problems at work.

     Store pesticides safely

    *    Do keep pesticides in their original containers. It is dangerous
         to transfer pesticide from one container to another. The
         pesticide may be mistaken for food or drink.

    *    Do keep pesticides in a safe and secure store. Seek advice from
         agricultural advisers on where to site the store and how to build
         it. It should be marked with warning signs and have locked doors
         and barred windows, to keep out unauthorized people, especially
         children.

    *    Do make a list of all products in the store and update it
         regularly. Do not keep the list in the store but keep it in a
         safe place where it will be accessible in the event of a fire. In
         the store, keep chemical safety data sheets and emergency
         telephone numbers.

    *    Do keep pesticides, particularly rodenticide baits and pesticide
         treated seeds, away from foodstuffs so they are not mistaken for
         food.

    *    Do not keep agricultural pesticides in living areas. Keep them in
         a separate shelter. The only pesticides that should be kept at
         home are those for killing household pests.

    *    Do not keep pesticides in drink bottles or other containers
         normally used for food or drink.

     Use pesticides safely

         Everyone who applies pesticide should first have training in the
    method of application, the operation, cleaning and maintenance of the
    equipment and the safety precautions to be taken.

         A pesticide, or any other chemical product, should have a label
    saying what it is, who made it and how to use it safely and
    effectively. There should also be information about possible hazards,
    safety precautions, first aid instructions and advice to health
    workers. If the container is small, this information may be given in a
    leaflet attached to the container. There may also be a product
    information leaflet and a chemical safety data sheet.

    *    Do read the label and any other product information you have been
         given, before you use the product. If you do not understand the
         information, ask someone who knows, such as your employer or the
         person who supplied the product. Never use a product until you
         have read and understood the label. If the product does not have
         a label ask the supplier to give you a labelled container. Make
         sure you know:

         -    what the contents are,

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

         -    how to use the product safely, and what equipment and
              clothing to use,

         -    the hazards associated with its use, and the first aid to
              give if there is an accident,

         -    when the pesticide should be used and how often.

         If you cannot find this information on the label ask the
    supplier, another user, a community leader, or an agricultural
    extension worker to give you the information.

    *    Do warn your neighbours before you spray pesticides.

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

    *    Do wear lightweight work clothes that cover as much of your skin
         as possible when you mix or apply pesticide, when you clean
         equipment and empty containers, and when you get rid of left-over
         pesticide. Wear boots or shoes to cover your feet. Gloves and
         goggles will give extra protection from splashes. Do have a clean
         change of clothing.

    *    Do wear protective clothing and use protective equipment if the
         label tells you to. If the label tells you to use protective
         clothing or equipment it is because the product could harm or
         even kill you if you do not have that protection. Make sure all
         protective clothing and equipment are properly checked,
         maintained and stored.

    *    Do mix only the amount of chemical that can be used in one day.
         Then you will not need to get rid of left-over pesticide or leave
         it overnight.

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

    *    Do wash gloves before you take them off.

    *    Do wash your hands thoroughly with soap and water after handling
         or using pesticides. Wash your hands with soap and water before
         you eat, drink, chew tobacco, smoke, rub your eyes or touch your
         mouth.

    *    Do make sure that you are never alone when you are mixing or
         using very poisonous pesticides.

         Stop work immediately if you are using a chemical and you get a
         rash or feel sick, if your eyesight troubles you, or you begin to
         sweat more than usual or feel unusually thirsty, or even if you
         have a headache or cold or flu symptoms. Tell your employer and
         go to a doctor at once. Show the product label, information
         leaflet or data sheet to the doctor.

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

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

    *    Do not use dirty or damaged protective equipment, or dirty or
         torn protective clothes, or leaking gloves or boots. They may be
         more dangerous than using nothing.

    *    Do not use bare hands to scoop powder out of packs, or dip bare
         arms or hands into liquids to stir mixtures. Use measures and
         mixing vessels for making up solutions (Fig. 10). Do not use
         these for anything except pesticides.

    *    Do not measure out or mix pesticides in or near houses, or where
         animals are kept.

    FIGURE 10

    *    Do not blow through or suck spray nozzles to clear blockages.
         Clean the nozzle with water or a grass stem.

    *    Do not spray pesticide when a strong wind is blowing because it
         may drift over you, or nearby animals or houses.

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

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

    *    Do not let children drink or play near spray equipment or near
         places where pesticides are mixed, or near a field that is being
         sprayed.

    *    Do not let children use pesticides.

     Get rid of empty containers and left-over pesticide safely

    *    Do ask agricultural advisers about the safest way to get rid of
         stocks of unwanted pesticide and empty pesticide containers. Most
         waste can be buried but this is not safe for all chemicals and
         may not be allowed in some areas. It is very important to choose
         both the method used and the place where waste is burnt or buried
         so as not to cause danger to people or to the environment. Do not
         get rid of pesticides or pesticide-contaminated waste in
         community waste pits used for household rubbish. More specific
         recommendations for getting rid of chemical waste are outside the
         scope of this book.

    *    Do use all the pesticide in a sprayer if possible, to avoid
         having to get rid of unused pesticide. If that is not possible,
         empty all unused pesticide out of spray tanks and get rid of
         small amounts of left-over diluted pesticide by tipping it into a
         hole in the ground away from dwellings, wells, waterways and
         crops. Ask professional advice about where to dig the hole, and
         check how much waste can be put in it and how often it can be
         used. Put a fence round the hole to keep children away, and put a
         sign on the gate showing that poisons have been buried there.

    *    Do wash all equipment after use and put it back in the store.
         Collect the washing water in an empty container and pour it into
         the hole used for small amounts of left-over diluted pesticide.

    *    Do wash out empty containers three times with water. Usually you
         empty containers when you are mixing pesticides for use. If you
         wash out the containers straight away you can get rid of the
         washings by adding them to the spray tank. Washings which cannot
         be reused should be collected and got rid of in the hole used for
         small amounts of diluted pesticide. After they have been cleaned,
         store empty containers in the pesticide store until they can be
         got rid of safely.

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

    *    Do wash all work clothes well every day. Wash work clothes
         separately from other clothes. Never wear work clothes at home,
         or leave dirty clothes in the house.

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

    *    Do not use empty containers to cook food or to store food or
         drinking-water for humans or animals, as it is impossible to
         clean out all the pesticide and to make the containers safe.
         Plastic containers should be washed as described above and holes
         punched in the base or sides so that they cannot be used again
         (Fig. 11). Treat steel drums and small tin containers in the same
         way (but do not make holes in pressurized containers).

    What employers can do to prevent poisoning at work

     General measures

         Employers should protect workers from the dangers of using
    chemicals. There are several things they can do to protect them.

    *    Comply with local and national health and safety regulations.

    *    Choose the least dangerous chemicals. If there are several
         different chemicals that do the same job, choose the least
         poisonous one.

    *    Choose safe equipment and safe ways of using it.

    *    Make sure workers are exposed to chemicals as little as possible.
         For example, where appropriate, use mechanical ventilators in
         buildings where chemicals are used or stored.

    FIGURE 11

    *    Provide workers with equipment and clothing, where appropriate,
         to protect them from exposure to chemicals. Maintain clothing and
         equipment in good condition.

    *    Use safety signs and notices.

         Employers should also:

         -    tell workers if they are using dangerous chemicals;

         -    teach workers about the dangers and make sure that they
              understand fully;

         -    train and encourage workers to use safety equipment and
              clothing and to use chemicals safely;

         -    check from time to time to see if the workers are using the
              safety equipment and clothing and are using chemicals
              safely. Warn those who are not doing so about the dangers.

     Checking the health of workers and their exposure to chemicals

         Workers should not be exposed to amounts of chemicals that might
    make them ill or damage their health. In the workplace the amount of
    chemicals in the air should be measured and recorded. Workers should
    be offered regular medical checks if appropriate, to see if they are
    being harmed by chemicals at work and to see whether measures need to
    be taken to prevent exposure.

     First aid and emergencies

    *    First aid should be available at every workplace.

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

         In every workplace the possible dangers from the use of poisonous
    substances should be assessed, and workers should be given the
    training, first aid equipment, and supplies they need to deal with the
    dangers, as well as some means of communication and transport in case
    of an accident.

    Training

         Employers should train all workers in what to do after any kind
    of accident, emergency or injury. They should teach workers how to
    give first aid. From time to time they should check that workers still
    remember what to do.

         In every workplace there should be one or more trained first
    aiders always on the site, to give first aid in an emergency, such as
    poisoning, injury or sudden sickness. In many countries, national
    labour regulations say that there must be a person trained in first

    aid in each workforce of a certain size, but trained first aiders are
    needed even in smaller organizations not covered by regulations. Even
    a person working alone should know first aid and know if the work is
    dangerous. The number of people who should be trained in first aid
    depends on the size of the danger. These people may be workers or
    supervisors or, if a person works at home, other adults in the family.

    Equipment

         First aid equipment should always be kept in workplaces where
    there are dangerous chemicals. For example, where there are corrosive
    liquids, an eye-wash fountain or a plastic bottle with an eye-wash may
    be needed. If there is a danger that the corrosive liquid could be
    spilt on the skin, an emergency shower may be needed. Emergency
    breathing equipment should be kept where irritant or poisonous gases,
    such as chlorine or carbon dioxide, are used, so that workers can
    escape or rescue others if there is a gas leak. In some cases special
    equipment may be needed to rescue people after an accident.

    Supplies

         Antidotes may need to be added to first aid kits in workplaces
    where very quick-acting poisonous chemicals are used. For example,
    amyl nitrite capsules should be kept in places where cyanide is used.

    Getting help and taking people to hospital

         The easiest way to get help when there is an accident at work is
    to shout to a fellow-worker or, for those working at home, a member of
    the family or a neighbour.

         Employers should know what to do and who to contact if there is
    an accident or emergency with dangerous chemicals.

         Where appropriate, there should be posters with clear
    instructions about what to do and who to contact if there is an
    accident or emergency with dangerous chemicals. The posters should
    give telephone numbers of the nearest emergency service, health
    service, or poisons centre, or instructions about how to contact them.
    They should also have pictures and instructions on how to give first
    aid and how to get medical help after first aid has been given.
    Employers should check from time to time that these procedures still
    work, and find out, for example, whether the people to contact have
    changed.

     Cooperation between employers and workers

         Employers, workers and their representatives should cooperate
    closely to apply these safety measures. Workers should take care of
    their own health and safety by following training and instructions
    given by their employers, by using protective equipment and clothing
    properly and by reporting at once to their supervisor any situation
    that could be dangerous.

         Workers should be given information about the dangers of using
    chemicals in their work, and be trained in ways of working that will
    protect them from those dangers.

    How to avoid snake bites

         When a person and a snake meet, the snake will usually try to get
    away if given the chance. Snakes usually bite only when they are
    surprised by a sudden movement and cannot get away.

    *    Do wear shoes when walking outdoors. Tall leather boots give the
         best protection for walking in long grass or undergrowth. Wear
         them with long trousers hanging outside the boots (Fig. 12).

    *    Do learn about the poisonous snakes in your area. Learn what they
         look like and where they live. Most snakes live on the ground but
         some live in trees or bushes. Find out if there are any snakes
         that spit venom and how they attack.

    FIGURE 12

    *    Do take care at night because that is when many snakes are
         active. Tell children to wear shoes and use a torch when walking
         around at night. Teach them to leave snakes alone.

    *    Do not go near snakes. Run away if you can. If you cannot run
         away, do not make sudden movements.

    *    Do not touch a snake even if it looks dead. Some snakes pretend
         to be dead to avoid attack.

    *    Do not turn over stones or logs, or put your hand or foot into a
         hole in the ground. Before stepping over a log look for snakes on
         the other side.

    *    Do not sleep on the ground. You might roll over onto a snake
         while asleep, or a snake may move next to you to get warm.

    How to prevent insect, spider and scorpion stings and bites

    *    Do find out about the poisonous insects, caterpillars, spiders,
         and scorpions in your area. Learn what they look like and where
         they live.

    *    To protect yourself from bee stings when working among flowers or
         fruits, do wear long trousers, long-sleeved shirts and gloves,
         and cover your head and face as much as possible (Fig. 13). Avoid
         wearing things that attract bees, such as bright flowery
         clothing, bright shiny jewellery, buttons or buckles, or using
         scented perfume, soap or shampoo.

    FIGURE 13

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

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

    *    Do not put your hands in leaf litter, rotten tree trunks or holes
         where insects, caterpillars, spiders, scorpions or centipedes
         might live.

    How to avoid eating poisonous plants, mushrooms and fish

    *    Do find out which plants and mushrooms in your community are
         poisonous and what they look like. Make sure you can recognize
         them - some edible plants, mushrooms and fish are very hard to
         distinguish from poisonous ones.

    *    Do learn how to prepare foods correctly. Some plants (like
         cassava) are poisonous if not properly prepared or cooked, and
         some plants and fish have poisonous parts that must not be eaten.

    FIGURE 14

    *    If you are preparing tropical fish, do separate the flesh from
         the head, skin and gut as soon as possible, because these may
         contain large amounts of poison.

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

    *    Do not eat fish that is not fresh. Some fish are good to eat when
         they are fresh, but become poisonous when they have been dead for
         some time.

    How to avoid infection from food contaminated with germs

    *    Do keep kitchens clean. Keep tables and other surfaces on which
         food is prepared clean, and keep kitchen utensils clean.

    *    Do protect food by keeping it covered or in boxes or cupboards
         with wire screens (Fig. 14).

    *    Do wash your hands well with clean soap and water before touching
         or preparing food. Cuts or sores on fingers should be covered
         with a clean dressing.

    *    Do boil plates and eating utensils used by  sick people before
         anyone else uses them.

    *    Do not keep food for a long time in a warm place. Do not keep
         left-over cooked food if you cannot keep it cool or keep it in a
         refrigerator.

    *    Do not let flies, other insects, worms, rats or other animals
         touch or crawl on food. They carry germs and spread disease.

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

    *    Do not leave food scraps or dirty dishes lying around, as these
         attract flies and let germs breed.

    *    Do not leave clean utensils lying on the ground.

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

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

    *    Do not eat food from cans that are swollen or that squirt out
         when opened. Be especially careful with canned fish.

    CHAPTER 4

    What to do in an emergency

    Objectives

    After studying this chapter, you should be able to:

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

    2.   Check for danger at the scene of an accident, fire or explosion,
         and warn other people.

    3.   Decide quickly when to get help to rescue a person who is
         overcome by poisonous gas, or trapped inside a burning building.

         A poisoned person may suddenly become very sick and need
    immediate first aid. When you help someone who has been poisoned or
    injured in a chemical accident, fire or explosion, or by carbon
    monoxide, you should be aware of the dangers, so that you can protect
    yourself and warn others.

    The dangers to look out for

    There may be a danger of poisoning:

    -    inside a room or building where there is a heater or cooker
         burning wood, oil or gas, where there is not enough fresh air;

    -    inside a garage where a car engine is running;

    -    inside an empty chemical storage tank;

    -    inside a grain store or silo;

    -    near a chemical fire or explosion, or a spill or leak of gases,
         solids or liquids, especially in a pit, trench or cellar;

    -    inside a burning building. Fires give off smoke and hot air,
         which may damage the lungs if breathed in, and poisonous gases,
         especially if chemicals or plastics are burning. The poisonous
         gases quickly build up in a closed space;

    -    from contact with skin or clothes of people who have been
         contaminated by very poisonous chemicals, such as cyanide or
         organo-phosphorus pesticides.

         There may also be a danger of injury at the scene of a chemical
    accident. For example, there may be a danger from traffic if the
    accident happened on the road, or a danger from collapsing buildings
    at the scene of a fire or explosion.

    What to do in an emergency

    When there is an emergency:

    *    Keep calm.

    *    Make sure you are safe.

    *    Raise the alarm and call for help.

    *    Move the victims away from danger.

    *    Give first aid.

     Keep calm

         Try to calm yourself before you approach a victim or an incident.
    Most people are frightened if they are injured or suddenly taken ill.
    By remaining calm you will help to relieve their fear. Act quickly and
    quietly.

     Make sure you are safe

         Before you do anything else, make sure that you are safe. If
    there is danger, you must protect yourself.  If you become another
    victim there may be no one to help you.

         Quickly check that there is no danger from:

         -    poisonous gas, smoke or fumes,

         -    poisonous liquids,

         -    fire and collapsing buildings,

         -    traffic.

         Check which way the wind is blowing and keep out of areas where
    smoke or fumes from leaks or spills might blow over you.

     Raise the alarm and call for help

         If you are the first person on the scene, shout to others in the
    area to warn them of any danger and to call for help.

         If there is more than one victim always shout for help before you
    do anything else.

         If there is a nurse, doctor, health worker or first aider living
    or working nearby, send someone to get help.

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

         If someone is unconscious in a room or building that might be
    full of poisonous gas:

    *    Open the door and open or break the windows from the outside, to
         let in fresh air. Wait until the room is full of clean air before
         you go in.

    *    Do not switch on an electric light and do not let anyone go into
         the room with a lighted cigarette or naked flame. These may cause
         an explosion.

         If someone is trapped inside a burning building:

    *    Do not go in unless you are wearing proper breathing equipment
         that you have been trained to use. If you go into a burning
         building with nothing to protect you from breathing poisonous gas
         and smoke, you may become unconscious and not be able to get out.
         A wet rag over the mouth and nose will not protect you.

         If someone is unconscious inside an empty storage tank:

    *    Use an air compressor to blow fresh air into the tank. Wait until
         the tank is full of clean air before you go in.

    *    If the storage tank cannot be cleared with a compressor, do not,
         go in unless you are wearing proper breathing equipment that you
         have been trained to use. If you go into an empty storage tank
         with nothing to protect you from breathing poisonous gas, you may
         become unconscious and not be able to get out.

         Protect yourself from being poisoned by contact with the victim.
    Put on gloves before you touch people who have been poisoned with
    cyanide, crowd-control gases, or organophosphorus pesticides. Poison
    on their skin or clothes could poison you.

     Give first aid

         Give first aid before you move the victim, unless it is dangerous
    to stay there (see Chapter 5).

         If there will be a delay in getting the victim to a doctor or to
    hospital, you may need to do more to help him or her (see Chapter 9).

    CHAPTER 5

    First aid

    Objectives

         After studying this chapter, you should be able to:

    1.   Tell when a person:

         - is unconscious,
         - is not breathing,
         - has no heartbeat.

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

    3.   Give first aid when a person:

         - has fits (convulsions),

         - has chemical in the eyes,

         - has chemical on the skin,

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

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

         This chapter can help you learn first aid, but you also need
    someone to teach you first aid, and check that you are doing it
    correctly. It is important to have someone show you the right way to
    do mouth-to-mouth respiration and heart massage. You should practise
    on a special training manikin (a life-size model). Never practise
    heart massage on another person, only on a manikin.

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

         People who are poisoned may:

         - be unconscious,

         - stop breathing,

         - have no heartbeat,

         - have fits (convulsions).

         They need immediate first aid to help them to breathe and to
    start the heart beating.

         When people get chemical in the eyes or on the skin, it may cause
    burns. These people need immediate first aid to wash the chemicals out
    of the eyes and off the skin. The chemical may also get into the body
    and cause poisoning.

         People who have been bitten or stung by a poisonous or venomous
    animal need first aid:

         - to remove stings, spines or tentacles,

         - to clean the wound and stop infection,

         - to slow the spread of poison through the body.

    Give first aid at once

         Immediate first aid may stop serious poisoning and may save life.
    If breathing and the heart stop, the person will die within a few
    minutes unless you give first aid at once.

    First aid for poisoning

         Here is an action list. Each step is explained in more detail
    below the list. Start with the first step and follow each step in the
    order given. Act as quickly as you can, but stay calm.

    1.   Check if the patient is conscious.

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

    3.   Check if the patient is breathing.

    4.   Clean out the mouth and clear the throat.

    5.   Give mouth-to-mouth respiration.

    6.   Check if the heart is beating.

    7.   If the heart is beating, but the patient is still not breathing,
         carry on with mouth-to-mouth respiration.

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

    9.   If the patient is breathing but is unconscious, turn him or her
         onto one side, into the recovery position.

    10.  Give first aid for fits if necessary.

    11.  Wash any chemical out of the eyes.

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

    13.  Give first aid for poisonous bites and stings.

     Check if the patient is conscious

         Try to make the patient wake up. Shout "Are you all right?" and
    gently shake the shoulders, but take care not to make any injuries
    worse (Fig. 15). Pinch the skin on the neck and watch the face. A
    patient who is just sleeping will wake up, but an unconscious patient
    will not.

     Open the airway

         The airway is the tube through which air passes from the mouth
    and nose to the lungs. If it is blocked the patient cannot breathe and
    air cannot get into or out of the lungs. A patient who cannot breathe
    will die within four minutes.

         In an unconscious patient the tongue may block the throat and the
    airway. Make sure the airway is open and air can get down the throat
    (Fig. 16):

    *    Place the patient on his or her back.

    *    Tilt the head back and lift the chin up with the finger and thumb
         of one hand on the bony part of the chin, while pressing the
         forehead back with the other hand (Fig. 17). This will open the
         airway and stop the tongue blocking the throat.

     Check whether the patient is breathing

         After opening the airway, quickly check whether the patient is
    breathing (Fig. 18):

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

    *    Feel the chest moving up and down.

    FIGURE 15

    FIGURE 16

    FIGURE 17

    *    Feel the patient's breath on your cheek.

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

         Use all four checks. Remember that the chest may move up and down
    even when the throat is completely blocked and air cannot get to the
    lungs.

    FIGURE 18

         A person may stop breathing because:

    *    Something is stuck in the throat.

    *    The throat is blocked by the tongue, or by blood, spit, vomit,
         food, or false teeth. (If you have tilted the head back, the
         tongue will not block the throat.)

    *    The throat is blocked because the patient has swallowed poison
         which has burnt the throat and made it swell.

    *    The patient has been poisoned.

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

    *    The patient has had a heart attack.

    *    The patient has nearly drowned.

     Clean out the mouth and clear the throat

         If the patient is not breathing after you have tilted the head
    back, something may be blocking the throat.

         Turn the head to one side. With one or two fingers (and
    preferably wearing gloves) scoop deeply round the mouth and throat to
    clear any blockage such as vomit (see Fig. 19). Take out the patient's
    false teeth.

         If the patient starts breathing turn him or her onto one side,
    into the recovery position. Check breathing and pulse frequently.

         Whatever the cause, if the patient does not start breathing you
    must act immediately to help the patient to breathe.

     Give mouth-to-mouth respiration

         You can help the patient to breathe by blowing air from your
    lungs into his or her lungs through the patient's mouth (mouth to
    mouth) or nose (mouth to nose). This is called mouth-to-mouth (or
    mouth-to-nose) respiration.

    FIGURE 19

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

         If there is poison on the patient's lips, or if corrosive
    chemicals have burnt the lips and chin, wipe the chemical off, cover
    the mouth with a cloth to protect yourself from getting poison on your
    lips or hands, and give mouth-to-nose respiration. Breathe into the
    patient's nose (see Fig. 20).

    FIGURE 20

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

    1.   With the patient lying flat on his or her back, clear any
         blockage from the mouth. Kneel beside the patient's head.

    2.   Tilt the head back.

    3.   Pinch the nose with one hand. With the other hand pull the mouth
         open (Fig. 21). Do not press on the neck. For mouth-to-nose
         respiration, close the patient's mouth with your thumb.

    4.   Breathe in deeply. Cover the patient's mouth completely with your
         own mouth and breathe out steadily and smoothly so that all your
         breath goes into the patient's mouth. Breathe out strongly to
         fill the chest (see Fig. 22). Look for the patient's chest
         rising. For mouth-to-nose respiration put your mouth around the
         patient's nose.

    5.   Lift your mouth away so that the patient can breathe out and you
         can take another breath of air. Turn your head, look for the
         chest falling, feel the breathed-out air on your cheek, and
         listen for the sound of the patient breathing out (see Fig. 23).
         For mouth-to-nose respiration you may have to open the patient's
         mouth to let air out.

    FIGURE 21

    FIGURE 22

    FIGURE 23

    6.   Take another breath of air. Once the chest has fallen, blow into
         the patient's mouth (or nose) again. Watch the patient breathe
         out again. Then check that the heart is beating.

         If the chest does not rise with each breath, and you cannot feel
    or hear the patient breathing out, then either the airway is blocked
    or some of your breath is not going into the patient's chest. Check
    that the head is held well back and clear the airway again. Make sure
    there is no air escaping when you breathe into the patient's mouth (or
    nose).

    How to give mouth-to-mouth respiration to a child or a baby

         Open the airway in a child or baby in the same way as for an
    adult, but do not tilt the head too far back or the soft airway may
    kink.

         If you can see something blocking the throat carefully remove it,
    but do not sweep your finger inside a baby's mouth if you cannot see
    anything there. If the throat is swollen because of an infection, you
    might make the swelling worse.

         Do not pinch the nose. Put your lips over both the nose and the
    mouth (Fig. 24). Breathe gently, just enough to move the chest. For a
    very small baby only small puffs are needed. Do not blow hard or you
    may harm the baby's chest. Blow into the chest every 3 seconds.

    FIGURE 24

     Check if the heart is beating

         Feel for the pulse in the neck, in the hollow between the voice
    box and the muscle. Place two fingers on the voice box (Adam's apple)
    and slide your fingers into the groove under the jaw (Fig. 25). Keep
    your fingers there for at least five seconds to feel if there is a
    pulse.

         If you cannot feel a pulse, the heart has stopped. This is called
    cardiac arrest. The patient will be unconscious and will probably have
    large pupils. If the patient has white skin it will probably have a
    blue-grey colour. If the patient has black or brown skin look for a
    blue colour to the nails, lips and the inside of the lower eyelids. If
    the heart stops, breathing will also stop and the patient will need
    both heart massage and mouth-to-mouth respiration.

     If the heart is beating, but the patient is still not breathing,
     carry on with mouth-to-mouth respiration

         Take a deep breath and blow once every 5 seconds, until the
    patient starts to breathe without help. You may have to do this for
    more than one hour.

         If the patient has breathed in an irritant gas, the mouth and
    throat may be full of froth. You cannot remove this froth by wiping,
    so do not waste time trying to remove it. As this froth is air
    bubbles, all you have to do to move air in and out of the lungs is to
    blow the froth into the lungs. So blow as usual.

         When the patient starts to breathe, turn him or her onto one side
    into the recovery position. The patient may vomit when breathing
    starts again but the vomit will not block the throat if the patient is
    lying on one side. Let the vomit come out and clear it out of the
    mouth with your finger.

    FIGURE 25

         Watch carefully in case the patient stops breathing again. If
    breathing stops turn the patient onto his or her back and start mouth-
    to-mouth respiration again.

     If the heart is not beating give heart massage

         If you cannot feel a pulse in the neck, you should try to start
    the heart beating again by giving heart massage (see below).

         Heart massage (or chest compression) means pressing down on the
    heart to push blood out of it and round the body. This may start the
    heart beating again. It will only be effective if the patient is lying
    on a hard surface.

         If there is no heartbeat, the patient will have stopped
    breathing. Always start mouth-to-mouth respiration before heart
    massage.

         Do not give heart massage if the heart is beating, even faintly.
    Stop as soon as you feel a pulse in the neck, but carry on with mouth-
    to-mouth respiration if the patient is still not breathing.

    How to give heart massage to an adult

    1.   Check that there is no heartbeat.

    2.   Lay the patient on his or her back on a firm surface. Kneel
         beside the patient's chest.

    3.   Find the right place to put your hands. Find the lower edge of
         the ribs. Follow the edge of the ribs to where they meet the
         breastbone. Place your middle finger on the base of the
         breastbone, and the index finger next to it (Fig. 26), then place
         the heel of your other hand next to these two fingers, on the
         breastbone in the midline of the chest (Fig. 27).

    4.   Now cover this hand with the heel of your other hand, lock your
         fingers together, keeping them off the chest (Fig. 28). Put your
         shoulders above the patient's chest and keep your arms straight.

    5.   Press down on the lower half of the breastbone 4-5 centimetres,
         keeping your arms straight. Then stop pushing. While counting
         "one and two and three and...", press 15 times, in time with the
         numbers (80 presses a minute). Presses should be regular and
         smooth, not jerky and jabbing.

    6.   Remember that both mouth-to-mouth respiration and heart massage
         are needed. After 15 presses tilt the head back again so that air
         can get down the throat, put your mouth round the patient's mouth
         and give two breaths.

    7.   Continue with 15 presses followed by two full breaths. After one
         minute check the heartbeat, then after 3 minutes or every 12
         cycles check the heartbeat again. As soon as the heartbeat
         returns stop heart massage immediately. You may see the patient's
         colour become more normal and the pupils return to normal size.

    8.   Continue mouth-to-mouth respiration at 12 breaths a minute, until
         the patient breathes without help. It may be some time before
         breathing starts again, even after the heart has started beating.
         When breathing starts again put the patient onto his or her side
         in the recovery position.

         If another person is with you, get him or her to do the breathing
    while you do the heart massage (Fig. 29). The other person should
    kneel by the patient's head while you kneel by the middle of the
    chest. The other person should give two breaths and check the
    heartbeat. If there is no heartbeat you should give five presses on
    the chest. Continue with the other person giving one breath and you
    giving five presses on the chest. Check the heartbeat after one minute
    then after every three minutes or 12 cycles.

    FIGURE 26

    FIGURE 27

    FIGURE 28

    How to give heart massage to a child or a baby

         The best place to feel the pulse in a small child or a baby is on
    the inside of the upper arm. With your thumb on the outside of the arm
    press your first and middle fingers into the groove below the muscle.

    FIGURE 29

    FIGURE 30

         When giving heart massage to a child or baby, press with less
    force but slightly faster than you would for an adult.

         For a child use one hand only and press lightly on the chest
    (Fig. 30). Press down 2.5-3.5 cm.

    FIGURE 31

         For a small child or a baby press on the chest with just two
    fingers. Press down 1.5-2.5 cm (Fig. 31).

         Keep your hand or fingers below the level of the nipples.

         Press down at a rate of 100 presses a minute giving 15
    compressions followed by two breaths.

     If the patient is breathing but is unconscious, turn him or her onto
     one side, into the recovery position

         An unconscious patient should be turned to lie on one side to
    stop the tongue blocking the throat and to allow fluid to come out of
    the mouth. This is called the recovery position.

         Before you turn the patient over:

    *    If breathing is noisy, sweep your finger round the mouth to
         remove anything blocking the airway, and take out the patient's
         false teeth if they are loose.

    *    Empty the patient's pockets of anything that would be
         uncomfortable to lie on.

    *    Take off the patient's spectacles in case they injure the eyes.

    *    Look for injury to the head or neck, and feel with your fingers
         to see whether the back of the neck or the backbone is bent or
         swollen.

    *    Get help if the patient has an injury to the head or neck. Three
         people should roll the patient keeping the head, neck and body in
         a straight line. Do not let the patient sit up when he or she
         wakes up.

         The patient should be turned onto one side with:

    -    the head, neck and body in a straight line,

    -    the head placed so that the tongue will not block the throat, and
         vomit or saliva can come out of the mouth;

    -    the arms and legs placed so that the patient stays in the same
         position.

    One way of turning a patient

    1.   Kneel beside the patient, turn the patient's face towards you,
         and tilt it back, with the jaw jutting forward so the airway
         stays open. Place the arm nearest you above the head. Place the
         patient's other arm across the chest. Raise the patient's far leg
         under the knee, to bend it (Fig. 32).

    2.   Protect the patient's face with one hand. With your other hand,
         grasp the patient's clothes at the hip and pull the patient
         towards you until he or she is resting on one side, against your
         knees (Fig. 33). The patient's head should be resting on the
         lower arm. Check that the airway is still open.

    3.   Take the patient's upper arm and place the hand under the face
         (Fig. 34). This will help to keep the head tilted back and the
         airway open. Now position the upper leg so that the bent knee
         rests on the ground and supports the patient's body.

    FIGURE 32

    FIGURE 33

    FIGURE 34

         If the patient is too heavy for you, get help. Someone else can
    support the patient's head while you do the turning, or can push the
    patient towards you as you pull.

     Give first aid for fits (convulsions) if necessary

    1.   If the patient has a fit, make him or her lie down in a safe
         place. Make sure there are no hard or sharp objects nearby and
         protect the patient from injury.

    2.   Turn the patient to lie on one side so that the tongue comes to
         the front of the mouth and froth can come out of the mouth
         easily.

    3.   Put a folded cloth under the patient's head, or hold the head so
         that it does not bang on hard things.

    4.   Do not try to stop the shaking movements.

    5.   Loosen any tight clothing.

    6.   Do not put anything in the patient's mouth or try to open it.

    7.   After the fit, let the patient rest in the recovery position.

     Wash any chemical out of the eyes

         Wash chemicals out of the eyes at once, with plenty of cool,
    clean water, before you wash the skin. Even a delay of a few seconds
    can make the injury worse.

    1.   Immediately gently brush or wipe any liquid or powdered chemical
         off the face. Let the patient sit or lie down with the head
         tilted back and turned towards the worst affected side. Gently
         open the eyelids of the affected eye or eyes and run cold water
         over from a tap or pour water from a jug. Make sure the water
         drains away from the face and does not go into the unaffected
         eye. Wash out the eye or eyes in this way for 15-20 minutes,
         timed with a watch if possible.

         The patient may be in great pain and may want to keep his or her
         eyes closed, but you must wash the chemical out of the eyes in
         order to prevent permanent damage. Gently pull the eyelids wide
         open, and keep them apart (Fig. 35).

    2.   While you are rinsing the eyes check that the inside of the
         eyelids has been well washed. Check that there are no solid
         pieces of chemical in the folds of skin round the eyes, or on the
         eyelashes or eyebrows. If you are not sure whether all the
         chemical has been removed, wash out the eyes for 10 more minutes.

    3.   Do not let the patient rub the eyes.

    FIGURE 35

    4.   The patient's eyes should be examined by a doctor even if there
         is no pain, because damage may be delayed.

    5.   If light hurts the patient's eyes, cover them with a sterile eye
         pad, a dry gauze pad, or a pad of clean cloth. Bandage the pad in
         place securely, but not too tightly. This will protect the eyes
         and help them to heal.

    6.   If the patient is in pain, give aspirin or paracetamol every four
         hours.

     Medical treatment of chemical contamination of the eye

    *    If the pain is severe the patient may need an intramuscular
         injection of morphine.

    *    Look for burns. Put drops of fluorescein in the eye. Burns will
         stain yellow.

    *    Prevent infection. If there are yellow stains with fluorescein,
         put chloramphenicol 1% eye ointment in the eye. Put more ointment
         into the eye every two hours. Continue until the eye is no longer
         red and the sclera is white, and then for another 24 hours.

     Remove contaminated clothing and wash any chemical off the skin
     and hair

    1.   Take the patient immediately to the nearest shower or source of
         clean water. If there is no water nearby dab or gently wipe the
         skin and hair with cloths or paper. Do not rub or scrub the skin.

    2.   Immediately wash the affected part of the body under cold or
         lukewarm running water, using soap if you have some. If there is
         no running water use buckets of water. Do it quickly and use a
         lot of water (Fig. 36). Wear gloves and an apron if needed, to
         protect yourself from splashes of chemical. Some chemicals give
         off vapour: be careful not to breathe it in.

    FIGURE 36

    3.   At the same time quickly remove any of the patient's clothes
         contaminated with chemical or vomit, as well as shoes and wrist
         watch if necessary. Speed is important - cut the clothes off if
         the chemicals are very poisonous or corrosive.

    4.   If large areas of the body are contaminated with chemical, wash
         the patient under a shower or a hose. Remember to clean the hair
         and under the fingernails, in the groin and behind the ears, if
         necessary.

    5.   Continue to pour water over the patient for 10 minutes, or longer
         if you can still see chemicals on the skin. If the skin feels
         sticky or soapy, wash it until the feeling disappears. This may
         take an hour or more.

    6.   Make sure the water drains away freely and safely as it will have
         chemical in it.

    7.   Dry the skin gently with a clean, soft towel. If clothing stays
         stuck to the skin even after water has been poured over it, do
         not remove it.

    8.   Remember that many chemicals can pass through the skin very
         quickly. Look for signs of poisoning (see Chapter 7).

    9.   Put contaminated clothes in a separate sealed container and do
         not use them again until they have been washed. Throw away shoes
         contaminated with chemical. If you have used cloths or paper to
         wipe the skin, put these in a container and burn them.

         If the patient has burns, and there is no doctor:

    1.   Do not break open blisters or remove skin. Where the skin is red
         and painful or raw, cover it and the skin round it with a
         sterile, dry dressing and bandage. Keep the bandage loose. This
         will protect the burn and speed up healing.

    2.   Dress the patient in clean clothes or cover with a sheet.

    3.   Replace fluid loss: if a large area is burnt give the patient
         half a cup of water every 10 minutes until the patient reaches
         hospital.

    4.   Treat pain: give aspirin every four hours until the pain is
         better.

    5.   Get the patient to a doctor or hospital as soon as possible.

     Give first aid for poisonous bites and stings

         This section gives general advice first, followed by specific
    advice for dealing with:

    -    snake bites,

    -    stings or bites by bees, wasps, hornets, fire ants, scorpions,
         spiders or ticks,

    -    stings by jellyfish,

    -    stings by venomous fish.

    General advice

    1.   People often panic if they have been bitten or stung. You should
         tell the patient that many snakes, spiders, insects and sea
         creatures are harmless and that even the bites and stings of
         dangerous animals often do not cause poisoning.

    2.   Keep the patient calm and still. Moving the bitten or stung limb
         speeds up the spread of venom to the rest of the body. Fear and
         excitement also make the patient worse. The patient should be
         told not to use the limb and to keep it still and below the level
         of the heart. The limb may swell after a while, so take off the
         patient's rings, watch, bracelets, anklets and shoes as soon as
         possible. A splint and a sling may help to keep the limb still.

    3.   The following measures should not be used. They may cause
         infection, or make the effects of the venom worse.

    -    Do not cut into the wound or cut it out.

    -    Do not suck venom out of the wound.

    -    Do not use a tourniquet or tight bandage.

    -    Do not put chemicals or medicines on the wound or inject them
         into the wound (potassium permanganate crystals for example).

    -    Do not put ice packs on the wound.

    -    Do not use proprietary snake bite kits.

         Time spent giving traditional remedies and herbal medicines would
    be better spent getting the patient quickly to hospital. Such
    "remedies" are often of no use and may be dangerous or even life-
    threatening.

    4.   The patient should lie on one side in the recovery position so
         that the airway is clear, in case or vomiting or fainting.

    5.   Do not give the patient anything by mouth - no food, alcohol,
         medicines or drinks. However, if it is likely to be a long time
         before the patient gets medical care, give the patient water to
         drink to stop dehydration.

    6.   Try to identify the animal, but do not try to catch it or keep it
         if this will put you, the patient or others at risk. If the
         animal is dead take it to hospital with the patient, but handle
         it very carefully, because even dead animals can sometimes inject
         venom.

    7.   As soon as possible, take the patient to a hospital, medical
         dispensary, or clinic where medical care can be given. The
         patient should not walk but should keep as still as possible. If
         there is no ambulance or car, carry the patient on a stretcher or
         trestle, or on the crossbar of a bicycle.

    8.   Antivenom should only be given in a hospital or medical centre
         where resuscitation can be given, because the patient may have an
         allergic reaction. If available, antivenom should be used if
         there is evidence of severe poisoning. It should not be used when
         there are no signs of poisoning.

    Using traditional medicines to treat poisonous bites and stings

         No home remedy or traditional cure for poisonous bites or stings
    (from snakes, scorpions, spiders or other poisonous animals) has any
    effect beyond that of the healing power of belief.

         Anyone who says that a traditional medicine kept a snake's venom
    from harming him or her was probably bitten by a snake that did not
    inject poison.

         Some traditional medicines may do some good. If a person believes
    in them he or she will feel less afraid, the pulse will slow down, the
    person will move and tremble less, and as a result, the poison will
    spread through the body more slowly. So there is less danger.

         But the benefit of these traditional medicines is very limited.
    Even when they are given traditional medicines, many people still
    become very ill or die from snake bite. Using traditional medicine may
    delay more effective treatment. It is better to use hospital
    treatment.

         Do not use traditional remedies that contain animal or human
    waste or that involve eating animals not usually used as food. They do
    not help at all. They are often dangerous and can cause serious
    infections.

     Medical treatment of poisonous bites and stings

    1.   Antivenom should only be given in a hospital or medical centre
         where resuscitation can be given, because the patient may develop
         an allergic reaction. If available, antivenom should be used if
         there are signs of severe systemic envenoming. It should not be
         used when there are no signs of systemic envenoming.

    2.   To decide whether venom has been injected, and how serious the
         poisoning is, look for these signs:

    -    swelling and local tissue injury at the site of the bite;

    -    blood that does not clot, causing bleeding from gums, nose,
         wounds and injection sites;

    -    shock caused by circulatory failure;

    -    neurotoxic paralysis (ptosis, ophthalmoplegia, dysarthria,
         peripheral muscle weakness, respiratory distress);

    -    generalized muscle pain and local tissue damage;

    -    kidney failure, red or black urine;

    -    tender swollen lymph nodes near the bite site.

         To test clotting time of whole blood: Place 2-3 ml of whole
         venous blood in a clean, dry, glass test-tube and leave
         undisturbed for 20 minutes at room temperature. Normal blood
         should have clotted by this time. Tip the tube to see if the
         blood is still liquid.

    3.   If the wound becomes infected, treat as for any other local
         infection. Use antibiotics if needed.

    4.   If there is local tissue injury, do not cover the wound but leave
         it open.

    What to do if someone is bitten by a snake

         Venomous snakes often bite without injecting venom. In other
    words, the bites are "dry". Many people survive being bitten by
    venomous snakes, even the most dangerous species, without being
    poisoned.

    1.   Keep the patient lying on one side, in the recovery position, to
         lessen the risk of vomit blocking the throat. Check breathing and
         heartbeat.

    2.   Do not use any of the harmful measures listed on page 62.

    3.   Clean the wound gently so that there is no venom left on the
         skin. Use clean water and soap, or wipe the wound gently with a
         clean cloth.

    4.   Give first aid as follows for the bites of elapid snakes that do
         not cause local tissue injury or swelling (coral snakes, kraits,
         mambas, some cobras, but not African and some Asian cobras or
         vipers). Apply a broad, firm bandage over the bite site, then
         bandage as much of the bitten limb as possible over the patient's
         clothing. The bandage should be firm but not so tight that it
         acts as a tourniquet. You should still be able to feel the pulse
         in the lower part of the limb. Severe pain in the bandaged limb
         may mean that the bandage is too tight. It is important to use a
         splint so that the patient cannot move the limb. Once the patient
         is in a hospital or medical centre the bandage should be taken
         off. It should not be taken off before then because, once the
         bandage is removed, venom may spread rapidly through the body.

    5.   Some snake bites cause severe pain, although most do not.
         Paracetamol can be given for the pain, but aspirin should not be
         given, as it may make the patient bleed.

    6.   If the snake has been killed, take it to the hospital with the
         patient so that it can be identified. Handle the dead snake very
         carefully, because it can still inject venom, even after the head
         has been cut off.

     Medical treatment of snake bites

         Snake bites may cause tetanus (lockjaw). The patient should be
    given an injection of tetanus antitoxin if possible.

         Do not give unnecessary injections because of the risk of
    bleeding if the blood does not clot.

         A patient with respiratory paralysis may need artificial
    ventilation for hours, days or even weeks.

         If the patient has kidney failure, make sure the patient is given
    the right amount of fluids and carefully monitor fluid balance.
    Dialysis may be needed, preferably haemodialysis or, if this is not
    possible, peritoneal dialysis.

         Shock and low blood pressure may be caused by fluid moving out of
    the blood vessels that have been damaged by the snake venom. This
    happens especially with viper bites. Intravenous fluids may be life-
    saving.

         Usually there is no need for surgery, and unnecessary surgery
    could cause complications or permanent damage to the bitten limb.

    What to do if someone is stung or bitten by bees, wasps, hornets, fire
    ants, scorpions, spiders or ticks

    1.   Scorpion stings and insect stings or bites cause local pain and
         swelling. Spider bites may cause deep ulcers or blisters. The
         greater the number of stings or bites, the more severe is the
         effect. Some spiders (for example, the brown recluse or violin
         spider, widow spiders) and at least one scorpion  (Hemiscorpion
         lepturus found in the Islamic Republic of Iran and Iraq) may
         cause local tissue injury and ulcers at the bite site, which may
         spread over the bitten limb.

    2.   Some people are sensitive to insect venom. They may get a local
         or generalized rash, itching, and red skin. In serious cases the
         patient will feel sick and as if there is a tight band around the
         chest, the face may swell, the patient may not be able to breathe
         properly, may wheeze and gasp for air, and may become
         unconscious. If breathing becomes difficult, lie the patient on
         his or her side in the recovery position. If breathing and
         heartbeat stop, give mouth-to-mouth respiration and heart
         massage. Patients should be given an intramuscular injection of
         epinephrine (adrenaline).

    3.   Bees leave their sting behind and can only sting once, but wasps
         and hornets do not leave their sting behind and can sting many
         times. If the sting has been left, remove it, but be careful not
         to squeeze the venom sac on the end. Either use tweezers to grasp
         the sting as near to the skin as possible and remove it (Fig.
         37), or scrape the sting off the skin. Take off the patient's
         rings, bracelets and anklets in case the limb swells.

    4.   A tick can sometimes be washed off with alcohol, or removed with
         the heat from a cigarette. If not, lever the tick off the skin
         using fine tweezers or forceps, but try not to squeeze its body.

    5.   A cold compress, using cold water but not ice, may help lessen
         the swelling, itching and pain.

    6.   Paracetamol may be given for pain, but aspirin should not be
         given.

     Medical treatment for scorpion stings and insect stings or bites

    1.   Antivenom is available in South America for some spiders: brown
         recluse spiders  (Latrodectus spp.), widow spiders ( Loxosceles
          spp.),  Phoneutria spp., and some scorpions (for example
         species of  Centruroides, Tityus, Buthotus, and  Leiurus).

    2.   Antivenom may be useful in treating local tissue injury by
          Loxosceles spp., and  Hemiscorpion lepturus, even when there
         are no signs of general poisoning. The wound should be treated
         open as for a burn.

    3.   Pain can be treated with local analgesia (e.g. lidocaine, digital
         nerve block, peripheral nerve block), or with systemic
         analgesics. Morphine should not be used to treat pain because of
         the risk of respiratory depression. Antivenom may be useful in
         treating pain caused by bites from  Latrodectus spp.

    FIGURE 37

    What to do if someone is stung by jellyfish

    1.   Jellyfish tentacles cling to the skin and can be hard to get
         off. Keep the patient calm and still to avoid the tentacles
         causing more stings.

    2.   There is no sure way to stop the tentacles stinging if they are
         moved, so it is best not to touch them until the first effect of
         the sting has worn off.

    3.   To stop the cells from stinging, immediately flood the area with
         vinegar (5% acetic acid), unless the jellyfish is known to be a
         bluebottle (Portuguese man-of-war;  Physalia species). If you do
         not have vinegar, use seawater. Do not use alcohol, methylated
         spirits, petrol or fresh water. Cold packs or crushed ice wrapped
         in a cloth may help to relieve pain caused by stings from
          Physalia and other jellyfish. Stings from box jellyfish and
         similar species  (Chironex) often have very serious effects.
         Patients may need mouth-to-mouth respiration and heart massage.

    4.   Gently scrape off the tentacles with a knife.

     Medical treatment of jellyfish stings

         Tetanus antitoxin should be given by intramuscular injection if
    available.

    What to do if someone is stung by a venomous fish

         Many venomous fishes, such as stonefish, lionfish, scorpion fish,
    and weever fish, have spines that puncture the skin. Venom is injected
    into the wound through the spines. The stingray may cause cuts that
    bleed a lot.

    1.   If the patient is stung while in the water, rescue from the
         water.

    2.   At once soak the wounded part of the body in a bowl or bath of
         water as hot as the patient can safely bear (not more than 45°C),
         until the pain goes, but for no longer than 30 minutes. The venom
         may be destroyed by heat and pain may disappear.

    3.   Clean the wound and remove any broken spines.

     Medical treatment of fish stings

         Tetanus antitoxin should be given by intramuscular injection if
    available,.

         Pain can be treated with local anaesthetics or pain killers such
    as paracetamol. It may be dangerous to give morphine because it may
    depress respiration.

    CHAPTER 6

    Getting medical help

    Objectives

         After studying this chapter, you should be able to:

    1.   Decide on the best action to take after you have given first aid
         to a poisoned patient.

    2.   Decide whether a poisoned patient should see a doctor before
         going to hospital.

    3.   Decide when it would be useful to obtain help by telephone from a
         poisons centre or hospital.

         Someone who has been poisoned should always be seen by a doctor
    as quickly as possible. After you have given first aid the best course
    of action is to get the patient to hospital without delay. However, if
    it is likely to take many hours to get to hospital, it may be better
    to try to get medical help more quickly somewhere else before you make
    the journey to hospital.

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

         Take the patient to hospital without delay as soon as you have
    given first aid.

         Do not move an unconscious patient until he or she can breathe
    without help. Keep an unconscious or drowsy patient in the recovery
    position.

    If you are a long way from a hospital

         If there is a health centre or doctor nearby, send the patient
    there. Treatment given by a doctor outside hospital may be life-saving
    if the journey to hospital takes a long time. If it is difficult to
    move the patient, send someone to ask the doctor to come to the
    patient.

         If there is no doctor nearby, telephone a poisons centre. The
    more you are able to tell the doctor in the poisons centre about how
    the poisoning happened and about the patient's signs and symptoms, the
    more help the doctor will be able to give. Before you go to the
    telephone examine the patient quickly but carefully (see Chapter 7),
    and look for any medicines, pesticides or other chemical products,
    plants or animals that might have caused the poisoning (see
    Chapter 8).

         If you think you know what might have caused the poisoning, take
    it to the telephone if you can, so that you will be able to describe
    it accurately and read the label on the container. (If poisoning has
    been caused by an animal, try to catch it and keep it, if you can do
    this without putting yourself or others at risk. Handle dead animals
    carefully; they may still be dangerous.)

         The doctor will be able to tell you if there is anything more you
    can do to help the patient before you take him or her to hospital. In
    some cases the doctor may be able to tell you that the chemical, plant
    or animal involved is not poisonous, and that the patient does not
    need to go to hospital.

         If you cannot telephone a poisons centre, telephone a hospital.

    If you cannot get medical help quickly

         Use this book to help you decide what to do next. Make a more
    thorough examination of the patient (see Chapter 7) and find out more
    about what happened (see Chapter 8). If you know what substance the
    patient was exposed to, look in Part 2 for more specific information
    about what to do.

         Chapter 9 describes how to look after the patient until he or she
    can get to a hospital. In some cases you may be able to prevent
    serious poisoning by making the patient vomit, or by giving activated
    charcoal, a laxative, or an antidote.

    Taking the patient to hospital

         Some poisons centres or hospitals may be able to arrange
    transport to hospital. If there is no ambulance ask someone with a
    car, lorry, truck, or cart to take the patient to hospital.

         If you have to carry the patient on a stretcher, make sure he or
    she is as comfortable as possible and cannot fall off. If the sun is
    very strong, fix a sheet above the stretcher to provide shade and let
    fresh air pass underneath.

         Someone should look after the patient during the journey to
    hospital. If you cannot go yourself, send someone who knows how to
    look after the patient.

         Send with the patient any chemical products, medicines,
    pesticides, plants or animals that might have caused the poisoning,
    and the notes you have made about the patient's condition and about
    what happened.

    What to do after you have read this chapter

         Make sure that you know the quickest way to the nearest hospital,
    and that you can explain it to someone else. Estimate how long it
    should take to get there.

         Make a list of telephone numbers and addresses of places such as
    the nearest hospital and poisons centre, where you might be able to
    get help if there is a case of poisoning. Write them in the back of
    this book.

    CHAPTER 7

    Examining the patient

    Objectives

    After studying this chapter, you should be able to:

    1.   Examine a patient for symptoms and signs of poisoning.

    2.   Describe the patient's condition to a doctor over the telephone
         or in writing.

    3.   Decide whether a patient is seriously ill.

    4.   Recognize common poisoning syndromes.

         If you are more than two hours journey from a hospital and there
    is no doctor or health centre nearby, your next step, after giving
    first aid, should be to examine the patient.

         It is important to examine the patient so that you can decide how
    to help the patient until he or she gets to hospital and so that you
    can give a clear account of the patient's condition if you contact a
    poisons centre or hospital by telephone or radio.

         This chapter describes how someone without medical training can
    examine a patient for the effects of poisoning. Reading it can help
    you learn what to do and what to look for, but it is best if a trained
    health care worker shows you how to carry out an examination. Practise
    counting the pulse and reading a thermometer until you are confident
    you can do both accurately.

         Poisons may cause many changes inside the body that can only be
    measured using medical equipment. Such changes are not discussed here.

    Symptoms and signs

         The effects of poisoning are known as symptoms and signs.

          Symptoms are effects that the person feels or senses, for
    example, pain, nausea, or thirst. To find out what symptoms the
    patient has, ask the patient these questions: "How do you feel?" "What
    do you feel?"

          Signs are effects that you can see, feel, hear or measure, for
    example, vomiting, fever, a fast pulse, noisy breathing and
    unconsciousness.

         Most poisons cause several symptoms and signs because they affect
    more than one part of the body.

         For each of the signs described in this chapter there is a box
    with a list of some of the common chemicals that cause it. To keep the
    lists short, some of the names are those of groups of chemicals (for
    example: atropine-like medicines) rather than the names of individual
    chemicals. The names used here are also used in Part 2, so you can
    check in Part 2 to see which individual chemicals are included in a
    group. The lists do not include every chemical that causes a
    particular effect, so it is possible that a person with one of the
    signs or symptoms could have been poisoned by a chemical that is not
    listed.

         Do not expect a patient to have all the signs and symptoms listed
    for a poison. Often it depends how badly poisoned the patient is. For
    example, ethanol (alcohol) can cause unconsciousness, but someone
    poisoned with ethanol may not be unconscious. He or she may simply be
    drunk and be unsteady and talkative.

         Remember, the patient may have taken more than one poison.

    What the examination cannot tell you

         If you have no clue about what the poison might be, the
    examination is unlikely to give you information that will point to one
    particular poison, because many poisons cause similar symptoms and
    signs. However if you already think you know what the poison might be,
    and what happened, you can check whether you might be right by
    comparing the patient's symptoms and signs with those listed for
    specific poisons in Part 2 of this book.

         You may not be able to tell, just by examining the patient, if
    the patient is poisoned or if he or she is suffering from another
    illness or injury, because:

         -    many poisons cause symptoms and signs that are similar to
              the symptoms and signs of diseases or injuries;

         -    sometimes a patient may be poisoned and suffering from the
              effects of another illness or injury.

         For this reason, when you examine the patient it is important to
    ask if he or she has now, or used to have, any sickness or disease,
    and to look for cuts and bruises and other signs of injury.

    When the patient does not have any symptoms or signs

         A patient who seems well may not have been poisoned. Remember,
    exposure to poison will not result in poisoning if a poisonous dose
    does not get into the body (see Chapter 1).

         Someone who has been poisoned may seem well because it is too
    soon for the poison to take effect. Some poisons may not cause any
    effects for many hours.  For example, a person who takes a poisonous 

    dose of paracetamol may be well for up to 48 hours afterwards. So it
    is important to ask what happened and how long ago.

    How to examine a patient and find out the symptoms and signs

         Carry out the examination in the order given in this chapter. As
    you examine the patient, write down all your findings with a note of
    the date and time. At regular intervals while you are looking after
    the patient, check how he or she is and write down any changes in
    signs and symptoms and the time when you notice them. Give your report
    to the doctor when you hand over the patient.

     Talk to the patient

         If the patient is conscious and can answer questions talk to the
    patient.

    Ask what happened

    Try to find out:

    -    what the poison is;

    -    whether the poison was swallowed, breathed in, injected, or in
         contact with the skin or the eye, or whether the patient was
         bitten or stung;

    -    how long ago the patient was poisoned. Did it happen a few
         minutes ago, or was it several hours or even days ago?

    -    how long the patient was exposed; for example, if the patient
         breathed in poison, for how long was it breathed in, or if the
         poison was spilt on the skin or clothes, how long was it before
         the patient washed or took off the clothes.

    -    if the patient feels sick, how long he or she has been feeling
         like this.

         Ask the patient if he or she has had a fall or injury. Ask if the
    patient knows anybody else in the family, in the village or at work
    who has had the same sickness.

         Sometimes the patient can tell you what happened. For example,
    people usually know if they have been bitten or stung by an animal and
    they will often tell you when they have taken an overdose of medicine.
    They may tell you that a chemical product or a pesticide they were
    using has made them ill.

         In some circumstances people do not know what happened. For
    example, people who have been poisoned by carbon monoxide gas may not
    know what has made them feel sick, because carbon monoxide has no
    smell and is invisible. People who are sick after using a chemical 

    product or pesticide may not realize that their sickness is due to
    poisoning.

         Even when people know what happened they may not be able to tell
    you much about the poison. People often use chemicals or take
    medicines without knowing what they contain. Even if they give you the
    bottle, there may not be any information on the label about the
    contents. People who have been bitten by a snake may not know what
    kind of snake it was, and may not be able to give a good enough
    description for anyone else to identify it. Sometimes people who think
    they know about wild plants and mushrooms make mistakes in
    identification.

         Sometimes people do not know how much poison they have taken.
    People who take poison because they want to harm themselves may not
    count how many tablets they take, or measure how much liquid they
    drink.

         Some people may not want to tell you the truth and may lie about
    what they have taken. A child may be too frightened to tell the truth.

         The patient may be dazed, in shock or confused and not able to
    answer properly. People who are unconscious cannot tell you anything,
    and children may be too young to talk or to understand.

         Later, you may be able to find out more about what happened by
    asking other people and looking for evidence (see Chapter 8), but
    examine the patient first.

    Ask the patient about symptoms

         Ask if the patient feels pain. Ask where the pain is. Ask whether
    the patient feels cold, hot, thirsty, weak, sick, dizzy, or faint. Ask
    how long the patient has felt like this. Ask whether the patient has
    been unconscious or asleep.

    A patient who is confused:

    -    may be agitated and frightened;

    -    may not be able to remember what day it is, what time of year it
         is, or where he or she is;

    -    may not be able to think properly or to remember things;

    -    may have hallucinations, which means seeing things that are not
         real, or feeling things like ants crawling on the skin.

     Some chemicals that may cause confusion or hallucinations

          Medicines: aminophylline, amitriptyline and other tricyclic
         antidepressants, antihistamines, atropine-like medicines,
         dapsone, ephedrine, insulin, propranolol and other ß-blockers,
         pseudoephedrine.

          Drugs of abuse: amfetamines, cannabis, cocaine.

          Pesticides: chlorophenoxyacetate weedkillers, organophosphorus
         and carbamate pesticides.

          Other chemicals: camphor, camphorated oil, ethanol, turpentine
         and other volatile oils.

         The patient may not be able to hear you. A person poisoned by
    aspirin or quinine may hear a ringing sound in the ears, or may become
    deaf.

     Look for signs of poisoning

         This section describes how to examine a patient for some common
    signs of poisoning:

    -    unconsciousness,

    -    changes in the skin, breathing, pulse, temperature, eyes, or
         behaviour,

    -    vomiting and diarrhoea,

    -    dehydration,

    -    not passing urine,

    -    fits,

    -    signs of liver damage.

    Watch the way the patient behaves

         Some poisons make the patient restless, overactive, or
    aggressive. This can also happen when people suddenly stop abusing
    drugs or drinking alcohol after doing so for a long time.

     Some chemicals that may cause overactivity, restlessness or
     irritability

          Medicines: aminophylline, atropine-like medicines,
    chlorpromazine and other phenothiazines, ephedrine.

          Drugs of abuse: amfetamines, cocaine.

         Strange behaviour may be a sign that the patient abuses drugs or
    other substances, or it may be a sign of mental illness.

    The unconscious patient

         A person who is losing consciousness may seem very drowsy, may
    only be able to say yes or no if you ask questions, or may only be
    able to obey commands such as "open your eyes" or "lift up your arm".
    The patient may soon become unconscious.

         Unconsciousness is a sign of dangerous illness. Put an
    unconscious patient in the recovery position so that the tongue does
    not block the airway.

         Try to find out whether the patient became unconscious suddenly
    or gradually became drowsy and fell asleep. Most poisons cause gradual
    unconsciousness if they have been swallowed.

     Some chemicals that may cause unconsciousness

          Medicines: amitriptyline and other tricyclic antidepressants,
         antihistamines, atropine-like medicines, barbiturates,
         carbamazepine, chloroquine, chlorpromazine and other
         phenothiazines, chlorpropamide-like medicines, diazepam and other
         benzodiazepines, insulin, iron-containing medicines, meprobamate,
         quinidine, quinine, sodium valproate.

          Other chemicals: benzene, carbon monoxide, carbon
         tetrachloride, cyanide, ethanol, ethylene glycol, methanol,
         toluene, trichloroethane, trichloroethylene, xylene.

         Many other medicines and chemicals taken in large amounts.

         Other common causes of unconsciousness are head injury, fainting,
    heavy bleeding, heart attack, stroke, lack of air, epilepsy, fits, and
    diabetes.

         Unconsciousness is probably caused by a head injury if the
    patient also has any of these signs:

         -    bleeding from the ears or nose,

         -    bruises or cuts on the body or head,

         -    pupils that are different sizes.

    Look at the patient

         Does the patient look ill or weak? Look at the patient's clothes
    to see if they are damp or stained with chemicals, urine or vomit.
    Look at the vomit to see whether there is blood, or pieces of tablets,
    plants, or food in it.

    Look at the skin

         Cuts, scratches, bruises, or bleeding may mean the patient is ill
    because of an injury.

         Bruises may be caused by a fall. The patient may have been dizzy,
    unsteady, or very drowsy because of alcohol or drugs.

         Cuts on the insides of the wrists or on the neck may have been
    made by the patient trying to kill himself or herself, and scar lines
    could mean that the patient tried to do this in the past.

         Marks on the arms near the inside of the elbow, or on the ankles
    or knees, with swollen veins, ulcers and abscesses may have been
    caused by injecting drugs. The patient may be dependent on drugs.

         Burns and stains may have been caused by corrosive or irritant
    liquids. Someone who has been working with a chemical may have burns
    on the legs, arms, chest, back, or feet. Someone who has swallowed a
    corrosive substance may have burns and stains on the chin and lips,
    and on the chest if liquid spilt out of a bottle.

         Blisters or red patches on the sides of fingers, ankles, knees,
    shoulders, or other parts of the body show that the patient has been
    lying unconscious in the same position for several hours.

         Scaly rashes may be caused by working with irritant chemicals,
    such as pesticides, or handling irritant plants. Rashes are also
    caused by some diseases and parasites.

         A hot pink skin may be caused by some medicines. If the patient
    has a black or brown skin, feel the skin and look at the hands and
    inside the lips.

         A blue colour to the skin and inside the eyelids and lips means
    that there is not enough oxygen in the blood. Usually this means that
    the patient cannot breathe properly, but some chemicals make the
    patient look blue even though breathing is good. If the patient has a
    brown or black skin it may be difficult to see a blue colour to the
    skin, but the lips, nails and inside of the lower eyelids will look
    blue and the skin will lose its shine. Blue-coloured skin is a sign of
    dangerous illness.

         A yellow skin may be caused by jaundice or by chemicals that
    stain the skin. Jaundice is caused by liver damage. The liver damage
    may be due to poisoning or infection, or damage to the blood. The
    whites of the eyes will also be yellow. It can take up to 48 hours
    after poisoning before the skin turns yellow.

         Some yellow or orange substances turn the skin yellow or orange.
    The medicine called rifampicin gives an orange-red colour to the skin
    (the stain washes off), urine, stools, tears, and whites of the eyes.

     Some chemicals that may make the skin change colour

          Pink, hot skin: atropine-like medicines, amfetamines, and borax.

          Yellow skin caused by jaundice: carbon tetrachloride, iron
         containing medicines, paracetamol, pentachlorophenol,
         trichloroethylene, and some poisonous mushrooms.

          Yellow or orange stain: dinitrophenol, dinoseb, DNOC, rifampicin
         (the stain washes off).

          Blue skin: dapsone, naphthalene, paradichlorobenzene, phenol,
         sodium chlorate, sodium nitrite.

    Feel the skin

         Poisons may cause sweating. Other causes of sweating are
    infection, shock, heart attack, and low blood sugar in diabetic
    patients.

         Some substances cause hot dry skin. A hot dry skin may also be
    caused by being in a very hot place, or by sickness that causes fever.

     Look inside the mouth

    *    Burns and stains inside the mouth and throat show the patient has
         swallowed a corrosive or coloured substance.

    *    Pieces of tablets in the mouth show the patient has swallowed
         tablets.

    *    A coloured tongue may be caused by coloured tablets, berries or
         liquids.

    *    Pieces of leaves or berries in the mouth show the patient has
         eaten a plant that may be poisonous.

    Smell the breath

         Many substances make the breath smell, even if only a small
    amount is swallowed. People may smell of alcohol but not be drunk.
    People often take alcohol when they take other poisons. If the patient
    smells of alcohol, look for evidence and signs of other poisons too.
    Look for evidence of head injury too.

     Some chemicals that may make breath smell

         Camphor, camphorated oil, carbon tetrachloride, cyanide, ethanol,
         methyl salicylate, paraffin, petrol, toluene, trichloroethylene,
         turpentine and other volatile oils, and many pesticides.

    Watch and listen to breathing

    *    Is the patient breathing more or less deeply than usual?

    *    Is breathing more noisy than usual?

    *    Is breathing difficult?

         Count how many times the patient breathes in one minute. If the
    patient sees what you are doing he or she may breathe faster, so a
    good plan is to count breathing after taking the pulse, while you are
    still holding the wrist. Always count for a full minute.

         Most adults breathe 12-18 times per minute, children and infants
    breathe 20-30 times per minute. People breathe more quickly when they
    are taking exercise or when they are excited or upset; they breathe
    more slowly when they are asleep or resting.

         In most cases changes in breathing are dangerous and the
    patient's life may be in danger.

         Slow and irregular breathing or fast and shallow breathing may be
    caused by poisoning, substances like vomit or kerosene getting into
    the lungs, unconsciousness, head injury, stroke, lung oedema (see
    below), lung infection, asthma, or diabetes.

         Noisy breathing, with gurgling or snoring noises, may mean that
    the throat is blocked and not enough air is getting through. The
    throat may be blocked by food or a foreign body. If the throat is
    burnt it swells and blocks the airway. In an unconscious patient the
    throat may be blocked by the tongue, vomit or saliva if the patient is
    not in the recovery position.

         Coughing or wheezing may be caused by irritant gases, smoke, or
    dust. The patient may also have stinging or severe pain in the eyes
    and nose. Kerosene and similar liquids cause coughing and choking if
    they are swallowed. Other causes of coughing and wheezing are
    infections of the lungs, asthma and cigarette smoking.

     Same chemicals that may change breathing

     Shallow breathing

          Medicines: amitriptyline and other tricyclic antidepressants,
         antihistamines, atropine-like medicines, barbiturates, diazepam
         and other benzodiazepines, meprobamate, chlorpromazine and other
         phenothiazines.

          Pesticides: carbamate and organophosphorus insecticides.

          Other chemicals: carbon monoxide, ethanol.

     Slow or irregular breathing

          Medicines: opiates.

          Pesticides: carbamate and organophosphorus insecticides.

     Fast breathing

          Medicines: aminophylline, aspirin and other salicylates, cocaine,
         chloroquine.

          Pesticides: dinoseb, DNOC, organochlorine pesticides,
         pentachlorophenol.

          Other chemicals: carbon monoxide (at first), ethanol, ethylene
         glycol, methanol, phenol.

    Lung oedema

         Lung oedema is a condition in which fluid fills the lungs and
    eventually stops the patient breathing. Lung oedema is a very serious
    condition and the patient's life may be in danger. The signs of lung
    oedema are:

    -    fast breathing (20-40 times per minute), which is often noisy;

    -    coughing with frothy spit so that the patient foams at the mouth
         and makes a gurgling noise in the throat;

    -    grey or blue skin colour;

    -    fast pulse;

    -    sweating;

    -    anxiety and fear;

    -    crackling noises in the lungs, if you listen with a stethoscope
         or put your ear to the patient's chest;

    -    difficulty in lying flat.

         Some poisons cause lung oedema after a few minutes, others after
    several hours. As the patient gets tired, breathing may become very
    slow and may eventually stop.

         The lungs may fill with fluid in conditions such as heart
    disease, but it happens in a different way.

     Some chemicals that may cause lung oedema

          Medicines: aspirin and other salicylates, chlorpromazine and
         other phenothiazines, opiates.

          Pesticides: carbamate and organophosphorus insecticides, dinoseb,
         DNOC, paraquat, pentachlorophenol.

          Other chemicals: ethylene glycol, petroleum distillates,
         turpentine and other volatile oils, irritant gases.

    Check the pulse

         The heart is a pump. It pushes blood through the blood vessels.
    Each time the pump pushes out blood a wave of pressure passes along
    the blood vessels. This is the heartbeat or pulse. It can be felt
    wherever the blood vessels are close to the surface of the body, by
    pressing the blood vessel gently against a bone.

         Have a watch with a second hand in front of you. To take the
    pulse at the wrist, press two fingertips of your right hand lightly on
    the patient's wrist on the same side as the thumb (Fig. 38). You
    should feel a regular beat; this is the pulse. Count for a full minute
    looking at your watch. The number of beats you count in one minute is
    the pulse rate.

         In children and babies, try to find the pulse on the inside of
    the upper arm between the elbow and the shoulder. With your thumb on
    the outside of the child's arm, press your first and middle fingers
    gently into the groove between the muscles, until you feel a pulse.
    Sometimes it is easier to feel the heartbeat directly on the left of
    the chest.

         A normal pulse is regular and strong. In an adult the pulse rate
    is between 60 and 80 per minute. In healthy young adults it may be
    slower (50-60 per minute). In young babies it is faster (120 per
    minute). The pulse rate is slower than normal during sleep, and faster
    than normal if the person is excited or moving about, so take the
    pulse when the person is resting.

    Note if the pulse is:

     -    fast or slow;

         -    strong or weak, or with some beats stronger than others;

    FIGURE 38

         -    regular, with the same time between each beat, or irregular,
              with missed beats so that you cannot tap your foot in time
              to it.

         If the pulse is very irregular when you feel it at the wrist,
    count the heartbeat by listening over the heart. You can hear the
    heartbeat if you put your ear against the nipple on the left side of
    the chest. The count may be higher this time because you will be able
    to hear heartbeats that were too weak to be felt at the wrist.

         Write down what you find.

         A change in the pulse can mean that the patient is dangerously
    ill.

         Poisons may cause a slow pulse or a fast pulse. Any very bad
    poisoning may affect the heart, so that the pulse becomes irregular or
    very slow and may even stop altogether.

     Some chemicals that may cause a slow pulse

          Medicines: barbiturates, digitalis, digitoxin, digoxin,
         meprobamate, opiates, propranolol and other ß-blockers.

          Pesticides: carbamate and organophosphorus insecticides.

         A fast, weak pulse can mean shock, bleeding, heart attack, heat
    exhaustion or fever.

         A fast, strong pulse can mean heat stroke, stroke, or heart
    disease.

     Some chemicals that may cause fast pulse

          Medicines: aminophylline, amitriptyline and other tricyclic
         antidepressants, antihistamines, aspirin and other salicylates,
         atropine-like medicines, ephedrine, isocarboxazid and other
         monoamine oxidase inhibitors, pseudoephedrine.

          Drugs of abuse: amfetamines, cannabis, cocaine.

          Pesticides: arsenic, chlorophenoxyacetate weedkillers, dinoseb,
         DNOC, pentachlorophenol.

          Other chemicals: carbon monoxide (at first).

         A slow pulse may be caused by a low body temperature.

    Measure body temperature

         It is wise to take a patient's temperature, even if there does
    not seem to be a fever. If the patient is very sick, take the
    temperature every 3 or 4 hours.

         If you do not have a thermometer, feel the temperature by placing
    the back of one hand on the patient's forehead and your other hand on
    your own forehead. The forehead of a patient with a fever will feel
    warmer than yours. If the forehead feels cooler than yours the patient
    may have a low body temperature.

         A thermometer can be used to measure temperature in the mouth,
    armpit, groin or rectum. You should not use the same thermometer in
    the rectum as you use for taking oral or armpit temperatures. Always
    use a thermometer with a round end for taking the temperature in the
    rectum as this will not damage the rectum.

    To measure temperature:

    *    Make sure that the column of mercury inside the thermometer is
         below about 35°C. If it is not, shake the thermometer until the
         level has gone down.

    *    If the patient is awake, put the bulb of the thermometer in the
         mouth, under the tongue, for 2 minutes.

    *    If the patient is drunk, agitated, confused or likely to have a
         fit, and might bite the thermometer, put it in the armpit, and
         place the arm firmly across the chest, for 5-10 minutes.

    *    If the patient is unconscious, use a thermometer for taking
         temperature in the rectum. Push it gently into the rectum for a
         distance of 5 cm, and leave for 2 minutes before reading it.

    *    If the patient is a child, take the temperature in the armpit,
         groin or rectum.

         A normal body temperature is usually 36-37°C. The temperature in
    the mouth is 37.5°C. The temperature in the groin or under the arm is
    0.5°C lower, and the temperature in the rectum is 0.5°C higher.

         If the temperature is above 37.5°C the patient has a fever; the
    higher the temperature, the greater the fever. A temperature higher
    than 39°C is a sign of dangerous illness. Fever may be caused by
    infection or illness such as malaria. Only a few poisons cause fever.

     Some substances that may cause a high body temperature and warm
     dry skin

          Medicines: atropine-like medicines, antihistamines (more commonly
         in children than adults).

          Plants: plants containing atropine.

     Some chemicals that may cause a high body temperature and sweating

          Medicines: aspirin and other salicylates (more commonly in
         children than adults), ephedrine, colchicine, isocarboxazid and
         other monoamine oxidase inhibitors, pseudoephedrine.

          Drugs of abuse: amfetamines, cocaine.

          Pesticides: dinoseb, DNOC, pentachlorophenol.

          Other chemicals: naphthalene, phenol.

         A low body temperature may be caused by a long period of
    unconsciousness, especially if the patient has been lying in an open
    or cold place.

     Some chemicals that may cause a low body temperature
     (less than 35°C)

          Medicines: amitriptyline and other tricyclic antidepressants,
         barbiturates, chlorpromazine and other phenothiazines,
         meprobamate, opiates.

          Other chemicals: carbon monoxide, ethanol.

    Look at the eyes

         Examine both the patient's eyes together. See if the pupils are
    the same size.

         Cover one eye at a time with your hand and see if the pupil
    changes size when the light changes. If you have a light you can shine
    it into the eyes and see if the pupils get smaller.

         Unequal pupils-pupils that are not the same size-may be caused by
    a chemical splashed in one eye. If there has not been chemical in the
    eye, this is usually a sign of eye disease or brain disease.

         Large pupils may be a sign of poisoning, or of severe lack of
    oxygen, or of very low body temperature.

         Look at the whites of the eyes. If these are yellow this usually
    means the patient has jaundice.

     Some chemicals that may affect the eyes

          Very small "pinpoint" pupils

          Medicines: opiates.

          Pesticides: organophosphorus and carbamate insecticides.

          Large pupils

          Medicines: amitriptyline and other tricyclic antidepressants,
         antihistamines, atropine-like medicines, carbamazepine,
         ephedrine, isocarboxazid and other monoamine oxidase inhibitors,
         quinine.

          Drugs of abuse: amfetamines.

          Other chemicals: methanol.

          Blurred vision

          Medicines: atropine-like medicines, ephedrine, pseudoephedrine.

          Other chemicals: ethanol, methanol.

          Loss of sight or complete blindness

          Medicines: chloroquine, quinine.

          Other chemical: methanol.

    Other signs of poisoning

          Vomiting and diarrhoea may be caused by almost any poison.
    Other causes of vomiting with diarrhoea are infections caused by
    bacteria, viruses, or worms, and malaria. Other causes of diarrhoea
    are allergies to certain foods, side-effects from certain medicines,
    such as antibiotics or laxatives, or eating too much unripe fruit or
    heavy, greasy foods. Other causes of vomiting are appendicitis or
    something blocking the gut, or almost any other sickness with high
    fever or severe pain, especially migraine headache, and infections of
    the liver, ears, and brain.

          Black stools. The black colour may be caused by blood from the
    gut if the gut has been damaged by corrosive fluids. Iron tablets may
    colour stools black or dark green, and activated charcoal also colours
    them black.

          Dehydration. Vomiting and diarrhoea may lead to dehydration. A
    person with vomiting or diarrhoea loses a lot of water from the body.
    If he or she does not drink enough to replace the lost water, the body
    dries out. People of any age can become dehydrated, but dehydration
    develops more quickly and is most dangerous in small children. People
    with burns, or people who are unconscious and unable to drink, may
    also become dehydrated.

    Signs of dehydration are as follows:

    *    The patient passes very little or no urine, and the urine is dark
         yellow.

    *    The patient has a dry mouth and dry lips. The patient may be very
         thirsty (but very dry people may not complain of thirst).

    *    When the skin is lifted between two fingers the skin fold does
         not fall back again at once but stays raised for a few seconds.

    *    Children may have sunken eyes.

         Very severe dehydration may cause a rapid weak pulse, fast deep
    breathing, fever, or fits.

          The patient does not pass urine. If a person does not pass
    urine this could mean any of the following:

    *    The kidneys are not making urine because the patient is
         dehydrated. The person has lost a lot of water through vomiting,
         sweating, diarrhoea, or from a bad skin burn.

    *    The kidneys are not making urine because they have been damaged
         and are not working. This is kidney failure. It may be caused by
         poisons or illness. Patients with kidney damage may have vomiting
         and lung oedema.

     Some chemicals that may cause kidney failure

          Medicines: aspirin and other salicylates, colchicine, iron
         containing medicines, isocarboxazid and other monoamine oxidase
         inhibitors, quinine, rifampicin.

          Pesticides: arsenic, dinoseb, dinitrophenol, DNOC, paraquat,
         pentachlorophenol, sodium chlorate, thallium.

          Other chemicals: boric acid, camphor, camphorated oil, carbon
         tetrachloride, ethylene glycol, methanol, naphthalene, phenol,
         sodium perborate, turpentine and other volatile oils.

    *    The kidneys are making urine but the bladder is not working; the
         bladder muscles will not relax and let the urine out. Do not
         confuse this reason for not passing urine with kidney damage. If
         the bladder is full you should be able to feel a rounded swelling
         in the lower part of the belly. Some medicines stop people
         emptying the bladder. This may also happen when a person has been
         unconscious a long time.

     Some medicines that may stop the patient emptying his or her bladder

         Amitriptyline and other tricyclic antidepressants,
    antihistamines, atropine-like medicines.

          Fits (convulsions). These are jerking movements that the
    patient cannot control. The patient may be just twitching or the whole
    body may move. The patient may suddenly become unconscious and foam at
    the mouth. The longer the fit lasts, the greater the danger to life.
    In severe cases, the patient does not stop having fits and finds it
    difficult to breathe.

         There are some kinds of fit where first the jaw and then the
    whole body becomes very stiff. This may be tetanus.

         Fits may be caused by poisoning, lack of oxygen - which may be a
    result of exposure to poison or of something blocking the airway -
    epilepsy, meningitis, malaria, or low blood sugar in a diabetic
    person. People dependent on alcohol or drugs may have fits if they
    suddenly stop taking them.

         In small children, fits may be caused by high fever or severe
    dehydration.

     Some chemicals that may cause fits

          Medicines: aminophylline, amitriptyline and other tricyclic
         antidepressants, antihistamines, aspirin and other salicylates,
         atropine-like medicines, chloroquine, colchicine, dapsone,
         ephedrine, insulin and other antidiabetic drugs, iron salts,
         isocarboxazid and other monoamine oxidase inhibitors, opiates,
         phenothiazines, propranolol and other ß-blockers,
         pseudoephedrine, quinidine, quinine.

          Drugs of abuse: amfetamine, cocaine.

          Pesticides: arsenic, carbamate and organophosphorus insecticides,
         metaldehyde, sodium chlorate, strychnine, thallium.

          Other chemicals: borax, boric acid, camphor, camphorated oil,
         carbon monoxide, cationic detergents, ethylene glycol, methanol,
         sodium perborate.

          Signs of liver damage. The liver is the place where the body
    changes many poisons into less harmful substances. If there is more
    poison than the liver can deal with, the poison that does not get
    changed may damage the liver. The symptoms and signs of liver damage,
    which do not show for 2 or 3 days after poisoning, are as follows.

    *    There is often nausea, vomiting and fever at first.

    *    The whites of the eyes may become yellow, then the skin becomes
         yellow.  This is often the first specific sign of liver damage.

    *    There may be pain in the belly.

    *    If the patient does not recover, and the liver damage gets worse,
         the patient becomes drowsy then unconscious, and may die within a
         few days.

     Some chemicals that may cause liver damage

          Medicines: iron-containing medicines, paracetamol, rifampicin.

          Pesticides: aluminium phosphide and zinc phosphide,
         pentachlorophenol,

          Other substances: benzene, camphor, camphorated oil, carbon
         tetrachloride, phenol, tetrachloroethane, toluene,
         trichloroethane, trichloroethylene, xylene.

         Poisonous mushrooms

     Signs that the patient is severely ill

    *    The patient is not breathing.

    *    Breathing is wheezy or noisy after you have cleaned the mouth and
         put the patient in the recovery position.

    *    The patient is unconscious and does not wake up when you pinch
         the hand.

    *    The pupils do not change size when you shine a light into them.

    *    The pulse is very slow (less than 50 beats per minute), or very
         fast (more than 110 beats per minute), or irregular, or very
         weak.

    *    The patient has continuous fits.

    *    The temperature in the mouth or rectum is over 39°C, or
         temperature under the arm or in the groin is more than 38°C.

    *    The patient has severe belly pain.

    *    There are signs of kidney failure.

    *    There are signs of liver damage.

    Patterns of symptoms and signs

         Some poisons cause patterns of symptoms and signs that could not
    be caused by anything else. These patterns are often called poisoning
    syndromes. The chemicals and medicines that cause some common
    poisoning syndromes are listed in Table 7.1.

        Table 7.1.  Poisoning syndromes

                                                                                                 

    Poisons                                    Symptoms and signs
                                                                                                 

    Atropine, amitriptyline,                   dry, hot skin, fever, thirst, dry mouth,
    antihistamines, Datura stramonium,         large pupils, fast pulse, difficulty in passing
    Atropa belladonna, some kinds of           urine, hallucinations, fits, shallow breathing,
    mushrooms                                  unconsciousness

    Organophosphorus and                       small pupils, wet mouth, sweating, wet eyes,
    carbamate insecticides, some kinds         vomiting, slow pulse, diarrhoea, fits,
    of mushrooms                               unconsciousness

    Opiates                                    small pupils, slow breathing, unconsciousness,
                                               low temperature, sbw, weak pulse, vomiting

    Amfetamines, cocaine,                      large pupils, fever, fast pulse, hallucinations,
    theophylline                               fits, anxiety, sweating, flushed skin, over-
                                               activity, confusion

    Barbiturates, diazepam and                 unconsciousness, low blood pressure, shallow
    similar drugs, meprobamate                 breathing, low temperature
    Drug withdrawal (a sudden stop in          diarrhoea, gooseflesh, fast pulse, watering
    taking ethanol (alcohol),                  eyes, yawning, cramps, hallucinations,
    barbiturates, diazepam and similar         restlessness, shaking
    medicines, opiates)
                                                                                                 
    
    CHAPTER 8

    Finding out what happened

    Objectives

    After studying this chapter, you should be able to:

    1.   Find out what the poison is when you suspect someone has been
         poisoned.

    2.   Find out how the poisoning happened.

         When a person has been poisoned it is important to know what
    happened. It is easier for a doctor to treat the patient if the poison
    and the circumstances of the poisoning are known, and it is more
    likely that the treatment will be successful. Also, it may be possible
    to take steps to prevent someone else being poisoned in the same way.

         There are two ways to find out what happened. You can ask people
    for information, and you can look for the poison and other things that
    show you what might have happened.

         However, your first priorities are to give first aid and then to
    get medical help. You should never delay taking the patient to
    hospital or to a local doctor. You may spend about ten minutes talking
    to people and looking for the poison, if you can do so without leaving
    the patient alone. You may be able to spend longer if you have to wait
    for a local doctor to visit, or for an ambulance. It may be possible
    to go back and have another look after you have handed the patient
    over to a doctor. When there is another person to help you, one of you
    can find out what happened, while the other looks after the patient or
    takes him or her to hospital.

     Remember!

         Never leave the patient alone while you talk to people or search
         for the poison.

         Do not delay in getting medical help.

    You need to find out as much as possible about:

    -    how the poisoning happened. Was the poison swallowed, breathed
         in, injected, or in contact with the skin or the eye, or was the
         patient bitten or stung?

    -    where the poisoning happened;

    -    what the poison is;

    -    how long ago the patient was poisoned. Did it happen a few
         minutes ago, or was it several hours or even days ago?

    -    how long the exposure lasted. For example, if the poison was
         breathed in, for how long was the patient breathing it in? If the
         poison was spilt on the skin or clothes, how long was it before
         the patient washed or took off the clothes?

    -    how many people were affected.

         You may be able to find out some information by talking to
    people, and you may be able to find things that show you what happened
    or what the poison is.

         As you gather information you may need to make notes to help you
    to remember all the facts.

    Talking to people

     The patient

         In some cases the patient is the best person to tell you what
    happened. You may have found out some of the facts by talking to the
    patient as you examined him or her, but a small child or a confused
    person may not be able to tell you much, and an unconscious patient
    cannot tell you anything. Some people who poison themselves may not
    want to tell you the truth.

     Other people

         You may be able to find out more about what happened from other
    people. Compare their story with what the patient tells you.

         If the patient is a child:

    *    Talk to anyone who was looking after the child, or playing with
         him or her. Someone may have seen the child drink from a bottle
         containing chemicals, open a bottle of medicine, or eat some
         leaves from a plant. Ask whether the child was left alone at any
         time, even if it was only for a few minutes, and ask where the
         child was left alone.

         If the accident happened at work:

    *    Talk with other workers who were with the patient. They may know
         what happened and they may know what substances the patient was
         using.

    *    Talk with the supervisor or nurse. They may know if this kind of
         accident has happened before and what chemicals are used or kept
         in the workplace.

         If you think the patient meant to take poison:

    *    If the patient cannot or will not tell you what happened, ask the
         patient's friends or family if he or she was unhappy or had
         problems.

         If no-one knows what happened:

    *    Find out if there are any chemicals or medicines the patient
         could have been exposed to in the home or at work. Ask people the
         following questions:

    -    Has the patient been taking medicines or home cures? Does
         anyone else in the family take medicines? What medicines,
         pesticides and cleaning products are kept at home? Where are they
         kept? Are they locked away? If the patient is a child, find out
         whether a child could reach them.

    -    Has the patient been in a place where poisonous snakes or animals
         are found?

    -    Has the patient eaten a plant, mushroom, or fish that might have
         been poisonous? Talk to the family, fellow workers or friends who
         may have eaten with the patient in the past two days. Ask them
         what food the patient ate. Is anyone else who ate the same meals
         also ill?

    -    Is it possible that the patient ate food contaminated with
         poison? Has food been near poisonous chemicals such as
         pesticides, in the shop, at home or when it was moved from one
         place to the other?

    -    Does the patient use chemicals, cleaning products or pesticides
         at home or at work? Where are these chemicals kept? Are they
         locked away or can anyone use them?

    -    Has the patient used chemicals recently, either at home or at
         work? How long for? Has the patient used the same chemicals
         before and in the same way? Was the patient wearing protective
         clothing if it was needed?

    -    Was anyone nearby using a chemical? For how long?

Look for the poison or other things that show you what happened

         Sometimes nobody can tell you what happened and the only way to
    find out is to look for the poison or for things that show you what
    might have happened.

         Even if people have been able to tell you what happened, you may
    still need to look for the poison. If the poison is a medicine, a
    pesticide, a household product or industrial chemical, you need to see

    the container so that you can check the exact name on the label, and
    see if there is any information about the chemicals in the product. Do
    not rely on the names that people tell you; they may read the label
    wrongly or be confused by the chemical names.

         Take a pencil and a notebook with you when you look for poisons,
    in case you find products that you cannot take away with you, such as
    large drums of pesticide. Carefully write down the information from
    the product label. Look for the name of the product, the names of
    chemicals, the name and address of the manufacturer, and any
    information about what to do in case of poisoning. Try to copy any
    symbols or pictures on the label, and write down any numbers. This
    information may help a poisons centre to identify the product.

         If the patient has been harmed by an animal that has been caught
    or killed, ask to see it. It is important to identify the animal.
    Snakes and spiders can be recognized by their colour and markings.
    Keep them in a safe container so that nobody else is harmed.

         If the patient has eaten a wild plant or mushroom, ask for a
    sample so that you can identify it. If necessary, ask where it was
    found and send a responsible person to get some.

     What to look for and where to look

         Search the place where the patient was found. Ask members of the
    patient's family if they will help you search the home. Ask the
    patient's employer if you can search the workplace.

         Look for:

    -    bottles, packets, boxes or other containers that might have
         contained tablets, medicine, household chemicals, or pesticides.
         Read the labels of any containers you find;

    -    drinks bottles that have been filled with pesticide or kerosene,
         which could be mistaken for fizzy drink or alcohol;

    -    old pesticide containers that are being used to store food or as
         toys;

    -    liquid fuel burners that are not working properly (you can
         usually see that they are not working properly because there will
         be black sooty marks near the air vent and outlet pipe);

    -    poisonous snakes, insects, or plants; rosaries or beads made from
         plant seeds.

         If the patient is a child:

    *    Look inside high cupboards as well as low cupboards because the
         child might have climbed onto a chair or table.

    *    Look inside the waste bin for containers that might not have been
         completely empty, and for button batteries.

    *    Look for chemicals that have been spilt on the floor or on the
         child's clothes. Look for stains or wet patches. When small
         children try to drink from bottles they often spill the liquid.

    *    Look for tablets on the floor and look for staining or pieces of
         tablets in the child's mouth. Look for the child's own medicines
         to see if the containers are open.

    *    Look for household products and pesticides in open bottles, jars,
         cups or buckets, for example, paint brush cleaner in ajar or cup,
         laundry detergent or another cleaner that has been added to a
         bucket of water, or rat poison in an open dish on the floor.

         If the patient is an adult:

    *    Look for poison on the patient's clothes or skin, and look for
         pieces of tablets, plants, or food in the vomit or inside the
         mouth.

    *    Look in the patient's pockets. Search the room where the patient
         was found and look in waste bins.

    *    Look for tablets, medicines, pesticides, or household chemicals.
         Look for a syringe, which could mean the patient abuses drugs and
         has just injected some. Look for a suicide note.

         Remember that some people take care to leave no evidence of the
    poison they have taken. Some people do not tell you the truth when you
    ask them what poison they took.

    What to do next

         When you telephone a hospital or poisons centre, have with you
    the chemical products, medicines, plants or animals, or the notes that
    you have made about them, so that you can describe them accurately and
    read product labels. Describe what happened and the condition of the
    patient.

         When the patient goes to hospital make sure the chemicals,
    medicines, plants or animals you have found go also, if it is possible
    to move them, together with the notes you have made.

    CHAPTER 9

    How to look after a poisoned patient outside hospital

    Objectives

         After studying this chapter, you should be able to:

    1.   Decide what to do when someone has swallowed poison.

    2.   Explain when a patient who has swallowed poison can safely:

    -    drink water,

    -    be made to vomit,

    -    be given activated charcoal.

         Explain when it is dangerous for a patient to be given anything
         by mouth, and when it is dangerous to make a patient vomit.

    3.   Decide when it is safe and useful to give a laxative to a patient
         with suspected poisoning.

    4.   Look after a patient until he or she gets to a hospital and know
         what to do if the patient:

         - has bad diarrhoea,

         - vomits for a long time,

         - does not pass urine,

         - is unconscious,

         - has a low temperature,

         - has fever,

         - has liver damage,

         - has lung oedema.

         This chapter describes how someone with no medical training can
    look after a person who has been poisoned, when there is no doctor.

         If you can get the patient to a local doctor or hospital within
    two hours, it is more important to go without delay than to do any of
    the things described here, except perhaps to give the patient some
    water to drink.

         The actions described in this chapter are not first aid. They are
    best carried out under the direct supervision of a doctor. You should
    undertake them only when it is impossible to get the patient to a
    local doctor or hospital within two hours.

         If possible contact a doctor or poisons centre by telephone
    before you proceed. Sometimes these actions can be dangerous and it
    may be difficult to know whether or not the patient will benefit.

         Make a note of everything you do and of any change in the
    patient's condition, with the time and date. Give the note to the
    doctor when you hand over the patient.

    What to do when the patient has swallowed poison

         Do not give anything by mouth if:

    -    the patient is unconscious, drowsy or having fits. Someone who is
         drowsy or having fits may choke if given anything by mouth.

    -    the patient cannot swallow. Do not force the patient to drink. If
         the patient has swallowed a corrosive substance and has burns
         inside the mouth he or she will not be able to swallow. In this
         case water will not help the burns and may make the damage worse.

         If the patient is awake ask him or her to rinse out the mouth
    several times with cold water and spit it out. Give small sips of
    water if the patient wants to drink.

         Do not make the patient drink a lot of liquid at once: the
    patient may vomit and this may be dangerous.

         If you intend to make the patient sick or to give activated
    charcoal (see below), do not give large amounts of water before doing
    so. The result may be that the poison moves out of the stomach more
    quickly and any action taken to stop the chemical getting into the
    blood will have less effect and the poisoning will be worse.

         After you have made the patient vomit, or given activated
    charcoal or a laxative, encourage the patient to drink plenty of
    liquid to prevent dehydration. Give frequent small drinks throughout
    the day. Do not give alcohol or coffee.

    How to stop poison getting into the blood after it has been swallowed

         When poisons are swallowed they go to the stomach and gut and
    pass through the gut walls into the blood. A poison will not have any
    systemic effect until it gets into the blood. If you can stop some or
    all of it getting into the blood, this may stop the patient getting
    severe poisoning.

         There are three ways to stop poison getting into the blood after
    it has been swallowed:

    -    make the patient vomit back the poison;

    -    give activated charcoal to bind the poison and stop it getting
         through the gut walls;

    -    give laxatives to make the poison move through the gut more
         quickly.

         Sometimes it may be dangerous to do any of these things, and it
    is usually best to wait until the patient gets to hospital if
    possible.

         However if it is safe and useful to take action it is important
    to do so as soon as possible, because the longer the chemical stays in
    the gut, the more will get into the blood and the worse the poisoning
    will be.

         So, if it will take several hours to get to a health centre or
    hospital, you will have to decide whether the patient would benefit
    from any of these treatments and give them yourself. It is therefore
    very important to understand when they should be used and when they
    should not be used.

         In each case, before you decide what to do, you should find out
    as much as possible about what the poison is and what happened, and if
    possible telephone a poisons centre, hospital or doctor and ask for
    advice.

    Making the patient vomit

         If you make the patient vomit when poison is still in the
    stomach, some of the poison may come out in the vomit. This may stop
    the patient getting severe poisoning.

    Do not make the patient vomit if:

    -    the substance is not likely to cause poisoning;

    -    vomiting might be dangerous (see below);

    -    it is more than four hours since the patient took the poison.
         Poisons only stay in the stomach for a short time after they have
         been swallowed and in most cases none will be left after four
         hours, so vomiting will not do any good;

    -    you do not know what substance the patient has swallowed or what
         effect it might have.

         It is dangerous to make a patient vomit if any one of the
    following is true:

    *    The patient is unconscious or very sleepy. An unconscious person
         cannot swallow or cough. If liquid or vomit gets into the airway
         it will not be coughed out and may block the airway or get into
         the lungs.

    *    The patient has swallowed a chemical that is likely to burn.
         Vomit might burn the throat and lungs.

    *    The patient has swallowed a petroleum distillate (kerosene,
         petrol, gasoline, white spirit), or a product containing these
         chemicals, for example, some pesticides and cleaners. The
         petroleum distillate may get into the lungs as the vomit passes
         the top of the airway. This could cause lung oedema. (A patient
         may swallow petroleum distillate with another substance that is
         even more dangerous. For example, some liquid pesticides are
         dissolved in petroleum distillate. In this case a doctor may tell
         you to make the patient vomit because the danger from the other
         poison is greater than the danger of lung oedema.)

    *    The patient has swallowed a substance that is likely to cause
         fits. The act of vomiting may start a fit. Vomiting during a fit
         may cause choking, or vomit may get into the airway and block it.

    *    The patient has swallowed a substance that might cause drowsiness
         or unconsciousness. The patient might become drowsy or
         unconscious before vomiting and choke.

         If you know what the patient has swallowed, find out what effect
    it might have by:

    -    looking in Part 2 of this book;

    -    contacting a poisons centre or local hospital.

         Sometimes it is hard to decide whether you should make the
    patient vomit. If you are not sure that it is safe, do not make the
    patient vomit.

     How to make the patient vomit

         Make the patient vomit by tickling the back of the throat or
    giving syrup of ipecacuanha.

         Do not give salt water to make the patient vomit. Too much salt
    is poisonous. In the past, patients given salt water to make them
    vomit have died from salt poisoning.

    Tickling the throat

         Make the patient lie face down, or sit well forward with the head
    lower than the chest, to stop vomit getting into the lungs. Children
    should lie face down over your knee.

         Ask the patient to touch the back of the throat with his or her
    fingers. If the patient cannot do it, lightly touch the back of the
    throat with your own finger or a blunt object such as a spoon. Take
    care not to damage the throat. Use two fingers of your other hand to
    force the patient's cheek between the teeth so that the patient cannot
    bite your finger.

    Giving ipecacuanha syrup

         Give ipecacuanha syrup or ipecacuanha paediatric emetic draught
    or ipecacuanha Adelaide Children's Hospital formula. Do not use fluid
    extract of ipecacuanha.

    Dose:     Adults: 30 ml (6 teaspoonfuls using a teaspoon that
              holds 5 ml).

              Children 6 months to 12 years: 10 ml (2 teaspoonfuls).

              Children under 6 months old: do not give ipecacuanha
              syrup.

         Give a drink of water afterwards. The patient should vomit 15-20
    minutes after the dose. If the patient does not vomit after 30
    minutes, give a second dose of ipecacuanha syrup. Do not give more
    than two doses.

         When the patient starts to retch and vomit, make the patient lie
    face down, or sit well forward with the head lower than the chest, to
    stop vomit getting into the lungs. Children should lie face down over
    your knee.

         Giving ipecacuanha syrup may remove more poison than tickling the
    throat because it makes the patient vomit more. However it may cause
    problems:

    *    The patient may vomit for a long time and become dehydrated.

    *    Vomiting may be delayed for up to one hour after the dose. If the
         patient becomes unconscious before then, or has a fit, there is a
         danger that he or she may choke on the vomit.

     After the patient has vomited

         Look at the vomit. You may be able to see small pieces of
    tablets, leaves, or berries, which could be the poison. Note the
    colour and smell of the vomit.

         Save some of the vomit in a small, closed container and take it
    to hospital with you so that the doctor can see it. The hospital may
    be able to test the vomit to show what the patient swallowed.

    Giving activated charcoal

         Activated charcoal is a fine black powder that binds most poisons
    so that they pass out of the body with the charcoal in the faeces. It
    may stop the patient getting worse and can prevent serious poisoning.

         It takes 10 g of activated charcoal to bind 1 g of chemical, so
    it is most useful when only a few grams of poison produce severe
    effects. Activated charcoal is most effective if it is given within 4
    hours of the poison being swallowed, while most of it is still in the
    stomach. You can give activated charcoal after you have made the
    patient vomit, but not until vomiting has stopped.

    Do not give activated charcoal:

    *    If the patient is unconscious, drowsy or having fits. Someone who
         is drowsy or having fits may choke if given anything by mouth.

    *    At the same time as, or just before, a dose of ipecacuanha syrup
         or any antidote by mouth. Charcoal binds ipecacuanha and some
         antidotes and stops them from working.

    *    For poisoning caused by acids, alkalis, boric acid, ethanol,
         iron-containing medicines such as ferrous sulfate, lithium,
         methanol or petroleum distillates.

     How to give activated charcoal

         Use activated charcoal that has been given to you by a pharmacist
    or a doctor. Charcoal that you make by burning bread or burning wood
    is not the same and will not work.

     Dose: Mix 5-10 g of activated charcoal with 100-200 ml of water.
    Stir the activated charcoal with the water until it looks like a thick
    soup. Make sure all the powder is wet.

         Adults: Give one 10-g dose every 20 minutes up to a maximum of
         50 g.

         Children: Give one 5-g dose every 20 minutes up to a maximum of
         15 g or 1 g/kg of body weight (whichever is lower).

         Sometimes people vomit after drinking charcoal. If this happens
    do not give any more. Tell the patient, or tell the parents if the
    patient is a child, that charcoal colours the faeces black.

         For some poisons, repeated doses of activated charcoal given over
    many hours remove a larger amount from the body than a single dose. If
    the poison is only slowly absorbed from the gut, additional doses of
    charcoal may remove poison still present in the gut after the first
    dose. Charcoal given after the poison has been absorbed from the gut
    may remove any poison that passes back into the gut from the blood.
    Repeated doses of activated charcoal can be given after poisoning from
    aspirin, carbamazepine, phenobarbital or theophylline.

    Dose:     Adult: 50 g every 4 hours for up to 2 or 3 days.

              Children: 15 g or 1 g/kg of body weight (whichever is lower)
              every 4 hours for up to 2 or 3 days.

         Activated charcoal may cause mild constipation. If giving
    repeated doses of charcoal, give one dose of laxative with the first
    dose of charcoal.

    Giving a laxative

         Laxatives are usually used to treat constipation but they may be
    used when someone has swallowed poison to make the poison move through
    the gut and leave the body more quickly. A laxative may be useful up
    to 24 hours after the patient swallowed poison.

         Do not give a laxative if:

    *    The patient is unconscious, drowsy or having fits. Patients who
         are drowsy or having fits may choke if they try to swallow
         anything.

    *    The patient has swallowed a corrosive substance and has burns
         inside the mouth. Giving a laxative may cause more damage to the
         gut.

    *    The patient has signs of dehydration. Diarrhoea will make the
         body lose more water and make the problem worse.

    *    The patient does not pass urine. This could mean the kidneys are
         not working properly. Laxatives can be dangerous if given to a
         patient with kidney damage.

         There are many medicines that are given as laxatives to treat
    constipation. Magnesium sulfate (Epsom salts), sodium sulfate or
    magnesium citrate are the only laxatives that should be used when
    someone has swallowed poison. Magnesium sulfate (Epsom salts) is the
    best one to give and the one you are most likely to have.

     Dose:    Give one dose only. Mix the following amount of magnesium
    sulfate in a glassful of water:

    Adults: 20-30 g.

    Children over 2 years: 250 mg/kg of body weight.

    Children under 2 years: not to be given.

    How to look after a very sick patient

         Keep the patient at rest in a quiet, comfortable place with
    plenty of fresh air and light. Watch for any change in the patient's
    condition that tells you if the patient is getting better or worse.
    Four times a day write down the temperature, pulse, and the number of
    breaths per minute.

         If the patient is awake and able to drink, encourage the patient
    to drink plenty of liquid. Give simple fluids, such as water, soup,
    maize porridge, or rice-water. Do not give alcohol or coffee. Give
    frequent small drinks throughout the day. An adult needs to drink two
    litres or more every day.

         Watch for signs of dehydration. Write down the amount of liquid
    drunk and the number of times the patient passes urine or has a bowel
    movement. Keep this information for the doctor.

         If the patient is dehydrated because of vomiting, diarrhoea, or
    skin burns, you will need to give more fluids.

         Do not give anything by mouth if

         -    the patient cannot swallow,

         -    the patient is unconscious, drowsy or having fits.

     What to do if the patient has bad diarrhoea

         Diarrhoea may be useful for getting poison out of the body but if
    it is very bad or lasts a long time the patient may lose too much
    water and become dehydrated. This problem is more likely to be caused
    by eating food contaminated by microorganisms than by poisoning from
    chemicals or medicines. Although many poisons cause diarrhoea it does
    not usually last long enough to cause dehydration.

         People of any age can become dehydrated but it happens more
    quickly and is most dangerous in small children. A child with
    diarrhoea very quickly loses large amounts of water and may die in a
    few hours.

         If the diarrhoea lasts a long time another danger is not getting
    enough food. It is very important to prevent dehydration and
    malnutrition by giving plenty of good food and drink.

         Diarrhoea can be very dangerous if:

    -    a small child with severe diarrhoea does not get better in 24
         hours or if a well nourished adult does not get better in 36
         hours;

    -    the patient is dehydrated and getting worse;

    -    the patient was very sick, weak or undernourished before the
         diarrhoea started, or if the patient is very young or very old.

         Medicines should not be given for diarrhoea, especially to small
    children.

    To prevent dehydration

         If a person with diarrhoea is given plenty of liquids from the
    start, water loss should not be a problem. A patient with watery
    diarrhoea must drink large amounts of liquid as soon as the diarrhoea
    starts in order to replace the water and salts lost from the body.

         Give simple fluids, such as water, soup, maize porridge, rice-
    water or whatever liquid is available that the patient will take. Give
    one or two cupfuls (200 ml) of fluid after every loose stool. Even if
    the patient does not want to drink, gently insist (unless the patient
    is unable to swallow).

         Do not stop giving the patient food. When you give large amounts
    of liquid for diarrhoea, keep giving food as well unless the patient
    is vomiting, and keep giving breast milk to babies. A baby, a small
    child, or anyone who is thin, weak and undernourished should eat as
    soon as they can. An older child or adult who is well nourished should
    begin taking food after 24 hours.

    To treat dehydration

         If the patient is already dehydrated, simple fluids will not be
    enough. Sugar and salts lost from the body (sodium, potassium and
    bicarbonate) must be replaced. If you have a packet of oral
    rehydration salts (ORS) mix it with water and give it to the patient
    to drink.

         To make up a drink with oral rehydration salts:

    *    Wash your hands. Measure one litre (or the amount stated on the
         packet) of clean drinking-water into a clean container. If
         possible use boiled water, but try not to lose time. Pour all the
         powder from one packet into the water and mix well until the
         powder is completely dissolved. Give the patient some of this to
         drink at once. Give at least 2 litres in the first 4 hours, if
         the patient is an adult; give 75 ml per kg of body weight if the
         patient is a child. The patient should continue to take frequent
         drinks of the mixture until the diarrhoea stops. Make up fresh
         ORS solution each day in a clean container and keep the container
         covered.

         If you do not have a packet of ORS you can make rehydration fluid
    with two teaspoonfuls of sugar and one two-finger pinch of salt in one
    cupful or mugful of water. This does not contain any potassium, so if
    possible, give orange juice, coconut water or a little mashed ripe
    banana, because these fruits contain potassium.

     What to do if the patient vomits for a long time

         A patient who vomits for a long time will lose a lot of water and
    become dehydrated.

         Give water or whatever liquids the patient will drink. Give sips
    every 5-10 minutes for 36 hours, or until the patient stops vomiting.

         Continue to give drinks even if the patient is vomiting. Give the
    drink a little at a time, very frequently - several sips or swallows
    every few minutes (not all of the drink will be vomited).

         Do not give food while the patient is vomiting a lot.

     Information for doctors

         If vomiting does not stop, the patient may need to be given a
         medicine like promethazine, diphenhydramine, or metoclopramide by
         injection.

     What to do if the patient does not pass urine

         With the patient fiat on his or her back, and the head tilted
    back so that the airway is open, feel the lower part of the belly. If
    the bladder is full, you should be able to feel a rounded swelling in
    the lower part of the belly.

    The patient has an empty bladder

         If the patient does not pass urine and has an empty bladder this
    means that:

    -    the patient is dehydrated; or

    -    the kidneys have been poisoned and have stopped working.

         Look for other signs of dehydration. If the patient is
    dehydrated, give fluids following the advice given above.

         To find out if the kidneys are working:

    *    Give liquids - water, tea, soup, fruit juice or any non-alcoholic
         drink. (Do not give anything by mouth if the patient is
         unconscious or cannot swallow.) Give sips of drink every five
         minutes and keep a record of how much the patient drinks.
         Continue to give drink often in small sips; even if the patient
         vomits, not all of the drink will be vomited.

    *    Measure the amount of urine passed during six hours.

    -    If the amount is more than 500 ml, the kidneys are working. Keep
         giving sips of drink every five minutes day and night until the
         patient begins to pass urine normally. A large person needs three
         or more litres a day. A small child needs at least one litre a
         day.

    -    If the amount of urine is less than 500 ml the kidneys are not
         working and it is dangerous to carry on giving large amounts of
         liquid. If the kidneys are not working, for the next six hours
         give fluid to drink equal to the amount of urine passed in the
         previous six hours, plus 200 ml. Give 200 ml more if the patient
         is sweating a lot (that is 400 ml plus the amount of urine
         passed). Carry on measuring the amount of urine passed. At the
         end of six hours again measure the amount of urine passed, and
         for the next six hours give fluid to drink equal to the amount of
         urine passed in the last 6 hours, plus 200 ml. Repeat this until
         the patient gets to hospital.

    The patient has a full bladder

         If the bladder is full you should be able to feel a rounded
    swelling in the lower part of the belly. If the bladder is full but
    the patient does not pass urine this means the kidneys are working but
    the bladder is not working and will not let the urine out. Do not give
    anything to drink. If the patient is awake, he or she should sit in a
    hot bath, and try to relax and to pass urine. You do not need to
    measure urine output in this case.

     What to do if the patient is unconscious

         Keep the patient in the recovery position. Do not leave an
    unconscious patient alone, as he or she may turn to lie on the back
    and then the airway might be blocked by vomit or the tongue.

         Check the level of consciousness, breathing and pulse every 10
    minutes until the patient shows signs of recovery, and every half hour
    after that. If breathing stops, give mouth-to-mouth or mouth-to-nose
    respiration and if the heart stops give heart massage.

         Make sure that the patient cannot fall onto the floor or hit
    against a hard edge or surface. Do not put pillows or other padding
    near the patient's face, as they may suffocate him or her.

         Gently roll the patient from one side to the other at least every
    three hours to prevent pressure sores. As you turn the patient keep
    the head back with the chin up and do not let the head fall forwards
    with the chin on the chest. This is to keep the airway clear and to
    prevent neck injuries.

         Make sure that all the joints are neither fully straight nor
    fully bent. Ideally they should all be kept in mid-position. Place
    pillows under and between the bent knees and between the feet and
    ankles.

         Make sure that the eyelids are closed and that they stay closed
    at all times, otherwise the eyeballs will get dry. Boil some water and
    let it cool. Every two hours open the lids slightly and drip some of
    the water gently into the corner of each eye so that the water runs
    across the eye and drains from the other corner.

         An unconscious patient must not be given anything to drink. If a
    patient is unconscious for more than 12 hours he or she will become
    dehydrated unless fluid can be given intravenously or via the rectum.

     What to do if the patient has a low temperature

         If the body temperature falls below 35°C measured in the mouth or
    rectum, cover the body, head and neck, but not the face, with
    blankets. If the patient is awake give hot sweet drinks. Put an
    unconscious patient in the recovery position. Keep the room warm, but
    do not try to warm the patient near a fire, or with hot water bottles
    next to the body. If the patient is very cold, the pulse and breathing
    may be very slow. If breathing and the heartbeat stop completely, give
    mouth-to-mouth respiration and heart massage. Check for the pulse for
    at least one minute before starting heart massage, because it is
    dangerous to give heart massage to a very cold patient if the heart is
    still beating.

     What to do if the patient has a fever

         A patient with a temperature higher than 38.5°C, measured by
    mouth, should lie down, undressed, with no covering, in a cool place.
    If the temperature becomes very high (over 40°C) it must be lowered at
    once. Undress the patient and sponge the whole body with cool water or
    cover the body with a cold, wet sheet and keep it wet. Fan the
    patient, until the patient's temperature drops to 38.5°C. If the
    patient is awake give sips of cold water to drink. Do not give aspirin
    for fever caused by poisoning.

         Check for other causes of fever besides poisoning. The patient
    may have malaria.

     What to do if the patient has liver damage

         The signs of liver damage are given in chapter 7.

         Keep the patient resting in bed and warm. If the patient is awake
    and can swallow, mix at least two tablespoonfuls of sugar in a glass
    of water or tea and give it to the patient every 2 hours. Get the
    patient to take these drinks with bread or rice, even if he or she
    feels very sick. Do not give foods containing protein such as meat,
    fish, eggs, milk or cheese.

         If the patient is also drowsy or unconscious, this means that the
    patient is very ill.

     What to do if the patient has lung oedema

         A patient with lung oedema will not be able to breathe properly.
    This is very serious and the patient should be taken to hospital,
    where oxygen can be given.

         If the patient is unconscious put him or her in the recovery
    position. If breathing and the heartbeat stop, give mouth-to-mouth
    respiration and heart massage.

         If the patient is awake, use pillows to support the patient
    sitting up at an angle of 45°. If the patient is able, he or she can
    sit up with his or her legs over the side of the bed.

         All patients who have had lung oedema must rest in bed for at
    least 48 hours after they seem to be completely recovered.

         If the spit becomes green or yellow after an attack of lung
    oedema, the patient may have an infection of the lungs and may need an
    antibiotic.

    CHAPTER 10

    Medicines and equipment

         This chapter gives suggestions about the medicines and first aid
    equipment you might want to keep to deal with poisoning and the other
    problems described in this book.

         A poisons centre will be able to tell you which antidotes and
    antivenoms you should keep, and how to get them. If there is no
    poisons centre in your region, ask the pharmacy of your district
    hospital.

         The amount of medicines you keep will depend on how many people
    you serve and how far you have to go to get more supplies.

    How to care for medicines and first aid equipment

    1.   Keep all medicines out of the reach of children.

    2.   Be sure that all medicines are properly labelled and that the
         directions for use are kept with each medicine. Keep this book in
         the same place as the medicines.

    3.   Keep all medicines and medical supplies together in a clean, dry,
         cool place, away from light and protected from cockroaches and
         rats. Some medicines need to be kept in a refrigerator. Protect
         instruments, gauze and cotton by wrapping them in sealed plastic
         bags.

    4.   Medicine containers should be marked with an expiry date. The
         medicines should not be used after this date. Some medicines may
         be dangerous if they are used after the expiry date. Check the
         date on each medicine container before you use the medicine.
         Regularly check the medicines in your kit. If the date has passed
         or the medicine looks spoiled, destroy it and get new medicine.

    Medicines

    *    Medicines that may be useful when poisons have been swallowed
         (see Chapter 9):

    -    syrup of ipecacuanha to cause vomiting,

    -    activated charcoal to bind poison,

    -    magnesium sulfate (Epsom salts) to use as a laxative to make
         poisons move through the gut quickly; it can also be used as an
         antidote when hydrofluoric acid has been swallowed.

    *    Antidotes that can be given by a person without medical training,
         when there is no doctor:

    -    calcium gluconate gel, to put on the skin when hydrofluoric acid
         has been in contact with the skin,

    -    magnesium hydroxide, to be given by mouth when hydrofluoric acid
         has been swallowed,

    -    methionine tablets, to be given by mouth for paracetamol
         poisoning,

    -    naloxone, to be given by intramuscular injection, for opiate
         poisoning.

    *    Medicines to treat some of the effects of poisoning:

    -    aspirin, 300 mg tablets, for fever or pain,

    -    hydrocortisone cream, for itching rash caused by irritant plants,

    -    paracetamol, 500 mg tablets for adults, and paracetamol elixir
         for children, for fever or pain,

    -    rehydration drink, prepackaged mix, for dehydration,

    -    tetanus antitoxin, for use after snake bite, spider bite or fish
         sting, when there is a danger of tetanus.

    First aid equipment

         The following will be useful for dealing with patients who have
    been exposed to a poison, bitten by a snake or stung by a spider,
    insect or fish:

    -    thermometers for taking temperature in the mouth,

    -    thermometers for taking temperature in the rectum,

    -    cotton wool and dressings,

    -    bandages and sticking plaster,

    -    cups and spoons to measure accurate doses of medicine: 1 litre,
         ยด litre, 5 ml,

    -    syringes and needles (if you are trained to give injections),

    -    soap, towels, nail brush,

    -    scissors,

    -    tweezers with pointed ends,

    -    sterile bottles for keeping samples of blood, urine or vomit,

    -    sterile bags,

    -    sterile gloves,

    -    notebook, pencils and pens.

    Medicines and antidotes that can be given by doctors outside hospital

    Antidotes+

         This is not a complete list of antidotes. It includes only those
    that can be given outside hospital.

     Acetylcysteine: given by mouth in paracetamol poisoning and carbon
    tetrachloride poisoning. Acetylcysteine should be given by injection
    only in a hospital or medical centre where resuscitation can be given
    if the patient has an allergic reaction.

     Ascorbic acid: given by mouth to treat methaemoglobinaemia from
    sodium chlorate poisoning.

     Atropine: for injection in poisoning from carbamate or
    organophosphorus pesticides.

     Calcium gluconate solution: for injection under the skin when
    hydrofluoric acid has been in contact with skin.

     Deferoxamine (desferrioxamine): for injection in iron poisoning.

     Dicobalt edetate, 1.5% solution: for injection in cyanide poisoning.

     Dimercaprol (also called British anti-Lewisite (BAL) compound): for
    arsenic poisoning and lead poisoning.

     4-Dimethylaminophenol (4-DMAP), 5% solution: for injection in
    cyanide poisoning.

     DMPS (dimercaptopropanesulfonate): for arsenic poisoning
    and lead poisoning.

     Hydroxocobalamin, 40% solution: for intravenous injection in cyanide
    poisoning.

     Methylthioninium (methylene blue): for cyanosis caused by
    methaemoglobin in dapsone poisoning.

     Obidoxime chloride: for poisoning from organophosphorus pesticides.

     Penicillamine: for lead poisoning.

     Phytomenadione (vitamin K): for injection in warfarin poisoning.

     Potassium ferricyanoferrate (Prussian blue) or ferric ferrocyanide:
    for thallium poisoning.

     Pralidoxime mesilate (P-2-S) or pralidoxime chloride (PAM2): for
    poisoning from organophosphorus pesticides.

     Pyridoxine: for intravenous injection in isoniazid poisoning.

     Sodium calcium edetate: for lead poisoning.

     Sodium hydrogen carbonate (sodium bicarbonate): given by mouth with
    sodium thiosulfate to treat methaemoglobinaemia from sodium chlorate
    poisoning.

     Sodium nitrite, 3% solution: for intravenous injection in cyanide
    poisoning.

     Sodium thiosulfate, 25% solution: for intravenous injection in
    cyanide poisoning; also given by mouth, with sodium hydrogen carbonate
    (sodium bicarbonate), to treat methaemoglobinaemia from sodium
    chlorate poisoning.

     Succimer (DMSA; dimercaptosuccinic acid): for arsenic poisoning and
    lead poisoning.

     Other medicines

     Antibiotic eye ointment: when there is a risk of infection after
    burns or injury to the eye.

     Antivenoms: as appropriate for snakes, spiders, scorpions and
    stinging fish that are found in the area.

     Antihistamine such as chlorphenamine or promethazine: for
    intravenous injection, in case of allergic reactions.

     Diazepam: for injection, to treat fits.

     Diphenhydramine: for injection or for giving by mouth, for itching
    rash caused by irritant plants.

     Epinephrine (adrenaline) injection, 1 in 1000 (1 mg/ml) for
    intramuscular injection: for severe allergic reactions (for example,
    to insect stings).

     Fluorescein: to detect damage to the eye from irritant or corrosive
    poisons.

     Metoclopramide: for intravenous injection, to stop persistent
    vomiting.

     Morphine: for severe pain.

     Salbutamol: for inhalation (or theophylline for intravenous
    injection) for asthma or wheezing caused by severe allergic reactions
    (for example, to insect stings).

    PART 2

    Information on specific poisons

    Introduction

         This part gives information about the effects of poisoning by
    specific substances and what to do if you are called on to help
    someone who might have been poisoned. The substances are in four main
    groups: pesticides, chemical products used in the home, medicines, and
    natural poisons including plants and animals.

    The information in each section

         Some sections cover more than one substance if the first aid for
    poisoning is more or less the same.

         Each section is arranged in the same way so that you can find
    information quickly. The information you will find under each heading
    is as follows:

    Uses: the common uses for the substance. Abuse is also covered under
    this heading.

    How it causes harm: how a poisonous dose affects the body.

    How poisonous it is: whether the substance is likely to cause harm and
    whether the harm is likely to be severe. It is not possible to give
    exact indications because the amount that causes severe poisoning may
    differ greatly for people of different age or weight, or in different
    circumstances.

    Special dangers: any special dangers in the way the chemical is used,
    the way it looks, or the way it is packed.

    Signs and symptoms: the effects of poisoning that you can find out by
    looking, feeling, and listening, and by talking to the patient. This
    part does not include information about signs and effects that can
    only be found out using tests or equipment in hospital.

         Information about how to examine the patient and look for these
    effects is given in Part 1. Part 1 describes the signs and symptoms of
    liver damage, kidney damage and lung oedema.

         The list of signs and symptoms starts with mild effects and ends
    with severe effects. The larger the dose or the longer the person has
    been exposed, the more likely you are to see the signs and symptoms
    further down the list. The list includes the more severe signs and
    symptoms that might happen if the patient had a very large dose and
    was not given any first aid or medical treatment.

    What to do: the first aid and things that can be done outside hospital
    by people with basic first aid and nursing skills. Information is also
    given for primary health care workers who can give injections.

    Look back to Part 1 for more information about how to give first aid
    and how to look after a patient outside hospital.

    What to do if there is a delay in getting to hospital: in most cases
    the patient should go to hospital and should begin the journey at
    once, but it may take some time to get there. This part tells you what
    you can do to try to stop severe poisoning if it is going to take more
    than 3-4 hours to get to hospital.

         Before you do anything listed under this heading check that the
    patient's signs and symptoms are roughly the same as those listed.

         Additional information for doctors about clinical effects and
    treatment is given in boxes. As this book is mainly concerned with
    treatment that can be given outside hospital it does not give details
    of hospital treatment. However, some information is given to indicate
    the kind of treatment, including antidotes or antivenoms, that the
    patient may need.

    Pesticides

    Aluminium phosphide and zinc phosphide

Uses

         Aluminium phosphide and zinc phosphide are used to preserve
    grain, especially wheat, and to kill rats. Grain preservative is
    usually sold as tablets, and rat killer is sold as pellets or bait.

    How they cause harm

    When damp, phosphides release poisonous phosphine gas. When aluminium
    phosphide or zinc phosphide is swallowed, poisonous effects are due to
    phosphine released in the gut. Phosphine affects the gut, liver,
    kidneys, lungs and heart.

    How poisonous they are

         Phosphine is very poisonous. People who swallow phosphides or
    breathe in phosphine may die within a few hours. High concentrations
    of phosphine in a closed space can kill almost immediately. Low
    concentrations of phosphine may cause chronic poisoning. As aluminium
    phosphide or zinc phosphide tablets and pellets give off phosphine
    when exposed to air, the tablets themselves soon become less
    poisonous.

    Special dangers

         In some countries, anyone can buy aluminium phosphide or zinc
    phosphide rat killers, and many people use these to try to kill
    themselves. Phosphine poisoning can also happen when:

    -    people work in the holds of boats carrying cargo treated with
         phosphides;

    -    welders use acetylene containing phosphine as an impurity;

    -    people live or work near grain warehouses where phosphide is
         used.

    Signs and symptoms

         From swallowing phosphide or from breathing in phosphide dust or
    fumes

    *    Acute poisoning:

         - severe vomiting and belly pain,

         - chest pain,

         - low blood pressure,

         - signs of shock: fast weak pulse and cold wet skin,

         - unconsciousness,

         - signs of lung oedema in 6-24 hours,

         - signs of kidney and liver failure within 12-24 hours.

    *    Chronic poisoning:

         - toothache,

         - weakness,

         - loss of weight and loss of appetite,

         - changes to bones causing them to break easily, particularly the
           jaw bone (phossy jaw).

    What to do

         If there are poisonous dusts, gases or fumes, move the patient
    into fresh air. Wear breathing equipment to protect yourself from
    being poisoned.

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes and keep the patient warm.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

     If the chemical was swallowed: if the patient is fully awake and
    breathing normally, and is not vomiting, give activated charcoal and
    water to drink.

         If the patient has signs of kidney failure treat as recommended
    in chapter nine; if there are signs of liver damage treat as
    recommended in chapter nine; if there are signs of lung oedema treat
    as recommended in chapter nine.

    Information for doctors outside hospital

         As well as the effects listed above, acute poisoning may cause
         disorders of heart rhythm, and chronic poisoning may cause liver
         and kidney damage, and anaemia.

         Monitor pulse, breathing and blood pressure. Monitor liver and
         kidney function. Supportive care, including oxygen and mechanical
         ventilation, should be given as needed:

    *    Give fluids and electrolytes to replace losses due to vomiting.

    *    Treat for shock.

         There is no antidote. In chronic poisoning, blood cell counts and
         other blood tests should be done.

    Arsenic and arsenic-containing chemicals

    Chemicals covered in this section

         This section covers arsenic and chemical compounds containing
    arsenic with other substances, for example:

    arsenic trioxide         dimethylarsinic acid

    arsenic pentoxide        lead arsenate

    calcium arsenate         methylarsonic acid

    copper acetoarsenite     sodium arsenite

    Uses

         Chemicals containing arsenic are used:

    -    in farming and forestry to kill weeds, ants, termites, insects,
         rats, and mice;

    -    to protect wood from decay;

    -    in the microelectronics industry;

    -    for worming animals;

    -    in some herbal and traditional remedies: for example, arsenic
         trioxide is used in herbal medicines; in India chemicals
         containing arsenic are prescribed by Ayurvedic practitioners;
         kushtay is an Indian aphrodisiac containing arsenic (these uses
         are not recommended).

         Exposure to arsenic may occur during copper smelting and
    industrial manufacture of glass, pigments, pesticides, wood
    preservatives, and silicon chips.

    How it causes harm

         Arsenic is irritant to skin, lungs and gut. It interferes with
    life-processes in cells in many parts of the body.

    How poisonous it is

         Arsenic and chemicals containing arsenic are very poisonous if
    swallowed, breathed in or in contact with skin. A very small amount
    can kill. Chronic poisoning can occur from repeatedly swallowing
    arsenic (for example, by eating contaminated food, or taking
    traditional remedies containing arsenic) or breathing in dust or
    fumes. Arsenic can also cause cancer of the skin, lungs or liver a
    long time after exposure.

    Special dangers

         People exposed to arsenic fumes or dust are at risk of chronic
    arsenic poisoning. They should wear protective clothing and may need
    to use a respirator.

    Signs and symptoms

    Acute poisoning

    *    If swallowed

         Within 30 minutes, or after several hours if taken with food:

    -    sudden belly pain and vomiting,

    -    severe diarrhoea,

    -    sore throat,

    -    dry mouth and thirst,

    -    the breath may smell of garlic,

    -    signs of shock: weak fast pulse, cold damp skin, low blood
         pressure and blue skin,

    -    delirium and sudden unconsciousness,

    -    fits.

         The patient may die within 24 hours. If not, after 24 hours there
    may be:

    -    jaundice and signs of liver damage,

    -    signs of kidney damage,

    *    If breathed in:

    -    same effects as when swallowed, but without belly pain, vomiting
         or diarrhoea.

    *    On the skin:

    -    same effects as when breathed in,

    -    redness, blisters.

    *    In the eyes:

    -    severe irritation with pain and redness.

    Chronic poisoning

         Long-term exposure to small doses over many weeks or years, by
    swallowing or breathing in, may result in:

         - weakness,

         - loss of appetite, nausea and vomiting,

         - diarrhoea or constipation,

         - skin rash,

         - thick skin on the palms of the hands or the soles of the feet,

         - hoarse voice and sore throat,

         - sometimes the patient can taste metal, and the breath and sweat
           smell of garlic,

         - yellow skin as a result of liver damage,

         - blood in the urine as a result of kidney damage,

         - numbness or pain in the soles of the feet because the nerves
           have been damaged,

         - hair loss,

         - white lines on the nails,

         - cancer of the skin, lungs or liver.

    What to do

    Acute poisoning

         If there are poisonous dusts, gases or fumes, move the patient
    into fresh air. Wear breathing equipment to protect yourself from
    being poisoned.

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes and keep the patient warm.

     In the eyes

         Wipe the face gently with a cloth or paper to soak up chemical.
         Wash the eyes for at least 15-20 minutes with water. Check that
         there are no solid bits of chemical on the lashes or eyebrows, or
         in the folds of skin round the eyes.

     On the skin

         Immediately remove contaminated clothing, shoes, socks
         and jewellery. Do not get any of the chemical on your own skin or
         clothes or breathe in vapours. Wash the patient's skin, nails and
         hair thoroughly with soap and cold or lukewarm water, for at
         least 15 minutes, if possible using running water. If a large
         area is affected use a shower or a hand-held hose but protect the
         patient's eyes.

         If the patient has a fit, treat as recommended in chapter five.

         If the patient is awake, give water to drink, two cupfuls per
    hour for 12 hours, to replace the water lost in diarrhoea.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

     If the chemical was swallowed: if it happened less than 4 hours ago,
    and if the patient is fully awake, breathing normally, and has not had
    muscle twitching or fits:

    *    Make the patient vomit, unless he or she has already vomited a
         lot.

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until vomiting has stopped.

    Chronic poisoning

         Take the patient to hospital.

    Information for doctors outside hospital

         Monitor breathing, pulse, blood pressure, fluid and electrolyte
         balance, and liver and kidney function. Supportive care,
         including oxygen and ventilation, should be given as needed:

         *    Fluid and electrolyte balance should be corrected.

         *    Low blood pressure should be treated with intravenous fluids
              and the patient kept lying with the feet raised higher than
              the head.

         *    For repeated fits diazepam should be given by intravenous
              injection.

    Dose:     Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30
              seconds, repeated if necessary after 30-60 minutes; this may
              be followed by intravenous infusion to a maximum of 3 mg/kg
              of body weight over 24 hours.

              Children: 200-300 µg/kg of body weight.

         If the patient has symptoms, an antidote should be given as soon
    as possible. Dimercaprol can be given by deep intramuscular injection.

    Dose:     Days 1 and 2: 2.5-3 mg/kg of body weight every 4 hours.

              Day 3: 3 mg/kg of body weight every 6 hours.

              Days 4-10: 3 mg/kg of body weight every 12 hours until
              symptoms of poisoning are gone.

          Side-effects of dimercaprol: pain at the injection site, itchy
    rash, burning feeling in lips, mouth and throat, fever, headache, low
    blood pressure or high blood pressure, vomiting, and fits.

         Succimer (DMSA; dimercaptosuccinic acid) or DMPS
    (dimercaptopropane-sulfonate) can be used instead of dimercaprol if
    available. They are less toxic than dimercaprol and can be given by
    mouth. Contact a poisons centre for more information.

    Chlorophenoxyacetate weedkillers

    Chemicals covered in this section

         This section covers a group of weedkillers known as
    chlorophenoxyacetate weedkillers (sometimes shortened to phenoxy or
    chlorophenoxy weedkillers). The following list gives the commonly used
    short names and the full chemical names of some of these products:

    2,4-D               2,4-dichlorophenoxyacetic acid

    MCPA                (4-chloro-2-methylphenoxy)acetic acid

    mecoprop (MCPP)     2-(2-methyl-4-chlorophenoxy)propionic acid

    dichlorprop (DCPP)  2-(2,4-dichlorophenoxy)propionic acid

    2,4,5-T             2,4,5-trichlorophenoxyacetic acid

         Many products are mixtures of more than one of these weedkillers.

    Uses

         They are used to kill broad-leaved weeds in cereal crops,
    grassland, parks and gardens, and weeds in ponds, lakes and irrigation
    canals.

    How they cause harm

         They irritate the skin, mouth and gut, cause heat exhaustion, and
    damage the muscles, nerves and brain. Some liquid products also
    contain petroleum distillates which may cause lung oedema if
    swallowed.

    How poisonous they are

         Most cases of poisoning are a result of people swallowing large
    amounts of concentrated liquid product. Some deaths have been
    reported. These chemicals can cause harm if they are breathed in or
    brought into contact with the skin, but only if people are exposed to
    very large amounts.

    Signs and symptoms

    *    If swallowed:

    -    burning pain inside the mouth,

    -    coughing and choking if the product contains petroleum
         distillate,

    -    belly pain, vomiting and diarrhoea,

    -    fever or low temperature,

    -    confusion,

    -    muscle pain, muscle weakness and twitching,

    -    low blood pressure,

    -    fast breathing and blue skin,

    -    unconsciousness,

    -    fits.

         Death may occur within a few hours.

         If the patient survives more than a few hours:

    -    lung oedema within 12-24 hours, if the product contains petroleum
         distillates,

    -    dark urine and signs of kidney damage.

    -    signs of liver damage.

    *    On the skin:

    -    redness and irritation.

         If large areas of skin are covered:

    -    muscle pain, muscle weakness and twitching,

    -    unconsciousness.

    *    If breathed in (large doses):

    -    muscle pain, muscle weakness and twitching,

    -    unconsciousness.

    *    In the eyes:

    -    redness and irritation.

    What to do

         Give first aid. If the patient stops breathing open the airway,
    wash chemical off the patient's lips, then give mouth-to-mouth or
    mouth-to-nose respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes.

         If the patient has a fit, treat as recommended in chapter five.

         If the patient has a fever, wash the body with cool water. If the
    patient has a low temperature, keep him or her warm.

     In the eyes

         Wash the eyes with water for at least 15-20 minutes. Check that
         there are no solid bits of chemical on the lashes or eyebrows, or
         in the folds of skin round the eyes.

     On the skin

         Immediately remove contaminated clothing, shoes, socks
         and jewellery. Wash the patient's skin thoroughly with soap and
         cold water for 15 minutes, if possible using running water.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

          If the pesticide was swallowed: if it happened less than 4
    hours ago, and if the patient is fully awake, breathing normally, and
    has not had muscle twitching or fits:

    *    Make the patient vomit unless he or she has already vomited a
         lot.

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until vomiting has stopped.

         Keep the patient in a quiet place.

    Information for doctors outside hospital

    As well as the effects listed above, there may be metabolic
    acidosis, and myoglobin and blood in the urine.

    Monitor breathing, pulse, blood pressure, fluid and electrolyte
    balance. Supportive care, including oxygen and ventilation, should be
    given as needed:

    * Fluid and electrolyte balance should be corrected.

    * For repeated fits give diazepam by intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

    Give sodium bicarbonate, 10-15 g daily, to make the urine alkaline and
    increase elimination.

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

    Chemicals covered in this section

         This section covers:

    *    dinitro-o-cresol (DNOC), dinitrophenol and dinoseb  (2-sec-butyl
         4,6-dinitrophenol);

    *    pentachlorophenol, also called chlorophen, PCP, and
         pentachlorphenol;

    *    sodium pentachlorophenate, also called pentachlorphenate sodium,
         pentachlorophenoxy sodium, sodium PCP, sodium pentachlorphenate,
         sodium pentachlorophenolate, and sodium pentachlorophenoxide.

    Uses

         They are used to kill weeds, insects and fungi, and to preserve
    wood from rot and decay.

    How they cause harm

         They speed up chemical processes in the body so that the body
    overheats, causing heat stroke or heat exhaustion. They also damage
    the liver and kidney and the nervous system. Liquid products may
    contain petroleum distillates or methanol.

    How poisonous they are

         Spray, dust and fumes are poisonous if breathed in or swallowed,
    or if they come into contact with the skin. Poisoning is worse if the
    patient is hot.

    Special dangers

         People may be poisoned by breathing in fumes or spray if
    pentachlorophenol is used inside buildings where there is too little
    fresh air. It is dangerous to use these chemicals without wearing
    protective clothing to cover the body and prevent skin absorption.

    Signs and symptoms

    *    If swallowed

         Within a few hours:

    -    yellow skin, especially on the palms of the hands, and yellow
         hair, but the whites of the eyes do not turn yellow (dinitro-o-
         cresol and dinoseb only),

    -    sweating and thirst,

    -    nausea and vomiting,

    -    high fever,

    -    dehydration,

    -    tiredness,

    -    anxiety, restlessness, headache and confusion,

    -    fast deep breathing,

    -    fast pulse,

    -    bright yellow urine (dinitro-o-cresol and dinoseb only),

    -    the patient passes very little urine, as a result of kidney
         damage,

    -    fits,

    -    unconsciousness,

    -    lung oedema.

    *    On the skin:

    -    rash,

    -    same effects as when swallowed.

    *    In the eyes:

    -    severe irritation, redness and watering.

    *    If breathed in:

    -    irritation of the nose and throat,

    -    shortness of breath and chest pain,

    -    same effects as when swallowed.

    What to do

         If there are poisonous sprays, dusts, gases or fumes, move the
    patient into fresh air. Wear breathing equipment to protect yourself
    from being poisoned.

         Give first aid. If the patient stops breathing open the airway,
    wash chemical off the patient's lips, then give mouth-to-mouth or
    mouth-to-nose respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes.

         If the patient has a fit, treat as recommended in chapter five.

         If the patient is awake, give water to drink, to replace the
    water lost by sweating.

         If the patient has a fever, wash the body with cool water. Do not
    give aspirin to treat the fever.

         Keep the patient lying down and resting.

     In the eyes

         Dab the face very gently with a cloth or paper to soak up
         chemical. Wash the eyes for at least 15-20 minutes with water.
         Check that there are no solid bits of chemical on the lashes or
         eyebrows, or in the folds of skin round the eyes.

     On the skin

         Immediately remove contaminated clothes, shoes, socks and
         jewellery. Wash the skin, nails and hair thoroughly with soap and
         cold or lukewarm water for at least 15 minutes, if possible using
         running water. If a large area is affected use a shower or a
         hand-held hose but protect the patient's eyes. Do not try to
         remove all the yellow colour - it is in the skin and will not
         wash off.

         Take the patient to hospital at once. Do not let the patient
    walk, as it will quickly exhaust him or her and make the poisoning
    worse.

    What to do if there is a delay in getting to hospital

         Keep the patient lying down in a cool place.

          If the chemical was swallowed: if it happened less than 4 hours
    ago, and if the patient is fully awake, breathing normally, and has
    not had muscle twitching or fits:

    *    Give activated charcoal and water to drink.

    *    Give 2 cupfuls of water every hour for the first 24 hours.

         Do not make the patient vomit. The patient may choke on the vomit
    if he or she becomes unconscious or has a fit.

         If the patient has lung oedema, treat as recommended in chapter
    nine. If the patient has signs of liver damage, treat as
    recommended in chapter nine. If the patient has signs of kidney damage,
    treat as recommended in chapter nine.

    Information for doctors outside hospital

         As well as the effects listed above, there may be metabolic
    acidosis. Monitor breathing, pulse, blood pressure, rectal
    temperature, blood glucose, and liver and kidney function. Supportive
    care, including oxygen and ventilation, should be given as needed:

    *    Intravenous glucose or frequent meals to make sure the patient
         has a good supply of energy.

    *    Fluid and electrolyte balance and acid-base balance should be
         corrected.

    *    For repeated fits diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

    Insect repellent

    Chemicals covered in this section

         Diethyl toluamide, also called N,N-diethyl-3-toluamide or deet.

    Uses

         Diethyl toluamide is used on the skin as an insect repellent to
    prevent bites from mosquitos, fleas and biting flies. It has no effect
    against stinging insects. Products may be in the form of lotions,
    cream sticks, aerosol sprays or towelettes. The concentration may vary
    from 5% to 100%.

    How it causes harm

         It damages the brain. Repeated use on the skin may cause rashes
    and dermatitis.

    How poisonous it is

         Severe poisoning does not happen very often. It is usually a
    result of swallowing a large amount of a highly concentrated product,
    or putting too much on the skin over a period of several weeks.
    Poisoning is reported more often in children than adults, and girls
    seem more likely to be poisoned than boys. Rarely, acute poisoning may
    cause brain damage in children.

    Special dangers

         Children have been poisoned by insect repellents that were
    sprayed on their skin over several weeks, and by sleeping in beds
    sprayed with deet. Acute poisoning in children may be mistaken for a
    viral infection.

    Signs and symptoms

    *    If swallowed

         From small amounts or products containing a low concentration:

    -    nausea and vomiting,

    -    belly pain,

    -    diarrhoea.

         From large amounts of highly concentrated products, within 30
         minutes to 6 hours:

    -    unconsciousness,

    -    fits,

    -    signs of liver damage.

         Rarely, acute poisoning in children may cause brain damage with:

    -    slurred speech,

    -    staggering walk,

    -    abnormal movements of fingers and toes,

    -    trembling,

    -    fits,

    -    shallow breathing,

    -    low blood pressure,

    -    fast pulse.

    *    In the eyes:

    -    irritation, which may be severe if the product is concentrated.

    *    On the skin

         If the solution is concentrated (>50% deet):

    -    a burning feeling,

    -    blisters and ulcers.

    After repeated use:

    -    redness and rash,

    -    signs of poisoning if large amounts have been used.

    What to do

         Give first aid. If the patient stops breathing open the airway
    and give mouth-to-mouth or mouth-to-nose respiration. If the patient
    is unconscious or drowsy, lay him or her on one side in the recovery
    position, check breathing every 10 minutes and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

     In the eyes

         Wash the eyes for at least 15-20 minutes with running water.

     On the skin

         If skin contact is greater than for normal use of insect
         repellent, immediately remove contaminated clothing. Wash skin,
         nails and hair thoroughly with soap and cold or lukewarm water,
         for at least 15 minutes, if possible using running water.

         Patients who have signs and symptoms showing that a large amount
    might have been swallowed, or who have severe irritation of skin or
    eyes, should go to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

          If the chemical was swallowed: if a large amount was swallowed
    less than 4 hours ago, and if the patient is fully awake, breathing
    normally, and has not had fits:

    *    Make the patient vomit unless he or she has already vomited a
         lot.

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until vomiting has stopped. Give sodium
         sulfate or magnesium sulfate with the charcoal.

         If the patient has signs of liver damage, treat as recommended
    in chapter nine.

    Information for doctors outside hospital

         Rarely, children may develop a toxic encephalopathy. This may be
         mistaken for viral encephalitis or epilepsy.

         In severe poisoning, monitor breathing, heart, blood pressure,
         fluids and electrolytes. Supportive care, including oxygen and
         ventilation, should be given as needed:

    *    Low blood pressure should be treated with intravenous fluids.

    *    For fits, increased muscle tone, opisthotonus or tremors,
         diazepam or phenobarbital should be given.

     Dose of diazepam by intravenous injection:

    Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds, repeated
    if necessary after 30-60 minutes; this may be followed by intravenous
    infusion to a maximum of 3 mg/kg of body weight over 24 hours.

    Children: 200-300 µg/kg of body weight.

    Metaldehyde

    Uses

         Metaldehyde is used to kill snails and slugs, and as solid fuel.
    Slug and snail killers may be in the form of small pellets containing
    metaldehyde and bran, or may be a liquid that needs to be diluted
    before use. Solid fuel is made in the form of tablets.

    How it causes harm

         Metaldehyde affects the gut, the brain, the liver and the
    kidneys.

    How poisonous it is

         Metaldehyde is poisonous if swallowed. The pellets used for
    killing slugs and snails usually contain very little metaldehyde (less
    than 5%) and do not usually cause severe poisoning. Metaldehyde liquid
    and solid fuel tablets contain a higher concentration and can cause
    severe poisoning and possibly death.

    Special dangers

         Metaldehyde pellets are often sold in packs that are easy for
    children to open. The pellets are put on top of the soil and children
    may pick them up.

    Signs and symptoms

    *    If swallowed

         Effects are usually seen within three hours, but may be delayed
         for up to 48 hours:

    -    nausea, vomiting and belly pain,

    -    wet mouth,

    -    flushed face,

    -    fever,

    -    drowsiness,

    -    fast pulse,

    -    trembling,

    -    muscle twitching and fits,

    -    unconsciousness.

    After 2-3 days:

    -    jaundice and signs of liver damage,

    -    the patient passes very little urine showing that the kidneys are
         damaged.

    What to do

         If the patient has swallowed only one or two pellets of slug bait
    containing less than 5% metaldehyde, there is no need to do anything.
    If the patient has swallowed more than this, proceed as follows.

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the chemical was swallowed less than 4 hours ago, and if the
    patient is fully awake and breathing normally, and has not had muscle
    twitching or fits:

    *    Make the patient vomit, unless he or she has already vomited a
         lot.

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until he or she has stopped vomiting.

         If the patient has signs of liver damage, treat as recommended
    in chapter nine. If the patient has signs of kidney damage, treat as
    recommended in chapter nine.

    Information for doctors outside hospital

         Monitor pulse, breathing, blood pressure and liver function.
         Supportive care, including oxygen and ventilation, should be
         given as needed. For repeated fits diazepam should be given by
         intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

    Organochlorine pesticides

    Pesticides covered in this section

         There are many organochlorine pesticides. Some of the more well
    known ones are aldrin, chlordane, DDT, dieldrin, endosulfan, endrin,
    and lindane (also known as gamma benzene hexachloride or gamma-HCH).

    Uses

         Organochlorine pesticides are widely used in agriculture, and to
    control disease-carrying insects such as malaria mosquitos. Lindane is
    also used to kill fleas, head lice, snails and slugs, and is sprayed
    on seeds to stop insects eating them.

         Products may be dusts, wettable powders, pellets or liquids. Some
    products are burnt to make smoke that kills insects. Products for
    killing head lice are made as lotions or shampoos.

    How they cause harm

         They affect the brain and breathing. Liquid products may also
    contain solvents such as petroleum distillates which may cause lung
    oedema if swallowed.

    How poisonous they are

         Organochlorine pesticides are poisonous if they are swallowed,
    breathed in, or brought into contact with the skin. The poisonous
    amount varies a lot between individual pesticides. Aldrin, dieldrin,
    endrin and endosulfan are more poisonous than chlordane, DDT and
    lindane.

    Special dangers

         People may be poisoned if they do not wash after using the
    pesticide, or if they go into houses that are being sprayed. Lindane
    shampoo can cause poisoning in young children if too much is used or
    if it is used too often. People have been poisoned by eating food
    contaminated with these chemicals.

    Signs and symptoms

         Effects usually begin after 1-6 hours. Poisoning with DDT may be
    delayed for up to 48 hours.

    *    If swallowed:

    -    vomiting, diarrhoea and belly pain,

    -    anxiety, excitement and weakness,

    -    headache and dizziness,

    -    shaking and trembling,

    -    fits,

    -    unconsciousness,

    -    fast breathing, blue skin and signs of lung oedema, if the
         product contains petroleum distillates.

    *    If breathed in:

    -    burning of the eyes, nose or throat,

    -    anxiety, excitement and weakness,

    -    headache and dizziness,

    -    shaking and trembling,

    -    fits,

    -    unconsciousness.

    *    In the eyes:

    -    irritation may occur.

    * On the skin:

    - irritation and rash may occur,

    - same effects as if breathed in.

    What to do

         If there are poisonous dusts, gases or fumes, move the patient
    into fresh air. Wear breathing equipment to protect yourself from
    being poisoned.

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes, and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         If the chemical has been swallowed do not give milk to drink, or
    anything fatty or oily by mouth.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water. Check that
         there are no solid bits of chemical on the lashes or eyebrows, or
         in the folds of skin round the eyes.

     On the skin

         Immediately remove contaminated clothes, shoes, socks and
         jewellery. Wash the skin, nails and hair thoroughly with soap and
         cold or lukewarm water for at least 15 minutes, if possible using
         running water.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

          If the chemical was swallowed: if it happened less than 4 hours
    ago, and if the patient is fully awake, breathing normally, and has
    not had fits:

    *    Make the patient vomit, unless he or she has already vomited a
         lot.

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until vomiting has stopped. Give sodium
         sulfate or magnesium sulfate with the charcoal.

         If the patient has signs of lung oedema, treat as recommended
    in chapter nine.

    Information for doctors outside hospital

         These chemicals affect respiratory control, muscle activity and
         heart rhythm. Monitor pulse, breathing and blood pressure.
         Supportive care, including oxygen and ventilation, should be
         given as needed. For repeated fits diazepam should be given by
         intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         There is no antidote. Dialysis, haemoperfusion, and diuresis are
    not useful.

    Organophosphorus and carbamate insecticides

    Insecticides covered in this section

         This section covers organophosphorus and carbamate insecticides.
    Some are listed below.

    Organophosphorus insecticides:

    azinphos-methyl          fenthion

    bromophos-ethyl          formothion

    bromophos                heptenophos

    carbophenothion          jodfenphos (iodofenphos)

    chlorfenvinphos          malathion

    cythioate                mevinphos

    demeton-S-methyl         parathion-methyl

    diazinon                 phorate

    dichlorvos               phosmet

    dimethoate               phoxim

    fenitrothion             pirimiphos methyl

    Carbamate insecticides:

    aldicarb                 methiocarb

    bendiocarb               methomyl

    carbaryl                 pirimicarb

    carbofuran               propoxur

         These insecticides may be in the form of dusts, granules or
    liquids. Some products need to be diluted with water before use, and
    some are burnt to make smoke that kills insects.

    Uses

         They are widely used in agriculture and in the home to kill
    insect pests. They are also used to kill malaria mosquitos and insect
    parasites living on humans or domestic animals.

    How they cause harm

         They poison the nerves that control glands, muscles, breathing
    and the brain. Although the clinical effects of the two groups are the
    same, organophosphorus insecticides do not affect the body in exactly
    the same way as carbamate insecticides, and there are some differences
    in the antidotes used to treat poisoning. Some products contain
    petroleum distillates, toluene or xylene, which may cause lung oedema.

    How poisonous they are

         They may cause serious poisoning and death if they are breathed
    in or swallowed, or come into contact with the skin or eyes. They
    differ widely from one another in the amount that causes poisoning.
    Serious poisoning may occur at lower doses in people who are re-
    exposed within a few weeks or months.

         Carbamate insecticides cause less severe poisoning than
    organophosphorus insecticides.

    Signs and symptoms

         Effects may occur very quickly or be delayed for up to 12 hours.

    *    If swallowed, breathed in, or on the skin:

    -    confusion, weakness and exhaustion,

    -    headache,

    -    nausea, vomiting, belly pains and diarrhoea,

    -    cold sweating, wet mouth,

    -    tightness in the chest,

    -    twitching eyelids and tongue, later twitching over the rest of
         the body,

    -    irregular or shallow breathing,

    -    slow pulse,

    -    small pupils,

    -    fits,

    -    unconsciousness,

    -    lung oedema,

    -    incontinence.

    *    In the eyes:

    -    irritation, watering and blurred vision,

    -    same effects as if swallowed or breathed in.

    What to do

         If there are poisonous dusts, gases or fumes, move the patient
    into fresh air. Wear breathing equipment and protective clothing to
    protect yourself from being poisoned.

         Give first aid. If the patient stops breathing open the airway,
    wash chemical off the patient's lips then give mouth-to-mouth or
    mouth-to-nose respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

     In the eyes

         Dab the face very gently with a cloth or paper to soak up
         chemical. Wash the eyes for at least 15-20 minutes with water.
         Check that there are no solid bits of chemical on the lashes or
         eyebrows or in the folds of skin round the eyes.

     On the skin

         Immediately remove contaminated clothes, shoes, socks and
         jewellery. Be careful not to get any of the chemical on your own
         skin or clothes, or to breathe in vapours.

         Wash the patient's skin, nails and hair thoroughly with soap and
         cold or lukewarm water for at least 15 minutes, if possible using
         running water. If a large area is affected use a shower or a
         hand-held hose, but protect the patient's eyes.

         Make the patient lie down and rest. The poisoning may get worse
    if the patient moves around.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting the patient to hospital

          If the chemical was swallowed: if it happened less than 4 hours
    ago, and if the patient is fully awake, breathing normally, has not
    had muscle twitching or fits, and is not vomiting, give activated
    charcoal and water to drink.

         If the patient has signs of lung oedema, treat as recommended
    in chapter nine.

    After the patient has recovered

         The body chemistry may take weeks or months to recover, even
    though the patient seems well again. A person who is re-exposed before
    the body has properly recovered from the first exposure may be very
    seriously poisoned by a dose that would not normally cause harm.
    People who have been poisoned with organophosphorus pesticides should
    not work with them again until they have been examined by a doctor who
    understands this problem.

    Information for doctors outside hospital

         As well as the effects listed above, there may be weakness of the
    muscles used in breathing, bronchospasm, and accumulation of fluid in
    the air passages and lungs.

         Monitor pulse, breathing, blood pressure and fluid loss.
    Supportive care, including oxygen and ventilation, should be given as
    needed:

    *    Secretions should be cleared from the airway.

    *    Fluid and electrolyte balance should be corrected.

    *    Diazepam can be given by intravenous injection to relieve anxiety
         and control fits.

     Dose: Adults: 10-20 mg repeated as needed.

    Children: 0.25-0.4 mg/kg of body weight repeated to a maximum dose of
    5 mg in children aged 1 month to 5 years, and to a maximum dose of
    10 mg in children aged more than 5 years.

         Antidotes should be given if there are signs of poisoning.
    Organophosphorus and carbamate insecticides act in slightly different
    ways, so pralidoxime, which is used to treat organophosphorus
    insecticide poisoning is not used to treat poisoning by carbamate
    insecticides.

     For both organophosphorus and carbamate insecticides

         Give atropine immediately by intravenous injection, until the
    patient's mouth becomes dry, the heart rate is more than 100 beats per
    minute, and the pupils are dilated.

     Dose: Adults: give a first dose of 2-4 mg. If the patient's mouth is
    still wet repeat this dose every 10 minutes until the mouth is dry.

    Children: give 0.05 mg/kg of body weight repeated every 10 minutes
    until the mouth is dry.

         Keep watching the patient. Repeat the dose as needed to correct
    wheezing and excess salivation. Patients may die if they are not given
    enough atropine. Large amounts may be needed for several days.

     For organophosphorus (but not carbamate) insecticides

         In severe cases and in cases that do not respond to atropine,
    give pralidoxime mesilate (P-2-S) or chloride (PAM2) in addition to
    atropine, to reactivate the enzyme inhibited by the insecticide. It
    may be given at the same time as atropine.

     Dose: 30 mg per kg of body weight by slow intravenous injection over
    5-30 minutes every 4-6 hours. It can be given intramuscularly if an
    intravenous dose cannot be given. Obidoxime chloride can be used if
    pralidoxime is not available.

    Paraquat

    Use

         Paraquat is used as a weedkiller. It is usually sold as a liquid,
    containing a 20% concentration of paraquat, which must be diluted
    before use. In some countries a granular solid product is also
    available for domestic garden use. This contains 2.5% paraquat and
    2.5% diquat, and is mixed with water before use.

    How it causes harm

         Paraquat damages the lungs, liver and kidneys. The 20% solution
    is corrosive.

    How poisonous it is

         Paraquat is very poisonous if swallowed. One mouthful of the 20%
    liquid may result in death from lung damage within 1-4 weeks. Larger
    amounts may cause death within 12 hours.

         Skin contact is unlikely to cause poisoning, unless contaminated
    clothes are worn for several hours, or a large amount of concentrated
    paraquat is in contact with damaged skin, or the patient is a child.
    Breathing in paraquat spray may irritate the nose and throat but is
    unlikely to cause poisoning.

    Special dangers

         Many poisonings have happened by accident when paraquat has been
    stored in bottles that previously held beer, wine or soft drinks. This
    is a dangerous way to store any poison, as other people may drink from
    the bottles by mistake, but it may be quite common in places where
    liquid paraquat is supplied only in large containers. People with
    small farms or gardens, who only want to buy small amounts, may take a
    small amount from the large container and put it into other
    containers. Pesticide sprayers can be severely poisoned if they
    swallow paraquat while trying to clear blocked spray pipes. Wearing
    clothes contaminated with liquid paraquat for several hours may result
    in absorption of a poisonous amount.

    Signs and symptoms

    *    If swallowed:

    -    vomiting and belly pain,

    -    diarrhoea, often bloody.

         After ingestion of large amounts, severe effects occur within a
    few hours:

    -    drowsiness, weakness, giddiness and headache,

    -    fever,

    -    unconsciousness,

    -    cough and irregular breathing,

    -    lung oedema within a few hours.

         The patient may die within 12 hours.

         After ingestion of smaller amounts, severe effects develop after
    24-48 hours:

    -    sore mouth and throat after 24-48 hours,

    -    in some cases there are white ulcers in the mouth and throat, the
         lining of the mouth and throat peels off, there is pain on
         swallowing, and the mouth is wet because the patient cannot
         swallow saliva,

    -    shortness of breath as lung disease develops,

    -    in some cases the patient passes very little urine, showing that
         the kidneys are damaged,

    -    in some cases, jaundice and signs of liver damage develop.

         Death may occur after 2-4 weeks from lung disease.

    *    On the skin

         Contact with the 20% paraquat solution may cause inflammation and
    blisters; nails may crack and fall off.

         Large amounts in contact with damaged skin for many hours may
    result in:

    -    shortness of breath as a result of lung disease,

    -    in some cases the patient passes very little urine, showing that
         the kidneys are damaged,

    -    in some cases, jaundice and signs of liver damage develop.

         The patient may die from lung disease.

    *    In the eyes:

    -    severe inflammation from the 20% paraquat solution, but the eyes
         recover completely if properly treated.

    *    If breathed in

         Spray or dust may make the nose bleed.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes and keep the patient warm.

     If swallowed

Do not give anything by mouth if the patient has bad ulcers
    inside the mouth, because the patient will probably not be able to
    swallow.

         For severe pain in the mouth, give mouthwashes or use local
    anaesthetic sprays. If the patient can swallow give ice-cold water or
    ice cream.

         If the chemical was swallowed less than 4 hours ago, and if the
    patient is fully awake, is not vomiting and can swallow, give
    activated charcoal and water to drink. Give sodium sulfate or
    magnesium sulfate with the charcoal.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water. Check that
    there are no solid bits of chemical on the lashes or eyebrows, or in
    the folds of skin round the eyes.

     On the skin

         Immediately remove contaminated clothes, shoes, socks and
    jewellery. Be careful not to get any of the chemical on your own skin
    or clothes. Wash the patient's skin, nails and hair thoroughly with
    soap and cold or lukewarm water for at least 15 minutes, if possible
    using running water.

    Take the patient to hospital as quickly as possible.

    What to do if there is a delay getting the patient to hospital

         If the chemical was swallowed, and if the patient is fully awake,
    breathing normally, and can swallow, give two cupfuls of water to
    drink every hour.

         If the patient has signs of lung oedema, treat as recommended
    in chapter nine.

    Information for doctors outside hospital

         Supportive care should be given as needed:

         - intravenous fluids,

         - morphine for pain.

         Oxygen may make lung damage worse, so do not give it unless the
    patient is distressed. Patients who are unlikely to recover can be
    given oxygen if it makes them more comfortable.

         There is no successful treatment for moderate or severe paraquat
    poisoning.

    Phenol and related substances

    Chemicals covered in this section

         This section covers phenol (also called carbolic acid), creosote
    (also called wood tar or coal tar), and cresol.

    Uses

         Phenol and cresol are used as disinfectants and antiseptics.
    Creosote is used as a wood preservative.

    How they cause harm

         These chemicals are corrosive but do not cause such bad burns as
    strong acids or alkalis. They affect the heart, the brain, breathing,
    the liver and the kidneys.

    How poisonous they are

         They are poisonous if swallowed or breathed in or absorbed
    through the skin. Exposure to large amounts may cause death.

    Signs and symptoms

    *    If swallowed:

    -    burns round mouth and inside mouth and throat,

    -    vomiting and diarrhoea,

    -    fast breathing at first,

    -    weak fast pulse,

    -    low blood pressure,

    -    unconsciousness,

    -    fits,

    -    signs of kidney failure: the patient passes very little urine
         and the urine is dark,

    -    signs of liver damage,

    -    lung oedema.

         The effects on heart and breathing may cause death.

    *    If breathed in:

    -    same effects as if swallowed, but without burning in the mouth
         and throat, vomiting or diarrhoea.

    *    In the eyes:

    -    severe pain, redness and watering,

    -    blindness.

    *    On the skin:

    -    chemical burns, which are usually painless,

    -    skin looks white and wrinkled (with cresol, skin looks red),

    -    same effects as if swallowed, but without burning in the mouth
         and throat, vomiting or diarrhoea.

    What to do

         Give first aid. If the patient stops breathing open the airway,
    wash chemical off the patient's lips then give mouth-to-mouth or
    mouth-to-nose respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes, and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

     In the eyes

         Dab the face very gently with a cloth or paper to soak up
    chemical. Wash the eyes for at least 15-20 minutes with water.

     On the skin

         Immediately remove contaminated clothes, shoes, socks and
    jewellery. Be careful not to get any of the chemical on your own skin
    or clothes. Wash the patient's skin, nails and hair thoroughly with
    soap and cold or lukewarm water for at least 15 minutes, if possible
    using running water. If a large area is affected use a shower or a
    hand-held hose but protect the patient's eyes.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the chemical was swallowed less than 4 hours ago, and if the
    patient is fully awake and is not having fits, give activated charcoal
    and water to drink. Do not make the patient vomit.

         If the patient has signs of lung oedema treat as recommended in
    chapter nine. If the patient has signs of kidney failure, treat as
    recommended in chapter nine.

    Information for doctors outside hospital

         As well as the effects listed above, these chemicals may cause
    corrosive injury to the gut, metabolic acidosis, heart rhythm
    disturbances, and methaemoglobinaemia.

         Monitor breathing, pulse and blood pressure. Supportive care,
    including oxygen and ventilation, should be given as needed:

    *    Low blood pressure should be treated with intravenous fluids.

    *    For repeated fits diazepam should be given by intravenous
         injection.

    Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

    There is no antidote.

    Pyrethrins and pyrethroid insecticides

    Chemicals covered in this section

         Pyrethrins are natural insecticides extracted from chrysanthemum
    plants; pyrethroids are manufactured insecticides with similar
    chemical structures.

         Pyrethrum and piperonyl butoxide are pyrethrins. The following
    chemicals are pyrethroids: bioresmethrin, cypermethrin, deltamethrin,
    fenvalerate, permethrin and resmethrin.

    Uses

         These chemicals are used in household insecticide sprays and some
    mosquito coils and mats. They are also used to control insect pests in
    places where food such as grain and flour is stored, and in
    agriculture, on vegetables, fruit trees and shrubs. They are sold as
    liquids, sprays, dusts and powders.

    How they cause harm

         They are irritant to the lungs and may affect the brain.

    How poisonous they are

         Pyrethrin and pyrethroid insecticides are not very poisonous to
    humans if swallowed, spilt on the skin or breathed in. They sometimes
    cause allergic reactions. Severe poisoning happens rarely, if a large
    amount of concentrated product is swallowed.

    Signs and symptoms

    *    If swallowed:

    -    nausea and vomiting,

    -    rarely, fits may occur after a very large dose.

    *    On the skin:

    -    irritation,

    -    skin rash and blistering.

    *    If breathed in:

    -    runny nose and sore throat,

    -    some people may get wheezing, sneezing, and shortness of breath.

    *    In the eyes:

    -    some may cause severe irritation.

    *    Allergic reactions:

    -    shock: pale skin, sweating, fast weak pulse,

    -    wheezing and shortness of breath.

    What to do

     If the patient has an allergic reaction

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         Put the patient flat on his or her back, with the head turned to
    one side, and the legs raised higher than the head (by resting the
    feet on a box, for example). This will help the blood to reach the
    brain and lessen the danger of vomit blocking the airway.

         A patient with an allergic reaction should go to hospital as soon
    as possible.

         If the patient has a fit, treat as recommended in chapter five.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water. Check that
    there are no solid bits of chemical on the lashes or eyebrows, or in
    the folds of skin round the eyes. If there is severe irritation take
    the patient to hospital.

     On the skin

         Immediately remove contaminated clothes, shoes, socks and
    jewellery. Be careful not to get any of the chemical on your own skin
    or clothes. Wash the patient's skin, nails and hair thoroughly with
    soap and cold or lukewarm water for at least 15 minutes, if possible
    using running water.

     Information for doctors outside hospital

     If the patient has a severe allergic (anaphylactic) reaction

         Give oxygen by face-mask in as high a concentration as possible.
    Insert an airway if the patient is unconscious.

         Give epinephrine (adrenaline), 1 in 1000 (1 mg/ml) as soon as
    possible by intramuscular injection, unless there is a strong central
    pulse and the general condition is good. Any delay may be fatal.

     Dose:

    Age                 Volume of epinephrine, 1 in 1000

    <1 year             0.05 ml

    1 year              0.1 ml

    2 years             0.2 ml

    3-4 years           0.3 ml

    5 years             0.4 ml

    6-12 years          0.5 ml

    Adults              0.5-1 ml

         These doses may be repeated every 10 minutes until blood pressure
    and pulse improve. Doses should be reduced for underweight children.

         It is useful to give antihistamines such as chlorphenamine or
    promethazine, by slow intravenous injection, after the epinephrine, to
    treat skin rash, itching or swelling and prevent relapse.

         If the patient does not get better, supportive care should be
    given as needed:

    -    oxygen and ventilation,

    -    intravenous fluids,

    -    inhaled salbutamol or intravenous theophylline may be useful for
         asthma or wheezing.

    Rat poisons

         Many different chemicals can be used to kill rats, mice and other
    small rodents:

    -    aluminium phosphide,

    -    arsenic,

    -    strychnine,

    -    thallium,

    -    warfarin and other chemicals that have the same effect
         (brodifacoum, bromadiolone, chlorophacinone, coumafuryl,
         difenacoum).

    Sodium chlorate

    Uses

         Sodium chlorate is used as a weedkiller, in match heads and in
    fireworks. It has sometimes been used in mouthwashes, but this is not
    recommended.

    How it causes harm

         It stops blood carrying oxygen and damages the liver and kidneys.
    It also irritates the skin and eyes.

    How poisonous it is

         It is poisonous if swallowed. People have died after swallowing
    2-3 teaspoonfuls.

    Special dangers

         It looks like white crystals and may be mistaken for sugar or
    salt if it is put in a food container, or kept in a place where food
    is normally kept.

    Signs and symptoms

    *    If swallowed:

    -    nausea, vomiting, diarrhoea and belly pain,

    -    shallow breathing,

    -    unconsciousness,

    -    fits,

    -    the skin and the inside of the lower eyelids turn a blue colour,

    -    the patient stops passing urine and has signs of kidney damage

    -    death may occur within a few hours.

    *    On the skin:

    -    irritation,

    -    redness,

    -    ulcers and burns.

    *    In the eyes:

    -    irritation,

    -    redness of the eyelids,

    -    ulcers and burns.

    What to do

         Give first aid. If the patient stops breathing open the airway,
    wash chemical off the patient's lips, then give mouth-to-mouth or
    mouth-to-nose respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes, and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water. Check that
    there are no solid bits of chemical on the lashes or eyebrows or in
    the folds of skin round the eyes.

     On the skin

         Immediately remove contaminated clothes, shoes, socks and
    jewellery. Wash the skin, nails and hair thoroughly with soap and cold
    or lukewarm water for at least 15 minutes, if possible using running
    water.

         Patients who have swallowed the chemical, or who have burns in
    the eyes or on the skin, should go to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the chemical was swallowed less than 4 hours ago and if the
    patient is fully awake and breathing normally, has not had muscle
    twitching or fits, and is not already vomiting, make the patient
    vomit.

         If the patient has signs of kidney damage, treat as recommended
    in chapter nine.

    Information for doctors outside hospital

         As well as the effects listed above, there may be blood disorders
    including methaemoglobinaemia and intravascular haemolysis, high serum
    potassium concentration, and protein and haemoglobin in the urine.

         Monitor pulse, breathing and blood pressure. Supportive care,
    including oxygen and ventilation, should be given as needed:

    *    Fluid and electrolyte balance should be corrected.

    *    For repeated fits diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         There are two chemicals that have been used as antidotes. It may
    be useful to give one of these.

    1.   Sodium thiosulfate. This is said to work by changing chlorate
         into chloride, which is less poisonous, but there is some doubt
         about how useful it is.

     Dose: 2-5 g of sodium thiosulfate in 200 ml of 5% sodium bicarbonate
         given as a drink.

    2.   Ascorbic acid. This is said to change methaemoglobin back to
         haemoglobin, but it works very slowly.

     Dose: 1 g every 4 hours given as a drink, or by slow intravenous
         injection.

         In severe poisoning the most useful treatment is exchange
    transfusion together with haemodialysis.

    Strychnine

         Strychnine is made from the seeds of the tree called  Strychnos
     nux-vomica.

    Uses

         Strychnine is used to kill rats, mice, and other animals. It used
    to be used in medicines such as tonics and laxatives but this is not
    recommended. In India,  kuchlla, a product for killing dogs, contains
    strychnine.

    How it causes harm

         If affects the nerves that control the muscles.

    How poisonous it is

         Strychnine is extremely poisonous if swallowed and works very
    quickly. Quite small amounts can cause death, but some patients
    recover if treated in hospital. It does not pass through the skin.

    Special dangers

         Most cases of poisoning happen when people try to kill
    themselves. Accidental poisoning is unusual.

    Signs and symptoms

    *    If swallowed

         After about 15 minutes:

    -    numbness and stiffness of face and neck,

    -    fear,

    -    muscle twitching,

    -    painful fits and muscle spasms lasting 1-2 minutes, occurring
         every 5-10 minutes; the arms and legs are stretched out and the
         body is arched so that it is supported only by the head and feet,

    -    the eyes bulge,

    -    the patient is usually fully awake,

    -    breathing is difficult and may stop when the patient is having a
         fit; the skin is blue,

    -    high temperature,

    -    signs of kidney damage.

    What to do

         Give first aid. If the patient stops breathing open the airway,
    wash chemical off the patient's lips then give mouth-to-mouth or
    mouth-to-nose respiration.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes and
    keep the patient warm.

         Keep the patient as quiet and still as possible, because movement
    may set off fits.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         Keep the patient in a quiet, dark room.

         Do not make the patient vomit because vomiting may set off fits.

         If the patient has no signs or symptoms, give activated charcoal
    and water to drink.

    Information for doctors outside hospital

         Repeated fits may cause high temperature, rhabdomyolysis (muscle
    breakdown) and kidney failure.

         Supportive care should be given as needed:

    *    Oxygen and ventilation may be needed during fits.

    *    For repeated fits diazepam should be given by intravenous
         injection; if this fails the patient may need to be paralysed and
         ventilated.

     Dose of diazepam:

    Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds, repeated
    if necessary after 30-60 minutes; this may be followed by intravenous
    infusion to a maximum of 3 mg/kg of body weight over 24 hours.

    Children: 200-300 µg/kg of body weight.

    Thallium

    Uses

         Thallium salts are used to kill rats, mice and other rodents, and
    ants, but in many countries they are banned from being sold as a
    pesticide. They have been used as a cream for removing body hair but
    this is not recommended. They are widely used in industry.

    How it causes harm

    Thallium affects the gut, nerves, skin and hair.

    How poisonous it is

         Thallium salts are very poisonous if they are swallowed or
    brought into contact with the skin. Exposure to small amounts over
    many weeks, by swallowing, skin contact or breathing in metal fumes,
    can cause chronic poisoning.

    Special dangers

         Thallium rat bait made with grain, biscuit crumbs or honey may be
    mistaken for food. Industrial workers may get chronic poisoning from
    breathing in fumes or dust, or from handling chemicals without wearing
    gloves.

    Signs and symptoms

    Acute poisoning

    *    If swallowed

         Effects appear slowly over 2-3 days:

    -    belly pain, nausea, vomiting and constipation,

    -    pain or numbness in the fingers and toes,

    -    tiredness,

    -    fits.

         After about 7 days:

    -    pain or numbness in the soles of the feet so that the patient
         cannot stand or move,

    -    dizziness,

    -    drooping eyelids,

    -    fever,

    -    jumbled speech and confused behaviour,

    -    trembling, strange movements of the arms and legs,

    -    signs of kidney damage.

         After 10-14 days:

    -    hair starts falling out.

         Death may occur up to five weeks after swallowing thallium.

    Chronic poisoning (from swallowing, skin exposure or breathing in
    fumes):

    -    hair falls out leaving bald patches,

    -    wet mouth,

    -    blue line on the gums,

    -    nausea, vomiting, belly pain and constipation,

    -    pain or numbness in the arms and legs.

    What to do

         Give first aid. If the patient has a fit, treat as recommended
    in chapter five.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water. Check that
    there are no solid bits of chemical on the lashes or eyebrows, or in
    the folds of skin round the eyes.

     On the skin

         Immediately remove contaminated clothes, shoes, socks and
    jewellery. Wash the skin, nails and hair thoroughly with soap and cold
    or lukewarm water for at least 15 minutes, if possible using running
    water.

         Take the patient to hospital.

    What to do if there is a delay in getting to hospital

         If the chemical was swallowed less than 4 hours ago, and if the
    patient is fully awake and breathing normally, and has not had muscle
    twitching or fits:

    *    Make the patient vomit unless the patient has already
         vomited a lot.

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until vomiting has stopped.

    Information for doctors outside hospital

         Monitor breathing, blood pressure, pulse, and liver and kidney
    function. Supportive care, including oxygen and ventilation, should be
    given as needed. For repeated fits diazepam should be given by
    intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         The antidote is potassium ferricyanoferrate (Prussian blue). If
    potassium ferricyanoferrate is not available, ferric ferrocyanide can
    be used instead. Contact a poisons centre to find out if the antidote
    is available.

          Dose: 250 mg/kg of body weight per day divided into four doses,
    by mouth or through a stomach tube, until the concentration of
    thallium in the urine is less than 0.5 µg over a 24-hour-period. The
    antidote may cause constipation so give a mild purgative (e.g. 50 ml
    of 15% sorbitol) with each dose.

         Haemodialysis should be carried out if there is kidney failure.

    Warfarin and other pesticides that stop blood clotting

    Chemicals covered in this section

         This section covers coumafuryl, warfarin and the "superwarfarins"
    (brodifacoum, bromadiolone, chlorophacinone and difenacoum).

    Uses

         These chemicals are used to kill rats and mice. The chemicals are
    usually mixed with corn, or made into pellets to make a bait that is
    often coloured blue or green so that people can see it is not food.
    Warfarin is also used as a medicine to stop blood clotting.

         For information on other chemicals sometimes used to kill rats
    and mice see Part Two (Rat poisons).

    How they cause harm

         These chemicals stop the blood clotting. This can lead to
    bleeding inside the body.

    How poisonous they are

          Warfarin, coumafuryl: swallowing a small amount is unlikely to
    have an effect. Repeated doses taken over several days or weeks may
    cause serious poisoning or even death. Doctors who prescribe long-term
    treatment with warfarin medicine should check the patient's blood
    clotting.

          Brodifacoum, bromadiolone, chlorophacinone and difenacoum:
    swallowing one dose may cause signs of poisoning, and the effects of
    poisoning may be severe and last for some time.

    Special dangers

         Rat poisons are often put on the ground in open dishes where they
    are easily found by children.

    Signs and symptoms

    *    If swallowed

         After 12-48 hours, any of these may occur:

    -    bleeding from cuts takes longer to clot than usual,

    -    bruising and skin rashes,

    -    blood in urine,

    -    patient coughs up blood,

    -    blood in the stools showing that there is bleeding inside the
         gut,

    -    back or belly pain.

         For warfarin and coumafuryl: the effects last 3-4 days.

         For brodifacoum, difenacoum, bromadiolone and chlorophacinone:
    the effects may last for weeks or months.

    What to do

         If the patient has swallowed just a few mouthfuls of rat bait
    containing warfarin or coumafuryl, there is no need to do anything. If
    you think the patient may have taken more than this, or if you do not
    know what the rat poison contains, take the patient to hospital as
    soon as possible.

     What to do if there is a delay in getting to hospital

         If the chemical was swallowed less than 4 hours ago and the
    patient is fully awake and breathing normally:

    *    Make the patient vomit. If the patient has been taking warfarin
    as a medicine, do not make the patient vomit, because this may cause
    bleeding in the gut.

    *    Give activated charcoal with water to drink. If you have made the
    patient vomit, wait until vomiting has stopped.

    Information for doctors outside hospital

         To stop active bleeding quickly, transfusions of either whole
    blood or fresh frozen plasma should be given. Blood clotting time or
    prothrombin time and full blood count should be monitored if possible.

          Brodifacoum, difenacoum, bromadiolone and chlorophacinone: even
    if there are no signs or symptoms, or if poisoning is mild,
    prothrombin time ratios should be measured after 24, 48 and 72 hours.

         The antidote is phytomenadione (vitamin K1). This brings the
    prothrombin time back to normal again and stops bleeding. It should
    restore the prothrombin time to normal within 12-36 hours, but regular
    daily doses may be needed for several weeks depending on which
    chemical was taken in overdose.

          Dose: For severe poisoning: a slow intravenous infusion of
    phytomenadione in 9 g/l (0.9%) sodium chloride solution or glucose.
    Adults: 100-200 mg per day may be needed for several days or weeks.
    Doses can be given every 6-8 hours. Prothrombin times should be tested
    frequently until they are normal; this may take weeks or months in
    severe cases.

         If blood clotting time or prothrombin time is longer than normal,
    but effects are not severe, give phytomenadione by intramuscular
    injection.

          Dose: adults: 5-10 mg; children: 1-5 mg.
    
INTOX Home Page


    Chemicals and chemical products used in the home and the workplace

    Aerosol sprays

    Chemicals covered in this section

         Aerosol sprays, sometimes called pressure packs, are metal cans
    containing chemicals under pressure, which form a cloud of tiny
    droplets when released from the can. This section covers the chemicals
    used as propellants to carry the active chemicals out of the can.
    Butane, propane, or chlorofluorocarbons may be used.

    Uses

         Many products in the home, such as window cleaner, furniture
    polish, air freshener, oven cleaner, hair spray, deodorant and
    insecticides, are sold in spray cans. Aerosol abuse is common in many
    countries: the spray is breathed in deeply and causes a "high" or
    feeling of euphoria.

    How they cause harm

         Butane, propane and chlorofluorocarbons quickly affect the heart
    if breathed in deeply, as happens when people abuse aerosols. (The
    active chemicals in the aerosol may be irritant, corrosive or
    poisonous and may also cause harm.)

    How poisonous they are

         Abuse of aerosols may cause sudden death as a result of the
    effect of the propellants on the heart. Aerosol abuse is habit-forming
    and may lead to dependence. People exposed to aerosols during ordinary
    use, or by accident, are unlikely to be harmed by the propellant. The
    effects of the active chemicals, which may be corrosive or poisonous,
    are dealt with elsewhere in the book.

    Signs and symptoms

    *    If breathed in deeply, as in aerosol abuse:

    -    coughing and choking,

    -    excitement,

    -    hallucinations,

    -    sudden unconsciousness.

         The patient may die suddenly or recover very quickly.

    *    In the eyes:

    -    stinging, watering eyes,

    -    red eyelids.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes and keep the patient warm and quiet.

     In the eyes

         Wash the eye for at least 15-20 minutes with water.

         If the patient has any signs or symptoms, take him or her to
    hospital. All patients should be kept lying down in a quiet place for
    at least 4 hours.

    Air-fresheners, deodorant blocks and moth-balls

    Chemicals covered in this section

         This section covers naphthalene and  para-dichlorobenzene (also
    called  p-dichlorobenzene).

    Uses

          para-Dichlorobenzene is used in solid air-fresheners and
    deodorant blocks for use in or near lavatories and rubbish bins.
    Liquid air-fresheners contain water, perfume and detergent rather than
     para-dichlorobenzene (see Soap and detergents). For air fresheners
    in aerosol cans see Part Two (Aerosol Sprays).

         Both  para-dichlorobenzene and naphthalene may be used in 
    mothballs and other products used to keep moths away. However, some
    mothballs are made of camphor (see Volatile oils).

    How they cause harm

    Both chemicals are irritant to the gut and may affect the brain.
    Naphthalene destroys blood cells and damages the kidneys,  para-
    Dichlorobenzene damages the liver. Repeated handling may cause skin
    irritation.

    How poisonous they are

         Naphthalene is more poisonous than  para-dichlorobenzene. In a
    young child, one naphthalene moth-ball may destroy blood cells, and
    four may cause fits.

         The poisonous amount of  para-dichlorobenzene is much larger and
    the amount likely to be eaten by children would probably not cause
    serious poisoning.

    Special dangers

         These products are often placed where children can see and reach
    them. For example, moth-balls may be hung in cupboards, and deodorant
    blocks on the side of bins, buckets or lavatory bowls.

    Signs and symptoms

    Naphthalene

    *    If swallowed:

    -    nausea, vomiting, diarrhoea and belly pain,

    -    sweating,

    -    fever,

    -    yellow skin caused by changes in the blood,

    -    urine becomes dark and may contain blood,

    -    the patient may stop passing urine,

    -    fits,

    -    unconsciousness.

    *    In the eyes:

    -    redness and irritation.

    *    On the skin:

    -    redness and irritation.

     para-Dichlorobenzene

    *    If swallowed:

    -    nausea, vomiting, diarrhoea and belly pain.

    *    In the eyes:

    -    redness and irritation.

    *    On the skin:

    -    redness and irritation.

    What to do

         Give first aid. If breathing stops, open the airway, wash
    chemical off the patient's lips, then give mouth-to-mouth respiration.
    If the patient is unconscious or drowsy, lay him or her on one side in
    the recovery position. Check breathing every 10 minutes and keep the
    patient warm.

         If the patient has a fit, treat as recommended in Chapter Five.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water.

     On the skin

         Wash the skin thoroughly with soap and cold water, if possible
    under running water.

     If swallowed

         If the patient is fully awake, give water to drink. Do not give
    milk or fatty foods for 2-3 hours.

         Take the patient to hospital as soon as possible in any of the
    following circumstances:

    *    The patient has swallowed any amount of naphthalene.

    *    The patient has swallowed a large amount of  para-dichlorobenzene
         (several moth-balls or a whole deodorant block).

    *    The patient has signs of severe poisoning.

    *    You do not know what the product contains.

    *    There is possible injury to the eyes.

    What to do if there is a delay in gelling the patient to hospital

         If the product was swallowed less than 4 hours ago and if the
    patient is fully awake and breathing normally, has not had fits, and
    has not already vomited a lot, make the patient vomit.

         If the patient stops passing urine, treat as recommended in
    chapter nine.

    Information for doctors outside hospital

         Naphthalene causes haemolysis in patients with 
    glucose-6-phosphate dehydrogenase deficiency. The haemoglobin can 
    cause renal tubular necrosis.

         Supportive care, including oxygen and mechanical ventilation,
    should be given as needed:

    *    If there is evidence of haemolysis, intravenous fluids should be
         given to reduce the possibility of renal failure.

    *    Bicarbonate may be given to make the urine alkaline (pH > 7.5).

    *    For repeated fits diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours;

    Children: 200-300 µg/kg of body weight.

    Benzene, tetrachloroethylene, toluene, trichloroethane,
    trichloroethylene and xylene

    Chemicals covered in this section

         This section covers three aromatic hydrocarbons - benzene,
    toluene and xylene - and three chlorinated hydrocarbons -
    tetrachloroethylene (also called perchlorethylene), 1,1,1-
    trichloroethane, and trichloroethylene (also called trichloroethene).

    Note: other chlorinated hydrocarbons and other aromatic hydrocarbons,
    for example carbon tetrachloride, may have different poisonous
    effects.

     Uses and abuses

         Benzene is used in many industrial processes and is also present
    in motor fuel. It is not usually put in household products.

         Toluene and xylene are used in many industrial processes. They
    are also used as solvents in glues, paints and thinners used in the
    home and in the workplace.

         Tetrachloroethylene is used in commercial dry-cleaning and
    degreasing products.

    1,1,1-Trichloroethane is used as a cleaner and degreaser and in
    typewriter correction fluids.

    Trichloroethylene is used in many kinds of household products:
    cleaners for walls, clothing, and rugs, typewriter correction fluids,
    paints, glues, dry-cleaners, insecticides and fungicides. It is also
    used in industry as a degreaser and dry-cleaner.

         Dry-cleaning fluid may contain trichloroethylene or
         tetrachloroethylene. Carbon tetrachloride is sometimes used as a
         dry-cleaning fluid, but this is not recommended because it is
         very poisonous.

         Some people abuse or "sniff" glues or other products containing
    toluene, benzene, trichloroethylene or trichloroethane.

    How they cause harm

         These chemicals affect the brain and heart. The kidneys and liver
    may also be affected by acute exposure to tetrachloroethylene,
    trichloroethylene and trichloroethane and by chronic exposure to
    toluene and trichloroethylene. Chronic exposure to benzene affects the
    production of red blood cells, resulting in anaemia, and may cause
    cancer of the blood cells (leukaemia).

         In liquid form these chemicals are irritant to the skin and eyes,
    and may cause lung oedema if swallowed. The vapour is irritant to
    eyes, nose and throat, and toluene and xylene vapour may cause lung
    oedema.

    How poisonous they are

         All of these chemicals are poisonous if breathed in or swallowed.
    Acute exposure may cause sudden death. Skin contact is unlikely to
    cause systemic poisoning. Abuse is habit-forming and may lead to
    dependence.

    Special dangers

         People who abuse solvents not only are at risk from the poisonous
    effects of the solvent, but may suffocate by breathing in solvent from
    a plastic bag or injure themselves while hallucinating. Working with
    these chemicals is dangerous if people do not use proper protection or
    safe work practices.

    Signs and symptoms

    Benzene

     Acute exposure

    *    If breathed in or swallowed:

    -    euphoria,

    -    weakness,

    -    headache,

    -    nausea,
-    blurred vision,

    -    irritation to nose and eyes,

    -    shaking,

    -    uncoordinated movements,

    -    tight chest and shallow breathing,

    -    irregular pulse,

    -    unconsciousness,

    -    fits,

    -    lung oedema.

    *    On the skin:

    -    redness,

    -    dry skin and blisters.

    *    In the eyes:

    -    pain,

    -    redness and watering,

    -    the patient cannot look at light.

         There may be damage to the eye.

     Chronic exposure

    *    If breathed in:

    -    headache,

    -    dizziness,

    -    loss of appetite,

    -    tiredness.

    *    On the skin:

    -    dry skin,

    -    blisters.

    Toluene and xylene

     Acute exposure

    *    If breathed in:

    -    excitement, euphoria, headache,

    -    dizziness,

    -    nausea,

    -    weakness,

    -    drowsiness,

    -    incoordination and staggering walk,

    -    confusion,

    -    irritation to eyes, nose and throat,

    -    unconsciousness,

    -    lung oedema,

    -    irregular pulse,

    -    heart or breathing may stop.

    *    If swallowed:

    -    vomiting and diarrhoea,

    -    lung oedema and same effects as if breathed in.

    *    On the skin and in the eyes:

    -    as for benzene.

     Chronic exposure

         If breathed in repeatedly:

    -    muscle weakness,

    -    abdominal pain, vomiting blood,

    -    brain damage,

    -    liver and kidney damage.

    Tetrachloroethylene, trichloroethane and trichloroethylene

     Acute exposure

    *    If breathed in:

    -    nausea and vomiting,

    -    euphoria,

    -    headache and confusion,

    -    dizziness,

    -    weakness,

    -    drowsiness,

    -    shaking,

    -    incoordination,

    -    fits,

    -    unconsciousness,

    -    low blood pressure,

    -    irregular pulse,

    -    liver and kidney damage,

    -    irritation to eyes, nose and throat,

    -    heart or breathing may stop.

    *    If swallowed:

    -    vomiting and diarrhoea,

    -    lung oedema and same effects as if breathed in.

    *    On the skin and in the eyes:

    -    as for benzene.

     Chronic exposure

         If breathed in repeatedly:

    -    weight loss, nausea and loss of appetite,

    -    tiredness,

    -    sometimes liver and kidney damage,

    -    heart disease.

    What to do

         Move the patient away from poisonous gases or liquid spills.
    Protect yourself by wearing breathing equipment and protective
    clothing.

         Give first aid. If breathing stops, open the airway, wash
    chemical off the patient's lips, and give mouth-to-mouth respiration.
    Give heart massage if the heart stops. If the patient is unconscious
    or drowsy, lay him or her on one side in the recovery position. Check
    breathing every 10 minutes and keep the patient warm.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water.

     On the skin

         Immediately remove contaminated clothing, shoes, socks and
    jewellery. Wash the skin well with soap and cold water for 15 minutes,
    if possible using running water. Be careful not to get any of the
    chemical on your own skin or clothing.

         Take the patient to hospital as soon as possible. If the patient
    has swallowed or breathed in chemical, keep him or her lying down
    because there is a risk of heart problems.

    What to do if there is a delay in getting the patient to hospital

          If the chemical was swallowed: if the patient is fully awake
    and breathing normally, and has not had fits:

    *    Make the patient vomit if more than 2-3 mouthfuls of
         chemical were swallowed less than one hour ago, and the patient
         is not already vomiting.

    *    Give activated charcoal and water to drink. Wait
         until the patient has stopped vomiting.

         Do not give any fatty food or drink.

         If the patient has signs of lung oedema, treat as recommended in
    Chapter Nine. If the patient has signs of liver damage, treat as
    recommended in Chapter Nine. If the patient has signs of kidney
    failure, treat as recommended in Chapter Nine.

    Information for doctors outside hospital

         Monitor breathing, heart rate and blood pressure. Supportive
    care, including oxygen and mechanical ventilation, should be given as
    needed. Do not give stimulant medicines such as epinephrine.

         In cases of severe poisoning, the heart should be monitored for
    12-24 hours after apparent full recovery, if possible, because there
    is a risk of arrhythmia. Chronic exposure to benzene may cause anaemia
    and leukaemia.

    Borax, boric acid, and sodium perborate

    Uses

         Borax is used in some ant killers, wood preservatives, water
    softeners, eye-drops, mouthwashes and skin creams. Boric acid has been
    used to disinfect and wash babies' nappies and has been added to
    talcum powder, but this is not recommended because it is too
    poisonous. Sodium perborate is used as a bleach, a cleaner for
    dentures (false teeth), and a water softener. It is added to some
    detergents and products for washing and disinfecting babies' nappies.

    How they cause harm

         Borates are irritant and poisonous if swallowed or in contact
    with wet, scratched or damaged skin. They damage the gut, brain and
    kidneys.

    How poisonous they are

         These chemicals are very poisonous. A single large dose causes
    acute poisoning, but the amount in most household products, such as
    detergents and ant killers, is small and one small mouthful taken by a
    child is unlikely to be poisonous. However, talcum powder containing
    borax or boric acid, used over a period of many days or weeks, may
    cause severe chronic poisoning in infants, and may result in death.
    There is also a danger of chronic poisoning from using mouthwash and
    repeatedly swallowing small amounts.

         Denture-cleaning tablets and powders are corrosive (see caustic
    and corrosive chemicals). If swallowed they may stick in the gullet
    and cause severe burns; the solution made by dissolving the tablets in
    water may also burn if swallowed.

    Special dangers

         Skin creams or talcum powders containing boric acid may cause
    serious poisoning in infants and young children. Elderly people with
    poor eyesight may swallow denture-cleaning tablets in mistake for
    sweets.

    Signs and symptoms

    Acute poisoning

    *    If swallowed:

    -    nausea,

    -    severe vomiting and diarrhoea,

    -    restlessness and agitation,

    -    fits,

    -    unconsciousness,

    -    a red skin rash, with peeling skin, particularly on the buttocks,
         palms and soles,

    -    signs of kidney failure.

    *    In the eyes:

    -    stinging and a burning feeling,

    -    watery eyes,

    -    red swollen eyelids.

    *    On the skin:

    -    itching and redness,

    -    if the skin was wet, cut or scratched, the patient may also have
         signs and symptoms as for swallowing.

    Chronic poisoning

         Repeated swallowing or skin contact may result in:

    -    loss of appetite and loss of weight,

    -    vomiting and mild diarrhoea,

    -    a red skin rash, with peeling skin, particularly on the buttocks,
         palms and soles,

    -    hair loss,

    -    signs of kidney failure,

    -    fits.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes and keep the patient warm and quiet.

         If the patient has a fit, treat as recommended in Chapter Five.

     In the eyes

         Gently brush or dab away any liquid or powder from the face. Wash
    the eyes for at least 15-20 minutes with water. Check that there are
    no solid bits of chemical on the lashes and eyebrows, or in the folds
    of skin round the eyes.

     On the skin

         Immediately remove contaminated clothing, shoes, socks and
    jewellery. Wash the skin thoroughly with soap and cold water, if
    possible using running water. Rinse for at least 15 minutes.

         Take the patient to hospital as soon as possible.

    What to do if there is a delay in getting to hospital

         If the patient passes less urine than normal, treat as
    recommended in Chapter Nine.

     Information far doctors outside hospital

         Supportive care should be given as needed:

         *    Give oxygen and mechanical ventilation.

         *    Take measures to prevent skin infection.

         *    For repeated fits diazepam should be given by intravenous
              injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Haemodialysis and peritoneal dialysis remove borate and may be
    useful in cases of serious poisoning.

    Button batteries

    Chemicals covered in this section

         Button batteries or disc batteries are small (less than 15 mm
    across) and round. There are several different types, each containing
    different chemicals, some of which are poisonous or corrosive:

    -    mercury cell: mercuric oxide, potassium hydroxide;

    -    silver cell: silver oxide, potassium hydroxide;

    -    alkaline manganese cell: manganese dioxide, potassium hydroxide;

    -    lithium/manganese cell: manganese dioxide, lithium perchlorate;

    -    zinc/air button cell: zinc metal, potassium hydroxide.

    Uses

         Button batteries are used in cameras, watches, calculators,
    hearing aids, gas-fired hair stylers, and electronic games.

    How they cause harm

         Potassium hydroxide and mercuric oxide are corrosive and may burn
    the gut if the battery leaks. Burns may also be caused by electric
    currents set up inside the body. Mercuric oxide may affect the
    kidneys.

    How poisonous they are

         In most cases batteries stay intact when swallowed and pass out
    of the body without causing harm. However, if a battery lodges in the
    gullet or any other part of the gut, there is a danger of burns from
    leaking chemicals or electric currents. There is also a danger of
    serious burns if batteries are pushed into the ear or nose. Alkaline
    manganese and mercury batteries are more dangerous than the other
    types. There is less danger of electrical burns from used batteries.

    Special dangers

         Children may be able to take batteries out of their packaging or
    out of the equipment where they are being used. Button batteries are
    small and easily swallowed by children.

    Signs and symptoms

    *    If swallowed

         If the battery is stuck in the gullet:

    -    difficulty in swallowing,

    -    coughing,

    -    vomiting,

    -    fever,

    -    loss of appetite and tiredness.

         If there are burns and injury to the gut:

    -    chest or belly pain,

    -    vomiting (vomit may be blood-stained),

    -    dark or blood-stained faeces.

    What to do

     If swallowed

         Do not make the patient vomit. The battery will not come out in
    the vomit.

         If the patient is well and has no signs or symptoms, let him or
    her eat and drink normally. Give a laxative (magnesium sulfate by
    mouth) and check the patient's faeces to see whether the battery has
    been passed. It usually takes between 14 hours and 7 days for the
    battery to pass out of the body.

         If the battery has not been passed out in the faeces within 7
    days, or if the patient has dark or blood-stained faeces, or any other
    signs or symptoms, take the patient to hospital.

     If the battery is stuck in the ear or nose

         Do not try to get the battery out. Take the patient to hospital
    without delay.

    Information for doctors outside hospital

         If there will be a delay in getting the patient to hospital, give
    antacids to make the stomach less acid and reduce the risk of the
    battery leaking. Give a laxative to make the battery move down the gut
    more quickly. Examine the stools to see if the battery has been passed
    out.

         When the patient reaches hospital, an X-ray of the chest and
    abdomen should be taken to show where the battery is and if it is
    leaking. If the battery does not move quickly down the gut or if it
    leaks, it will need to be removed endoscopically or surgically.

         If a battery containing mercury leaks in the gut, the serum
    mercury concentration should be measured. However, the risk of mercury
    poisoning in such cases is very low.

         Button batteries that are stuck in the ear or nose should be
    removed without delay because they may seriously damage the eardrum or
    burn a hole through the nose. Do not use saline solutions or drops
    because this may increase the electric current round the battery.

    Carbon monoxide

         Carbon monoxide is a colourless gas with no smell. It is produced
    by burning gas, oil, petrol, solid fuel, or wood. Common sources are
    fires, stoves, heaters, ovens, and petrol engines.

    How it causes harm

         Carbon monoxide affects the blood so that it is not able to carry
    as much oxygen as usual, and affects cells so that they are not able
    to use all the oxygen that reaches them. The lack of oxygen chiefly
    affects the brain and heart.

    How poisonous it is

         Carbon monoxide is very poisonous and may cause death. People who
    survive serious poisoning may be left with permanent brain damage.

    Special dangers

         It is dangerous to have stoves, heaters, boilers or fires burning
    in rooms, huts or tents that have no chimney, flue, or other opening
    to let carbon monoxide out and fresh air in. Poisoning is particularly
    likely in cold weather when people close their doors and windows to
    keep out cold air, or if the equipment is not working properly.

         Often people do not know that there is a danger of poisoning and
    so they do nothing to make the situation safe. Carbon monoxide is a
    non-irritant gas with no colour or smell. Sometimes the fumes or smoke
    can be detected by their colour or smell but there is often nothing to
    warn people that they are being poisoned. The symptoms of poisoning
    are often mistaken for symptoms of influenza or illness caused by
    eating contaminated food.

         Depending on what is burnt, other poisons may also be present in
    the fumes or smoke. Patients may also be poisoned by irritant gases
    such as ammonia, chlorine, hydrogen chloride, phosgene or cyanide, as
    well as carbon monoxide.

    Signs and symptoms

         Mild to moderate poisoning:

    -    weakness, tiredness and drowsiness,

    -    headache,

    -    dizziness and confusion,

    -    nausea and vomiting,

    -    chest pain,

    -    fast pulse at first.

         Serious poisoning:

    -    low body temperature,

    -    unconsciousness,

    -    shallow irregular breathing; breathing may stop,

    -    fits,

    -    slow pulse, which may be irregular,

    -    low blood pressure.

         Complete recovery after serious poisoning may take many weeks.
    Sometimes people become ill again up to four weeks after they seem to
    have recovered. Some people suffer permanent brain damage and have
    memory problems.

    What to do

         Move the patient away from the poisonous gas. If going into a
    room filled with gas, or smoke from a fire, wear breathing equipment
    to protect yourself from being poisoned.

         Give first aid. If the patient has stopped breathing, open the
    airway, then give mouth-to-mouth or mouth-to-nose respiration. If the
    patient is unconscious or drowsy, lay him or her on one side in the
    recovery position. Check breathing every 10 minutes, and keep the
    patient warm and quiet.

         If the patient has a fit, treat as recommended in Chapter Five.

         Take the patient to hospital as soon as possible.

    What to do if there is a delay in getting to hospital

         Keep the patient lying down and at rest for two days so that the
    body uses as little oxygen as possible.

    Information for doctors outside hospital

         As well as the effects listed above, there may be metabolic
    acidosis, disturbances of heart rhythm, cerebral oedema and
    rhabdomyolysis (muscle breakdown).

         Immediately give 100% oxygen if necessary. The patient may need
    mechanical ventilation. If the patient has been in a fire, check the
    airway for swelling caused by burns or other injury. If it is possible
    to measure blood carboxyhaemoglobin concentration, this should be done
    as soon as possible.

         Monitor breathing, heart and blood pressure. Supportive care
    should be given as needed. For repeated fits diazepam should be given
    by intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Any patient who has had headache and vomiting or loss of
    consciousness should have absolute bedrest for at least 48 hours.

         The use of hyperbaric oxygen treatment should be discussed with a
    poisons centre.

         Patients who survive may develop neurological effects, such as
    disorders of personality and memory, within 2-4 weeks. These effects
    may be temporary or permanent.

    Carbon tetrachloride

    Uses

         Carbon tetrachloride is mostly used in industry to make other
    chemicals. It has been used in fire extinguishers, and as a grease
    remover and dry-cleaning fluid, but none of these uses is recommended
    nowadays because less poisonous chemicals can be used instead.

    How it causes harm

         It is irritant to the skin, eyes and lungs. It is poisonous if
    swallowed, breathed in or spilt on the skin, affecting the brain,
    liver and kidneys. When it burns it produces phosgene gas which is
    also poisonous.

    How poisonous it is

         It is very poisonous and may cause death. Poisoning is more
    severe in people who smoke.

    Signs and symptoms

    *    If swallowed:

    -    nausea, vomiting and diarrhoea,

    -    a burning feeling in mouth, throat and belly,

    -    dizziness and confusion,

    -    drowsiness and unconsciousness,

    -    fits,

    -    low blood pressure,

    -    slow or irregular heartbeat, which may result in sudden death.

         After 2-14 days:

    -    signs of liver damage,

    -    kidney damage; the patient stops passing urine.

    *    If breathed in:

    -    cough, sneezing and mild breathlessness,

    -    the same effects as if swallowed,

    -    signs of lung oedema after 2-3 days.

    *    On the skin:

    -    redness and irritation,

    -    blisters if left on the skin for a long time,

    -    the same effects as if swallowed.

    *    In the eyes:

    -    redness and severe irritation.

    What to do

         Move the patient away from the source of the poison. Protect
    yourself by wearing breathing equipment and protective clothing.

         Give first aid. If the patient stops breathing, wash chemical off
    the patient's lips, then give mouth-to-mouth or mouth-to-nose
    respiration. Give heart massage if the heart stops. If the patient is
    unconscious or drowsy, lay him or her on one side in the recovery
    position. Check breathing every 10 minutes and keep the patient warm.

         If the patient has a fit, treat as recommended in Chapter Five.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water.

     On the skin

         Immediately remove contaminated clothing, shoes, socks and
    jewellery. Be careful not to get any of the chemical on your own skin
    or clothes. Wash the patient's skin thoroughly with soap and cold
    water, if possible using running water. Rinse for at least 15 minutes.

         Take the patient to hospital as soon as possible.

    What to do if there is a delay in getting to hospital

          If the chemical was swallowed: if it happened less than 4 hours
    ago, and if the patient is fully awake, breathing normally, and has
    not had fits, make the patient vomit. Do not give milk to drink, or
    anything containing oil, fat, or alcohol to eat or drink.

         If the patient has signs of lung oedema, treat as recommended
    in chapter nine. If the patient has signs of liver damage, treat as
    recommended in chapter nine. If the patient stops passing urine,
    treat as recommended in chapter nine.

    Information for doctors outside hospital

         Monitor breathing, pulse and blood pressure. Supportive care
    should be given as needed:

    *    Low blood pressure should be treated with intravenous fluids.

    *    For repeated fits, diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Do not give epinephrine (adrenaline).

    Antidote: acetylcysteine should be given if available, by intravenous
    injection, if the patient was exposed less than 24 hours ago. Dose is
    as for poisoning with paracetamol.

         Carbon tetrachloride is radio-opaque and should be visible on an
    abdominal X-ray if swallowed recently.

         Patients with liver or kidney failure may need haemodialysis or
    haemoperfusion.

    Caustic and corrosive chemicals

    Chemicals covered in this section

         Many chemicals irritate, burn or damage skin and other living
    tissues. These include mineral and organic acids, alkalis and
    oxidizing agents.

     Examples of acids:

    acetic acid                                  nitric acid

    aminosulfonic acid (sulfamic acid)           oxalic acid

    formic acid                                  phosphoric acid

    hydrochloric acid                            sulfuric acid

    hydrofluoric acid

     Examples of alkalis:

    ammonia                                      potassium polyphosphate

    calcium oxide                                sodium carbonate

    calcium hydroxide                            sodium hydroxide (caustic
    soda,
                                                 lye)

    potassium carbonate                          sodium phosphate

    potassium hydroxide (caustic potash)         sodium polyphosphate

          Oxidizing agents. These are chemicals that release oxygen.
    Oxygen may kill bacteria, bleach coloured substances and damage living
    tissue. Examples of oxidizing agents commonly used as bleach are:
    calcium hypochlorite, hydrogen peroxide, sodium hypochlorite,
    troclosene sodium (sodium dichloroisocyanurate), and sodium perborate.

          Corrosive gases: chlorine, chloramine, hydrogen chloride and
    sulfur dioxide.

         Many products used in homes and workplaces contain acid or
    alkali.

    *    Bleach

    -    Household liquid bleach, for cleaning kitchens, bathrooms and
         lavatories, usually contains sodium hypochlorite in an alkaline
         solution.

    -    Household bleaching powder usually contains troclosene sodium,
         with detergent and small amounts of acid.

    -    Laundry bleach usually contains sodium hypochlorite, sodium
         perborate or troclosene sodium.

    -    Bleach for swimming-pools usually contains sodium hypochlorite.

         The concentration of available chlorine in sodium hypochlorite
    bleach is usually:

    -    household bleach <5%;

    -    concentrated household bleach 10-12%;

    -    industrial bleach 15-20%.

    *    Car batteries usually contain sulfuric acid.

    *    Denture cleaners (cleaners for false teeth) are powders or
         tablets that contain sodium perborate. They form a corrosive
         solution in water or inside the mouth or gut.

    *    Descalers, used to remove lime scale from kettles, baths, and
         water pipes, are acidic. Liquid products usually contain formic
         or phosphoric acid, powder products usually contain aminosulfonic
         acid.

    *    Drain cleaners are alkaline; they usually contain sodium
         hydroxide or potassium hydroxide. Drain cleaners are made as
         solid crystals or liquids.

    *    Floor cleaners: some are alkaline. Washes for concrete floors may
         contain sodium carbonate; floor-polish removers and strippers may
         contain sodium hydroxide.

    *    General household cleaners: some are alkaline and contain sodium
         carbonate or ammonium hydroxide.

    *    Glass cleaners: some are alkaline and contain sodium hydroxide.

    *    Grease removers: some are alkaline and contain sodium hydroxide
         (but others contain carbon tetrachloride or trichloroethylene).

    *    Laundry detergents: many contain alkalis such as sodium
         carbonate, sodium phosphate, and sodium polyphosphate.

    *    Lavatory-cleaning liquids, for removing stains and lime scale,
         usually contain either hydrochloric acid, sulfuric acid, oxalic
         acid, or sodium carbonate. They may be acid or alkaline.

    *    Lavatory-cleaning powder is usually acid and may contain
         troclosene sodium with detergent and small amounts of acid or
         sodium bisulfate.

    *    Oven cleaners are alkaline and usually contain sodium hydroxide
         or potassium hydroxide.

    *    Rust removers, for removing rust from metal or fabric, are acid;
         some contain phosphoric acid or hydrofluoric acid.

    *    Sterilizers for wine-making equipment, drinking-water or babies'
         feeding bottles may contain sodium hypochlorite or troclosene
         sodium.

    *    Tablets for checking sugar in urine, used by diabetics, contain
         sodium hydroxide and acid.

    How they cause harm

         These chemicals are irritant or corrosive. They inflame, burn or
    destroy skin and other tissues. Acid fumes or irritant gases, such as
    ammonia, chlorine, chloramine, hydrogen chloride, and sulfur dioxide,
    irritate the lungs and cause lung oedema. Acid may also upset the
    chemical balance of the body if swallowed and cause signs of general
    systemic poisoning. Oxalic acid also causes kidney damage.

         Tablets for detecting sugar in urine not only cause chemical
    burns, but also heat burns, because they give out heat as they
    dissolve in body fluids.

    How poisonous they are

         The injury caused by caustic and corrosive chemicals can range
    from mild irritation to severe burns. The severity of injury depends
    on:

    -    the amount swallowed or in contact with the skin. A large amount
         of liquid will injure a larger area. If a large amount of liquid
         is swallowed, the patient is more likely to vomit.

    -    how long the chemical is in contact with the tissues. The burns
         caused by solids, such as denture-cleaning tablets, sterilizing
         tablets or sodium hydroxide crystals, are usually worse than
         those caused by liquids, because solids are in contact with the
         lining of the mouth and gullet for longer than liquids. The most
         serious damage happens when corrosive tablets stick in the gullet
         or stomach.

    -    the concentration of the chemical.

         If swallowed, strongly corrosive or caustic chemicals may cause
    severe burns to the mouth, throat, gullet and gut. Later, scars may
    block the gullet so that the patient cannot swallow solid food.

         Alkali burns are usually more severe than acid burns because
    alkalis dissolve the tissues and go deep below the surface of the skin
    or lining of the gut. They continue to cause damage even after they
    have been washed off the surface of the tissue.

         The pattern of injury caused by acids differs from that caused by
    alkalis. Acids tend to cause more severe injury to the stomach than to
    the throat and gullet. Even when the stomach is badly damaged, there
    may be only slight injury to the throat and gullet. In contrast,
    alkalis usually cause more severe injury to the gullet than to the
    mouth, throat and stomach. The lower part of the gullet may be badly
    injured even when there are no burns in the mouth and throat.

         Hydrofluoric acid is different from other acids because it goes
    deep below the skin causing severe damage to deep tissues and bone. It
    is the fluoride in the acid that makes it so dangerous.

         Acids cause systemic poisoning only if large amounts are
    swallowed.

    Special dangers

         Corrosive or caustic household products are a danger to young
    children if they are not stored safely locked away from children. It
    is particularly dangerous to store such products in bottles that
    previously held drink.

         Denture-cleaning tablets or urine-testing tablets may be mistaken
    for sweets or indigestion tablets by old people who cannot see very
    well.

         Dilute kettle descaler may be drunk by mistake from a kettle that
    is being descaled. Descaler diluted with water is unlikely to cause
    serious harm.

         Household cleaners, lavatory cleaners, and bleaches are dangerous
    if mixed together, but people sometimes misuse them in this way. When
    liquid bleach is mixed with acid lavatory cleaner or descaler,
    chlorine gas is given off. When liquid bleach is mixed with ammonia,
    chloramine gas is given off. Chlorine and chloramine are acid gases.

    Signs and symptoms

    *    If swallowed:

    -    immediate burning feeling in the mouth and throat,

    -    ulcers inside the mouth; the tongue and lining of the mouth
         change colour (grey with hydrochloric acid, yellow with nitric
         acid, white or black with sulfuric acid),

    -    wet mouth,

    -    pain on swallowing so that the patient does not want to drink
         anything,

    -    great thirst,

    -    swelling in the throat; this may block the airway so that the
         patient wheezes when breathing,

    -    pain in the chest and belly,

    -    nausea, retching and vomiting, with blood in the vomit,

    -    diarrhoea which may be blood-stained,

    -    signs of shock: weak fast pulse, cold damp skin and low blood
         pressure,

    -    acid or alkali may burn holes in the throat, gullet, or stomach;
         if the chemical burns a hole in the stomach the patient will have
         fever, a band of pain under the ribs round to the back, severe
         belly pain, and a hard rigid belly,

    -    unconsciousness.

    *    If fumes or gases are breathed in:

    -    watering eyes and sneezing,

    -    coughing and choking,

    -    tight feeling in the chest or chest pain,

    -    wheezing and difficulty in breathing,

    -    rapid breathing,

    -    headache,

    -    blue colour to face, lips, and under eyelids,

    -    dizziness,

    -    fluid in the lungs (lung oedema) usually many hours afterwards.

    *    In the eyes:

    -    stinging or burning,

    -    watering eyes,

    -    red, swollen eyelids,

    -    the patient does not want to open the eyes,

    -    severe pain and burns on the eyelids and ulcers in the eyes,

    -    blurred vision, loss of sight,

    -    permanent blindness.

         Alkali burns are usually more severe than acid burns.

    *    On the skin:

    -    a burning feeling (with hydrofluoric acid there may not be any
         pain at first),

    -    redness and swelling,

    -    severe burns with severe damage to the skin,

    -    alkalis cause ulcers, and make the skin feel slippery and soapy,

    -    shock because of the pain: weak fast pulse, cold damp skin and
         low blood pressure,

    -    unconsciousness.

         Alkali burns are usually more severe than acid burns. With
    hydrofluoric acid severe injury may develop later even if there is no
    sign of injury at first.

    What to do

         Move the patient away from gases, fumes or spilt liquids. Be
    careful not to get any of the chemical on your own skin or clothes or
    to breathe in vapours. Wear breathing equipment and protective
    clothing as needed to protect yourself.

         Give first aid. If the patient has stopped breathing, open the
    airway, wipe chemical off the patient's lips, then give mouth-to-mouth
    respiration. If the mouth is badly burnt, give mouth-to-nose
    respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm and quiet.

     In the eyes

         Dab the face very gently with a cloth or paper to soak up
    chemical. Gently brush or dab away any liquid or powder from the face.
    Wash the eyes for at least 15-20 minutes with water. Check that there
    are no solid bits of chemical on the lashes and eyebrows, or in the
    folds of skin round the eyes.

     On the skin

         Immediately remove contaminated clothing, shoes, socks and
    jewellery. Be careful not to get any of the chemical on your own skin
    or clothes or to breathe in vapours. Dab the patient's skin very
    gently with a cloth or paper to soak up chemical. Wash the skin
    thoroughly with soap and cold water, if possible using running water.
    If a large area is affected, wash the patient under a cold or lukewarm
    shower or hand-held hose, but protect the patient's eyes. Rinse for at
    least 15 minutes.

          For alkalis: wash until the skin no longer feels soapy or
    slippery. This may take an hour or more.

          For hydrofluoric acid: in all cases, immediately flood the skin
    with water then put calcium gluconate gel on the affected area and
    massage it continuously until the pain goes. This will take at least
    15 minutes. Cover the area with dressing soaked in the gel and bandage
    lightly. If you do not have any calcium gluconate gel, soak the skin
    in a solution of magnesium sulfate (Epsom salts), or a calcium salt.
    Immediate use of these salts may prevent deep burns, but once the acid
    has gone below the skin they will be less effective.

     If swallowed

         If the chemical was swallowed less than 10 minutes ago, give four
    cupfuls of water to drink at once. If it was swallowed more than 10
    minutes ago, do not give anything to drink. Water will not make the
    damage any less. If the patient is awake and alert, tell him or her to
    rinse the mouth with cold water and spit it out.

         Do not make the patient vomit. The vomit may burn the throat as
    it comes up.

          Hydrofluoric acid. If the patient is alert and can swallow,
    immediately give a drink of milk, or medicine containing calcium or
    magnesium, such as magnesium sulfate, magnesium hydroxide or calcium
    carbonate.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

          If the chemical was swallowed: if the patient is awake and
    there are no signs of burning in the mouth, or wetness round the mouth
    which shows that he or she cannot swallow, give one or two cupfuls of
    water or milk. Take care not to make the patient vomit and stop if the
    patient feels sick.

         Do not try to neutralize the chemical with another chemical.

         Do not give  fizzy drinks.

         Do not give anything to drink if the patient is unconscious or if
    there are burns inside the mouth.

         Do not give anything to eat until a doctor has checked that there
    is no damage to the throat.

         If the patient has signs of lung oedema, treat as recommended
    in chapter nine.

    Information for doctors outside hospital

         Supportive care should be given as needed, including oxygen and
    mechanical ventilation, and morphine for severe pain.

         It is difficult to judge the severity of injury to the oesophagus
    or gut from the signs and symptoms. To see how severe the injury is,
    endoscopy should be carried out if it is less than 48 hours since
    ingestion and the patient has any of the following:

    -    burns in the mouth,

    -    signs or symptoms,

    -    upper airway obstruction.

         If acids or alkalis perforate the gut or oesophagus, the patient
    will probably die.

         Steroids (for example, prednisolone) may lessen the possibility
    of stricture developing, if given within 48 hours. They should not be
    given if there is a high risk of perforation, or if the patient has a
    history of peptic ulcer or active infection.

     Hydrofluoric acid

         Systemic poisoning may cause hypocalcaemia or hyperkalaemia.

         For pain or burns following skin contact, 10% calcium gluconate
    solution can be injected subcutaneously into the affected areas using
    no more than 0.5 ml per finger, or 1 ml per cm2 for other areas.

    Cosmetics and toiletries

    Products covered in this section

         This section covers most cosmetics and toiletries, in two groups.
    The products in the first group are unlikely to cause harm, but the
    products in the second group may be harmful.

    Cosmetics and toiletries that are unlikely to be harmful

    The following are not poisonous:

    -    face make-up, lipstick and eye make-up (but black eye make-up may
         be poisonous; see below),

    -    skin cream, oil and lotion used to soften or protect skin,

    -    toothpaste.

         The following contain poisonous chemicals but are usually sold in
    small bottles so that it is unlikely that anyone would swallow enough
    to be poisoned:

    -    antiperspirants and deodorants that contain ethanol,

    -    nail hardeners and nail strengtheners, which contain irritant
         chemicals,

    -    nail polishes and nail lacquers, which contain acetone, toluene,
         xylene or ethanol.

    Cosmetics and toiletries that may cause harm

         Most accidental acute exposures cause nothing more than nausea,
    vomiting and diarrhoea. However, there may be more serious effects in
    some cases:

    *    Black eye make-up, called  surma in India,  tiro in Nigeria, and
          kohl in Arab countries, may contain lead and may cause chronic
         lead poisoning from long-term use or acute poisoning if swallowed
         in large amounts.

    *    Hair bleaches and hair lighteners contain hydrogen peroxide. Weak
         solutions are mildly irritant but some products contain more than
         10% hydrogen peroxide, could be corrosive if swallowed and may
         give off oxygen gas in the belly causing wind and pain.

    *    Hair colourants contain dyes, isopropanol, and irritant
         chemicals. There is a risk of acute poisoning from the
         isopropanol.

    *    Hairsprays: if breathed in deeply the propellant may cause harm
         (see Aerosol sprays).

    *    Hair straighteners contain caustic soda which could cause burns
         (see Caustic and corrosive chemicals.

    *    Hair-waving lotions and wave neutralizers may contain sodium
         perborate, sodium bromate, potassium bromate, or mercuric
         chloride.

    *    Nail-polish removers usually contain acetone or ethyl acetate.
         Brands sold in large bottles are a hazard, but it is unusual for
         people to be poisoned by these products.

    *    Perfumes, colognes and toilet waters contain ethanol
         and large bottles may contain enough to cause poisoning.

    *    Talcum powders, baby powders and face powders: if the powder is
         spilt on a baby's face, the fine particles could be breathed into
         the lungs and may cause lung oedema. The powders themselves are
         not poisonous, unless they contain boric acid.

    Signs and symptoms (for products not covered in other sections)

         Hair bleaches and hair lighteners containing hydrogen peroxide

    *    If swallowed:

    -    nausea, vomiting and belly pain,

    -    burns inside the mouth and throat.

    *    In the eyes:

    -    redness and stinging or burning,

    -    possibly severe pain and burns in the eyes.

    Hair-waving lotions and wave neutralizers containing sodium bromate or
    potassium bromate

    *    If swallowed (effects begin within 2 hours):

    -    nausea, vomiting and diarrhoea,

    -    deafness within 4-16 hours,

    -    low blood pressure,

    -    unconsciousness,

    -    fits,

    -    signs of kidney damage.

    *    In the eyes:

    -    redness and stinging.

    Nail polish removers

    *    If swallowed:

    -    nausea and vomiting

    -    drowsiness or unconsciousness.

    *    In the eyes:

    -    redness and stinging.

    Talcum powder

    *    If breathed in:

    -    coughing and choking,

    -    signs of lung oedema.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes and keep the patient warm and quiet.

         If the patient has a fit, treat as recommended in chapter five.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water.

         Take the patient to hospital as soon as possible if he or she has
    signs or symptoms of poisoning, has swallowed a cosmetic which may
    cause harm, or may have injured the eye.

    What to do if there is a delay in getting to hospital

          For hair-waving lotions and wave neutralizers containing sodium
     bromate or potassium bromate: if the chemical was swallowed less
    than 4 hours ago, and if the patient is fully awake, breathing
    normally, has not had fits, and is not already vomiting, make the
    patient vomit. Give activated charcoal and water to drink.

    Information for doctors outside hospital

     Sodium bromate or potassium bromate:

         Monitor pulse, blood pressure, breathing, fluid and electrolyte
    balance and the patient's hearing. Supportive care should be given as
    needed.

         There is a danger of renal tubular damage, which may be
    permanent. Monitor kidney function.

         If the patient has repeated fits diazepam should be given by
    intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

    Cyanides

    Chemicals covered in this section

         This section covers cyanide, hydrogen cyanide (also called
    hydrocyanic acid or prussic acid), sodium cyanide, and potassium
    cyanide.

         Cyanide-releasing substances are found naturally in many plants,
    the stones of apricots and peaches, bitter almonds, cassava and
    tapioca. Cassava (also called manihot or manioc) is grown throughout
    the tropics and is a basic food in parts of Africa and South America.
    It is a bush or tree with green flowers and nuts. The root is solid
    and white.

          cyanide when they burn. When people are overcome by breathing
    smoke from fires, some of the effects may be due to cyanide poisoning.

    Uses

         Cyanide is used in industry and for pest control. Hydrogen
    cyanide is used to fumigate buildings, ships and aircraft infested
    with rodents or insects. Sodium cyanide and potassium cyanide are used
    in metal cleaning, ore extraction in mines, electroplating and the
    manufacture of synthetic fibres.

         A preparation called Laetrile, made from peach stones, has been
    used to treat cancer, but there is no evidence that it does any good
    and it can cause cyanide poisoning.

    How they cause harm

         These chemicals stop living cells taking up oxygen and so the
    brain and heart are damaged by lack of oxygen. They are poisonous if
    swallowed, breathed in or spilt on the skin or in the eye. Chronic
    poisoning, from eating cassava as a major part of the diet, may damage
    the nervous system and thyroid gland.

    How poisonous they are

         These chemicals are highly poisonous and work very fast.

         The toxicity of plants containing cyanide varies widely depending
    on where they grow and whether fertilizers are used. Some parts of the
    same plant may be more poisonous than others. All parts of the cassava
    plant are poisonous, but the leaves and skin of the root are the most
    poisonous parts. The poison is removed by washing and boiling.

    Special dangers

         It is important for people who use cyanide at work to use safe
    work practices to avoid being poisoned.

         Cassava poisoning can happen if the root is not properly prepared
    and cooked. Mild cases of poisoning are common in poor areas,
    especially in undernourished children.

    Signs and symptoms

    Acute poisoning

    *    If swallowed, breathed in or spilt on the skin

         Symptoms appear within seconds or minutes, but may be delayed by
    1-2 hours if cyanide is swallowed with food.

    At first:

    -    burning tongue and mouth (if cyanide is swallowed),

    -    dizziness,

    -    throbbing headache,

    -    anxiety,

    -    palpitations,

    -    confusion,

    -    fast breathing,

    -    vomiting.

         These may be the only signs and symptoms in cases of mild
    poisoning.

         In moderate poisoning:

    -    difficulty in breathing,

    -    chest pain,

    -    drowsiness,

    -    short periods of unconsciousness,

    -    fits.

         In severe poisoning:

    -    deep coma,

    -    slow pulse,

    -    low blood pressure,

    -    large pupils,

    -    breathing stops.

         Death may occur within minutes. After a very large dose, the
    patient falls to the ground, wheezing, with violent fits and dies
    almost immediately.

    *    In the eyes:

    -    irritation

    -    watering

    -    same effects as if swallowed, breathed in or spilt on the skin.

    Chronic poisoning

         Weakness of the legs with pain or numbness, loss of sight,
    difficulty in coordination, swollen thyroid gland (in front of the
    neck).

    What to do

         Do not go into an area thought to be contaminated by cyanide gas
    unless you have breathing equipment approved for cyanide exposure, and
    protective clothing. Put on gloves and overalls before touching the
    patient.

         Move the patient away from any poisonous gases into fresh air or
    away from spilt liquids or solids.

         Give first aid. If the patient stops breathing open the airway,
    wash chemical off the patient's lips and mouth, then give mouth-to-
    mouth or mouth-to-nose respiration. Give heart massage if the heart
    stops. Keep on giving mouth-to-mouth respiration and heart massage for
    at least 30 minutes, even if the patient seems dead.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing and pulse every 3
    minutes.

     In the eye

         Gently brush or dab away any liquid or powder from the face. Wash
    the eyes with water for at least 15-20 minutes. Check that there are
    no solid bits of chemical on the lashes and eyebrows, or in the folds
    of skin round the eyes.

     On the skin

         Immediately remove contaminated clothing, shoes, socks and
    jewellery, cutting them off if necessary. A delay of only seconds may
    make the poisoning worse. Wash the skin thoroughly with soap and water
    for 15 minutes, using running water if possible. If you have breathing
    equipment approved for cyanide exposure, wear this while you wash the
    patient, and wear protective clothing and rubber gloves so that none
    of the chemical gets on your own skin or clothes.

         Take all patients with symptoms to hospital as quickly as
    possible.

    What to do if there is a delay in getting to hospital

          If the chemical was swallowed: if the patient is fully awake,
    breathing normally and has not had muscle twitching or fits, make the
    patient vomit.

    Information for doctors outside hospital

         Acute poisoning

    *    Severe poisoning

         Continue cardiopulmonary resuscitation for at least 30 minutes or
         until the patient recovers.

         General supportive care may be life-saving. Always give oxygen to
         patients with cyanide poisoning. If an antidote is not available,
         serious poisoning can sometimes be successfully treated with
         supportive care and oxygen alone.

         Low blood pressure should be treated with intravenous fluids and
         dopamine.

         Antidotes: There are four antidotes. They can be harmful if too
         much is given or if they are given to people who have not been
         poisoned with cyanide.

         Give an antidote only if the patient is losing consciousness or
         is already deeply unconscious and you are sure of the diagnosis.
         Give 50 ml (12.5 g) of sodium thiosulfate 25% intravenously over
         10 minutes. Then give one of the following:

         1.   Dicobalt edetate solution 1.5%: give 20 ml (300 mg)
              intravenously over one minute.

         2.   Sodium nitrite solution 3%: give 10 ml (300 mg)
              intravenously over 20 minutes.

         3.   4-Dimethylaminophenol (4-DMAP) 5%: give 5 ml (250 mg)
              intravenously over one minute.

         4.   Hydroxocobalamin solution 40%: give 10 ml (4 g)
              intravenously over 20 minutes.

              Some severely poisoned patients may fail to respond to the
    first dose of antidote. While repeat doses of hydroxocobalamin or
    sodium thiosulfate are unlikely to cause harm, any other specific
    antidote may itself be poisonous if too much is given or if it is
    given to someone who has not been poisoned with cyanide, if the
    patient does not respond, seek expert advice from a poisons centre
    before giving a repeat dose of any specific antidote other than sodium
    thiosulfate or hydroxocobalamin.

    *    Moderate poisoning

    -    Give 50 ml (12.5 g) of sodium thiosulfate 25%, intravenously over
         10 minutes.

    -    Give 100% oxygen for 12-24 hours, but no longer.

    *    Mild poisoning

         No antidote is needed. Give supportive care, including oxygen,
         and bed rest.

     Chronic poisoning

         Chronic poisoning from cassava is not reversible. It may be due
    to poor preparation of the cassava or to too little protein in the
    diet. Education is necessary to prevent cases occurring

    Disinfectants and antiseptics

    Products covered in this section

         This section covers household disinfectants and antiseptics,
    which usually contain one or more of these chemicals:

    -    cationic detergents such as benzalkonium, cetrimide,
         cetylpyridinium, chlorhexidine,

    -    ethanol,

    -    hydrogen peroxide,

    -    phenol, cresol, chlorocresol, chloroxylenol, or tar acids,

    -    pine oil,

    -    soap.

         Disinfectants and antiseptics used in hospitals or workplaces
    such as farms, factories and dairies may contain other chemicals.

    Uses

         Disinfectants and antiseptics destroy germs and are widely used
    in the home. Disinfectants are used to clean places and objects,
    antiseptics are used to clean skin and wounds.

    How they cause harm

         Ethanol causes unconsciousness and affects breathing; cationic
    detergents burn the inside of the mouth and throat and affect muscles;

    hydrogen peroxide is irritant; phenol is corrosive and affects the
    brain, breathing, heart, liver and kidneys. These chemicals are
    poisonous if swallowed. Phenol can also cause poisoning if absorbed
    through the skin.

    How poisonous they are

         Disinfectants and antiseptics for use in the home do not usually
    cause serious harm if a small amount is swallowed. Large amounts may
    cause serious poisoning and possibly death. Disinfectants and
    antiseptics for use in workplaces are more likely to cause severe
    poisoning than those for use in the home. They usually contain greater
    concentrations of chemical and may contain other chemicals more
    harmful than those listed above. Disinfectants containing a high
    concentration of phenol may cause poisoning if large amounts are spilt
    on the skin.

    Signs and symptoms

    *    If swallowed:

    -    nausea, vomiting and diarrhoea,

    -    irritation in mouth and throat.

         If the product contains cationic detergent:

    -    burns to mouth, throat and gullet,

    -    muscle weakness,

    -    the patient cannot breathe,

    -    unconsciousness,

    -    fits,

    -    low blood pressure,

    -    lung oedema.

         If the product contains ethanol:

    -    drowsiness,

    -    unconsciousness,

    -    low body temperature,

    -    shallow breathing.

         If the product contains hydrogen peroxide:

    -    nausea, vomiting and belly pain,

    -    burns in the mouth and throat.

         If the product contains phenol:

    -    there may be burns in the mouth and throat,

    -    fast breathing,

    -    fits,

    -    weak irregular pulse,

    -    unconsciousness,

    -    low blood pressure,

    -    dark urine,

    -    signs of liver and kidney damage.

    *    In the eyes:

    -    redness and watering,

    -    stinging or burning,

    -    there may be burns to the eye.

    *    On the skin:

    -    redness and irritation,

    -    concentrated products may cause burns,

    -    products containing large amounts of phenol may cause fits, fast 
         breathing and unconsciousness.

    What to do

         Give first aid.

         If the disinfectant was made for use in the home, and if the
    patient has swallowed only a small amount, the only effects are likely
    to be nausea and vomiting. The patient will recover quickly, and does
    not need to go to hospital. Give milk to drink.

         If the patient stops breathing, open the airway, wipe chemical
    off the patient's lips, then give mouth-to-mouth or mouth-to-nose
    respiration.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position, check breathing every 10 minutes and
    keep the patient warm and quiet.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible in the
    following cases:

    -    the patient has swallowed a large amount of disinfectant;

    -    the patient has swallowed a product made for use in hospital or
         industry;

    -    the patient has signs and symptoms of poisoning.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water. Take the
    patient to hospital as quickly as possible if there seems to be injury
    to the eye.

     On the skin

         Remove contaminated clothes, shoes, socks and jewellery. Wash the
    skin thoroughly with soap and cold water, if possible using running
    water. Take the patient to hospital as quickly as possible if there
    are skin burns or signs and symptoms of poisoning.

    What to do if there is a delay in getting to hospital

          If the chemical was swallowed: if the patient is fully awake
    give a cup of milk or water to drink. Do not make the patient vomit,
    as the disinfectant may burn the throat.

    Information for doctors outside hospital

         Monitor breathing, pulse and blood pressure. Supportive care
    should be given as needed including oxygen. The patient may need
    mechanical ventilation.

         See also the sections on soap and detergents, ethanol and
    isopropano, phenol and related substances and volatile oils, if the
    product contains these chemicals.

    Ethanol and isopropanol

    Chemicals covered in this section

         This section covers ethanol (also called ethyl alcohol or grain
    alcohol) and isopropanol (also called isopropyl alcohol or rubbing
    alcohol). When people talk about "alcohol" they usually mean ethanol.

     Uses and abuses

         Alcoholic drinks (beers, wines and spirits) contain ethanol.
    Methylated spirit and surgical spirit contain mainly ethanol, with a
    small amount of methanol. Ethanol is also an ingredient of some liquid
    medicines, mouthwashes, antiseptics, disinfectants, and cosmetics such
    as aftershaves, perfumes, and colognes.

         Alcohol abuse is common in many societies, and chronic abuse can
    lead to dependence. People who try to poison themselves by taking
    large doses of medicine often take alcohol at the same time.

         Ethanol content of drinks and other products:

         Distilled spirits   40-50%

         Wines               10-20%

         Beers               2-10%

         Mouthwashes         up to 75%

         Colognes            40-60%

         Isopropanol is used as a sterilizing agent and as rubbing
    alcohol, and is added to some antifreezes, car windscreen washes,
    window cleaners, aftershaves and disinfectants. Car windscreen washes
    may also contain methanol.

    How they cause harm

         Both ethanol and isopropanol slow down the brain, causing
    unconsciousness and shallow breathing. Isopropanol vapour is irritant
    to eyes, nose and throat and poisonous if breathed in. Isopropanol can
    cause poisoning if absorbed through the skin. Regularly drinking large
    amounts of ethanol causes chronic poisoning, resulting in many changes
    in the body, particularly in the brain, the liver, and the heart.

    How poisonous they are

         Acute and chronic poisoning may cause serious illness and death.
    The effect of a dose of ethanol depends on how much alcohol a person
    regularly drinks. Someone who does not usually drink much alcohol may
    be badly affected by an amount that would have very little effect on a
    person who regularly drinks large amounts. Children may get severe
    poisoning after drinking just a mouthful of aftershave, mouthwash or
    perfume. Isopropanol is more poisonous than ethanol. Serious poisoning
    can be caused by using isopropanol as rubbing alcohol, if large
    amounts are rubbed on the skin and absorbed into the body.

    Signs and symptoms

    Acute poisoning

    *    If swallowed:

    -    the patient's clothes and breath may smell of alcohol; patients
         who have swallowed isopropanol smell of acetone (a strong sweet
         smell),

    -    slurred speech,

    -    difficulty in performing simple tasks,

    -    staggering walk,

    -    nausea, vomiting, and abdominal pain which are more severe after
         swallowing isopropanol,

    -    drowsiness,

    -    blurred or double vision,

    -    unconsciousness,

    -    fits,

    -    low blood pressure,

    -    low body temperature,

    -    shallow breathing.

    *    If spilt on the skin or breathed in:

         For isopropanol: the same effects as if swallowed.

         Chronic ethanol poisoning

         Long-term abuse of alcohol results in:

    -    weight loss,

    -    loss of appetite,

    -    diarrhoea caused by damage to the liver and gut,

    -    pale skin due to anaemia,

    -    memory loss, tremor, loss of mental abilities.

    What to do

    Acute poisoning

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes and keep the patient warm.

         Take the patient to hospital as soon as possible if:

    -    the patient is a child,

    -    the patient has severe poisoning,

    -    the patient has swallowed isopropanol.

    What to do if there is a delay in getting to hospital

          If the chemical was swallowed: if it happened less than one
    hour ago and if the patient is fully awake and breathing normally, and
    has not had fits, make the patient vomit, unless he or she has already
    vomited a lot.

    Chronic poisoning

         Take the patient to see a doctor.

    Information for doctors outside hospital

         As well as the effects listed above, the blood glucose may be low
    (more commonly in children than in adults), and there may be metabolic
    acidosis and electrolyte imbalance. Do a full medical examination to
    exclude other causes of the patient's condition, such as head injury.

         Ensure the airway is clear and the patient remains in the
    recovery position. Monitor breathing, blood pressure, pulse, and blood
    glucose. Supportive care, including oxygen and ventilation, should be
    given as needed:

         *    Fluid and electrolyte balance should be corrected.

         *    Hypoglycaemia should be treated with oral or intravenous
              glucose.

    Ethylene glycol and methanol

    Chemicals covered in this section

         Ethylene glycol and methanol (also called methyl alcohol, wood
    alcohol and wood spirit).

    Uses

         Ethylene glycol is used in antifreeze and has many uses in
    industry.

         Methanol is used in antifreeze for radiators, air brakes, petrol
    and diesel oil; in windscreen washing fluid; as fuel for small
    engines, picnic stoves and soldering torches; and in some inks, dyes,
    resins, adhesives, paint removers and varnish removers. It is widely
    used in industry and as a laboratory chemical.

         Small amounts of methanol are present in preparations of ethanol
    meant for commercial, medical or industrial uses, for example,
    denatured alcohol, surgical spirit and methylated spirit.

    *    Antifreezes may contain methanol, isopropanol or ethylene glycol.
         Some products contain more than one of these chemicals. The
         concentrations vary.

    *    Cleaners for car windscreens contain either isopropanol or
         methanol.

    How they cause harm

         Ethylene glycol and methanol are poisonous if swallowed, and most
    poisonings happen in this way. Methanol is also poisonous if breathed
    in or absorbed through the skin. People who work with methanol may be
    poisoned by breathing in the fumes. Ethylene glycol affects the brain
    and the kidneys. Methanol affects the brain and the eyes and can cause
    blindness.

    How poisonous they are

         If swallowed, just a few mouthfuls may cause death, although
    people with severe poisoning may recover if treated in hospital
    without delay. Severe poisoning may result in permanent brain damage.
    Methanol spilt on the skin may cause severe poisoning if large amounts
    are absorbed.

    Special dangers

         Methanol poisoning is often caused by drinking methylated spirit
    or denatured alcohol because it is cheaper, or more easily available
    than alcoholic drink. Sometimes methanol poisoning is caused by
    contaminated alcoholic drink and may affect many people at the same
    time.

         Antifreeze and windscreen washing liquid may be swallowed by
    mistake if they are kept in drink bottles, instead of their original
    containers.

    Signs and symptoms

         Ethylene glycol

    *    If swallowed

         At first:

    -    vomiting,

    -    headache,

    -    the patient appears to be drunk, but the breath does not smell of
         alcohol.

         After 24-72 hours:

    -    fast breathing,

    -    fast pulse,

    -    low blood pressure,

    -    lung oedema,

    -    unconsciousness,

    -    fits.

         Death may occur within 24 hours. If the patient survives more
    than 24 hours, there may be kidney damage and the patient may stop
    passing urine.

    *    In the eyes:

    -    irritation and redness.

    Methanol

    *    If swallowed

         At first:

    -    mild drunkenness and drowsiness.

    After 8-36 hours:

    -    headache,

    -    belly pain, vomiting and diarrhoea,

    -    fast breathing,

    -    drowsiness,

    -    pale, cold and clammy skin,

    -    large pupils which do not change size if a light is shone in the
         eyes,

    -    patient sees flashing lights or complains that things look
         blurred or that he or she is blind,

    -    unconsciousness,

    -    fits,

    -    lung oedema,

    -    slow pulse,

    -    low blood pressure.

    *    On the skin:

    -    irritation and redness,

    -    if large areas of skin are covered, or exposure lasts a long
         time, effects are the same as if swallowed.

    *    In the eyes:

    -    irritation and redness.

    *    If breathed in:

    -    coughing and sneezing,

    -    shortness of breath,

    -    the same signs and symptoms as if swallowed.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as soon as possible.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water. Take the
    patient to hospital if pain or irritation continues.

     On the skin

         Remove contaminated clothing, shoes, socks and jewellery. Wash
    the skin well with soap and cold water, if possible using running
    water. Take the patient to hospital as soon as possible if methanol
    has been spilt on a large area of skin.

    What to do if there is a delay in getting to hospital

          If the chemical was swallowed: if it happened less than one
    hour ago and the patient is fully awake and breathing normally, has
    not had fits and has not already vomited a lot:

    *    Make the patient vomit.

    *    Give ethanol to drink if the patient has signs of serious
         poisoning. Ethanol is an antidote to ethylene glycol and methanol
         poisoning. Give 150 ml of any strong alcoholic drink, like rum,
         whisky or gin (25 ml for a child). Dilute the alcohol in fruit
         juice and give small swallows over 10-15 minutes. If the patient
         shows signs of low blood sugar (dizziness, confusion, pale sweaty
         skin, rapid pulse, shallow breathing, drowsiness) give fruit
         juice or sugar.

         If the patient stops passing urine, treat as recommended in
    chapter nine. If the patient has signs of lung oedema, treat as
    recommended in chapter nine.

    Information for doctors outside hospital

         As well as the effects listed above ethylene glycol may cause
    severe metabolic acidosis, electrolyte imbalance, disturbed heart
    rhythm, and kidney failure. Methanol tends to cause severe metabolic
    acidosis with hyperventilation; blindness is common in severe cases.

         Monitor breathing, blood pressure, pulse, and fluid and
    electrolyte balance. Supportive care, including oxygen and mechanical
    ventilation, should be given as needed:

    *    Fluid and electrolyte balance should be corrected.

    *    For repeated fits diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         The antidote is ethanol. It should be given as soon as possible,
    preferably by intravenous infusion. A poisons centre can tell you what
    dose to give. Blood sugar should be measured frequently while ethanol
    is being given, as it may cause hypoglycaemia, especially in children.
    Haemodialysis may be necessary if the patient has severe poisoning or
    has taken a large amount.

    Glue

    Products covered in this section

         This section covers glues that contain cyanoacrylate and glues
    that are water-based, sometimes called gums or pastes. For glues and
    adhesives that contain benzene, toluene, trichloroethylene or xylene
    see Part Two (Benzene, etc.)

    Uses

         These glues are widely used in the home and in craft and hobby
    activities. Cyanoacrylate glues also have many industrial uses.

    How they cause harm

         Water-based glues may be mildly irritant to the gut.

    How poisonous they are

         They are not poisonous if swallowed. Cyanoacrylate glue becomes
    solid as soon as it gets into the mouth and does not dissolve. These
    glues do not produce poisonous vapours.

    Special dangers

         Cyanoacrylate glues harden very quickly and it is difficult to
    separate surfaces that are stuck together with them. People may glue
    their fingers or eyelids together by mistake.

    Signs and symptoms

         If cyanoacrylate glue is swallowed there are no signs or
    symptoms. The glue may stick to the teeth or the inside of the mouth.

         If water-based glue is swallowed it may cause nausea and
    vomiting.

         For cyanoacrylate glue on the skin or in the eyes

         The glue does not irritate or burn the skin. However if fingers
    or eyelids are stuck together, there is a risk of injury if you try to
    force them apart. Glue may damage the surface of the eye, but does not
    cause chemical burns.

    What to do

    Cyanoacrylate glue

     In the mouth

         There is no need to remove glue from the teeth or the inside of
    the mouth. It will come off by itself in a few days.

     On the skin

         There is no need to remove glue from the skin unless the fingers
    are stuck together or stuck to something else. Soak affected parts in
    warm soapy water and use a thin, blunt object, like the handle of a
    spoon, to gently push the fingers apart. Do not force them apart
    because the skin may tear.

     In the eye

         If the eyelids are stuck together do not force them apart. Cover
    the eye with a gauze patch. The eyelids will come apart within 2-3
    days.

    Water-based glue

     If swallowed

         Give water to drink. There is no need to take the patient to
    hospital.

    Lead

    Chemicals covered in this section

         This section covers metallic lead, inorganic lead salts and
    organic lead compounds such as tetraethyl lead.

    Uses

         Lead is used in storage batteries, solder, electric cable
    insulations, paints, pottery and ceramic glazes. Tetraethyl lead is
    often added to petrol.

         Some traditional and folk remedies contain lead. Black eye make-
    up (called  tiro, surma or  kohl) may contain lead.

         Lead has been used for water-supply pipes, in house-paints and in
    pottery, which may be used for eating, drinking or cooking. These uses
    are known to have caused poisoning and are now banned in many
    countries. However, lead paints and water-pipes may still be found in
    old houses.

    How it causes harm

         Lead affects the nervous system, kidneys, reproductive system and
    blood. Inorganic lead builds up in bone, tissue, and blood. Organic
    lead is broken down by the liver, but the products damage the brain
    and nervous system.

         Children are more likely to get lead poisoning than adults
    because the body absorbs lead more easily in childhood and is less
    able to get rid of it.

         Poisoning is usually a result of chronic exposure from repeatedly
    breathing in or swallowing low doses. However, a single acute exposure
    can cause poisoning, for example, if a lead object is swallowed and
    stays in the gut for several days, if lead bullets are left in the
    body, or if a large amount of organic lead is swallowed. Skin contact
    with cold metallic lead will not cause lead poisoning, but organic
    lead compounds are absorbed through the skin.

    How poisonous it is

         Lead is very poisonous. A single exposure rarely causes
    poisoning, but repeated exposures can result in permanent brain damage
    or death.

    Special dangers

         Work that is likely to create lead dust or fumes includes lead
    smelting and refining, lead-battery making and breaking, welding,
    heat-stripping or sanding where lead paints have been used. There is a
    danger of breathing in lead unless adequate precautions are taken to
    ensure ventilation and use of protective clothing and respirators.
    There is a danger of swallowing lead if people eat, drink or smoke in
    areas where there are lead fumes or dust. People may also be poisoned
    by eating and drinking from lead-glazed pottery. "Sniffing" petrol
    that contains lead may also result in lead poisoning. Most childhood
    poisoning is caused by eating paint or dust containing lead, or by
    using black eye make-up.

     Symptoms and signs

         If swallowed or breathed in, usually after repeated exposures

    In children:

    -    irritability, memory loss, clumsiness and low intelligence (these
         may occur with no other symptoms),

    -    pale skin due to anaemia,

    -    loss of appetite, headache, and tiredness,

    -    vomiting and colicky belly pain,

    -    metallic taste in the mouth.

         With higher concentrations a life-threatening illness may
    develop:

    -    persistent forceful vomiting,
-    uncoordinated movements,

    -    periods of unconsciousness,

    -    fits.

         Brain damage is usually permanent.

    In adults:

    -    colicky belly pain and constipation,

    -    pain in the joints, headache and weakness,

    -    wrist drop or foot drop,

    -    blue line on the gums,

    -    personality changes, poor memory and slow reactions,

    -    difficulty in coordinating movement.

         Lead from petrol (tetraethyl lead) may also cause:

    -    insomnia, vivid dreams,

    -    mental disturbances,

    -    hallucinations,

    -    fits.

    What to do

    For a child with life-threatening poisoning

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

     What to do if there is a delay in getting to hospital

          For acute poisoning from swallowing lead salts or compounds
    (but not metallic lead): if the patient is fully awake and not
    vomiting, give activated charcoal and water to drink.

          If the patient has swallowed a metallic lead object or pieces of
      lead-based paint: give a laxative (magnesium sulfate by mouth) and
    check whether the object is passed in the faeces.

    For a patient with signs and symptoms of chronic lead poisoning
    but no acute sickness

         Take the patient to a doctor as soon as possible. Treatment with
    an antidote may be needed.

    In all cases of lead poisoning

         Always identify the source of lead and make sure there is no risk
    that the patient will be re-exposed.

    Information for doctors outside hospital

         As well as the effects listed above, lead may cause cerebral
    oedema, anaemia and peripheral neuropathy. The life-threatening
    effects are due to an acute encephalopathy.

         Acute encephalopathy should be treated promptly. Supportive care
    should be given as needed:

    *    Give fluids to keep a good urine flow, but be careful not to give
         too much.

    *    Monitor kidney function.

    *    For repeated fits diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         There are several antidotes which may be of use: dimercaprol,
    sodium calcium edetate, penicillamine, succimer (DMSA; 2,3-
    dimercaptosuccinic acid) and DMPS (dimercaptopropane sulfonate). The
    decision to use an antidote, the choice of antidote, and the dose will
    depend on the symptoms and signs, and the concentration of lead in the
    body. Discuss with a poisons centre which antidote to use and how much
    to give.

         If the patient has swallowed a metallic lead object or pieces of
    lead-based paint, use X-rays to check if they are still in the gut.
    Give magnesium sulfate to move the objects quickly through. Lead
    bullets should be removed if possible.

    Petroleum distillates

    Chemicals covered in this section

         This section covers a large group of chemicals made from
    petroleum. Petroleum distillates are complex mixtures of aromatic and
    aliphatic hydrocarbons.

         They may be liquids that flow easily, spread across a surface
    very rapidly, and evaporate readily at room temperature, such as:

    -    diesel oil,

    -    fuel oil,

    -    kerosene (also called paraffin oil),

    -    mineral seal oil,

    -    mineral spirit (also called white spirit, turpentine substitute,
         petroleum spirit),

    -    petrol (also called gasoline),

    -    petroleum ether,

    -    petroleum naphtha.

         Some other hydrocarbons are liquids that flow slowly, such as:

    -    lubricating oil,

    -    asphalt,

    -    tar,

    -    petrolatum.

         Soft paraffin is semi-solid and paraffin wax is solid.

     Uses and abuses

         Kerosene is used as fuel for stoves and lamps. Solid firelighters
    are soaked in kerosene. Mineral spirits are used as paint thinners,
    paint removers and paintbrush cleaners. Mineral seal oil is used in
    furniture polish. There are petroleum distillates in some shoe
    polishes, window cleaners, furniture polishes, paints, pesticides, and
    degreasers.

    *    Floor and car polishes: most contain petroleum wax and water, but
         some contain a large amount of liquid petroleum distillates.

    *    House paint and varnishes contain petroleum distillates, but
         some, such as emulsion paints, contain only small amounts.

    *    Metal cleaners and polishes may contain petroleum distillates,
         sometimes with small amounts of ammonia or acid (not enough to
         cause burns). Some are solutions made with water rather than
         petroleum distillates.

    *    Window cleaners usually contain petroleum distillates but some
         kinds contain only water and detergents (see Soap and
         detergents).

         Petrol (gasoline) and petroleum ethers are sometimes abused by
    breathing in the vapour (solvent sniffing). White spirit and paraffin
    do not give off enough vapour to be abused in this way.

    How they cause harm

         Liquid petroleum distillates irritate and inflame body tissues.
    Those that spread quickly across a surface can enter the air passages
    when they are swallowed, or during vomiting, and inflame and damage
    lung tissues. This is particularly likely to happen if mineral spirit,
    kerosene, mineral seal oil or petroleum naphtha is swallowed.
    Swallowing or breathing in petroleum distillates may affect the brain.
    These chemicals are irritant to skin and eyes.

         Abuse of petrol affects the brain and may affect the heart.
    Chronic abuse may damage the liver and kidneys and cause permanent
    brain damage. Abuse of petrol containing tetraethyl lead as an
    antiknock agent may cause lead poisoning.

    How poisonous they are

         Even very small amounts of those liquid petroleum distillates
    that flow easily, sometimes as little as one or two mouthfuls, can
    cause severe lung oedema. The risk from slow-flowing liquids is not so
    great. The brain is not usually affected unless a large amount has
    been swallowed or breathed in.

    Special dangers

         Kerosene fuel, polishes, paint thinners and paint-brush cleaners
    are commonly found in the home and are common causes of childhood
    poisoning. While in use they may be left in open containers in places
    where children can easily reach them. There is a risk of swallowing
    small amounts of petrol when siphoning fuel from car fuel tanks.
    Petrol vapour is heavier than air and collects in pits or cellars.
    Someone who goes into a pit or cellar that is full of petrol vapour
    may die from lack of oxygen.

    Signs and symptoms

    Acute exposure

    *    If liquid is swallowed:

    -    coughing and choking almost immediately,

    -    vomiting,

    -    sore throat and a burning feeling in the mouth.

    From large amounts there may also be:

    -    weakness, dizziness and headache,

    -    drowsiness,

    -    unconsciousness,

    -    slow shallow breathing,

    -    fits.

    After 6-24 hours:

    -    wheezing and fast breathing,

    -    lung oedema.

         Death may be due to lung oedema or to infection in the damaged
    lung.

    *    If vapour is breathed in:

    -    dizziness and headache,

    -    other effects as when a large amount of liquid is swallowed, but
         usually without lung oedema; breathing in a large amount, as in
         abuse, may cause sudden death.

    *    On the skin:

    -    redness,

    -    blistering and pain, if in contact with skin for a long time, for
         instance if wet clothes are worn for several hours.

    *    In the eyes:

    -    mild irritation.

    Chronic exposure

         Repeated abuse may result in:

    -    loss of appetite,

    -    loss of weight,

    -    muscle weakness,

    -    mental changes,

    -    sleeplessness, irritability, restlessness,

    -    fits.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water. Take the
    patient to hospital if irritation is severe.

     On the skin

         Immediately remove contaminated clothing, shoes, socks and
    jewellery. Wash the skin well with soap and cold water for 15 minutes,
    if possible using running water. Take the patient to hospital if
    irritation is severe or there are burns.

    What to do if there is a delay in getting to hospital

          If the chemical was swallowed: if the patient is awake and can
    swallow, give water to drink. Do not make the patient vomit, because
    liquid might get into the lungs as the patient vomits. Do not give
    activated charcoal, because it does not bind petroleum distillates.

         For lung oedema, treat as recommended in chapter five.

    Information for doctors outside hospital

         Monitor breathing. If the patient is coughing or wheezing, the
    chemical has probably entered the lungs. A chest X-ray will help
    confirm chemical pneumonitis. If possible, repeat lung function tests
    (such as peak flow or similar tests) every 2-4 hours.

         Supportive care, including oxygen and mechanical ventilation,
    should be given as needed. For repeated fits diazepam should be given
    by intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Patients who stay free of symptoms for 12 hours can be sent home.

    Phosgene

         Phosgene is a colourless gas that smells like mouldy hay.

    Uses

         Phosgene is used in the manufacture of resins, dyes, and
    pesticides, and has been used as a chemical weapon. It is produced
    when chemicals containing chlorine are heated or burn, such as in a
    fire.

    How it causes harm

         It damages the lungs, liver and kidneys. It dissolves slowly in
    water to produce hydrochloric acid, which irritates the eyes, throat
    and lungs. Because it dissolves only slowly, low concentrations may
    not have any effect at first and people may not be aware that they are
    breathing poison. It does not affect the skin.

    How poisonous it is

         Large doses may cause death.

    Signs and symptoms

    *    If breathed in:

    -    irritation and watering of eyes,

    -    coughing, choking,

    -    tightness in chest,

    -    nausea, vomiting, retching.

    After a delay of up to 24 hours:

    -    rapid, shallow breathing,

    -    painful cough,

    -    frothy white or yellowish sputum,

    -    low blood pressure,

    -    fast pulse.

         The patient may die within 48 hours.

    What to do

         Move the patient away from the gas or smoke. Wear breathing
    equipment and protective clothing as needed to protect yourself.

         Give first aid. If the patient has stopped breathing open the
    airway, wipe chemical off the patient's lips, then give mouth-to-mouth
    respiration.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm and quiet.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the patient has signs of lung oedema, treat as recommended
    in chapter nine.

    Information for doctors outside hospital

         Supportive care, including oxygen, should be given as needed. The
    patient may need mechanical ventilation. There is no antidote.

         The patient should be observed for at least 12-24 hours because
    lung oedema may be delayed.

    Soap and detergents

    Chemicals covered in this section

         Soap is a natural product made from animal or vegetable fats or
    oils. Deter-gents are synthetic chemicals. They are more effective
    cleaning agents than soap and do not cause scum in hard water. There
    are three groups: nonionic, anionic and cationic. It is important to
    be able to distinguish the cationic detergents from other kinds,
    because they are more harmful.

         The most common cationic detergents are benzalkonium, cetrimide,
    cetylpyridinium and dequalinium. They are sometimes called quaternary
    ammonium compounds.

         Detergent products usually also contain other chemicals such as
    phosphates, carbonates and silicates to improve the cleaning action,
    bleaches, perfumes, chemicals to kill bacteria, and stain removers.

    Uses

         Anionic detergents are used in most household products for
    washing dishes, clothes, or hair or for general household cleaning.
    Nonionic detergents are used in low-lather laundry products.

         Cationic detergents are used as antiseptics and disinfectants in
    the home, in the food and dairy industries, in health centres and in
    hospitals.

         Soap is usually sold in solid blocks or bars, liquids or flakes
    for washing the skin or washing fabrics.

    How they cause harm

         Most household products containing anionic or nonionic detergents
    are mild irritants. Detergents for use in automatic dishwashers are
    corrosive, and so are many products used in hospitals, agriculture or
    industry. Cationic detergents may burn the inside of the mouth and
    throat and are also poisonous when swallowed, affecting the muscles.

         Some shampoos for killing lice or other insects contain
    insecticides. If the shampoo is not used in the right way, people may
    be poisoned by the insecticide.

    How poisonous they are

         Household detergents do not usually cause harm if swallowed in
    small amounts, except for automatic dishwasher detergents which can
    cause burns. Cationic detergents may cause serious poisoning that may
    result in death.

    Signs and symptoms

    *    If swallowed

         Soap, nonionic and anionic detergents:

    -    soreness in the mouth,

    -    swelling of lips and tongue if a block of soap is sucked,

    -    vomiting and diarrhoea.

         Cationic detergents:

    -    burns in the mouth, throat and gullet,

    -    vomiting and diarrhoea,

    -    muscle weakness,

    -    the patient cannot breathe,

    -    unconsciousness,

    -    fits,

    -    low blood pressure,

    -    lung oedema.

    *    On the skin

         Repeated contact may make skin dry and cracked.

    *    In the eyes

         Cationic detergents may cause serious burns.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital at once in any of the following
    circumstances:

    *    The patient has swallowed a product containing cationic
         detergent.

    *    The patient vomits for a long time or has other signs or symptoms
         of poisoning.

    *    The patient has burns in the mouth.

         If the patient does not need to go to hospital, give milk to
    drink.

     In the eyes

         Gently brush or dab away any liquid or powder from the face then
    wash the eyes for at least 15-20 minutes with water. Check that there
    are no solid bits of chemical on the lashes or eyebrows or in the
    folds of skin round the eyes. Take the patient to hospital if pain or
    irritation continues.

     On the skin

         Remove contaminated clothing, shoes, socks and jewellery. Wash
    the skin well with cold water, if possible using running water.

    What to do if there is a delay in getting to hospital

          If the chemical was swallowed: if the patient is awake, give a
    cup of water to drink. Do not try to make the patient vomit, because
    the vomit may burn the throat.

         If there are signs of lung oedema, treat as recommended in
    chapter nine.


    Information for doctors outside hospital

         Monitor breathing, pulse, blood pressure, and fluid and
    electrolyte balance. Supportive care, including oxygen and
    ventilation, should be given as needed. For repeated fits diazepam
    should be given by intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

    Tobacco products

         This section covers cigarettes, cigars, and pipe and chewing
    tobacco made from cultivated tobacco  (Nicotiana tabacum). In some
    societies other leaves may be smoked or chewed with tobacco, and other
    plants may be added to tobacco to flavour cigarettes. Tobacco contains
    nicotine.

    How they cause harm

         Nicotine affects the brain and nervous system.

    How poisonous they are

         Nicotine is very poisonous. Serious poisoning from swallowing
    cigarettes is uncommon although two cigarettes made from cultivated
    tobacco contain enough nicotine to cause severe poisoning in small
    children. Even a cigarette end may cause poisoning.

    Special dangers

         Products like cigarettes, cigarette ends and loose tobacco are
    often left within easy reach of children.

    Signs and symptoms

    *    If swallowed:

    -    vomiting,

    -    agitation,

    -    diarrhoea,

    -    wet mouth, sweating and pallor,

    -    weakness,

    -    pupils may be wide or very small,

    -    fast pulse at first, becoming slow or irregular later,

    -    a short period of unconsciousness,

    -    jerking limbs,

    -    fits.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes and keep the patient warm and quiet.

         If the patient has a fit, treat as recommended in chapter five.

         If the patient is fully awake, breathing normally and not
    vomiting, give activated charcoal and water to drink. Do not make the
    patient vomit.

         Children who swallow more than one cigarette or a similar amount
    of loose tobacco should be taken to a doctor and watched for several
    hours.

    Volatile oils

    Chemicals covered in this section

         This section covers a group of chemicals that evaporate at room
    temperature. Sometimes they are called essential oils because they are
    made from the essences or perfume oils of plants. Camphor, clove oil,
    eucalyptus oil, pine oil, and turpentine oil are some common volatile
    oils.

    Note: turpentine oil is made from pine wood and is not the same
    chemical as turpentine substitute, which is a petroleum distillate.

    Uses

         Camphor, eucalyptus oil, menthol and turpentine oil are used in
    liniments for rubbing on the skin to treat muscle pains; eucalyptus
    oil, camphor and menthol are also used in preparations for rubbing on
    the chest, and preparations meant to be breathed in. Camphor has been
    used as nose drops or sprays for treating colds, but this is not
    recommended.

         These oils also have many non-medical uses. Turpentine oil is
    used as a paintbrush cleaner. Camphor, in the form of crystals,
    tablets or balls, is used to keep moths away. However, moth repellents
    may be made of naphthalene or  para-dichlorobenzene rather than
    camphor (see Air-fresheners, deodorant blocks and moth-balls.)

     Products containing camphor

    *    Camphorated oil, camphor liniment: camphor, 200 g/kg (20%) in
         oil.

    *    Compound camphor liniment, ammoniated camphor liniment: camphor,
         125 g/l (12.5%) in strong ammonia solution (300 ml/l).

    *    Camphor spirit: camphor, 100 g/l (10%) in alcohol.

         Perfume oils are used in cosmetics and toiletries such as perfume
    and aftershave (see Ethanol and isopropanol), air-fresheners (see Air-
    fresheners, deodorant blocks and moth-balls), and other household
    products. Pine oil is used in disinfectants (see Disinfectants and
    antiseptics). However these products contain only small amounts of
    volatile oils, and if they are swallowed harmful effects are usually
    due to other chemicals rather than the volatile oils.

    How they cause harm

         Volatile oils are mildly irritant to the skin. Poisoning is
    usually caused by swallowing the liquid, but in some cases it may be
    caused by skin contact or breathing in the vapour. Volatile oils are
    irritant to the gut, may cause lung oedema, and may affect the brain
    and kidneys.

    How poisonous they are

         They may cause serious poisoning and even death. Children have
    died after swallowing just a few mouthfuls of turpentine oil,
    eucalyptus oil or camphor-containing products. Liniments and paint-
    brush cleaners containing turpentine have caused serious poisoning in
    young children.

         Large amounts of camphor liniment, spirits or oil rubbed on the
    skin may cause severe poisoning. Camphor nose drops can cause
    poisoning in infants.

    Special dangers

         Camphorated oil is sometimes swallowed in mistake for castor oil.
    Household products and medications containing essential oils are often
    stored where children can easily get hold of them.

    Signs and symptoms

    *    If swallowed

         The patient may have symptoms within a few minutes of swallowing
    the oil:

    -    breath smells of the oil,

    -    burning feeling in mouth, throat and belly,

    -    nausea, vomiting and diarrhoea,

    -    anxiety, excitement and hallucinations,

    -    dizziness,

    -    twitching,

    -    fits, which may happen suddenly, without warning, within 5
         minutes of swallowing the oil,

    -    unconsciousness,

    -    slow, shallow breathing.

         Death may occur early during fits. If not the patient may
    develop:

    -    signs of lung oedema,

    -    signs of kidney failure, and may pass less urine than
         normal.

    *    In the eyes:

    -    irritation and redness, but serious injury is unlikely.

    *    On the skin:

    -    redness and irritation,

    -    large amounts rubbed on the skin may cause effects similar to
         those of swallowing.

    What to do

         Give first aid. If breathing stops, open the airway, wash
    chemical off the patient's lips, then give mouth-to-mouth or
    mouth-to-nose respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes and keep the patient warm and quiet.

         If the patient has a fit, treat as recommended in chapter five.

     In the eyes

         Wash the eyes for at least 15-20 minutes with water.

     On the skin

         Immediately remove contaminated clothing, shoes, socks and
    jewellery. Wash the skin thoroughly with soap and cold water, if
    possible using running water. Rinse for at least 15 minutes.

         Take the patient to hospital as soon as possible if any amount
    has been swallowed, or if there is continuing pain or irritation in
    the eye, or burns or signs of poisoning following skin contact.

    What to do if there is a delay in getting to hospital

          If the chemical was swallowed: if the patient is fully awake
    and breathing normally, has not had muscle twitching or fits, and is
    not vomiting, give activated charcoal and water to drink. Do not make
    the patient vomit because liquid or vapour might get into the lungs
    causing lung oedema, and vomiting might set off a fit.

         If the patient has signs of lung oedema, treat as recommended
    in chapter nine.

         After 24 hours, if the patient is passing urine as often as
    usual, give 3-4 litres of water to drink each day for the next 5 days.

         If the patient has signs of kidney failure, treat as recommended
    in chapter nine.


    Information for doctors outside hospital

         As well as the effects listed above there may be liver and kidney
    damage. Monitor pulse, breathing, blood pressure, and liver and kidney
    function. Supportive care, including oxygen and ventilation, should be
    given as needed. For repeated fits diazepam should be given by
    intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

         Children: 200-300 µg/kg of body weight.

    Products that are not usually harmful

         The following would not be expected to cause any ill-effects:

    *    Ink: ball-point pens, felt-tip pens, and fountain pens contain so
         little ink that there is not enough to cause poisoning if it is
         sucked from a pen. Some inks may cause soreness in the mouth.
         Large amounts of ink swallowed from a bottle could be irritant,
         but serious poisoning has not been reported.

    *    Pencils and wax crayons: "lead" pencil is not lead but graphite,
         which is harmless.

    *    Silica-gel drying crystals used to keep things dry by absorbing
         moisture.

    *    Thermometers: if the end is bitten off a glass thermometer and
         the contents swallowed the small amount of liquid will not cause
         poisoning. Metallic mercury will pass through the body unchanged.
         The broken glass may cause injury.

    What to do

         Give a cup of water. There is no need to do anything else.

         If the patient has bitten a thermometer, check that there is no
    broken glass inside the mouth.

    Medicines

    Acetylsalicylic acid, choline salicylate, methyl salicylate,
    salicylic acid

    Medicines covered in this section

         This section covers acetylsalicylic acid (aspirin), choline
    salicylate, methyl salicylate (oil of wintergreen) and salicylic acid.
    All these medicines are known as salicylates.

    Uses

         Acetylsalicylic acid is widely used to treat pain, fever,
    influenza, and inflammation of bones and muscles such as arthritis. It
    is usually given by mouth as tablets. Pain killers and medicines for
    treating colds may also contain paracetamol, caffeine, meprobamate or
    opiates. Aspirin should not be given to children under 12 years old.

         Choline salicylate gel or liquid is rubbed onto children's gums
    to treat teething pain.

         Methyl salicylate is made into liniments and ointments that are
    put on the skin to treat pain in the bones and rheumatism.

         Salicylic acid is used in powders, lotions or ointments to treat
    skin diseases. It is also used for removing warts.

    How they cause harm

         Salicylates make breathing faster and deeper, and upset the
    balance of chemicals and water in the body. The change in the balance
    of chemicals affects the brain and the heart.

    How poisonous they are

         Salicylates are very poisonous if large amounts are taken. More
    than 300 mg/kg of body weight is likely to cause serious poisoning and
    over 500 mg/kg may cause death. Children and old people may be
    poisoned if given repeated high doses for 24 hours or more. Methyl
    salicylate liniments are very dangerous because they are usually
    strong solutions. One millilitre may contain more than 4 times as much
    salicylate as one 300 mg tablet of aspirin, and children have died
    after drinking only a teaspoonful. Salicylates are absorbed into the
    body when ointments, lotions or gels are put on skin and gums, and can
    cause poisoning if too much is used.

    Special dangers

         Aspirin is widely used, many people keep it at home, and it is a
    common cause of acute poisoning in small children. Poisoning in
    children may not be recognized when aspirin is given to treat feverish
    illness because the symptoms of poisoning (fever and sweating) are
    like the effects of the illness.

    Signs and symptoms

         Effects may be delayed for 12 hours or more, because aspirin
    tablets dissolve very slowly in the stomach.

    Mild poisoning:

    -    belly pain, nausea and vomiting,

    -    dizziness,

    -    ringing in the ears and deafness,

    -    fast breathing.

    Moderate poisoning:

    -    fast breathing,

    -    confusion and restlessness,

    -    fever and sweating,

    -    dry tongue.

    Severe poisoning:

    -    drowsiness or unconsciousness,

    -    fits,

    -    shallow, fast breathing,

    -    signs of lung oedema,

    -    signs of kidney damage,

    -    heart and breathing may stop.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes.

         If the patient has a fit, treat as recommended in chapter five.

         If the patient has fever, sponge the body with cool water.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

          If the medicine was swallowed: if it happened less than 12
    hours ago, and if the patient is fully awake and breathing normally
    and has not had fits:

    *    Make the patient vomit unless he or she has already vomited a
         lot.

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until vomiting has stopped.

         Give repeated doses of activated charcoal: for adults, 50 g every
    2-4 hours; for children, 10-15 g every 2-4 hours. With each dose of
    charcoal give sodium sulfate or magnesium sulfate, 30 g for adults,
    250 mg/kg of body weight for children, until the stools look black.

         If the patient has signs of lung oedema, treat as recommended
    in chapter nine.

    Information for doctors outside hospital

         The effect on the respiratory centre results in a respiratory
    alkalosis (except in children), dehydration and a fall in plasma
    potassium concentration. A mild acidosis also develops. Blood glucose
    may be low or high. Urine may be alkaline at first but soon becomes
    acid.

         Monitor fluid and electrolyte balance, blood glucose and urine
    pH. Supportive care should be given as needed:

    *    Fluid and electrolyte balance should be corrected, particularly
         potassium; this may be all that is needed to treat mild
         poisoning.

    *    For repeated fits, diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

    *    Pulmonary oedema should be treated with oxygen and mechanical
         ventilation.

         Plasma salicylate concentrations are valuable in assessing the
    severity of poisoning after single doses. Plasma salicylate should be
    measured every two hours as long as the plasma concentration is
    rising. Generally patients with plasma salicylate concentrations of
    between 350 and 600 mg/l (250-450 mg/l in children and old people) six
    hours after taking an overdose have only mild poisoning; patients with
    concentrations of 600-800 mg/l (450-700 mg/l in children and old
    people) have moderate poisoning; patients with concentrations of above
    800 mg/l (700 mg/l in children and old people) have severe poisoning.

         To speed up the clearance of aspirin from the body, give repeated
    doses of activated charcoal, as described above. Other ways to remove
    salicylates from the body are:

    -    by making the urine alkaline (pH 7.5-8.5) by giving sodium
         hydrogen carbonate (sodium bicarbonate),

    -    haemodialysis, which is more useful in serious poisoning
         (salicylate level over 800 mg/l) because it improves the balance
         of fluid and electrolytes.

    Amfetamine-like medicines, atropine-like medicines,
    antihistamines, cocaine, ephedrine, and pseudoephedrine

    Medicines covered in this section

         Amfetamine and medicines like amfetamine, such as:

    amfepramone (diethylpropion)      methylphenidate

    amfetamine                        pemoline

    dexamfetamine                     phenmetrazine

    fenfluramine                      phentermine

    metamfetamine

         Atropine and medicines like atropine, such as:

    atropine                          homatropine

    belladonna                        procyclidine

    benzatropine                      scopolamine (hyoscine)

    dicycloverine (dicyclomine)

    Examples of antihistamines:

    chlorphenamine                    pheniramine

    cyclizine                         promethazine

    dimenhydrinate                    triprolidine

    diphenhydramine

         The word "antihistamine" describes what these medicines do - they
    act against histamine. Histamine is a chemical made in the body that
    produces allergic effects such as rashes, itching and hay fever, when
    the body is in contact with some chemical substances. Antihistamines
    stop these effects.

         Cocaine, ephedrine and pseudoephedrine do not belong to any of
    the above groups, but are included in the same section because the
    first aid treatment of poisoning with them is similar.

     Uses and abuses

    Amfetamine-like medicines

         Amfetamine-like medicines are used to treat some kinds of mental
    disorder. They are used by some doctors to help overweight people to
    lose weight. They may be misused by people who want to keep alert and
    active for a long time, or abused because they make people feel good
    or "high". Long-term misuse or abuse of amfetamines can lead to
    dependence.

         Amfetamines are given by mouth as capsules or tablets, some of
    which are called "sustained-release preparations", which means that
    their effects last for many hours. People who abuse amfetamines may
    swallow tablets, sniff powder, or use injections.

    Atropine-like medicines

         Atropine, homatropine and hyoscine are put into the eye, as drops
    or ointment, during eye examination or to treat some eye conditions.
    Atropine, belladonna and hyoscine are sometimes given by mouth or by
    injection to treat stomach problems. Atropine is given by injection to
    treat poisoning with organophosphorus and carbamate insecticides.
    Benzatropine is given by mouth or by injection to treat Parkinson
    disease. Dicycloverine is used to treat stomach ulcers. Procyclidine
    is given by mouth or injection to treat Parkinson disease. Scopolamine
    and hyoscine are given by mouth to prevent travel sickness.

    Antihistamines

         These are used to treat allergy, travel sickness and cough. They
    are given by mouth as tablets, capsules and liquid, and by injection.
    They are also used in ointments for stings, sunburn, and skin rash.

    Cocaine

         Cocaine is used as a local anaesthetic on the skin. It is made
    from dried leaves of the coca plant,  Erythroxylon coca, or can be
    made from chemicals. It is abused because it makes people feel good,
    "high" and self-confident. Drug abusers usually take the drug as a
    powder which they sniff (snort) or smoke. Sometimes it is injected. In
    some countries people chew coca leaves.

    Ephedrine and pseudoephedrine

         These are used to treat coughs, colds and asthma. They are given
    by mouth as tablets and liquids. Many products contain pseudoephedrine
    mixed with other medicines. Ephedrine nose drops are given to clear a
    blocked nose.

    How they cause harm

         All these medicines excite the brain, although antihistamines
    sometimes have the opposite effect and slow down the brain. They also
    have other effects:

    *    Amfetamine-like medicines, cocaine, ephedrine and pseudoephedrine
         affect the nerves that control the heart.

    *    Antihistamines affect the nerves that control the heart, gut and
         bladder. They sometimes slow down the brain causing drowsiness
         and unconsciousness.

    *    Atropine-like medicines affect the nerves that control the heart,
         eyes, gut and bladder. They make the skin and mouth dry, and
         cause fever, wide pupils, fast heart-beat and fast breathing.

    *    Cocaine affects the nerves that control breathing.

         These effects occur when any of these medicines are swallowed or
    injected. General systemic effects can also occur when atropine-like
    medicines are put into the eye, and when amfetamine, cocaine and
    ephedrine are in contact with the inside of the nose. Antihistamines
    do not cause systemic effects if put on the skin.

    How poisonous they are

         All these medicines can cause serious illness and death if too
    much is taken or if they are abused, especially if they are injected,
    smoked or sniffed. The poisonous doses of amfetamines and ephedrine

    are only slightly larger than the doses used for treatment. Repeated
    use or abuse of amfetamines can cause tolerance, so that a dose which
    produces effects of poisoning in a person who has never taken
    amfetamines will not have any effects on a person who regularly takes
    them. Children are more likely than adults to get serious poisoning
    from antihistamines, atropine-like medicines, ephedrine and
    pseudoephedrine.

    Special dangers

         Medicines containing antihistamines, for treating colds and
    coughs, are often kept in the home, in places where children can
    easily get hold of them. These medicines are usually liquids that are
    sweet or taste of fruit, they taste good to children and are easy to
    swallow. Travel sickness tablets are often mistaken for sweets by
    children.

         Drug smugglers who swallow large amounts of cocaine in sealed
    bags get severe poisoning if the bags burst inside the body.

    Signs and symptoms

    Amfetamine-like medicines

         When amfetamines are taken by mouth, effects begin within 30-60
    minutes and last for 4-6 hours. If large amounts are taken, or if
    sustained-release preparations are taken, the effects may last much
    longer. When amfetamines are injected, effects begin within seconds:

    -    restlessness and sleeplessness,

    -    trembling,

    -    dry mouth,

    -    nausea, vomiting and belly pain,

    -    flushing and sweating,

    -    wide pupils,

    -    confusion and panic,

    -    hallucinations,

    -    high blood pressure at first,

    -    fast breathing and chest pain,

    -    irregular pulse,

    -    fits,

    -    fever (temperature measured in the rectum may be higher than
         40°C),

    -    unconsciousness,

    -    low blood pressure in severe poisoning.

    Antihistamines

         The usual effects are:

    -    drowsiness,

    -    dry mouth,

    -    headache,

    -    nausea,

    -    fast pulse,

    -    the patient cannot pass urine, - drowsiness and confusion,

    -    hallucinations,

    -    unconsciousness,

    -    shallow breathing.

         Some people, especially children, may have different signs and
    symptoms:

    -    wide pupils,

    -    shaking,

    -    excitement,

    -    high temperature and warm skin,

    -    fits.

    Atropine-like medicines

         Effects are:

    -    red, dry skin,

    -    wide pupils,

    -    blurred vision,

    -    dry mouth and thirst,

    -    confusion and hallucinations,

    -    excitement and aggression,

    -    fast pulse,

    -    the patient cannot pass urine,
    -    unconsciousness,

    -    fever,

    -    fits.

    Cocaine

         Effects are:

    -    fast, irregular pulse,

    -    fast, deep breathing,

    -    excitement, restlessness and anxiety,

    -    hallucinations,

    -    shaking, twitching,

    -    high blood pressure at first, low blood pressure later,

    -    fits,

    -    raised temperature,

    -    fast, shallow breathing, which may stop completely,

    -    unconsciousness,

    -    paralysis of muscles.

         When cocaine is injected, the patient may die within a few
    minutes.

    Ephedrine and pseudoephedrine

         Effects are:

    -    nausea and vomiting,

    -    headache and irritability,

    -    hallucinations,

    -    fever,

    -    fast pulse,

    -    wide pupils,

    -    blurred vision,

    -    high blood pressure,

    -    breathing in gasps,

    -    muscle spasms and fits,

    -    unconsciousness.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position, and check breathing every 10 minutes.

         If the patient has a fit, treat as recommended in chapter five.

         If the patient has fever, sponge the body with cool water.

         A patient who is anxious, confused, very restless, or aggressive,
    or who has hallucinations, should be kept in a quiet, dimly lit place
    and protected from injury. Stay calm and quiet yourself to reassure
    the patient.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

          If the substance was swallowed: if it was taken less than 4
    hours ago (6 hours for atropine, 12 hours for sustained-release
    amfetamines) and if the patient is fully awake and breathing normally,
    and has not had fits:

    *    Make the patient vomit unless he or she has already vomited a
         lot. This should be done even if the patient has taken medicine
         to stop travel sickness, because these medicines do not usually
         stop vomiting caused by ipecacuanha or touching the throat. If
         you give the patient ipecacuanha but this does not cause
         vomiting, do not give another dose.

    *    If the patient is fully awake give repeated doses of activated
         charcoal and water to drink. If you have made the patient vomit,
         wait until vomiting has stopped.

     Dose: adults, 50 g every 2-4 hours; children, 10-30 g every 2-4
    hours. With each dose of charcoal give sodium sulfate or magnesium
    sulfate, 30 g to adults, 250 mg/kg of body weight to children, until
    the stools look black.

    Information for doctors outside hospital

         As well as the effects listed above, all of these medicines may
    cause heart rhythm disturbances in overdose.

         Monitor breathing and blood pressure. Supportive care, including
    oxygen and mechanical ventilation, should be given as needed:

    *    For low blood pressure, intravenous fluids should be given but
         fluid output must be monitored carefully because there is a
         possibility of kidney failure.

    *    For repeated fits, diazepam should be given by intravenous
         injection, but there is a danger that diazepam might affect
         breathing.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Do not use chlorpromazine to treat agitated patients who are
    poisoned by amfetamine or atropine.

     Amfetamine and cocaine

         If the rectal temperature rises above 40°C cover the patient with
    a cold wet sheet and blow air onto the patient with a fan, until the
    temperature falls to 39°C. Measure temperature, pulse and breathing
    every 10-15 minutes.

         If fits do not stop after the patient has been given diazepam, it
    may be necessary to paralyse the patient with pancuronium and give
    mechanical ventilation. High blood pressure does not usually last a
    long time, so there is no need to use medicine to treat it.

     Atropine and antihistamines

         It may be necessary to catheterize a patient who cannot pass
    urine. Physostigmine given intravenously may be useful in life-
    threatening atropine poisoning but may itself have life-threatening
    side-effects, so it should only be given in hospital with the patient
    on a heart monitor.

    Aminophylline and theophylline

    Uses

         These medicines are used to treat asthma. They are given by mouth
    as tablets, capsules, or liquids, and may also be given by injection.
    In some countries aminophylline may be available as suppositories to
    be given by rectum. Some tablets are "sustained-release" preparations;
    this means that the effects of the medicine last a long time and fewer
    doses are needed per day compared with ordinary tablets.

    How they cause harm

         Aminophylline and theophylline upset the balance of chemicals in
    the body and this affects the heart and causes fits.

    How poisonous they are

         Poisoning may be caused by a single overdose, or by repeatedly
    taking too large a dose of prescribed medicine for more than 24 hours.
    Amounts only a little larger than the therapeutic dose may cause
    poisoning. Serious poisoning may cause death. Elderly people and
    patients with asthma are particularly at risk.

    Signs and symptoms

         Effects may be delayed for 12 hours or more if sustained-release
    preparations have been taken:

    -    nausea and vomiting,

    -    fast pulse,

    -    restlessness, headache and sleeplessness,

    -    hallucinations,

    -    fast breathing,

    -    unconsciousness in some cases,

    -    vomiting blood,

    -    fits, which may occur suddenly,

    -    low blood pressure,

    -    irregular pulse.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm.

         If the patient is fully awake and breathing normally, has not had
    fits, and is not vomiting, give 50-100 g (10-15 g for children) of
    activated charcoal and water to drink.

         If the patient has a fit, treat as recommended in chapter five.

         If the patient has hallucinations, keep the patient in a quiet,
    dimly lit room, and protect from injury. Stay calm and quiet yourself
    to reassure the patient.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the patient is fully awake, give repeated doses of activated
    charcoal and water to drink (adults, 50 g every 2-4 hours; children,
    10-15 g every 2-4 hours). With each dose of charcoal give sodium
    sulfate or magnesium sulfate, 30 g for adults, 250 mg/kg of body
    weight for children, until the stools look black.

         Keep the patient in bed. If possible raise the foot of the bed so
    that the patient's feet are higher than the head. This will help blood
    to reach the brain if the blood pressure is low.

    Information for doctors outside hospital

         As well as the effects listed above, there may be a low serum
    potassium concentration, metabolic acidosis, respiratory alkalosis,
    and serious disorders of heart rhythm (supraventricular or ventricular
    arrhythmias).

         Monitor breathing, pulse, blood pressure and serum electrolytes.
    In moderate to severe poisoning, acid-base balance should be
    monitored. Supportive care, including oxygen and mechanical
    ventilation, should be given as needed:

    *    Correct fluid and electrolyte balance, particularly potassium.

    *    Treat low blood pressure with intravenous fluids.

    *    For repeated fits, diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         If the patient is vomiting and unable to take activated charcoal,
    metoclopramide should be given intravenously to stop the vomiting.

         Dose of metoclopramide to be given intravenously over 1-2
    minutes:

    child up to 3 years (up to 14 kg): 1 mg

    child 3-5 years (15-19 kg): 2 mg

    child 5-9 years (20-29 kg): 2.5 mg

    children over 9 years and young adults (30-60 kg): 5 mg

    adults: 10-50 mg.

         Charcoal haemoperfusion or haemodialysis may be indicated in
    severe poisoning.

         Measurement of serum theophylline concentration may be helpful in
    showing how severe the poisoning is. Patients with signs and symptoms
    of poisoning usually have plasma theophylline concentrations of
    25 mg/l or more, and in severe poisoning, plasma concentrations are
    usually above 50 mg/l. However, some patients with low plasma
    concentrations may have severe poisoning, especially if toxicity is
    chronic, and some patients with high plasma concentrations may be free
    of severe effects. It is therefore important that treatment should be
    based on the clinical condition as well as the plasma drug
    concentration. Measurements should be repeated at regular intervals if
    possible.

    Amitriptyline-like medicines, chloroquine, quinidine,
    and quinine

    Medicines covered in this section

         This section covers amitriptyline and similar medicines (also
    called tricyclic antidepressants), chloroquine, quinidine and quinine.

    These are examples of amitriptyline-like medicines:

    clomipramine        imipramine

    desipramine         nortriptyline

    dosulepin           protriptyline

    doxepin             trimipramine

    Uses

         Medicines in the amitriptyline group are given to patients who
    are depressed, to make them feel happier. They are given by mouth as
    liquids, tablets or capsules; some of these are "sustained-release"
    preparations, which means that their effects last for many hours.

         Chloroquine is used to prevent and treat malaria and to treat
    amoebic liver disease and some kinds of arthritis. It is given by
    mouth as tablets or syrup, or by injection.

         Quinidine is used to treat heart disease. It is given by mouth as
    tablets or by injection.

         Quinine is used to treat malaria and is sometimes given to people
    who get cramp during the night. It is given by mouth as tablets or by
    intravenous infusion. It is sometimes misused to cause abortions.

    How they cause harm

         All these medicines affect the heart and the brain. Overdose can
    cause serious heart rhythm disturbances and low blood pressure. In
    addition:

    -    amitriptyline-like medicines affect the nerves controlling the
         heart, gut and bladder, in the same way as atropine-like
         medicines;

    -    chloroquine affects the eyes;

    -    quinine affects muscles, the eyes, and the ears.

    How poisonous they are

         All these medicines can cause serious poisoning and death if too
    much is taken. For many of these medicines, the dose that causes
    poisoning is often only slightly bigger than the dose used to treat
    illness.

    Special dangers

         Depressed people may try to kill themselves by taking too much
    medicine. They may be careless with their medicines and leave them
    where children can easily find them. People who take quinine for night
    cramps sometimes leave their tablets on a bedside table where children
    can easily reach them.

         Women misusing quinine to cause abortion may take a dose that
    causes serious poisoning.

    Signs and symptoms

    Amitriptyline-like medicines

         Effects are:

    -    dry mouth,

    -    medium size or wide pupils,

    -    blurred vision,

    -    fast or irregular pulse,

    -    the patient may not be able to pass urine,

    -    hallucinations and confusion,

    -    unconsciousness,

    -    shallow breathing,

    -    fits,

    -    low blood pressure,

    -    heart and breathing may stop, causing sudden death.

    Chloroquine

         Within 1-3 hours:

    -    vomiting and diarrhoea,

    -    headache and dizziness,

    -    drowsiness within 10-30 minutes, then excitement,

    -    unconsciousness (sometimes),

    -    fits,

    -    low blood pressure,

    -    shallow, fast breathing,

    -    irregular pulse,

    -    heart and breathing may stop, causing death.

         The patient may be very ill within 1 hour and may die within 2-3
    hours of taking the medicine. Patients who survive for 48 hours
    usually recover completely. Patients who become blind after taking one
    large dose always recover their sight.

    Quinidine

         Effects may begin within 2-4 hours:

    -    nausea and vomiting,

    -    irregular pulse,

    -    low blood pressure,

    -    unconsciousness,

    -    fits,

    -    shallow breathing,

    -    heart and breathing may stop, causing death.

         Patients who survive for 48 hours usually recover.

    Quinine

         Effects are:

    -    nausea and vomiting,

    -    ringing sound in the ears, deafness,

    -    large pupils,

    -    blurred vision,

    -    disturbed colour vision,

    -    blindness, partial or complete, within 30 minutes or after many
         hours,

    -    dizziness,

    -    headache,

    -    fever,

    -    excitement and confusion,

    -    rapid, shallow breathing,

    -    fast pulse,

    -    fits,

    -    low blood pressure,

    -    unconsciousness,

    -    heart and breathing may stop.

         If the patient does not die within a few hours there may be signs
    of kidney failure after a few days. Sight may return after 14-24 hours
    or after several weeks, but may never be as good as it was before.
    Sometimes blindness is permanent. Hearing usually returns quickly and
    completely.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops. It
    may be necessary to continue heart massage for a long time. Some
    patients with amitriptyline poisoning have needed heart massage for
    over an hour before the heart started beating by itself.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes and
    keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         If the patient has hallucinations or is confused, keep him or her
    in a quiet, dimly lit place, protected from injury. Stay calm and
    quiet yourself to reassure the patient.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the patient is fully awake and breathing normally, and is not
    vomiting:

    *     For amitriptyline: if the medicine was swallowed less than 12
         hours ago, give activated charcoal and water to drink and a dose
         of sodium sulfate or magnesium sulfate.

    *     For chloroquine, quinidine and quinine: give repeated doses of
         charcoal for 24 hours (adults, 50 g every 2-4 hours; children,
         10-30 g every 2-4 hours). With each dose of charcoal give sodium
         sulfate or magnesium sulfate, 30 g to adults, 250 mg/kg of body
         weight to children, until the stools look black.

         Keep the patient in bed. If possible raise the foot of the bed so
    that the patient's feet are higher than the head. This will help blood
    to reach the brain if the blood pressure is low.

    Information for doctors outside hospital

         Monitor breathing, pulse, blood pressure, fluids and
    electrolytes, blood glucose and kidney function. Supportive care,
    including oxygen and mechanical ventilation, should be given as
    needed:

    *    Low blood pressure should be treated with intravenous fluids;
         keep the patient lying with the feet higher than the head.
         Isoprenaline, dopamine or norepinephrine (noradrenaline) can be
         used if needed.

    *    For repeated fits diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

    *    Fluid and electrolyte balance should be corrected.

     Chloroquine

         Serum potassium concentration may be low, but potassium chloride
    infusion should only be given if the plasma potassium concentration
    can be measured frequently during the infusion. The plasma potassium
    may rise suddenly and become dangerously high.

         Diazepam may protect the heart from the effects of chloroquine,
    but may depress breathing and should only be given if it is possible
    to ventilate the patient.

     Dose: 0.5 mg/kg of body weight, given by intravenous injection.

         If poisoning is severe, diazepam can be given by continuous
    intravenous infusion for 24-48 hours.

     Dose: 5-10 mg per hour for adults; 0.25-0.4 mg/kg of body weight per
    hour for children.

     Quinine

         The patient's eyes should be examined frequently. Look for pallor
    of the optic disc, contraction of retinal blood vessels, retinal
    oedema and constricted visual fields.

    Barbiturates, chlorpromazine-like medicines, diazepam-like
    medicines and meprobamate

    Medicines covered in this section

         This section covers barbiturates, chlorpromazine-like medicines
    (also called phenothiazines), diazepam-like medicines (also called
    benzodiazepines), haloperidol and meprobamate.

    Examples of barbiturates:

    amobarbital         phenobarbital

    barbital            secobarbital

    pentobarbital

    Examples of chlorpromazine-like medicines (phenothiazines):

    chlorprothixene     prochlorperazine

    fluphenazine        thioridazine

    perphenazine        trifluoperazine

    Examples of diazepam-like medicines (benzodiazepines):

    chlordiazepoxide    nitrazepam

    chlorazepate        oxazepam

    lorazepam

     Uses and abuse

         Phenobarbital is given for epilepsy (fits); it can make fits
    happen less often or stop them altogether. The other barbiturates are
    used to help people sleep. They are supplied as tablets or capsules.
    Barbiturates may be abused and some abusers become dependent on them.
    Some abusers mix the powder from inside the capsules with water, or
    crush tablets in water, and inject themselves with the solution.

         Chlorpromazine-like medicines and haloperidol are used to calm
    violent people, and to help people with mental disorders behave
    normally. Chlorpromazine is also used to stop vomiting. They are given
    by mouth as tablets or liquid, or by injection.

         Diazepam and some similar medicines are given to anxious people
    to make them feel calm. Some, such as nitrazepam, are given to help
    people sleep. Diazepam is also used to stop fits. The medicines are
    given by mouth as tablets, capsules or liquid, or by injection.

         Meprobamate is given to anxious people to help them sleep. It is
    given by mouth as tablets.

    How they cause harm

         All these medicines slow down the brain, and big doses cause
    unconsciousness and may make breathing shallow. Chlorpromazine-like
    medicines and haloperidol can also cause fits, restlessness and
    strange movements the patient cannot control. The heartbeat may be
    irregular and blood pressure may be low.

    How poisonous they are

         Barbiturates, chlorpromazine-like medicines, and meprobamate are
    very poisonous and overdose may cause death. Long-term treatment with
    phenobarbital for weeks or months may cause chronic poisoning because
    the medicine builds up in the body.

         Diazepam-like medicines and haloperidol do not usually cause
    severe poisoning, and unconscious patients normally recover completely
    if given medical care. However, people may get serious poisoning if
    they take diazepam-like medicines with other medicines that slow down
    the brain.

         People are more likely to get serious poisoning if they take any
    of these medicines with alcohol.

    Signs and symptoms

    Barbiturates

    *    Acute poisoning:

    -    drowsiness,

    -    unconsciousness which may last for many days,

    -    low temperature,

    -    low blood pressure,

    -    shallow breathing,

    -    skin blisters between the fingers, or on the body, knees or
         ankles,

    -    no bowel sounds - this means that the gut has stopped working and
         that poisoning is very serious.

         The patient may die because heart and breathing stop. Patients
    who are unconscious for a long time may die from lung oedema.

    *    Chronic poisoning:

    -    drowsiness,

    -    the patient cannot walk properly,

    -    slurred speech.

    Chlorpromazine-like medicines and haloperidol

         Effects are:

    -    drowsiness,

    -    unconsciousness,

    -    low blood pressure,

    -    low temperature,

    -    fast pulse which may also be irregular,

    -    rigid, stiff limbs,

    -    abnormal eye movements and grimaces,

    -    restlessness and fits,

    -    shallow breathing.

    Diazepam-like medicines

         Effects are:

    -    staggering walk,

    -    slurred speech,

    -    drowsiness,

    -    unconsciousness (but the patient is usually rousable),

    -    shallow breathing (rare).

    Meprobamate

         Effects are:

    -    weakness and confusion,

    -    low blood pressure,

    -    low temperature,

    -    drowsiness,

    -    unconsciousness,

    -    shallow breathing.

         Patients who are unconscious for a long time may die from lung
    oedema.

    What to do

    Acute poisoning

         Give first aid. If breathing stops open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm.

          For chlorpromazine-like medicines and haloperidol: if the
    patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

          If the medicine was swallowed: if it happened less than 4 hours
    ago, and if the patient is fully awake and breathing normally, and has
    not had fits:

    *    Make the patient vomit.

    *    When the patient has stopped vomiting give activated charcoal and
         water to drink. Give sodium sulfate or magnesium sulfate with the
         charcoal.

     For phenobarbital: repeat the dose of charcoal every 4 hours
    (adults, 50 g; children, 10-15 g). With each dose of charcoal give
    sodium sulfate or magnesium sulfate, 30 g for adults, 250 mg/kg of
    body weight for children, until the stools look black.

         If the patient is an epileptic taking phenobarbital regularly,
    wait for 48 hours after the patient has woken up, before you start
    giving doses of phenobarbital again.

    Chronic poisoning

         A patient who has signs of chronic poisoning after taking
    prescribed doses of phenobarbital should go back to the doctor who
    prescribed the medicine. If the patient cannot get to the doctor
    straight away, he or she should stop taking the medicine for 48 hours
    then take half the usual dose each day.

    Information for doctors outside hospital

         Monitor breathing, pulse, blood pressure, fluids and
    electrolytes, and kidney function. Supportive care should be given as
    needed:

    -    oxygen and mechanical ventilation

    -    intravenous fluids for low blood pressure.

     Barbiturates and meprobamate

         For severe poisoning charcoal haemoperfusion may be useful.

     Chlorpromazine-like medicines and haloperidol

         Treat low blood pressure by keeping the patient lying with the
    head lower than the feet. This will help blood to reach the brain. Do
    not give epinephrine or dopamine. For repeated fits, give diazepam by
    intravenous injection, but note that there is a risk that diazepam
    might affect breathing.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

    Carbamazepine, phenytoin and valproic acid

    Medicines covered in this section

         This section covers carbamazepine, phenytoin and valproic acid
    (sodium valproate). Other medicines used to treat fits are not
    included because the treatment for poisoning is different.

    Uses

         These medicines are given to patients who have epilepsy (fits);
    they can make the fits happen less often or stop them. Carbamazepine
    is also used to treat some kinds of very painful headache, and some
    illnesses affecting the mind. It is given by mouth as tablets or
    syrup. Phenytoin is also used in hospital to treat fits due to
    poisoning and irregular heart rhythms. It is given by mouth as

    capsules, tablets or liquid or by intravenous injection. Valproic acid
    is given by mouth as capsules, tablets, or liquid.

    How they cause harm

         These medicines affect the brain. Carbamazepine also affects
    breathing, heart, and muscles.

    How poisonous they are

         Carbamazepine and valproic acid may cause serious poisoning, but
    most patients recover if treated in hospital, and deaths are rare.
    Phenytoin rarely causes serious poisoning. People on long-term
    treatment with carbamazepine and phenytoin may get chronic poisoning
    even though they are taking the dose prescribed by the doctor.

    Signs and symptoms

    Carbamazepine

    *    Acute poisoning

         Signs of poisoning may be delayed because it takes several hours
         for tablets to dissolve in the gut, and for the medicine to reach
         the bloodstream:

    -    aggressive or violent behaviour,

    -    dry mouth,

    -    dizziness and unsteadiness,

    -    drowsiness,

    -    wide pupils,

    -    blurred vision,

    -    nausea, vomiting and diarrhoea,

    -    trembling, jerking movements the patient cannot control,

    -    fast or slow or irregular pulse,

    -    unconsciousness,

    -    low or high blood pressure,

    -    shallow, irregular breathing,

    -    the patient passes very little urine or none at all,

    -    low temperature.

    *    Chronic poisoning:

    -    dizziness and unsteadiness,

    -    blurred vision.

    Phenytoin

    *    Acute poisoning:

    -    nausea and vomiting,

    -    drowsiness,

    -    the patient cannot walk properly,

    -    slurred speech,

    -    the eyes move from side to side,

    -    blurred vision,

    -    the hand shakes when the patient reaches out to touch something,

    -    unconsciousness.

         The effects may last for 48-72 hours.

    *    Chronic poisoning:

    -    the patient cannot walk properly,

    -    slurred speech,

    -    blurred vision.

    Valproic acid

    *    Acute poisoning:

    -    confusion,

    -    restlessness,

    -    drowsiness and unconsciousness,

    -    shallow breathing,

    -    low blood pressure.

    What to do

    Acute poisoning

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes, and keep the patient warm.

          For carbamazepine: if the patient has a fit, treat as
    recommended in chapter five. If the patient is aggressive, keep him 
    or her in a quiet, dimly lit place and protect from injury. Stay calm
    and quiet yourself to reassure the patient.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

          If the medicine was swallowed: if it happened less than 4 hours
    ago (12 hours for carbamazepine), and if the patient is fully awake
    and breathing normally, and has not had fits:

    *    Make the patient vomit, unless the patient has already vomited a
         lot.

    *    When the patient has stopped vomiting give activated charcoal and
         water to drink.

          For carbamazepine, give repeated doses of activated charcoal:
    adults, 50 g every 2-4 hours; children 10-15 g every 2-4 hours. With
    each dose of charcoal give sodium sulfate or magnesium sulfate, 30 g
    for adults, 250 mg/kg of body weight for children, until the stools
    look black. If the patient has low blood pressure raise the foot of
    the bed so that the patient's feet are higher than the head. This will
    help blood to reach the brain.

         If the patient has epilepsy and is being treated with any of
    these medicines, wait for 48 hours after the patient wakes up and can
    talk normally before starting to give the medicine again.

    Chronic poisoning

         If an epileptic patient on long-term treatment has poisoning from
    the dose prescribed by the doctor, tell the patient to go back to the
    doctor who prescribed the medicine. If there is a delay in seeing the
    doctor, the patient should stop taking the medicine for 48 hours, then
    take half the usual dose each day until he or she sees the doctor.

    Information for doctors outside hospital

         Monitor breathing, pulse, blood pressure, fluids and
    electrolytes, and kidney function. Supportive care, including oxygen
    and mechanical ventilation, should be given as needed:

    *    Intravenous fluids should be given for low blood pressure but
         urine output must be measured, as there is a danger of giving the
         patient too much fluid if the kidneys are not making enough
         urine. Dopamine or norepinephrine (noradrenaline) can be used if
         needed.

    *    For repeated fits due to carbamazepine, give diazepam by
         intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Charcoal haemoperfusion may be useful in carbamazepine poisoning
    if a severely ill patient is not responding to medical care. It is not
    useful for treatment of poisoning with phenytoin or valproic acid.
    Neither haemodialysis nor forced diuresis is useful for treating
    poisoning with any of these medicines.

    Chlorpropamide-like medicines and insulin

    Medicines covered in this section

         This section covers chlorpropamide and similar medicines (also
    called sulfonylureas), and insulin. Examples of medicines like
    chlorpropamide are glibenclamide, tolazamide and tolbutamide.

    Uses

         These medicines are used to treat diabetics who have too much
    sugar in their blood. Insulin is given by injection, but
    chlorpropamide, glibenclamide, tolazamide and tolbutamide are given by
    mouth as tablets.

    How they cause harm

         These medicines reduce the amount of sugar in the blood. Sugar is
    the body's source of energy and if the amount of sugar falls too low
    the body cannot work properly, the patient becomes unconscious, the
    brain may be damaged, and the patient may die.

    How poisonous they are

         Poisoning may cause permanent brain damage and death. Poisoning
    is more likely to be serious if alcohol is taken as well. Insulin is
    not poisonous when taken by mouth, because it is destroyed in the gut.

    Signs and symptoms

         If insulin is injected, or if chlorpropamide, glibenclamide,
    tolazamide and tolbutamide are swallowed, the effects are the same
    whether the patient is diabetic or not:

    -    anxiety, confusion and abnormal behaviour,

    -    shaking,

    -    sweating without fever,

    -    fast pulse,

    -    blurred vision,

    -    drowsiness,

-    unconsciousness,

    -    fits.

    What to do

         If the patient has injected insulin or has swallowed
    chlorpropamide, glibenclamide, tolazamide or tolbutamide, give first
    aid. If breathing stops, open the airway and give mouth-to-mouth
    respiration. If the patient is unconscious or drowsy, lay him or her
    on one side in the recovery position. Check breathing every 10
    minutes, and keep the patient warm.

         If the patient is awake and able to swallow, give something sweet
    to eat or drink, such as a sugary drink, glucose solution, very sweet
    tea, fruit juice, honey, sugar cubes, chocolate or other sweet food.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

         If the patient has swallowed insulin there is no need to do
    anything.

    Information for doctors outside hospital

         Take a blood sample to test blood sugar level with test strips
    and glucometer. Give glucose immediately.

     For a conscious patient:

         Give 10-20 g of glucose orally in a solution, or give any of the
    high carbohydrate foods listed above.

     For an unconscious patient:

         Give glucose solution by intravenous injection (adults, 50%
    glucose, 50 ml; children, 25% glucose, 2-4 ml/kg of body weight).

         If the patient does not recover, give another dose. As soon as
    possible, and even if the patient recovers consciousness, the patient
    should be given a continuous intravenous infusion of 10% glucose.
    Monitor blood glucose levels every 15-30 minutes during treatment; aim
    to keep the blood glucose concentration within the range 5-10 mmol/l
    (about 90-180 mg/dl).

         Note that a patient may have a dangerously low blood glucose
    concentration but have no symptoms. On the other hand, a patient may
    stay unconscious even after the blood glucose concentration has
    returned to normal.

         If the patient has been unconscious for some time, the response
    to treatment may be slow. In severe poisoning from chlorpropamide,
    glibenclamide, tolazamide, tolbutamide, or long-acting insulin,
    treatment may need to be continued for several days.

         Monitor breathing, pulse, blood pressure, fluid and electrolytes,
    and liver and kidney function. Supportive care should be given as
    needed:

    *    For low blood pressure keep the patient lying with the head lower
         than the feet. Intravenous fluids should be given but care must
         be taken to avoid fluid overload. If needed, dopamine or
         norepinephrine (noradrenaline) can be used.

    *    For repeated fits give diazepam by intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

    Colchicine

    The medicine covered in this section

         This section covers colchicine and the plants that contain it:

    *     Colchicum autumnale (autumn crocus): a bulb that produces
         crocus-like flowers with white or light violet petals. It is
         found in Europe and north America.

     *   Gloriosa superba (glory lily): a climbing plant with a tuberous
         root and yellow, dark orange or scarlet flowers. It is found in
         tropical Africa, India, Malaysia, Myanmar and Sri Lanka.

         Colchicine is found in all parts of the plants but the roots are
    most poisonous.

         Medicine is made from the root and seeds of  Colchicum
     autumnale.

    Uses

         Colchicine is used to treat gout and familial Mediterranean
    fever. It is given by mouth as tablets, or by injection.

    How it causes harm

         It affects the gut, muscles, nerves, blood and liver.

    How poisonous it is

         Colchicine poisoning is uncommon, but may cause serious illness
    and death. Poisoning is more often caused by taking the medicine than
    by eating plants. The poison is not destroyed if the plant is cooked.

    Special dangers

         In some countries  Gloriosa is eaten by people who want to kill
    themselves and is sometimes used to cause abortions. It may be
    mistaken for a sweet potato plant because it often grows near sweet
    potatoes and looks very like them.

    Signs and symptoms

         Effects may start after 2 hours or be delayed for up to 12 hours:

    -    burning throat and skin,

    -    nausea, vomiting, belly pain and severe diarrhoea, making the
         patient very dehydrated,

    -    shallow breathing,

    -    low blood pressure,

    -    confusion,

    -    unconsciousness,

    -    fits,

    -    the patient passes very little urine, and it may be dark or
         blood-stained,

    -    bleeding from wounds and gums, with blood taking longer than
         usual to clot (this may occur within a few hours or after 3-4
         days).

         The patient may die within 2-3 days because of the effects on
    breathing and the heart. If the patient survives, after 10-12 days the
    hair may begin to fall out and may not start to grow again for about a
    month.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes, and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the patient has severe vomiting or diarrhoea, give several
    sips of water every few minutes to replace water lost from the body.

         If the medicine was swallowed less than four hours ago (or if the
    plant was swallowed less than 24 hours ago), and if the patient is
    fully awake, breathing normally, has not had fits and is not vomiting:

    *    Give activated charcoal and water to drink. Give one dose every
         4-6 hours (adults, 50 g; children, 10-15 g). If the patient does
         not have diarrhoea, with each dose of charcoal give sodium
         sulfate or magnesium sulfate, 30 g for adults, 250 mg/kg of body
         weight for children, until the stools look black.

    Information for doctors outside hospital

         As well as the effects listed above, colchicine may cause
    electrolyte imbalance, liver damage, bone marrow depression with
    leukocytosis and leukopenia, blood clotting disorders and peripheral
    neuropathy. Kidney failure may occur as a complication.

         Monitor breathing, pulse, blood pressure. Supportive care,
    including oxygen and mechanical ventilation, should be given as
    needed:

    *    Fluid and electrolyte balance should be corrected.

    *    Low blood pressure should be treated with intravenous fluids;
         dopamine or dobutamine can be given if blood pressure does not
         respond to fluids.

    *    Morphine should be given for severe belly pain.

    *    For repeated fits, diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Antibiotics should be given to prevent infection with Gram-
    positive, Gram-negative and anaerobic bacteria.

         Haemodialysis may be needed to treat kidney failure but will not
    remove the poison.

    Dapsone

    Uses

         Dapsone is used to treat leprosy, infectious skin diseases and
    malaria. It is given by mouth as tablets.

    How it causes harm

         It affects the blood cells so that the blood cannot carry the
    normal amount of oxygen. This may mean that the brain does not get
    enough oxygen to work properly.

    How poisonous it is

         Large single doses may cause severe poisoning and sometimes
    death. Sometimes patients get signs and symptoms of poisoning after
    being treated for several weeks with dapsone.

    Signs and symptoms

         Signs may be delayed for up to 24 hours after a single dose:

    -    blue colour to skin and lips,

    -    restlessness,

    -    drowsiness,

    -    nausea, vomiting and severe belly pain,

    -    fast pulse,

    -    low blood pressure,

    -    fast breathing,

    -    dizziness,

    -    hallucinations,

    -    unconsciousness,

    -    fits.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes, and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         A patient who has hallucinations should be kept in a quiet, dimly
    lit room and protected from injury. Stay calm and quiet yourself to
    reassure the patient.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the patient is awake and breathing normally and has not had
    fits:

    *    Make the patient vomit, unless the medicine was swallowed more
         than four hours ago or the patient has vomited a lot already.

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until vomiting has stopped. Give repeated
         doses every 2-4 hours for up to 3 days (adults, 50 g; children
         10-15 g). With each dose of charcoal give sodium sulfate or
         magnesium sulfate, 30 g for adults, 250 mg/kg of body weight for
         children, until the stools look black.

         Keep the patient in bed. If possible raise the foot of the bed so
    that the patient's feet are higher than the head. This will help blood
    to reach the brain if the blood pressure is low.

    Information for doctors outside hospital

         Monitor breathing, blood pressure, and pulse. Supportive care
    should be given as needed. For repeated fits, diazepam should be given
    by intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours;

    Children: 200-300 µg/kg of body weight.

         Repeated doses of activated charcoal, in the doses given above,
    reduce the time taken for dapsone to leave the body.

     For cyanosis

         There is no specific treatment for cyanosis that can be given
    outside hospital. Oxygen is not useful for treating cyanosis due to
    dapsone.

         Cyanosis in dapsone poisoning may have several causes.
    Methaemoglobinaemia is one cause. Methylthioninium chloride (methylene
    blue) may be of use in treating cyanosis caused by methaemoglobin, but
    the dose depends on the concentration of methaemoglobin so it should
    only be given in hospital where methaemoglobin can be measured.
    Methylthioninium chloride will not treat cyanosis from other causes.
    Patients have survived severe poisoning without methylthioninium
    chloride treatment.

     Dose: Adults and children: 1-2 mg/kg of body weight, given
    intravenously over 5-10 minutes. The dose may have to be repeated over
    several days (to a maximum of 7 mg/kg of body weight) as dapsone is
    excreted slowly.

         Dapsone poisoning is worse in patients who are deficient in
    glucose-6-phosphate dehydrogenase.

    Digitalis, digitoxin and digoxin

    Medicines covered in this section

         Digitalis, digoxin and digitoxin are prepared from the foxglove
    plant  Digitalis purpurea.

    Uses

         These medicines are used to treat heart disease. Digoxin is given
    by mouth as tablets or liquid, or intravenously by injection or
    infusion.

    How they cause harm

    These medicines affect the heart.

    How poisonous they are

         These medicines can cause serious poisoning and death,
    particularly in old people with heart disease who have been taking
    them for some time. Serious poisoning is uncommon in children.
    Patients on long-term treatment with these medicines sometimes get
    mild poisoning from the prescribed doses. The leaves, roots and seeds
    of the foxglove plant are poisonous.

    Special dangers

         These medicines are often prescribed for old people, who may
    forget to lock their tablets away when children visit.

    Signs and symptoms

    Acute poisoning

         Effects are:

    -    nausea, vomiting, and sometimes diarrhoea,

    -    pulse may be fast, slow or irregular,

    -    drowsiness and confusion,

    -    low blood pressure.

         The effect on the heart may be delayed for up to 6 hours.

    Chronic poisoning

         Long-term treatment may result in:

    -    feeling ill,

    -    tiredness and weakness,

    -    loss of appetite,

    -    nausea and vomiting,

    -    headache,

    -    confusion and hallucinations.

    What to do

    Acute poisoning

         Give first aid. Give heart massage and mouth-to-mouth respiration
    if the heart stops. If the patient is unconscious or drowsy, lay the
    patient on one side in the recovery position. Check breathing every 10
    minutes, and keep the patient warm.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

          If the medicine was swallowed: if it happened less than four
    hours ago, and if the patient is fully awake and breathing normally:

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until vomiting has stopped.

         Give repeated doses of activated charcoal and water to drink
    (adults, 50 g every 2-4 hours; children 10-15 g every 2-4 hours). With
    each dose of charcoal give sodium sulfate or magnesium sulfate, 30 g
    for adults, 250 mg/kg of body weight for children, until the stools
    look black.

         Keep the patient lying down with the feet higher than the head.
    This will help blood to reach the brain if the blood pressure is low.

    Chronic poisoning

         Patients with chronic poisoning should be taken to hospital.

    Information for doctors outside hospital

         As well as the effects listed above, there may be changes in
    heart rhythm (commonly bradycardia, heart block or tachydysrhythmias)
    and electrolyte imbalance. In acute poisoning, plasma potassium
    concentration may be higher than normal, while the plasma magnesium
    concentration may be lower than normal.

         Monitor heart rhythm, breathing, blood pressure, and electrolytes
    (magnesium, sodium, calcium and potassium). Supportive care should be
    given as needed and fluid and electrolyte balance should be corrected.

    Glyceryl trinitrate, hydralazine, and propranolol-like medicines

    Medicines covered in this section

         This section covers glyceryl trinitrate, hydralazine, and
    propranolol and similar medicines. Propranolol and similar medicines
    are called beta-adrenoceptor blocking agents, or beta-blockers.

         Examples of propranolol-like medicines: atenolol and oxprenolol.

         Glyceryl trinitrate is also called nitroglycerin or glycerol
    trinitrate.

    Uses

         Glyceryl trinitrate is used to treat heart disease. It may be
    given as tablets that are put under the tongue and dissolved in the
    mouth, as tablets that are swallowed whole, by injection or by
    intravenous infusion.

         When given as tablets that dissolve in the mouth, the medicine
    starts working within a few minutes and the effects last for less than
    30 minutes. These tablets are taken by people with heart disease, to
    treat sudden chest pain.

         The tablets that are meant to be swallowed whole are sustained-
    release tablets; these have effects lasting for many hours. They are
    taken to prevent chest pain.

         Hydralazine is used to treat high blood pressure. It is given as
    tablets by mouth, by injection or by intravenous infusion.

         Propranolol-like medicines are used to treat high blood pressure
    and heart disorders. They are given by mouth as tablets or capsules
    (some of which are sustained-release preparations and have an effect
    lasting many hours), or by injection.

    How they cause harm

         The main effects of poisoning with all the medicines covered in
    this section are low blood pressure and changes in heart rate.
    Glyceryl trinitrate and hydralazine make the muscles in the walls of
    the blood vessels relax, so that the blood pressure falls.
    Propranolol-like medicines cause low blood pressure by affecting the
    nerves that control the heart rate and blood vessels. They also affect
    breathing and the brain.

    How poisonous they are

         Serious poisoning with glyceryl trinitrate is rare. Large doses
    of propranolol-like medicines may cause serious poisoning and death.

    Special dangers

         Some people with heart disease take glyceryl trinitrate when they
    have a sudden attack of chest pain. They need to be able to get their
    tablets quickly and often keep them where children can easily get hold
    of them too.

    Signs and symptoms

    Glyceryl trinitrate

         Effects usually start within 30 minutes and last for less than an
    hour if the short-acting tablets have been taken, or for several hours
    if the sustained-release tablets have been taken:

    -    throbbing headache,

    -    warm face,

    -    dizziness,

    -    palpitations,

    -    low blood pressure.

    Hydralazine

         Effects are:

    -    warm skin,

    -    nausea and vomiting,

    -    headache,

    -    fast, irregular pulse,

    -    low blood pressure.

    Propranolol-like medicines

         Effects usually start very soon but may last for a day or more:

    -    slow pulse,

    -    nausea and vomiting,

    -    hallucinations,

    -    drowsiness,

    -    low blood pressure,

    -    fits,

    -    unconsciousness,

    -    the heart and breathing may stop completely.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm.

          For propranolol-like medicines: if the patient has a fit, treat
    as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         Glyceryl trinitrate passes out of the stomach very quickly so it
    is no use making the patient vomit or giving activated charcoal unless
    the patient has taken sustained-release tablets.

          If sustained-release glyceryl trinitrate tablets, hydralazine or
     propranolol-like medicines were swallowed: if it happened less than
    four hours ago, and if the patient is fully awake and breathing
    normally, and has not had fits:

    *    Make the patient vomit, unless he or she has already vomited a
         lot.

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until vomiting has stopped. Give sodium
         sulfate or magnesium sulfate with the charcoal.

         Keep the patient in bed. If possible raise the foot of the bed so
    that the patient's feet are higher than his head. This will help blood
    to reach the brain if the blood pressure is low.

    Information for doctors outside hospital

         Monitor breathing, pulse, blood pressure, fluids and
    electrolytes, and kidney function.

         Supportive care, including oxygen and mechanical ventilation,
    should be given as needed:

    *    Give intravenous fluids for low blood pressure.

    *    For repeated fits give diazepam by intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

     Hydralazine

         If blood pressure does not return to normal with intravenous
    fluids, dopamine or norepinephrine (noradrenaline) can be used.

     Propranolol-like medicines

         If blood pressure does not return to normal with intravenous
    fluids, intravenous isoprenaline should be used. Large doses may be
    needed to raise the blood pressure. Blood pressure should be monitored

    carefully, since isoprenaline may make blood pressure lower in some
    cases.

     Dose: Adults: 5-50 µg/minute.

    Children: 0.02 µg/kg of body weight per minute to a maximum of
              0.5 µg/kg of body weight per minute.

         Monitor blood glucose. Intravenous glucose should be given if
    blood glucose is low.

         For bronchospasm, intravenous salbutamol or aminophylline should
    be given.

    Ibuprofen

    Uses

         Ibuprofen is used as a pain killer. It is given by mouth as
    tablets or liquid. It is also made as an ointment to be rubbed on the
    skin.

    How poisonous it is

         It does not usually cause serious poisoning even in very large
    amounts.

    Signs and symptoms

         Effects are:

    -    nausea, vomiting and abdominal pain,

    -    headache,

    -    dizziness,

    -    shaking,

    -    drowsiness,

    -    unconsciousness after a large overdose.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes, and keep the patient warm.

         If the patient is awake, give activated charcoal with water to
    drink.

         If the patient has taken a large amount or is very sick take the
    patient to hospital as quickly as possible.

    Information for doctors outside hospital

         Very rarely, kidney failure may occur after acute overdose. Give
    plenty of fluids so that the patient does not become dehydrated.

    Iron-containing medicines

    Medicines covered in this section

         This section covers iron salts such as ferric ammonium citrate,
    ferrous fumarate, ferrous gluconate, and ferrous sulfate.

    Uses

         Medicines containing iron are used to treat anaemia (thin blood)
    that is caused by not having enough iron in the diet, or by losing too
    much iron from the body, as in hookworm infestation. Iron salts are
    given by mouth as tablets or liquid. Some vitamin tablets contain
    small amounts of iron.

    How they cause harm

         Iron salts damage the gut, the liver, the brain, the blood
    vessels and the blood.

    How poisonous they are

         Poisoning may cause death. More than 20 mg/kg of body weight of
    elemental iron may cause poisoning. It takes only a very few tablets
    of preparations containing 60 mg of elemental iron per tablet to
    poison a young child.

    Special dangers

         Iron tablets are often found in homes with young children because
    they are given to pregnant women. Iron tablets are often brightly
    coloured and shiny and look like sweets.

    Signs and symptoms

    Within 6 hours of the overdose:

    -    vomiting, belly pain and diarrhoea; vomit and stools may be
         coloured black by the iron, or may be dark because they contain
         blood,

    -    drowsiness and unconsciousness,

    -    fits.

         The patient usually improves after 6-24 hours, then either
    recovers or deteriorates.

    From 12 to 48 hours:

    -    low blood pressure,

    -    unconsciousness,

    -    fits,

    -    yellow skin, caused by liver damage,

    -    lung oedema,

    -    low output of urine and signs of kidney damage.

         Patients may die from liver failure.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes, and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the patient vomits for a long time, give frequent drinks to
    replace water lost from the body.

         If the medicine was swallowed less than 12 hours ago, and if the
    patient is fully awake and breathing normally, and has not had fits,
    make the patient vomit unless he or she has vomited a lot already. Do
    not give activated charcoal because it does not bind iron.

         Keep the patient in bed. If possible raise the foot of the bed so
    that the patient's feet are higher than the head.

         If the patient passes very little urine, treat as recommended
    in chapter nine.

         If the patient looks yellow and has signs of liver damage, treat
    as recommended in chapter nine.

         If the patient has signs of lung oedema, treat as recommended 
    in chapter nine.

    Information for doctors outside hospital

         As well as the effects listed above, there may be hyperglycaemia
    at first and hypoglycaemia later. In severe poisoning there may be a
    metabolic acidosis, gastrointestinal haemorrhage, shock and
    cardiovascular collapse.

         Monitor blood pressure, fluid and electrolyte balance, white
    blood cell count, blood glucose, and liver and kidney function.
    Supportive care, including oxygen and mechanical ventilation, should
    be given as needed:

    *    Fluid and electrolyte balance should be corrected.

    *    For repeated fits, diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Patients who do not have signs or symptoms of poisoning within 6
    hours do not need any treatment.

         The antidote is deferoxamine. It can be given intramuscularly or
    intravenously, but it is better to give deferoxamine by intravenous
    infusion if possible. Rapid intravenous bolus injection may cause
    hypotension or an anaphylactoid reaction. Local pain may occur at
    intramuscular injection sites, and large intramuscular injections may
    cause hypotension.

         Deferoxamine should be given to all patients with signs and
    symptoms of severe poisoning such as shock, unconsciousness,
    convulsions, severe vomiting or acidosis, or a serum iron
    concentration greater than 5 mg/l.

         It may be useful to give deferoxamine to patients with signs and
    symptoms of mild to moderate poisoning. However, it is best to discuss
    such cases with a poisons centre because it is difficult to interpret
    serum iron concentrations, especially if a sustained-release
    preparation was taken.

     Dose by slow intravenous infusion:

         adults and children: 15 mg/kg of body weight per hour (do not
    give more than 80 mg/kg of body weight in 24 hours).

     Dose by intramuscular injection:

         adults and children: 1-2 g intramuscularly every 3-12 hours.

         Do not give more than 6 g in 24 hours.

         Kidney failure should be treated with haemodialysis.

         Patients with corrosive damage to the gut may develop strictures
    after 2-6 weeks.

    Isocarboxazid, phenelzine and tranylcypromine

    Medicines covered in this section

         This section covers isocarboxazid, phenelzine and
    tranylcypromine. They are called monoamine oxidase inhibitors (MAOIs).

    Uses

         These medicines are antidepressants; they are given to people who
    are depressed to make them feel happier. They are given by mouth as
    tablets or capsules.

    How they cause harm

         These medicines affect the brain and the nerves that control the
    heart and muscles.

    How poisonous they are

         They are very poisonous and may cause death if too large a dose
    is taken.

    Special dangers

         Depressed patients may try to kill themselves by taking too much
    of their medicine. Depressed people are often careless with their
    medicines and leave them where children can easily find them.

         When these medicines are taken with alcohol, certain foods (like
    cheese, chocolate, large amounts of coffee, broad beans, and pickled
    herring) or certain medicines, they cause severe illness. People on
    long-term treatment with monoamine oxidase inhibitors should have been
    told which foods and drinks they must not have, and that they must
    check with a doctor before they take any other medicines.

    Signs and symptoms

         The effects of a single large dose may be delayed for 12-24
    hours:

    -    excitement and irritability,

    -    sweating, warm skin,

    -    fast, irregular pulse,

    -    fast breathing,

    -    stiff muscles, stiff neck and back, the patient cannot open the
         mouth, and cannot breathe easily,

    -    shaking of the body and limbs,

    -    low blood pressure or high blood pressure,

    -    fits,

    -    high temperature,

    -    wide pupils which do not get smaller in the light,

    -    unconsciousness,

    -    breathing or the heart may suddenly stop, causing death.

         If a patient taking these medicines also takes the wrong food or
    medicine, the effects are:

    -    throbbing headache,

    -    very high blood pressure,

    -    vomiting,

    -    fits,

    -    unconsciousness.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         If the patient has warm skin and stiff muscles, keep the patient
    cool and sponge with tepid water; however this may not bring the
    temperature down.

         A patient who is very excited should be kept in a quiet, dimly
    lit place. Stay calm and quiet yourself to reassure the patient.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the medicine was swallowed less than two hours ago, and if the
    patient is fully awake, breathing normally, and has not had fits:

    *    Make the patient vomit, unless he or she has already vomited a
         lot.

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until vomiting has stopped.

    Information for doctors outside hospital

         Secondary complications include haemolysis, breakdown of the
    muscles (rhabdomyolysis), kidney failure and lung oedema.

         Monitor breathing, pulse and blood pressure for at least 24
    hours. Supportive care, including oxygen and mechanical ventilation
    should be given as needed:

    *    Low blood pressure should be treated with intravenous fluids.

    *    For repeated fits, diazepam should be given by intravenous
    injection; this may not always stop the fits.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Rigid muscles may make the body temperature rise and may make it
    hard for the patient to breathe. To make the muscles relax, dantrolene
    may be given at a dose of 1 mg/kg of body weight by rapid intravenous
    injection. This can be repeated as needed up to a total dose of
    10 mg/kg. If the patient has a very high temperature (above 39°C) the
    best way to lower the temperature is to give pancuronium to paralyse
    the muscles, but this can only be done if the patient can be
    ventilated.

    Isoniazid

    Uses

         Isoniazid is used to treat tuberculosis. It is given by mouth as
    tablets or liquid, or by injection. Some medicines are a mixture of
    isoniazid with rifampicin, or isoniazid with pyridoxine.

    How it causes harm

         It affects the brain, causing fits.

    How poisonous it is

         It can cause serious poisoning and death.

    Signs and symptoms

         Within 30 minutes to 3 hours:

    -    nausea, vomiting and belly pain,

    -    large pupils, blurred vision,

    -    slurred speech and dizziness,

    -    fever,

    -    fits,

    -    unconsciousness,

    -    fast pulse,

    -    patient passes less urine, and there may be blood in the urine,

    -    low blood pressure,

    -    shallow breathing.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes, and keep the patient cool.

         If the patient has a fit, treat as recommended in chapter five.

         If the patient has a fever, sponge the body with cool water.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If isoniazid was swallowed less than four hours ago, and if the
    patient is fully awake and breathing normally, and is not vomiting,
    give activated charcoal and water to drink.

         The patient should not be made to vomit because this may cause a
    fit and the patient might choke.

         If the patient stops passing urine, treat as recommended in
    chapter nine.

    Information for doctors outside hospital

         Complications of severe poisoning include lactic acidosis,
    ketoacidosis, high blood glucose, raised white blood cell count and
    kidney failure.

         Monitor pulse, breathing, blood pressure, liver and kidney
    function, blood glucose and serum electrolytes. Potassium
    concentration may be lower or higher than normal. Supportive care,
    including oxygen and mechanical ventilation, should be given as
    needed:

    *    Low blood pressure should be treated with intravenous fluids.

    *    Fluid and electrolyte balance should be corrected.

    *    For repeated fits, give intravenous diazepam.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Diazepam may not control fits until pyridoxine has been given.
    The two medicines should not be given in the same infusion because
    diazepam has a low solubility and may precipitate rapidly.

          Dose of pyridoxine: adults: give 5 g intravenously over 5
    minutes. If the patient has severe symptoms with fits, acidosis and
    unconsciousness, the dose may be repeated every 30 minutes as needed,
    until fits have stopped or the patient is awake. Note that large doses
    may be neurotoxic.

    Lithium carbonate

    Uses

         Lithium carbonate is used to treat mental disorders. It is given
    by mouth as tablets. Some tablets are sustained-release preparations.
    This means that the effects of the medicine last a long time and fewer
    doses are needed per day compared with ordinary tablets.

    How it causes harm

         Lithium affects the brain, kidneys and heart.

    How poisonous it is

         Poisoning may be caused by amounts only a little larger than a
    therapeutic dose. People on long-term lithium treatment may get
    chronic poisoning. Patients usually recover from acute or chronic
    poisoning if treated in hospital.

    Special dangers

         Many other medicines interact with lithium. Patients on long-term
    treatment with lithium should check with their doctor before they take
    other medicines.

    Signs and symptoms

         After acute overdose, symptoms may be delayed for 12 hours or
    more. Effects are:

    -    nausea, vomiting and diarrhoea,

    -    thirst,

    -    some patients pass more urine than normal,

    -    confusion,

    -    dizziness,

    -    drowsiness,

    -    shaking,

    -    unconsciousness,

    -    fits,

    -    low blood pressure.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes, and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If more than the prescribed dose was taken less than 12 hours
    ago, and if the patient is fully awake, breathing normally, and has
    not had fits:

    *    Make the patient vomit unless he or she has vomited a lot
         already.

    *    Give frequent drinks of water to replace water passed out in the
         urine.

         Do not give activated charcoal because it does not bind lithium.

    Information for doctors outside hospital

         The plasma concentration of sodium may fall and in severe
    poisoning the concentration of potassium may rise. In unconscious
    patients there may be changes in heart rhythm. Fluid and electrolyte
    balance should be measured every 6-12 hours so that any imbalance or
    dehydration can be corrected. Severe poisoning may lead to kidney
    failure.

         For repeated fits, diazepam should be given by intravenous
    injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Haemodialysis may be useful in removing lithium from the body in
    cases of severe poisoning.

    Magnesium hydroxide, magnesium sulfate, phenolphthalein and senna

    Uses

         These medicines are all laxatives (also called cathartics or
    purgatives). They are given to people who cannot pass stools easily,

    or who pass hard stools. These medicines are usually taken by mouth.
    Some products are made as tablets, capsules or liquids, some as
    granules or powders that have to be mixed with water, and some are put
    in biscuits or bars of chocolate.

    How they cause harm

         Poisoning causes diarrhoea so that the patient loses too much
    water from the body.

    How poisonous they are

         Large amounts of laxatives can cause serious poisoning and death,
    but children who take a few tablets in mistake for sweets do not
    usually get serious poisoning.

    Special dangers

         Some laxative tablets look and taste like sweets or chocolate and
    children may eat them by mistake.

    Signs and symptoms

         Effects are:

    -    diarrhoea, vomiting and belly pain,

    -    pink urine if phenolphthalein has been taken,

    -    blood in stools,

    -    low blood pressure,

    -    fast pulse,

    -    unconsciousness.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes, and keep the patient warm.

         If the patient is conscious and alert, give drinks to replace the
    water lost in the vomit and stools.

         It is not necessary to make the patient vomit.

    Information for doctors outside hospital

         Monitor fluid and electrolyte balance, particularly serum
    potassium. Supportive care should be given as needed:

    *    Fluid and electrolyte balance should be corrected.

    *    Intravenous fluids should be given for severe dehydration.

    *    Potassium chloride should be given if serum potassium
         concentration is low.

    Opiates

    Medicines covered in this section

         Opiates (also called opioids or narcotics) are a group of
    medicines that have similar effects to morphine. Examples of opiates
    are:

    codeine                  methadone

    dextromethorphan         morphine

    dextropropoxyphene       opium

    diamorphine/heroin       pentazocine

    dihydrocodeine           pethidine

    diphenoxylate            pholcodine

    loperamide

     Uses and abuse

         Opiates are used to treat pain, cough and diarrhoea. Some
    preparations contain mixtures of opiates and other medicines. Codeine,
    dextropropoxyphene, diamorphine, dihydrocodeine, methadone, morphine,
    pentazocine, and pethidine are used to treat pain. Some preparations
    contain acetylsalicylic acid (aspirin) or paracetamol as well as an
    opiate. Codeine, dextromethorphan, methadone and pholcodine are used
    in cough syrups and linctuses. Codeine, diphenoxylate, loperamide and
    morphine are used to treat diarrhoea. Preparations of diphenoxylate
    with atropine are widely available.

         Opiates are abused because they make people feel relaxed.

     How they cause  harm

         Opiates affect the brain so that the patient becomes deeply
    unconscious; breathing becomes slower and may stop suddenly.

         When diphenoxylate is taken together with atropine, it may be
    many hours before the opiate affects breathing. Atropine slows down
    the absorption of the opiate from the gut into the blood.

    How poisonous they are

         Poisonous amounts of opiates can cause death within an hour
    particularly if taken with alcohol or other substances that slow down
    the brain.

    Special dangers

         People treated with opiates may become dependent on them. People
    taking opiates for a long time may need to take larger doses to get
    the same effects, and may take a fatal dose by mistake.

         Diphenoxylate with atropine can cause serious poisoning if given
    to young children to treat diarrhoea. Diphenoxylate with atropine is
    specially dangerous if more than the therapeutic dose is taken,
    because atropine delays the effect of the opiate for many hours,
    sometimes up to 30 hours after the dose. If patients with suspected
    poisoning are sent home too soon, before the opiate has started to
    take effect, they may stop breathing and die before there is time to
    get them back to hospital.

    Signs and symptoms

         Effects are:

    -    very small pupils,

    -    drowsiness then unconsciousness,

    -    slow breathing,

    -    twitching or fits (from codeine, dextropropoxyphene, pethidine),

    -    low body temperature,

    -    low blood pressure (sometimes),

    -    lung oedema,

    -    the patient may suddenly stop breathing and die very quickly,
         within minutes of an injection into a vein or within 1-4 hours of
         taking opiate by mouth. Patients who are unconscious for a long
         time may die from pneumonia.

         Patients who are dependent on opiates may have needle marks.

         When diphenoxylate is taken together with atropine, it may be
    many hours before the opiate affects breathing. Atropine slows down
    the absorption of the opiate from the gut into the blood.

    How poisonous they are

         Poisonous amounts of opiates can cause death within an hour
    particularly if taken with alcohol or other substances that slow down
    the brain.

    Special dangers

         People treated with opiates may become dependent on them. People
    taking opiates for a long time may need to take larger doses to get
    the same effects, and may take a fatal dose by mistake.

         Diphenoxylate with atropine can cause serious poisoning if given
    to young children to treat diarrhoea. Diphenoxylate with atropine is
    specially dangerous if more than the therapeutic dose is taken,
    because atropine delays the effect of the opiate for many hours,
    sometimes up to 30 hours after the dose. If patients with suspected
    poisoning are sent home too soon, before the opiate has started to
    take effect, they may stop breathing and die before there is time to
    get them back to hospital.

    Signs and symptoms

         Effects are:

    -    very small pupils,

    -    drowsiness then unconsciousness,

    -    slow breathing,

    -    twitching or fits (from codeine, dextropropoxyphene, pethidine),

    -    low body temperature,

    -    low blood pressure (sometimes),

    -    lung oedema,

    -    the patient may suddenly stop breathing and die very quickly,
         within minutes of an injection into a vein or within 1-4 hours of
         taking opiate by mouth. Patients who are unconscious for a long
         time may die from pneumonia.

         Patients who are dependent on opiates may have needle marks.

    Diphenoxylate with atropine

         Soon after the overdose:

    -    warm face,

    -    fast pulse,

    -    temperature higher than normal,

    -    hallucinations.

         Within 2-3 hours, or as long as 30 hours after the overdose:

    -    small pupils,

    -    drowsiness then unconsciousness,

    -    slow pulse,

    -    slow breathing, which may stop altogether.

         The patient may begin to recover, but become ill again many hours
    later.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         The antidote is naloxone. Naloxone should be given if the patient
    is taking fewer than 10 breaths per minute.

     Dose: 1 ml (0.4 mg) by intramuscular injection, for adults and
    children. If the patient does not wake up and begin to breathe
    normally after 2-3 minutes, give another injection. Up to four doses
    can be given if the patient still does not recover.

         Keep watching breathing closely. If breathing again becomes slow,
    give more naloxone until breathing is normal. Several doses may be
    needed.


    If there is no effect after four doses of naloxone:

    -    the patient may have taken other drugs with opiates;

    -    the patient may not have taken opiates; something else may have
         made the patient unconscious, such as a head injury;

    -    the poisoning may be so bad that the patient has brain damage;

    -    the patient may have been unconscious for a long time and be very
         cold.

          For diphenoxylate with atropine: if the patient has fever,
    sponge the body with cool water. If the patient has hallucinations,
    keep him or her in a quiet, dimly lit place, and protect from injury.
    Stay calm and quiet yourself to reassure the patient.

         Take the patient to hospital as quickly as possible. A patient
    who has taken diphenoxylate together with atropine may be in danger
    even if there are no signs or symptoms.

         Drug dependence should be treated in hospital.

    What to do if there is a delay in getting to hospital

          If the medicine was swallowed: if it happened less than 4 hours
    ago, and if the patient is fully awake, breathing normally, and has
    not had fits:

    *    Make the patient vomit, unless the patient has
         already vomited a lot.

    *    Give activated charcoal and water to drink. If you have made the
         patient vomit, wait until vomiting has stopped; give sodium
         sulfate or magnesium sulfate with the charcoal.

         If you think the patient is dependent on drugs, ask someone to
    stay and help you because he or she may be violent on waking up.

    Information for doctors outside hospital

         As well as the effects listed above, the patient may have low
    blood glucose, and there may be breakdown of the muscles
    (rhabdomyolysis) leading to kidney failure.

         Monitor breathing, pulse, blood pressure, fluid and electrolyte
    balance, and blood glucose. A patient given an opiate for diarrhoea
    may be dehydrated. Supportive care, including oxygen and mechanical
    ventilation, should be given as needed:

    *    Intravenous fluids should be given for low blood pressure.

    *    Fluid and electrolyte balance should be corrected.

    Antidote: Naloxone can be given intramuscularly, as described in the
    text, or intravenously.  For adults, the dose of naloxone given
    intravenously is 0.4-2 mg. If there is no response give repeated doses
    of 2 mg every 2-3 minutes until the patient responds or until 10 mg
    have been given. If the patient responds, start a continuous
    intravenous infusion at a rate of 0.4-0.8 mg per hour. Assess the
    patient's condition after 10 hours. The infusion may need to be
    continued for up to 48 hours.  For children, give 0.01 mg/kg of body
    weight every 2-3 minutes to a maximum of 0.1 mg/kg of body weight.

         A patient who has taken diphenoxylate with atropine should be
    watched for at least 24-36 hours in case he or she becomes
    unconscious.

    Oral contraceptives

    Medicines covered in this section

         This section covers oral contraceptives containing an estrogen or
    a progestogen or both.

         Examples of estrogens: ethinylestradiol, mestranol.

         Examples of progestogens: etynodiol, gestodene, levonorgestrel,
    lynestrenol, medroxyprogesterone, megestrol, norethisterone,
    noretynodrel, norgestrel.

    Uses

         These medicines are used for family planning. They are taken by
    women to stop them having babies. They are given by mouth as tablets.

    How poisonous they are

         Single large doses are not harmful, and children do not usually
    have any symptoms even when they have taken 20 or 30 tablets.

    Special dangers

         Women often keep oral contraceptives in places where children can
    easily reach them.

    Signs and symptoms

         Effects are:

    -    nausea and vomiting,

    -    girls over 4 years of age may have bleeding like a monthly
         period.

    What to do

         There is no need to do anything. If the patient is a small girl,
    warn the girl and her parents that she may bleed but that it will soon
    stop.

    Paracetamol

    Uses

         Paracetamol (also known as acetaminophen) is widely used to treat
    pain, colds and influenza. It is given by mouth as tablets, capsules
    or liquid. Some medicines contain a mixture of paracetamol with
    acetylsalicylic acid (aspirin), antihistamines, barbiturates, or
    opiates.

    How it causes harm

    Large doses of paracetamol damage the liver and kidneys.

    How poisonous it is

         A dose of 150 mg/kg of body weight may cause liver damage.
    Children rarely get serious poisoning after swallowing paracetamol.

    Special dangers

         Many people keep paracetamol at home, often in places where
    children can easily find it.

    Signs and symptoms

         For the first 24 hours, the patient may not have any signs of
    poisoning, or there may be:

    -    nausea,

    -    vomiting,

    -    belly pain.

    After 24-48 hours:

    -    pain on the right side of the belly.

    After 2-6 days:

    -    yellow colour to skin and whites of eyes, showing that the liver
         is damaged,

    -    vomiting as a result of liver damage,

    -    fast, irregular pulse,

    -    confusion,

    -    unconsciousness.

         The patient may die as a result of liver damage.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes, and keep the patient warm.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the paracetamol was swallowed less than 15 hours ago and the
    patient is fully awake and breathing normally, give methionine as an
    antidote (dose given below).

         Do not give activated charcoal because this will bind methionine
    and stop it working as an antidote.

     Dose of methionine:

         adults: 2.5 g by mouth, every 4 hours for 4 doses.

         children: 1 g by mouth, every 4 hours for 4 doses.

         The first dose of methionine should not be given more than 15
    hours after the paracetamol was taken. If the patient vomits within 1
    hour of taking methionine, repeat the dose once.

         If the patient has signs of liver damage, treat as recommended
    in chapter nine.

    Information for doctors outside hospital

         Monitor fluid, electrolytes, blood glucose, and liver and kidney
    function. Supportive care should be given as needed and fluid and
    electrolyte balance should be corrected.

    Antidotes. These are most effective if given within 8-10 hours, and
    are probably not effective later than 24 hours after the patient took
    the paracetamol. If it is likely that the patient has taken a
    poisonous dose, start giving an antidote at once. If possible discuss
    this with a poisons centre first. Doses given here are only a guide.
    Do not give activated charcoal if giving antidote by mouth.

     Methionine may be given if it is less than 15 hours since the
    paracetamol was swallowed and if the patient can be given medicine by
    mouth. Doses are given in the main text.

     Acetylcysteine may be used if the paracetamol was swallowed less
    than 24 hours ago. It can be given intravenously or by mouth. When
    given by mouth it may cause nausea and vomiting. Intravenous
    acetylcysteine may cause nausea, flushing, skin reactions and, rarely,
    angio-oedema, wheezing, and respiratory distress. If serious reactions
    occur, stop the infusion, give antihistamine then either restart the
    infusion or give methionine instead.

     Dose for adults and children:

    -    150 mg/kg of body weight in 200 ml of 5% dextrose, by slow
         intravenous infusion over 15 minutes;  then

    -    50 mg/kg of body weight by intravenous infusion in 500 ml of 5%
         dextrose over 4 hours;  then

    -    100 mg/kg of body weight in 1000 ml of 5% dextrose over 16 hours.

         This gives a total dose of 300 mg/kg of body weight, given over
    20 hours 15 minutes.

         If you do not have a preparation of acetylcysteine that can be
    given intravenously, preparations meant for treating chronic asthma
    can be given by mouth.

         These are usually 10% or 20% solutions of acetylcysteine. They
    should be diluted immediately before use with fruit juice, soft drink
    or water to make a 5% solution.

     Dose of 5% acetylcysteine solution, given as a drink: a total dose
    of 1330 mg of acetylcysteine per kg of body weight should be given
    over 72 hours as follows:

    -    140 mg/kg of body weight at first;  then

    -    70 mg/kg of body weight every 4 hours, 17 times (over 68 hours).

         If the patient vomits less than one hour after a dose it should
    be repeated.

         The plasma paracetamol concentration, measured at least 4 hours
    after a single overdose, shows the likelihood of liver damage and the
    need for an antidote. The result should be discussed with a poisons
    centre if possible. If the plasma paracetamol concentration is low,
    stop giving the antidote. Plasma concentrations are unreliable if the
    patient has taken more than one large dose. All such patients should
    be given acetylcysteine.

    Penicillin and tetracycline antibiotics

    Medicines covered in this section

         This section covers penicillin and tetracycline and similar
    antibiotics.

         Examples of medicines similar to penicillin: amoxicillin,
    ampicillin, benzyl-penicillin, and cloxacillin.

         Examples of medicines similar to tetracycline: doxycycline,
    oxytetracycline.

    Uses

         These medicines are given to treat infections. They are given by
    mouth as tablets, capsules or liquid, by injection or by intravenous
    infusion.

    How poisonous they are

         Single large doses of these medicines taken by mouth are not
    poisonous, but some people are allergic to penicillin-like medicines.
    After one dose they may get a mild allergic reaction, like a rash, or
    a severe reaction that may cause death.

    Special dangers

         Some liquid antibiotic medicines have a sweet or fruity taste and
    children may think they are soft drinks.

    Signs and symptoms

         If the patient is not allergic:

    -    nausea, vomiting and diarrhoea.

         If the patient is allergic:

    -    itching and rash,

    -    difficulty in swallowing,

    -    swelling round the eyes,

    -    wheezing, gasping for air and difficulty in breathing,

    -    weakness and dizziness,

    -    cold, sweaty skin,

    -    chest pain,

    -    fast, weak pulse,

    -    low blood pressure,

    -    unconsciousness.

    What to do

         No treatment is needed unless the patient has an allergic
    reaction.

         If the patient has an allergic reaction

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         Put the patient flat on his or her back, with the head turned to
    one side, and the legs raised higher than the head (by resting the
    feet on a box, for example). This will help the blood to reach the
    brain and lessen the danger of vomit blocking the airway. Check
    breathing every 10 minutes, and keep the patient warm.

         Take the patient to hospital as quickly as possible.

    Information for doctors outside hospital

         If the patient has a severe allergic (anaphylactic) reaction:

    *    Give oxygen by face-mask in as high a concentration as possible.
         Insert an airway if the patient is unconscious.

    *    Give epinephrine (adrenaline) by intramuscular injection as soon
         as possible, unless there is a strong central pulse and the
         general condition is good. Any delay may be fatal.

    Age                 Dose of epinephrine (1 in 1000, 1 mg/ml)

    Under 1 year                    0.05 ml

    1 year                          0.1 ml

    2 years                         0.2 ml

    3-4 years                       0.3 ml

    5 years                         0.4 ml

    6-12 years                      0.5 ml

    Adult                           0.5-1 ml

         These doses may be repeated every 10 minutes until blood pressure
    and pulse improve. Doses should be reduced for underweight children.

         It is useful to give antihistamines, such as chlorphenamine or
    promethazine, by slow intravenous injection after the epinephrine, to
    treat skin rash, itching or swelling and prevent relapse.

         If the patient does not get better, supportive care should be
    given as needed:

    -    oxygen and mechanical ventilation,

    -    intravenous fluids,

    -    inhaled salbutamol or intravenous theophylline may be useful for
         asthma or wheezing.

    Proguanil

    Uses

         Proguanil is used to prevent and treat malaria. It is given by
    mouth as a tablet.

    How poisonous it is

         It does not cause serious poisoning, even when quite large
    overdoses are taken.

    Signs and symptoms

         Effects are:

    -    nausea, vomiting and diarrhoea,

    -    blood in the urine.

    What to do

         If the patient has vomiting and diarrhoea, give frequent drinks
    of water to replace water lost from the body. There is no need to make
    the patient vomit.

    Rifampicin

    Uses

         Rifampicin is used to treat tuberculosis and other diseases
    caused by bacteria. It is used with dapsone to treat leprosy. It is
    given by mouth as tablets, capsules or liquid or by intravenous
    infusion.

    How it causes harm

         It affects the blood, liver and kidneys.

    How poisonous it is

         Poisoning from taking a single large dose can result in death,
    but most patients recover if they are given treatment. Some people on
    long-term treatment may develop chronic poisoning. Poisoning is more
    severe in people who frequently drink large amounts of alcohol or have
    liver disease.

    Signs and symptoms

    Acute poisoning

         Effects are:

    -    orange-red colour in the skin, urine, faeces, sweat and tears;
         the red colour can be removed from the skin by washing,

    -    warm skin, itching, sweating and swelling of the face,

    -    nausea, vomiting and belly pain,

    -    lethargy and unconsciousness,

    -    after 6-10 hours, the whites of the eyes become yellow,

    -    fits.

         Death may occur suddenly.

    Chronic poisoning

         Effects are:

    -    nausea, vomiting, constipation or diarrhoea, and belly pain,

    -    skin rash, itching and warm skin,

    -    influenza-like symptoms,

    -    signs of liver and kidney damage.

    What to do

    Acute poisoning

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes, and keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If rifampicin was swallowed less than 4 hours ago, and if the
    patient is fully awake and breathing normally:

    *    Make the patient vomit unless he or she has vomited a
         lot already.

    *    Give activated charcoal mixed with water to drink. If
         you have made the patient vomit, wait until vomiting has stopped.

         Give repeated doses of activated charcoal and water every 2-4
    hours for 24 hours (adults, 50 g per dose; children, 10-15 g per
    dose). With each dose of charcoal give sodium sulfate or magnesium
    sulfate, 30 g for adults, 250 mg/kg of body weight for children, until
    the stools look black.

    Chronic poisoning

         If the patient has signs of liver damage, treat as recommended in chapter nine.
    If there are signs of kidney damage, treat as recommended in chapter nine.

    Information for doctors outside hospital

    Acute poisoning

         Monitor pulse, breathing, blood pressure and kidney function.
    Supportive care, including oxygen and mechanical ventilation, should
    be given as needed. For repeated fits, diazepam should be given by
    intravenous injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

     Chronic poisoning

         Chronic poisoning may cause blood disorders such as
    thrombocytopenia, eosinophilia, leukopenia, and haemolytic anaemia.
    Complete blood counts and platelet counts should be done. Liver
    function should be monitored.

    Salbutamol

    Uses

         Salbutamol is used to treat asthma. It is given by mouth as
    tablets, intravenously by injection or infusion, or as preparations,
    such as sprays or aerosols, that can be breathed in.

    How it causes harm

         It affects the nerves that control the heart and breathing.

    How poisonous it is

         Salbutamol does not usually cause serious poisoning.

    Special dangers

         Salbutamol is commonly prescribed for children with asthma, and
    is often kept where children can easily find it. Young teenagers
    sometimes abuse salbutamol because it causes feelings of excitement.
    They spray the aerosol into their mouths.

    Signs and symptoms

    Effects are:

    -    excitement and agitation,

    -    hallucinations,

    -    fast pulse,

    -    palpitations,

    -    shaking,

    -    fits,

    -    lung oedema.

    What to do

         Give first aid. For fast pulse or palpitations, make the patient
    rest until the pulse is normal again.

    Information for doctors outside hospital

         Serious complications include low plasma potassium concentration,
    heart rhythm disorders including ventricular tachyarrhythmias, high
    blood glucose and lactic acidosis.

         Monitor pulse and blood pressure, fluid and electrolyte balance,
    and blood glucose. Supportive care should be given as needed: fluid
    and electrolyte balance should be corrected, particularly plasma
    potassium.

         There should not be any need to treat tachycardia. Severe
    arrhythmias can be treated with a small dose of propranolol by slow
    intravenous injection (adult dose 1-2 mg). Do not give propranolol to
    an asthmatic patient because it may cause an asthmatic attack.

    Plants, animals and natural toxins

    Plants that contain atropine

    Plants covered in this section

         All the plants in this section contain atropine. The most common
    are  Atropa belladonna (commonly called deadly nightshade or
    enchanter's nightshade),  Datura stramonium (commonly called thorn
    apple, jimson weed or angel's trumpet), and  Hyoscyamus niger 
    (commonly called henbane).

     Atropa belladonna is a shrub with bell-shaped purple or red flowers
    and purple or black berries, found in Europe, north Africa and west
    Asia.  Datura stramonium is a herb that grows 1-1.5 m high, with
    funnel-shaped white or mauve flowers. The fruits are prickly or spiny
    capsules containing several black seeds. The plant has an unpleasant
    smell. It is native to north America but is found throughout the
    world.  Hyoscyamus niger is a herb with yellow flowers, some with
    purple markings, and has an unpleasant smell. It is found in north and
    south America, Europe, India, and western Asia.

     Uses and abuse

     Datura stramonium is used in folk medicine to prevent or treat
    asthma.  Atropa belladonna and  Datura are abused for their
    hallucinogenic effects. The seeds of  Datura are most commonly used.
    Sometimes the leaves are infused in water to make a drink, or made
    into cigarettes and smoked. In some countries these plants are used to
    cause abortion.

    How they cause harm

         They excite the brain and affect the nerves that control the
    heart, eyes, gut and bladder. They make the skin and mouth dry, and
    cause fever, wide pupils, fast heartbeat and fast breathing.

    How poisonous they are

         All parts of these plants are poisonous if eaten, even when cooked
    or boiled, because the poison is not destroyed by heat.  Atropa
     and Hyoscyamus both contain sap that is irritant to the skin and
    eyes. The sap of  Atropa may cause poisoning if it gets in the eye.

         The amount of atropine that causes poisoning varies. Most people
    recover from poisoning within 24 hours, but poisoning may be severe,
    especially in old people and young children.

    Special dangers

         There is a danger of poisoning when these plants are abused for
    their hallucinogenic effects. Children may eat the berries of  Atropa 
    and the flowers and seeds of  Datura. Some cases of poisoning have
    occurred as a result of  Datura being mistaken for an edible plant
    such as spinach, and berries of  Atropa for edible fruit.

    Signs and symptoms

    *    If swallowed:

    -    red, dry skin,

    -    wide pupils,

    -    blurred vision,

    -    dry mouth and thirst,

    -    confusion and hallucinations,

    -    excitement and aggression,

    -    fast pulse,

    -    the patient cannot pass urine,

    -    unconsciousness,

    -    fever,

    -    fits (rarely).

    *    On the skin  (Atropa belladonna and  Hyoscyamus niger):

    -    redness and irritation,

    -    blistering.

    *    In the eyes:

    -    same effects as if swallowed.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes.

         If the patient has a fit, treat as recommended in chapter five.

         If the patient has fever, sponge the body with cool water.

         A patient who is confused, very restless or aggressive, or who
    has hallucinations, should be kept in a quiet, dimly lit place and
    protected from injury. Stay calm and quiet yourself to reassure the
    patient.

         Take the patient to hospital as quickly as possible.

     On the skin

          Atropa belladonna and  Hyoscyamus niger

         As soon as possible wash exposed skin with soap and water and a
    soft sponge. Relieve itching and inflammation with cold compresses.
    Tell the patient not to scratch the skin.

         If the patient has a mild skin reaction (redness, dry rash) apply
    hydrocortisone cream. If the rash is oozing or if there are blisters
    do not use hydrocortisone cream. Take the patient to hospital.

     In the eyes

         Wash the eyes for at least 15-20 minutes with running water. Take
    the patient to hospital.

    What to do if there is a delay in getting to hospital

         If the patient swallowed one of these plants less than 6 hours
    ago, is fully awake and breathing normally, and has not had fits:

    *    Make the patient vomit unless he or she has already
         vomited a lot.

    *    Give activated charcoal and water to drink. If you
         have made the patient vomit, wait until vomiting has stopped.
         Give repeated doses of activated charcoal every 4 hours (adults
         50 g, children 10-30 g). With each dose of charcoal give sodium
         sulfate or magnesium sulfate, 30 g for adults, 250 mg/kg of body
         weight for children, until the stools look black.

    Information for doctors outside hospital

         As well as the effects listed above, there may be heart rhythm
    disturbances.

         Monitor breathing and blood pressure. Supportive care, including
    oxygen and ventilation, should be given as needed. For repeated fits,
    diazepam should be given by intravenous injection, but there is a risk
    that diazepam might affect breathing.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Do not use chlorpromazine to treat agitated patients.

         Physostigmine may be useful in life-threatening poisoning but may
    itself have life-threatening side-effects, so it should only be given
    in hospital with the patient on a heart monitor.

    Cannabis

    The substance covered in this section

         Cannabis, also known as marijuana, Indian hemp, hashish, ganja,
    pot, dope and grass, is made from the Indian hemp plant  Cannabis
     sativa.

    Uses and abuse

         Cannabis is often abused and, in some countries, is used almost
    as much as alcohol or tobacco. It makes people feel relaxed and makes
    colours and sounds seem brighter and louder. The dried plant is made
    into cigarettes or put in a pipe and smoked. Sometimes it is taken
    with food. Some people inject it.

    How it causes harm

    Cannabis affects the brain.

    How poisonous it is

         It does not cause much harm to adults, unless it is injected.
    Children are likely to get signs of poisoning but usually recover.

    Signs and symptoms

         Effects start within 10 minutes of smoking the drug and last for
    about 2-3 hours. When the drug is eaten the effects start within 30-60
    minutes and last for 2-5 hours. The effects are:

    -    usually a feeling of well-being, happiness and sleepiness, but
         high doses may cause fear, panic and confusion,

    -    fast pulse,

    -    the person cannot balance when standing up,

    -    hallucinations,

    -    drowsiness,

    -    slurred speech,

    -    coughing if the drug is breathed in, as when smoking cigarettes.

         If the drug is injected it may cause more serious problems:

    -    severe headache,

    -    dizziness,

    -    irregular breathing,

    -    fever,

    -    low blood pressure,

    -    unconsciousness.

    What to do

         Give first aid. If the patient is unconscious or drowsy, lay him
    or her on one side in the recovery position. Check breathing every 10
    minutes.

         A patient who is anxious or confused should be kept in a quiet,
    warm room.

     If the cannabis was swallowed: there is no need to make the patient
    vomit. If the patient is fully awake, breathing normally, and not
    vomiting, give activated charcoal and water to drink.

         A patient who has injected cannabis should be taken to hospital
    as quickly as possible.

    Information for doctors outside hospital

         If the patient is hallucinating or violent, give chlorpromazine,
    50-100 mg (adult dose), intramuscularly.

     If cannabis has been injected

         Monitor breathing, pulse, blood pressure, temperature. Supportive
    care, including oxygen and mechanical ventilation, should be given as
    needed:

    *    Low blood pressure should be treated by keeping the patient lying
         with the feet higher than the head; intravenous fluids can be
         given.

    Irritant plants

    Plants covered in this section

         The plants covered in this section cause skin reactions. Some are
    poisonous if swallowed.

         The cashew nut tree  (Anacardium occidentale) is found in most
    tropical countries. The nut shell, but not the kernel, contains an
    irritant brown, oily juice. Roasting the shell destroys these
    chemicals.

         Dumb-cane ( Dieffenbachia species) has a thick, fleshy stem and
    oval or lance-shaped green leaves, often with yellow or white
    markings. It grows wild in tropical areas but is a common houseplant
    in many countries.

         The spurges ( Euphorbia species) are a large group of plants
    ranging from trees to herbs.

         Poison ivy,  Rhus radicans (Toxicodendron radicans), and poison
    oak,  Rhus toxicodendron (Toxicodendron toxicarium), grow wild mainly
    in northern America and northern Mexico. They are sometimes found in
other countries as garden plants. Poison ivy is a climbing plant and
    may be found clinging to trees or houses. Poison oak is a shrub-like
    plant, forming a bush or small tree. The plants have white flowers and
    green berries, and green leaves that turn red, yellow, violet or
    orange in autumn. African poison ivy  (Smodingium argutum) contains
    poison similar to that of the American species.

         The mango  (Mangifera indica) is a large tree with green to
    yellow-red fruit, found in east Asia, Myanmar, some parts of India,
    and Central America.

         The common stinging nettle,  Urtica dioica, is an annual or
    perennial herb that grows as a weed on wasteland in temperate areas.

    How they cause harm

         The sap of spurge plants irritates the skin and affects the brain
    if swallowed. Sap from cut leaves or stems of dumb-cane causes severe
    irritation of the lips and inside of the mouth and throat, and can
    affect the heart and muscles if swallowed. Skin reactions to the
    common stinging nettle are caused by brushing against stinging hairs
    on the stem and leaves that release irritant chemicals. This plant is
    not poisonous if swallowed.

         Cashew nut shells, mango leaves, stems and fruit skins, African
    poison ivy, poison ivy, and poison oak cause intense allergic skin
    reactions in sensitive individuals. Allergic reactions to African
    poison ivy, poison ivy and poison oak can be caused by contact with
    bruised or broken plant tissue, wood sap, sawdust or smoke from 

    burning plants. Contaminated fingers or clothing may spread the rash
    over the body.

    How poisonous they are

         Stinging nettles and spurges usually produce only mild skin
    reactions. Dumb-cane may be dangerous if swelling blocks the airway.
    The severity of the skin reactions to cashew nut shells, mango,
    African poison ivy, poison ivy and poison oak depends on the
    sensitivity of the individual; people vary greatly in their
    sensitivity. People rarely swallow enough of any of these plants to
    get systemic poisoning.

    Signs and symptoms

    Dumb-cane

    *    If swallowed:

    -    swollen lips, mouth and tongue which may make it difficult to
         talk, swallow or breathe,

    -    severe burning pain inside the mouth,

    -    rarely, slow heart rate and muscle cramps.

    *    In the eyes:

    -    intense pain that is worse in bright light,

    -    redness and watering,

    -    injury to the surface of the eye.

    *    On the skin (contact with sap):

    -    irritation, burning and redness,

    -    blistering.

    Poison ivy, poison oak, cashew nut shells and parts of the mango tree

    *    If swallowed:

    -    flushed face,

    -    burning and itching of the lips and mouth,

    -    drowsiness,

    -    severe vomiting and diarrhoea,

    -    fever.

    *    On the skin

         The effects usually occur within 24-48 hours but may appear
         sooner or be delayed for 1-2 weeks:

    -    intense itching, burning, redness,

    -    blisters,

    -    swelling of face and eyelids,

    -    oozing rash with crusting and scaling.

    *    In the eyes:

    -    pain that is worse in bright light,

    -    redness, watering and swelling of the eyelids.

    Spurges

    *    If swallowed:

    -    burning pain and redness in the mouth and throat,

    -    vomiting and diarrhoea,

    -    rarely, fits and unconsciousness.

    *    In the eyes:

    -    burning pain,

    -    blurred vision,

    -    watering.

    *    On the skin (within 24 hours):

    -    painful rash,

    -    itching and burning,

    -    blisters.

    Stinging nettle

    *    On the skin:

    -    immediate stinging, itching and burning,

    -    redness and rash within an hour of contact.

    What to do

          If swallowed

         If the patient can swallow, give cold drinks or ice to relieve
    pain. Do not make the patient sick. If there is severe swelling of the
    tongue or throat or difficulty in breathing, take the patient to
    hospital.

          On the skin

         As soon as possible wash exposed skin with soap and water and a
    soft sponge. The poisons from poison ivy and similar plants are
    absorbed through the skin within 15 minutes; after that washing will
    not remove them.

         Relieve itching and inflammation with cold compresses. Tell the
    patient not to scratch the skin.

         If the patient has a mild skin reaction (redness, dry rash) apply
    hydrocortisone cream.

         If the rash is oozing or if there are blisters do not use
    hydrocortisone cream. Take the patient to hospital.

          In the eye

         As soon as possible wash the eye for at least 15-20 minutes with
    running water. If this does not relieve symptoms take the patient to
    hospital.

    Information for doctors outside hospital

         Supportive care should be given as needed. Give an antihistamine
    such as diphenhydramine, by mouth or by intramuscular injection, to
    relieve itching.

         For moderate to severe dermatitis from poison ivy give systemic
    corticosteroids such as prednisone.

    Oleanders

    Plants covered in this section

         This section covers the common oleander,  Nerium oleander, and
    the yellow oleander,  Thevetia peruviana.

          Nerium oleander is an evergreen shrub with clusters of white,
    pink, dark red, orange or yellow flowers with a sweet smell. It is
    found in China, India and places with Mediterranean climates, and is

    grown as a garden plant. All parts of the plant are poisonous and
    crushed leaves and stems are irritant to the skin.

          Thevetia peruviana is a small ornamental tree with bright
    yellow flowers and fleshy round fruits which are green when unripe and
    black when ripe, and which contain a nut. The plant has milky white
    sap. It grows wild in Central and South America, and in gardens in
    tropical and subtropical regions.

    How it causes harm

         Both plants contain poisons that affect the heart in a similar
    way to digitalis. The poisons are found in all parts of the plants.

    How poisonous they are

         Serious poisonings and deaths have been reported in children and
    adults from eating the fruit of  Thevetia. Nerium oleander is also
    reported to have caused deaths.

    Special dangers

         The bright flowers of both plants and the green fruit of
     Thevetia are attractive to children. In Sri Lanka, the seeds of
     Thevetia are eaten by people who want to kill themselves, and in
    Bengal they are used to cause abortions.

    Signs and symptoms

         Effects are:

    -    numbness or burning pain in the mouth,

    -    nausea and vomiting, which may be severe,

    -    diarrhoea,

    -    belly pain,

    -    pulse may be fast, slow or irregular,

    -    drowsiness,

    -    unconsciousness,

    -    possibly fits.

         The effect on the heart may result in death.

    What to do

         Give first aid. If breathing stops open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the plant was swallowed less than 4 hours ago, and if the
    patient is fully awake and breathing normally, has not had fits, and
    is not already vomiting:

    *    Make the patient vomit.

    *    When the patient has stopped vomiting, give activated charcoal
         and water to drink. Give sodium sulfate or magnesium sulfate with
         the charcoal.

    Information for doctors outside hospital

         As well as the effects listed above there may be changes in heart
    rhythm, including bradycardia, heart block, ventricular tachycardia
    and ventricular fibrillation. Heart rhythm may be disturbed for up to
    5 days. Plasma potassium concentration may be raised.

         Monitor breathing, pulse, blood pressure, fluids and
    electrolytes. Give supportive care as needed.

    Ornamental beans

    Plants covered in this section

         This section covers the bean-shaped seeds of  Ricinus communis 
    (castor oil bean) and  Abrus precatorius (jequirity bean).

          Abrus precatorius is a climbing plant with clusters of small
    pink flowers. The fruit is a flat pod containing 3-5 small seeds,
    which are shiny red with a black patch. It grows in countries with
    subtropical or tropical climates such as south China, India,
    Philippines, Sri Lanka, Thailand, and tropical Africa.

          Ricinus communis is a large non-woody plant, growing up to 3
    metres high, with large palm-like leaves and round, prickly fruits.
    The bean-shaped seeds are usually mottled pink and grey. The plant is
    common in the tropics where it is grown as a crop and is also found
    scattered on farmland and roadsides.

    Uses

         The beans of both these plants are made into necklaces and
    rosaries, and children may be given seeds to use in handicrafts and as
    an aid to counting. However, these uses are not recommended. Castor

    oil beans are used to make castor oil. Castor oil that has been
    treated to destroy the poison is used as a laxative.

    How they cause harm

         They contain poisons that damage the blood cells, the gut and the
    kidneys.

    How poisonous they are

         The beans can cause death if they are chewed, but because the
    outer shell is very hard, poisoning does not occur if the beans are
    swallowed whole. Contact with the eyes may cause irritation and
    blindness, and skin contact may result in a rash.

    Special dangers

         Children have been poisoned by chewing and eating beans from
    necklaces. The brightly coloured seeds of the jequirity bean are
    especially attractive to children.

    Signs and symptoms

    *    If swallowed

         Effects are delayed for 2 hours or up to 2 days:

    -    burning pain in the mouth and throat,

    -    severe vomiting,

    -    belly pain,

    -    diarrhoea with blood,

    -    dehydration,

    -    drowsiness,

    -    fits,

    -    the patient passes blood-stained urine, in smaller volumes than
         normal.

         Death may occur up to 14 days later.

    *    In the eyes:

    -    reddening and swelling,

    -    sometimes blindness.

    *    On the skin:

    -    redness,

    -    rash.

    What to do

         Take any bits of seed out of the mouth. If the patient has a fit,
    treat as recommended in chapter five.

     In the eyes

         For eye contact with  Abrus seeds: wash the eye for at least
    15-20 minutes with running water.

     On the skin

         Wash the skin thoroughly with soap and water.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

     If the poison was swallowed: if it happened less than 4 hours ago,
    and if the patient is fully awake and breathing normally, has not had
    fits, and is not already vomiting:

    *    Make the patient vomit.

    *    When the patient has stopped vomiting, give activated charcoal
         and water to drink. Give sodium sulfate or magnesium sulfate with
         the charcoal.

    Information for doctors outside hospital

         The poisons in  Abrus precatorius and  Ricinus communis cause
    haemorrhage and oedema in the gut; secondary complications include
    cerebral oedema and irregular heart rhythm.

         Monitor breathing, pulse, blood pressure, fluids and
    electrolytes, and kidney function. Give supportive care as needed.
    Give analgesics for pain. There is no antidote.

         For repeated fits, diazepam should be given by intravenous
    injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

         Peritoneal dialysis or haemodialysis may be needed for treatment
    of kidney failure.

    Mushrooms

    Plants covered in this section

         This section covers  Amanita species, including  Amanita
     muscaria, A. pantherina (the panther),  A. phalloides (death cap),
     A. verna (destroying angel) and  A. virosa, and species of
     Clitocybe, Coprinus (common ink cap),  Cortinarius, Inocybe,
     Lepiota, Psilocybe semilanceata (liberty cap) and  Psilocybe
     cubensis (magic mushroom).

    How they cause harm

          A. muscaria and  A. pantherina cause hallucinations and sleep
    or unconsciousness;  A. phalloides, A. virosa, A. verna, Cortinarius
     speciosissimus and Lepiota species contain poisons that damage
    cells;  Clitocybe and  Inocybe species contain a poison that causes
    sweating and affects the gut;  Coprinus atramentarius only causes
    poisoning when alcohol is taken as well.  Psilocybe semilanceata and
     P. cubensis cause hallucinations without sleep.

    How poisonous they are

         Most mushrooms cause only mild to moderate poisoning but some
    kinds can cause severe poisoning and death. Mushrooms that contain
    cell-damaging poisons are highly poisonous and may cause death. Many
    people have died after eating  Amanita phalloides.

    Special dangers

         Identification of mushrooms is very difficult. It is often
    difficult to distinguish poisonous mushrooms from non-poisonous ones
    and most poisonings happen when poisonous kinds are eaten by mistake.
    Cooking may destroy the poison in some cases, but many kinds,
    including  Amanita species, are poisonous even after cooking.

    Signs and symptoms

         A. muscaria and  A. pantherina

         Within 30 minutes to 2 hours:

    -    dizziness,

    -    incoordination,

    -    staggering,

    -    muscle jerking or tremors,

    -    agitation, anxiety, euphoria or depression,

    -    hallucinations,

    -    deep sleep or unconsciousness.

     A. phalloides, A. virosa, A. verna, and  Lepiota species

         Effects may be delayed for 6-14 hours and sometimes for as long
    as 24 hours:

    -    belly pain, nausea, severe vomiting, intense thirst, and
         diarrhoea, lasting about 2-3 days.

    After 3-4 days:

    -    jaundice,

    -    fits,

    -    unconsciousness,

    -    signs of kidney damage.

         Death may occur within 6-16 days as a result of liver and kidney
    failure.

     Clitocybe and  Inocybe species

         Effects may occur within a few minutes or be delayed a few hours:

    -    sweating,

    -    wet mouth and wet eyes,

    -    belly pain, nausea, vomiting and diarrhoea,

    -    blurred vision,

    -    muscle weakness.

         Effects may last for up to 24 hours.

     Coprinus atramentarius

         If alcohol is taken at the same time or within a few hours or
         days:

    -    a metallic taste in the mouth,

    -    red face and neck,

    -    palpitations and chest pain,

    -    headache,

    -    dizziness,

    -    sweating,

    -    nausea, vomiting, and diarrhoea.

     Cortinarius speciosissimus

         Effects may be delayed 36-48 hours:

    -    nausea, vomiting, diarrhoea,

    -    muscle aches and back pain,

    -    headache,

    -    chills.

         After 2-17 days:

    -    the patient stops passing urine,

    -    signs of kidney failure.

     Psilocybe semilanceata and  P. cubensis

         Within 30 minutes to 2 hours:

    -    laughing,

    -    muscle weakness,

    -    drowsiness,

    -    hallucinations, increased perception of colour,

    -    anxiety,

    -    nausea.

         The effects last several hours.

         More serious poisoning may occur in small children, producing
    fits and unconsciousness.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm.

         If the patient has a fit treat as recommended in chapter five.

         If the patient has hallucinations or is very agitated, keep him
    or her in a quiet, dimly lit place, protected from injury. Stay calm
    and quiet yourself to reassure the patient.

         Take the patient to hospital as quickly as possible.

    What to do if there is a delay in getting to hospital

         If the mushroom was eaten less than 4 hours ago, and if the
    patient is fully awake, breathing normally, has not had fits, and is
    not already vomiting:

    *    Make the patient vomit.

    *    When the patient has stopped vomiting give activated charcoal and
         water to drink. Give sodium sulfate or magnesium sulfate with the
         charcoal.

         If the patient has signs of liver damage, treat as recommended
    in chapter nine. If the patient has signs of kidney damage, treat as
    recommended in chapter nine.

    Information for doctors outside hospital

         Monitor breathing, heart, blood pressure, fluids and
    electrolytes. Supportive care, including oxygen and mechanical
    ventilation, should be given as needed:

    *    Fluid and electrolyte balance should be corrected.

    *    For repeated fits, diazepam should be given by intravenous
         injection.

     Dose: Adults: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 30 seconds,
    repeated if necessary after 30-60 minutes; this may be followed by
    intravenous infusion to a maximum of 3 mg/kg of body weight over 24
    hours.

    Children: 200-300 µg/kg of body weight.

          Amanita spp. and  Lepiota spp.: monitor liver and kidney
    function. Liver failure is reversible but the risk of fatal
    complications is high.

          Clitocybe and  Inocybe species: severe poisoning should be
    treated with atropine to clear secretions.

          Cortinarius, Amanita spp.,  Lepiota spp.: monitor kidney
    function. Haemodialysis may be needed to treat kidney failure.

          Psilocybe spp.: for severe agitation give diazepam or
    chlorpromazine.

    Snakes

    Snakes covered in this section

    This section covers:

    *     Elapid snakes: coral snakes ( Micrurus species) found in South,
         Central and North America; cobras ( Naja species) found in
         Africa and Asia; kraits ( Bungarus species) found in Asia; and
         mambas ( Dendroaspis species) found in Africa.

    *     Viperid snakes: lance-headed vipers ( Bothrops species) found in
         Central and South America; green pit vipers  (Trimeresurus 
         species) found in Asia; puff adders ( Bitis species) found in
         Africa; saw-scaled vipers ( Echis species) found in Africa, Asia
         and the Eastern Mediterranean; true vipers  (Vipera species)
         found in Africa, Asia and Europe; rattlesnakes ( Crotalus 
         species) found in North, Central and South America; moccasins
         ( Agkistrodon species) found in North America; and pit vipers
         ( Agkistrodon or  Calloselasma species) found in Asia.

    *     Hydrophid snakes: sea snakes.

    How they cause harm

    Elapid snakes

         The venoms affect the nervous system causing paralysis. Venoms
    from African and some Asian cobras can cause marked swelling,
    blistering and damage to the skin near the bite. Venoms from kraits,
    mambas, coral snakes and other cobras cause swelling but no local skin
    damage.

    Viperid snakes

         The venoms affect the blood, the heart, and the circulation.
    Usually venoms also cause severe damage to the skin and muscle near
    the bite.

    Hydrophid snakes

         The venoms affect the nervous system and cause paralysis.

    How poisonous they are

         Many venomous snakes can cause death. However, many people
    survive bites even from very poisonous snakes, because snakes
    sometimes bite without injecting venom or inject too little venom to
    cause serious envenomation. For example, although the carpet viper
     (Echis carinatus) probably bites and kills more people than any
    other species of snake, in the Benue Valley of northeastern Nigeria
    88% of people survive after being bitten, and in northern Ghana 72% of
    people survive.1

    Special dangers

         It is dangerous to disturb or handle any snake. In areas where
    snakes live, it is dangerous to walk through tall grass, forests,
    jungles, or deep sand, or to climb rocks and trees, especially at
    night; people should wear boots, socks and long trousers to protect
    themselves. Farmers, plantation workers, herders, hunters and fishers
    in rural areas of the tropics are particularly at risk, as well as
    children. Some snakes, such as Asiatic kraits and African cobras, may
    enter dwellings at night and bite people while they are asleep.

    Signs and symptoms

    Elapid snakes

    *    Local effects

         From kraits, mambas, coral snakes and some cobras:

    -    mild pain,

    -    little or no swelling or damage to the skin near the bite.

         From African spitting cobras and some Asian cobras:

    -    severe pain,

    -    blisters,

    -    large areas of skin destroyed near the bite.

    __________

    1    Warrell DA. Injuries, envenoming, poisoning, and allergic
         reactions caused by animals. In: Weatherall D J, Ledingham JGG,
         Warrell DA, eds,  Oxford textbook of medicine, 3rd ed. Oxford,
         Oxford University Press, 1996:1127.

    *    Early signs of poisoning, within 15 minutes after the bite or
         delayed for up to 10 hours:

    -    paralysis of the muscles in the face, lips, tongue and throat,
         causing slurred speech, drooping eyelids, difficulty in
         swallowing,

    -    muscle weakness,

    -    lips and tongue blue or pale,

    -    headache,

    -    cold skin,

    -    vomiting,

    -    blurred vision,

    -    numbness round the mouth,

    -    dizziness.

    *    Later:

    -    paralysis of neck muscles and limbs,

    -    paralysis of muscles used in breathing, so that breathing is slow
         and difficult,

    -    low blood pressure,

    -    slow pulse,

    -    unconsciousness.

         Death may occur within 24 hours.

         With some snakes it may be difficult to know whether the bite has
    injected venom if there is no damage to skin near the bite and the
    symptoms and signs are delayed for up to 12 hours.

    *    Venom in the eye (from spitting cobras):

    -    intense pain,

    -    spasms of the eyelids,

    -    swelling round the eye,

    -    damage to the surface of the eye.

    Viperids

    *    Local effects, within 15 minutes or after several hours:

    -    swelling near the bite that spreads quickly to the whole limb,

    -    pain near the bite.

    *    Early signs of poisoning, within 5 minutes or after several
         hours:

    -    vomiting,

    -    sweating,

    -    colic,

    -    diarrhoea,

    -    bleeding from gums, cuts and wounds made by the snake's fangs,

    -    nose bleeds,

    -    blood in vomit, urine and stools.

         Episodes of vomiting and diarrhoea last only a short time and may
    be repeated.

    *    Over the next few days:

    -    bruising, blistering and tissue damage; this is particularly
         severe with rattlesnakes,  Bothrops, Asian pit vipers and the
         African giant viper  (Bitis),

    -    kidney damage,

    -    lung oedema,

    -    sometimes low blood pressure and fast pulse (some North American
         rattlesnakes and vipers).

    With a few species:

    -    paralysis (South American rattlesnakes),.

    -    twitching of the face, head, neck or limbs.

    Hydrophids

    *    Early signs of poisoning:

    -    headache,

    -    tongue feels thick,

    -    sweating,

    -    vomiting.

    *    After about 30 minutes to several hours:

    -    general aching and stiffness,

    -    spasm of jaw muscles,

    -    muscle paralysis,

    -    dark brown urine, kidney failure,

    -    heart stops beating.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm.

         Take off the patient's rings, bracelets, anklets and shoes as
    soon as possible.

         Clean the wound, but leave blisters alone. Do not cover the
    wound.

         Tell the patient to keep the limb still and lower than the heart.
    A splint and a sling may help to keep the limb still, but do not use a
    tight bandage.

         For elapid snakes that do not cause tissue damage (coral snakes,
    kraits, mambas, some cobras  but not some Asian cobras or vipers)

         Apply a broad, firm bandage over the bite site, then bind as much
    of the bitten limb as possible over the patient's clothing. The
    bandage should be firm but not tight. You should still be able to feel
    the pulse in the lower part of the limb. Severe pain in the bandaged
    limb may mean that the bandage is too tight. Put a splint on the limb
    so that the patient cannot bend it. Do not take the bandage off until
    the patient is in hospital.

         The wound may become infected. Find out if the patient has been
    immunized against tetanus and give tetanus toxoid if appropriate.

         Paracetamol may be given for pain, but aspirin should not be
    given because it may make the patient bleed.

         Venom in the eye (from spitting snakes)

         Wash the eyes with water.

    Information for doctors outside hospital

         If the limb has been bandaged do not take off the bandage before
    the patient gets to a hospital where antivenom is available. When the
    bandage is removed, venom may spread through the body very rapidly.

         Antivenom should only be given in a hospital or medical centre
    where resuscitation can be given if the patient has an allergic
    reaction.

         When available, antivenom should only be used if there are signs
    of systemic envenoming.

         Monitor breathing, heart, blood pressure, fluids and electrolytes
    and kidney function. Supportive care, including oxygen and mechanical
    ventilation, should be given as needed. Low blood pressure should be
    treated with intravenous fluids.

         Do not give unnecessary injections because of the risk of
    bleeding if the blood is not able to clot.

         For kidney failure dialysis may be needed, preferably
    haemodialysis, but even peritoneal dialysis is useful.

     Local tissue injury

         Leave the wound open. Blisters usually heal in about 2 weeks
    without infection. Usually there is no need for surgery, and
    unnecessary surgery could cause complications or permanent damage to
    the bitten limb.

     Infection of the wound

         Treat as for any other local infection. Use antibiotics if
    needed.

    Spiders

    Spiders covered in this section

         This section covers species of  Latrodectus, including
     Latrodectus mactans mactans, the black widow spider, found in
    temperate and tropical regions worldwide;  Loxosceles, the brown or
    violin spiders, found in Central and South America, North Africa, and
    the Mediterranean area; and  Phoneutria including  Phoneutria
     nigriventer, the banana spider, found in Central and South America.

    How they cause harm

         Venom from  Latrodectus and  Phoneutria spiders affects the
    nervous system but does not cause local tissue damage. The main effect
    of  Loxosceles spider venom is local tissue damage but general
    envenoming may develop.

    How poisonous they are

         Some spider bites have caused death, but this is unusual. Most
    bites are painless or cause only mild poisoning, except black widow
    spider bites which are very painful.

    Special dangers

         Some poisonous spiders live in or near to houses and huts and may
    get inside clothing, shoes and beds.

     Signs and symptoms

    Latrodectus and  Phoneutria species

         Effects are:

    -    intense pain affecting the whole body,

    -    nausea and vomiting,

    -    sweating,

    -    abdominal cramps, painful muscle spasms and tremors,

    -    chest pain or tightness, difficulty in breathing,

    -    fast pulse,

    -    high blood pressure,

    -    restlessness and irritability,

    -    spasms of face and jaw with swollen eyelids and sweating.

     Loxosceles species

    Effects:

    -    burning pain, swelling near the bite.

    Within 24-48 hours:

    -    fever,

    -    chills,

    -    nausea and vomiting,

    -    muscle pain,

    -    unconsciousness,

    -    fits,

    -    blood in urine.

         Death may occur within a few days but most patients survive.

         A blue scab which turns black forms at the bite site and drops
    off after a few weeks leaving an ulcer. This may spread over the
    bitten limb and take 6-8 weeks to heal.

    What to do

         Give first aid. Take off the patient's rings, bracelets, anklets
    and shoes as soon as possible. Keep the patient calm and still. Lay
    him or her on one side in the recovery position. Check breathing every
    10 minutes, and keep the patient warm.

         Clean the wound, but leave blisters alone. Do not cover the
    wound.

         Tell the patient to keep the limb still and lower than the heart.
    A splint and a sling may help to keep the limb still.

         There is no effective treatment for pain. Neither paracetamol nor
    aspirin should be given.

         The wound may become infected. Find out if the patient has been
    immunized against tetanus and give tetanus toxoid if appropriate.

    Information for doctors outside hospital

         Antivenom is available for some spiders:  Latrodectus 
    (worldwide),  Loxosceles (South America),  Phoneutria (South
    America). It may cause an allergic reaction and should be given only
    in a hospital or medical centre where resuscitation can be given.

     Local injury

         The wound should be treated open as for a burn. Antivenom may be
    useful to treat local tissue injury by  Loxosceles, even when there
    are no signs of general poisoning.

    Venomous fish

    Fish covered in this section

         This section covers fish with spines, many of which live in the
    Indo-Pacific seas and other tropical areas, but some of which live in
    temperate waters. They include Rajiformes (stingrays and mantas),
    Scorpaenidae (scorpionfish, stonefish and lionfish), Siluroidei
    (catfish), Squaliformes (sharks and dogfish), and Trachinidae
    (weevers).

    How they cause harm

         Venomous fishes inject venom through their spines. The venom
    causes intense pain near the bite and affects the muscles.

    How poisonous they are

         Fish stings may cause death but this is rare. Stonefish are the
    most poisonous. Deaths have happened when people have lain or fallen
    on a fish and a spine has punctured the chest or belly. Venom from
    dead fish is still poisonous for up to 24 hours after the fish has
    died.

    Special dangers

         These fish generally live in shallow water near the shore, or
    near reefs, and lie hidden in sand or among rocks. People may be stung
    on the soles of the feet when wading near the shore or near coral
    reefs. Fishermen may be stung when handling fish.

    Signs and symptoms

         Effects are:

    -    immediate sharp pain which may last 24 hours,

    -    swelling of the stung limb.

    Rajiformes and Scorpaenidae:

    -    nausea and vomiting,

    -    low blood pressure,

    -     fits.

    What to do

         If the patient is stung while he or she is in the water, rescue
    him or her from the water.

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. If the patient is unconscious or drowsy,
    lay him or her on one side in the recovery position. Check breathing
    every 10 minutes, and keep the patient warm.

         Soak the wounded part of the body at once in a bowl or bath of
    water as hot as the patient can safely bear (about 50°C), for not more
    than 30 minutes.

         Clean the wound and remove any broken spines.

         Lacerated wounds from stingrays may become infected. Find out if
    the patient has been immunized against tetanus and give tetanus toxoid
    if appropriate.

    Information for doctors outside hospital

         Local anaesthetics or painkillers, even morphine, are usually
    ineffective.

         Antivenom is available for stonefish stings (Australia-Pacific).
    It may cause an allergic reaction and should be given only in a
    hospital where resuscitation can be given, and only if the patient is
    very badly affected.

    Poisoning from eating seafood

    Poisoning covered in this section

         This section covers the following:

    *    Ciguatoxin poisoning from tropical reef fish such as barracuda,
         grouper, red snapper and amber jack, found in the Caribbean and
         Pacific.

    *    Poisoning from shellfish (mussels, clams, oysters, cockles, and
         scallops) contaminated by feeding on poisonous dinoflagellates.
         This is called paralytic shellfish poisoning because the poison
         affects the nervous system.

    *    Tetrodotoxin poisoning from porcupine fish, puffer fish and sun
         fish.

    *    Scombrotoxin poisoning from fish that have begun to spoil: fresh
         or canned scombroid fish such as tuna, bonito, skipjack,
         mackerel, and canned fish of other types, such as sardines and
         pilchards. The poison is made by bacteria.

    How they cause harm

         Ciguatoxin, tetrodotoxin and poisons from shellfish affect the
    gut and the nervous system. Tetrodotoxin and the poison from shellfish
    paralyse muscles, including the muscles that are used in breathing.
    Scombrotoxin causes an allergic type of reaction.

    How poisonous they are

         The most dangerous is tetrodotoxin, which often causes death.
    People are more likely to survive poisoning from ciguatera fish and
    contaminated shellfish, although death may sometimes occur.
    Scombrotoxin poisoning rarely causes death.

         Shellfish are most poisonous at times of year when the
    dinoflagellates on which they feed multiply and form "red tides".

    Special dangers

         Poisonous fish usually look no different from fish that are good
    to eat. Cooking does not destroy the poison.

    Signs and symptoms

    Ciguatoxin poisoning

    Within 1-6 hours after eating fish containing ciguatoxin:

    -    watery diarrhoea,

    -    vomiting,

    -    abdominal cramps.

    Within 12 hours:

    -    headache,

    -    numbness and tingling of lips, mouth and limbs,

    -    trembling,

    -    aching muscles,

    -    weakness and dizziness,

    -    itching (may be delayed more than 30 hours),

    -    reversal of hot and cold sensations, so that cold objects feel
         hot.

         Less commonly:

    -    low blood pressure,

    -    slow heart rate,

    -    shallow breathing,

    -    fits.

    Paralytic shellfish poisoning

    Within 30 minutes:

    -    nausea,

    -    vomiting,

    -    headache,

    -    numbness and tingling of the lips and mouth, spreading to the
         legs, arms and the whole body,

    -    muscle paralysis, causing blurred vision, difficulty in
         swallowing, weakness and dizziness,

    -    aching muscles,

    -    reversal of hot and cold sensations, so that cold objects feel
         hot.

    Less commonly:

    -    low blood pressure,

    -    paralysis of muscles used in breathing, so that the patient is
         unable to breathe,

    -    death.

    Tetrodotoxin poisoning

         Effects are similar to those of paralytic shellfish poisoning.
    Within 10-45 minutes muscles become weak, then paralysed. The muscles
    used in breathing are affected, so that the patient is unable to
    breathe and dies.

    Scombrotoxin poisoning

    Within a few minutes to a few hours:

    -    headache,

    -    red itching skin over the face and body,

    -    nausea, belly pain and diarrhoea.

    Rarely:

    -    skin rash,

    -    breathlessness and wheezing.

    What to do

         Give first aid. If breathing stops, open the airway and give
    mouth-to-mouth respiration. Give heart massage if the heart stops.

         If the patient is unconscious or drowsy, lay him or her on one
    side in the recovery position. Check breathing every 10 minutes, and
    keep the patient warm.

         If the patient has a fit, treat as recommended in chapter five.

         Take the patient to hospital as quickly as possible.

    Information for doctors outside hospital

         Monitor breathing, heart, blood pressure, fluids and
    electrolytes. Supportive care, including oxygen and mechanical
    ventilation, should be given as needed. Low blood pressure should be
    treated with intravenous fluids.

         Antihistamine can be given for scombrotoxin poisoning.


    Word list1

     absorption  The movement of a chemical through gut, skin or lungs,
      into the bloodstream.

     abuse  Misuse or excessive use of a drug or other chemical
      substance to change mood or behaviour, or to avoid withdrawal
      syndrome.

     acute exposure  A single contact with a poison, lasting for
      seconds, minutes or hours, or several exposures over about a day or
      less.

     acute poisoning  The effects occurring within a few hours
      or at most a few days after a single dose of a chemical, or several
      exposures over about a day or less.

     acid  A chemical that combines with an alkali to form a
      salt, and turns blue litmus paper red.

     agitation  Restless movement of the body caused by distress, anxiety
    or by a problem in the brain.

     alkali  A substance that neutralizes an acid to form a salt,
      and turns pink litmus paper blue.

     allergy  Special sensitivity of a person to such things as plants
    and plant products, insect bites and animal hair.

     anaesthetic, general A medication that produces
      unconsciousness.

     anaesthetic, local  A substance that causes loss of feeling,
      especially of pain, when put on the skin or injected.

     anaemia  A condition in which the concentration of the
      oxygen-carrying part of the blood, the haemoglobin, is below
      normal. The symptoms of severe anaemia may include tiredness, pale
      skin and, sometimes, difficulty in breathing.

     antidote  A chemical that lessens, or counteracts, the
      harmful effect of a poison.

     antiseptic  A liquid that stops some germs (bacteria)
      growing. Usually used to clean skin.

    __________

    1    The definitions given here refer to the use of terms in this
         book; they are not necessarily applicable in other contexts.

     antivenom  A medicine that acts against poison or venom
      from an animal such as a snake, fish, insect, or spider.

     asthma  A condition in which a person has attacks of difficult
      breathing. The person wheezes when breathing out, and may not be
      able to get enough air.

     bacterium (plural  bacteria)  A scientific name for a kind of
      microorganism, which may cause disease.

     blister  A bubble just under the surface of the skin filled
      with watery liquid; caused by burning or rubbing.

     blood  vessel  A tube that carries blood inside the body.
      Vessels carrying blood away from the heart are called arteries.
      They have a pulse. Vessels that carry blood back to the heart are
      called veins. They do not have a pulse.

     caustic  Describes chemicals that burn or corrode living
      things.

     chronic exposure  A contact with a poison that lasts for
      many days, months or years. It may be continuous or broken by
      periods when there is no contact.

     chronic poisoning  The effects developing slowly as a
      result of continuous or repeated exposure over a long time to small
      doses of poison.

     concentrate  A product with a high concentration of
      chemicals, which is meant to be diluted for use. Many pesticides
      are sold as concentrates.

     concentration  The proportion of an ingredient in a
      mixture.

     contamination  The soiling of an object or substance by
      covering or mixing it with an unwanted substance. For example, the
      soiling of clothing or skin with insecticide.

     corrosive  Describes a substance that destroys living
      tissues on contact, by direct chemical action.

     dehydration  Excessive loss of water from the body.

     delirium  A state of mental confusion and semi-consciousness.

     dermatitis  Inflammation of the skin. May be caused by contact
      with a substance to which the skin is sensitive, such as cosmetics
      or certain plants.

     detergent  A chemical cleaning agent; sometimes used instead
      of soap.

     diabetes  A disease in which a person has too much sugar in the
      blood. Some diabetic people need special medicine such as insulin.

     dilute  To make a chemical solution less concentrated, usually by
      adding water. Pesticides are often sold as concentrates which have
      to be diluted by adding water.

     disinfectant  A cleaning agent that stops some germs (bacteria)
      growing.

     dissolve  The action of a solid when it is mixed with a liquid so
      that it disappears and forms a solution.

     distillate  A substance that is separated from a mixture, usually by
      heating the mixture to a particular temperature, and collecting the
      vapour as it cools and turns to liquid. The different components of
      the mixture will turn to vapour at different temperatures.
      Petroleum distillate is the mixture produced by this method from
      petroleum.

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

     envenomation  The injection of venom into the body.

     epilepsy  A condition that causes fits. It is caused by problems in
      the brain.

     exposure  Contact with a chemical. The chemical may or may not enter
      the body.

     euphoria  A feeling of great elation.

     evaporate  To change from a liquid or solid to a vapour.

     faeces  Stools; the waste from the body that passes out in a "bowel
      movement".

     fertilizer  A product, usually added to soil, containing chemicals
      essential for plant growth.

     fever  A body temperature that is higher than normal.

     first aid  The immediate treatment of poisoning or injury.

     fit  Jerking movements that a person cannot control; also called
      seizures or convulsions. A fit happens when there is a problem in
      the brain.

     germ  A very small, living organism; a microorganism or microbe;
      usually refers to microorganisms that cause sickness or disease if
      they get inside the body.

     gut  The tube that goes between the stomach and the anus. Also
    called
      the intestines.

     hallucination  Something a person sees, hears or smells which seems
      real to them, but which does not exist; caused by a disturbance in
      the brain.

     hallucinogenic  Producing hallucinations.

     hydrocarbon  One of a group of chemical compounds made up of only
      hydrogen and carbon, found naturally in petroleum.

     infection  A sickness caused by germs.

     inflammation  Tissue response to injury, characterized by local
      redness, swelling, pain and increased temperature.

     ingestion  Taking into the body. Usually used to mean taking in
      through the mouth and swallowing.

     inhalation  Breathing into the lungs through the mouth and nose.

     intramuscular injection  An injection into a muscle, usually in the
      arm or buttock.

     intravenous injection  An injection into a vein. A vein is a blood
      vessel that carries blood towards the heart.

     irritant  Describes chemicals that cause inflammation following
      immediate, prolonged or repeated contact with skin or other
      tissues.

     jaundice  A yellow colour in the eyes and skin caused by liver
      damage. The liver may be damaged by poison, by infection or by
      problems in the blood.

     kidney  One of two large bean-shaped organs in the lower back; they
      take waste out of the blood and make urine.

     lacerate  To tear the skin and muscle making a wound with jagged
    edges.

     laxative  A medicine that makes a person pass faeces. Laxatives are
      sometimes given to people who have swallowed poison to make the
      poison move through the gut, and leave the body quickly.

     liver  A large organ under the lower right ribs. Many poisons are
      changed into non-poisonous chemicals by the liver.

     local effect  An effect limited to the part of the body in contact
      with a chemical.

     lukewarm  Slightly warm; blood-warm; neither hot nor cold.

     lung oedema  A condition in which fluid fills the lungs and the
      patient is unable to breathe.

     medicine  A substance used to maintain, improve or restore health.

     metabolite  A chemical substance produced by chemical reactions
      inside the body.

     nausea  A feeling of a need to vomit.

     nervous system  The brain, spinal cord and nerves.

     oedema  Accumulation of fluid in tissue as a result of injury,
      inflammation or allergy.

     paralysis  Loss of movement in the muscles.

     pesticide  A chemical for killing or controlling pests such as
      insects or weeds.

     poison  Any substance that causes harm if it gets into the body.

     poisonous  dose  A dose that causes poisoning.

     prescription  A written instruction from a doctor to the health
      professional who dispenses medicines, with details of the name of
      the medicine to be dispensed, the dose to be taken, how often it
      should be taken and other instructions as needed.

     protective clothing  Clothes that protect people from exposure to
      chemicals, usually by covering skin. Some protective clothing also
      includes masks to cover the mouth and nose to stop chemical being
      breathed in, or goggles to protect the eyes.

     pulse  The pulse is a wave of pressure in the arteries (blood
      vessels) each time the heart beats and pushes out blood. You can
      feel the pulse wherever an artery is close to the surface of the
      body.

     pupil  The black centre of the eye. It gets small in bright light
      and wide in the dark. Medicines and poisons can make the pupil
      change size.

     rectum  The last part of the gut.

     rehydration  Giving of water, or other liquids, to a person who has
      lost a lot of water in diarrhoea, vomit or sweat. Special
      rehydration drinks can be made with packets of oral rehydration
      salts.

     respirator  Equipment that prevents the wearer from breathing in
      dangerous chemicals. It may cover half the face, including the
      mouth and nose, or be full-faced, covering nose, mouth and eyes. It
      should only be used by people who have been trained to use and
      maintain it correctly.

     rodenticide  A poison for killing rodents, such as rats and mice.

     route  Way, path. Route of exposure is the way a poison gets into
      the body.

     saliva  Spittle; spit; the liquid inside the mouth.

     signs  Effects you can see, feel, hear or measure, such as fever,
      fast pulse, noisy breathing.

     solution  A solid stirred into a liquid so that you cannot see it,
      or two liquids mixed together to look like one.

     solvent  A liquid in which one or more chemical substances will
      dissolve (disappear when stirred) to form a solution. Many liquids
      are solvents: for example, water is a solvent for salt; kerosene
      and similar chemicals are solvents for some pesticides.

     spasm  A sudden, violent and painful, involuntary contraction of a
      muscle or group of muscles.

     stethoscope  An instrument used to listen to noises inside the body,
      such as the noise made by the heart beating or by air moving in the
      lungs.

     sustained release  Describes a medicine that breaks down slowly in
      the body, so that it takes many hours for all the medicine to pass
      into the bloodstream. The medicine goes on working for many hours
      after it is swallowed.

     symptoms  Effects that a person feels or senses, such as nausea,
      pain, or thirst.

     systemic effects/systemic poisoning  Effects of a poison on the
      body as a whole. Systemic effects only occur if a poisonous
      substance is absorbed and distributed to sites distant from the
      entry point.

     target organ  The organs most affected by a particular poison.


     temperature  A measure of the heat of a person's body. You can find
      out a person's temperature by feeling the skin, or by using a
      thermometer.

     tetanus  Lockjaw; a disease caused when germs that live in the
      faeces of people or animals get into the body through a wound.
      Tetanus causes very stiff muscles and fits.

     thermometer  An instrument used to measure how hot, or cold, a
      person's body is.

     threshold dose  The smallest amount that causes poisoning.

     toxin  Poison made by a living creature, plant or microorganism.

     tremor  Trembling or quivering.

     ulcer  An open sore resulting from destruction of the skin or mucous
      membrane, such as caused by a corrosive chemical.

     unconsciousness  A state in which a person does not respond to
      outside stimuli such as noise or pain. It is caused by disturbance
      of, or damage to, part of the brain.

     vapour  The gas produced by a substance when it boils. Vapour is
      also present above the surface of a liquid at temperatures below
      its boiling-point.

     venom  The poisonous fluid produced by animals such as snakes,
      spiders and fish, and injected into prey by a bite or sting or
      through spines which puncture the skin.

     womb  The place inside a woman's belly where a baby grows when she
      is pregnant.
   




        
The following information has been extracted from our CHEMINFO database, which also contains hazard control and regulatory information. [More about...] [Sample Record]

Access the complete CHEMINFO database by contacting CCOHS Client Services.

             
        
SECTION 1. CHEMICAL IDENTIFICATION

CHEMINFO Record Number:    10
CCOHS Chemical Name:    Calcium hydroxide
Synonyms:
Calcium dihydroxide
Calcium hydrate
Agricultural lime
Biocalc
Calvital
Caustic lime
Hydrated lime
Lime hydrate
Lime water
Slaked lime
Hydroxyde de calcium
Chemical Name French:    Hydroxyde de calcium
Chemical Name Spanish:    Hidróxido de calcio
CAS Registry Number:    1305-62-0
Other CAS Registry Number(s):    1333-29-5 7719-01-9
RTECS Number(s):    EW2800000
EU EINECS/ELINCS Number:    215-137-3
Chemical Family:    Calcium and compounds / inorganic calcium compound / alkaline earth metal hydroxide
Molecular Formula:    Ca-H2-O2
Structural Formula:    Ca(OH)2

SECTION 2. DESCRIPTION

Appearance and Odour:
White crystals or soft powder or granules; impure material has gray or buff colour; odourless; readily absorbs carbon dioxide from the air to form calcium carbonate.(12,14,15)
Odour Threshold:
Odourless.(15)
Warning Properties:
POOR - odourless
Composition/Purity:
Commercial material has 95% purity or more. May contain magnesium hydroxide, magnesium oxide, silicon dioxide, calcium carbonate, etc. in trace amounts.
Uses and Occurrences:
Manufacture of mortar, plaster, cement and other building and paving materials; lubricants; drilling fluids; petrochemicals; fireproofing coatings; pesticides; pigments; and water-based paints; buffer and neutralizing agent; recovery of ammonia from ammonium chloride in Solvay process; caustizing soda; used in nonferrous metallurgy (used for extraction of gold and silver, recovery of nickel, tungsten, uranium, magnesia and magnesium metal; alumina production); in the iron and steel industry; water and sewage treatment; used to neutralize acid wastes; to precipitate metals from industrial effluents; flue gas desulfurization; soil conditioner; sugar refining; chemical intermediate for calcium hypochlorite, bleaching powder and calcium salts; water softening agent, food additive, component of dental cement, accelerator for low grade rubber compounds; in SBR rubber vulcanization; manufacture of paper pulp; dehairing hides.(12,13,14)

SECTION 3. HAZARDS IDENTIFICATION


    
EMERGENCY OVERVIEW:
White, odourless crystals or soft powder or granules; impure material has gray or buff colour. Does not burn. Can decompose at high temperatures forming irritating calcium oxide. Very irritating to the respiratory tract. CORROSIVE. Causes severe skin and eye burns. May cause blindness and permanent scarring.




POTENTIAL HEALTH EFFECTS

Effects of Short-Term (Acute) Exposure

Inhalation:
Dusts or mists of concentrated solutions are likely to be very irritating to the nose, throat and upper respiratory tract, based on information for calcium oxide (calcium oxide reacts with moisture to form calcium hydroxide).
Skin Contact:
Many cases of chemical burns to the skin have been reported after exposure to wet (calcium oxide-containing) cement for as little as half an hour.(1,2,3,4,5) The calcium oxide in the cement reacts with water forming calcium hydroxide. Often, no pain is experienced immediately, so the exposure (skin contact) is allowed to continue.
Eye Contact:
Many case reports have been written about severe chemical burns of the eye cause by calcium oxide or calcium hydroxide, commonly known as "lime burns". These burns are reportedly caused most commonly by a splash of a thick, moist, pasty material (plaster, mortar or cement), less commonly by a splash of milky fluid, and rarely by a clear solution of calcium hydroxide. Solid particles react with moisture in the eye to form clumps of moist compound which are difficult to remove, resulting in a similar effect. In severe cases, the injury may be permanent and blindness may result.(6,7)
Ingestion:
Calcium hydroxide is low in oral toxicity, based on animal information. Effects could include severe pain and burning of the mouth, throat and esophagus, stomach cramps, vomiting and diarrhea. Ingestion is not a typical route of occupational exposure.
Effects of Long-Term (Chronic) Exposure

There is no relevant animal or human information available.
Carcinogenicity:
There is no human or animal information available.
The International Agency for Research on Cancer (IARC) has not evaluated the carcinogenicity of this chemical.
The American Conference of Governmental Industrial Hygienists (ACGIH) has not assigned a carcinogenicity designation to this chemical.
The US National Toxicology Program (NTP) has not listed this chemical in its report on carcinogens.
Teratogenicity and Embryotoxicity:
There is no human or animal information available.
Reproductive Toxicity:
There is no human or animal information available.
Mutagenicity:
There is no information available.
Toxicologically Synergistic Materials:
There is no information available.
Potential for Accumulation:
Does not accumulate in the body. Calcium ions are normally found in the body. About one third of ingested calcium ion is absorbed. Calcium ion is excreted mainly in the feces and the urine.

SECTION 4. FIRST AID MEASURES


    
Inhalation:
Remove source of contamination or have victim move to fresh air. Obtain medical advice.
Skin Contact:
Avoid direct contact. Wear chemical protective clothing, if necessary. As quickly as possible, remove contaminated clothing, shoes and leather goods (e.g. watchbands, belts). Quickly and gently blot or brush away excess chemical. Immediately flush with lukewarm, gently flowing water for at least 60 minutes. DO NOT INTERRUPT FLUSHING. If necessary, and it can be done safely, continue flushing during transport to emergency care facility. Quickly transport victim to an emergency care facility. Completely decontaminate clothing, shoes and leather goods before re-use or discard.
Eye Contact:
Avoid direct contact. Wear chemical protective gloves, if necessary. Quickly and gently blot or brush chemical off the face. Immediately flush the contaminated eye(s) with lukewarm, gently flowing water for at least 60 minutes, while holding the eyelid(s) open. If a contact lens is present, DO NOT delay irrigation or attempt to remove the lens until flushing is done. Neutral saline solution may be used as soon as it is available. DO NOT INTERRUPT FLUSHING. If necessary, continue flushing during transport to emergency care facility. Quickly transport victim to an emergency care facility.
Ingestion:
NEVER give anything by mouth if victim is rapidly losing consciousness, is unconscious or convulsing. Have victim rinse mouth thoroughly with water. DO NOT INDUCE VOMITING. If vomiting occurs naturally, have victim rinse mouth with water again. Quickly transport victim to an emergency care facility.
First Aid Comments:
Provide general supportive measures (comfort, warmth, rest).
Consult a doctor and/or the nearest Poison Control Centre for all exposures except minor instances of inhalation.
All first aid procedures should be periodically reviewed by a doctor familiar with the material and its conditions of use in the workplace.




SECTION 5. FIRE FIGHTING MEASURES

Flash Point:
Non-combustible (does not burn)
Lower Flammable (Explosive) Limit (LFL/LEL):
Not applicable
Upper Flammable (Explosive) Limit (UFL/UEL):
Not applicable
Autoignition (Ignition) Temperature:
Not applicable
Sensitivity to Mechanical Impact:
Probably not sensitive. Stable material.
Sensitivity to Static Charge:
Not applicable. Not combustible.
Combustion and Thermal Decomposition Products:
Calcium oxide fumes can be generated by thermal decomposition at elevated temperatures.
Fire Hazard Summary:
Calcium hydroxide will not burn or support combustion. During a fire corrosive fumes of calcium oxide may be given off. Closed containers may explode in the heat of a fire.
Extinguishing Media:
Calcium hydroxide does not burn. Use extinguishing media appropriate to the surrounding fire conditions. DO NOT use carbon dioxide as an extinguishing agent.

    
Fire Fighting Instructions:
Evacuate area and fight fire from a safe distance or a protected location. Approach fire from upwind. If possible, isolate materials not involved in the fire and protect personnel.
Move containers from fire area if it can be done without risk. Otherwise, use water in flooding quantities as a spray or fog to keep fire-exposed containers cool and absorb heat to help prevent rupture. Water spray may also be used to knock down irritating/toxic combustion products which may be produced in a fire. Apply water from as far a distance as possible.
At high temperatures, decomposition occurs giving off strong, corrosive fumes of calcium oxide. Do not enter without wearing specialized protective equipment suitable for the situation. Firefighter's normal protective clothing (Bunker Gear) will not provide adequate protection. Chemical resistant clothing (e.g. chemical splash suit) and positive pressure self-contained breathing apparatus (MSHA/NIOSH approved or equivalent) may be necessary.




NATIONAL FIRE PROTECTION ASSOCIATION (NFPA) HAZARD IDENTIFICATION

NFPA - Comments:
NFPA has no listing for this chemical in Codes 49 or 325.

SECTION 9. PHYSICAL AND CHEMICAL PROPERTIES

Molecular Weight:    74.10
Conversion Factor:
Not applicable
Physical State:    Solid
Melting Point:    Not applicable (decomposes).
Boiling Point:    Not applicable (decomposes).
Decomposition Temperature:    580 deg C (1076 deg F) (15)
Relative Density (Specific Gravity):    2.24 at 20 deg C (water = 1) (15)
Solubility in Water:    0.185 g/100 mL at 0 deg C; 0.071 g/100 mL at 100 deg C (14)
Solubility in Other Liquids:    Soluble in acids, glycerol and ammonia salt solutions; insoluble in ethanol.(12,15)
Coefficient of Oil/Water Distribution (Partition Coefficient):    Not available
pH Value:    11.3 (0.01% at 25 deg C); 12.5 to 12.7 (saturated solution (0.18 g/100 mL) at 25 deg C) (14,15)
Vapour Density:    Not applicable
Vapour Pressure:    Zero (does not form vapour)
Saturation Vapour Concentration:    Not applicable
Evaporation Rate:    Not applicable

SECTION 10. STABILITY AND REACTIVITY

Stability:
Normally stable. Absorbs carbon dioxide from the air to form calcium carbonate.(14,15)
Hazardous Polymerization:
Does not occur.
Incompatibility - Materials to Avoid:
NOTE: Chemical reactions that could result in a hazardous situation (e.g. generation of flammable or toxic chemicals, fire or detonation) are listed here. Many of these reactions can be done safely if specific control measures (e.g. cooling of the reaction) are in place. Although not intended to be complete, an overview of important reactions involving common chemicals is provided to assist in the development of safe work practices.


STRONG ACIDS (e.g. sulfuric acid) - may react violently.(16)
MALEIC ANHYDRIDE - may react explosively with decomposition.(17)
NITROALKANES (e.g. nitromethane, nitroethane, nitropropane) - react to form explosive salts.(17)
PHOSPHORUS - yields phosphines which may ignite spontaneously in air.(17)
Hazardous Decomposition Products:
Calcium carbonate.
Conditions to Avoid:
High temperatures, generation of dust .
Corrosivity to Metals:
Corrosive to aluminum.(18) Not corrosive to certain grades of stainless steel (302, 304, 316, 410, 430) at room temperature and to nickel-chromium-molybdenum alloy.(15,18)
Stability and Reactivity Comments:
Calcium hydroxide reacts readily with carbon dioxide in air to form calcium carbonate.(14,15) Attacks some metals.(19)

SECTION 11. TOXICOLOGICAL INFORMATION

LD50 (oral, rat): 7340 mg/kg (8)
LD50 (oral, mouse): 7300 mg/kg (9, unconfirmed)
Eye Irritation:
Application of 10 mg (0.01 g) of solid calcium hydroxide caused severe irritation or corrosion in rabbits in a modified Draize test. Healing did not occur within 21 days.(10) Injury to the corneas of rabbits resulted from exposure to a paste of calcium hydroxide for 1 minute, followed by cleaning and rinsing with a physiological salt solution. This injury reached a maximum at 24 hours after exposure and the eye had not returned to normal after 3 months.(11) Further details on this study are not available.
Effects of Long-Term (Chronic) Exposure:
Ingestion:
Male rats were given tap water containing 50 or 350 mg/L. At 2 months, the rats were restless, aggressive and had reduced food intake. At 3 months, there was a decrease in body weight and a decrease in certain blood components (for example, red blood cells, hemoglobin).(11) Further details on this study were not available. Its relevance to occupational exposures is questionable.

SECTION 16. OTHER INFORMATION

Selected Bibliography:
(1) Vickers, H.R., et al. Cement burns. Contact Dermatitis. Vol. 2 (1976). p. 73-78
(2) Buckley, D.B. Skin burns due to wet cement. Contact Dermatitis. Vol. 8, no. 6 (1982). p. 407-409.
(3) Tosti, A., et al. Skin burns due to transit-mixed Portland cement. Contact Dermatitis. Vol. 21, no. 1 (1989). p. 58
(4) Hannuksela, M., et al. Caustic ulcers caused by cement. British Journal of Dermatology. Vol. 95 (1976). p. 547-549.
(5) Flowers, M.W. Burn hazard with cement. British Medical Journal. Vol. 1, no. 6122. (May, 1978). p. 1250.
(6) Grant, W.M., et al. Toxicology of the eye. 4th edition. Charles C. Thomas, 1993. p. 298-302
(7) McLaughlin, R.S. Chemical burns of the human cornea. American Journal of Ophthalmology. Vol. 20, no. 11 (November, 1946). p. 1355- 1362.
(8) Smyth Jr., H.F., et al. Range-finding toxicity data: list VII. American Industrial Hygiene Association Journal. Vol. 30, no. 5 (September-October, 1969). p. 470-476
(9) RTECS record for calcium hydroxide. Date of last update: 9504.
(10) Griffith, J.F., et al. Dose-response studies with chemical irritants in the Albino rabbit eye as a basis for selecting optimum testing conditions for predicting hazard to the human eye. Toxicology and Applied Pharmacology. Vol. 55 (1980). p. 501-513
(11) Pierce, J. O. Alkaline materials. In: Patty's industrial hygiene and toxicology. 4th edition. Edited by G.D. Clayton, et al. Volume II, Part A. John Wiley and Sons, 1993. p. 762-764
(12) HSDB record for calcium hydroxide. Date of last revision: 96/03/21
(13) Petersen, R.L., et al. Calcium compounds: survey. In: Kirk-Othmer encyclopedia of chemical technology. 4th edition. Volume 4. John Wiley and Sons, 1992. p. 788-796
(14) Oates, T. Lime and limestone In: Ullmann's encyclopedia of industrial chemistry. 5th completely revised edition. Volume A 15. VCH Verlagsgesellschaft, 1990. p. 334-345
(15) Environmental and technical information for problem spills: calcium oxide and hydroxide. Environmental Protection Service, Environment Canada, March, 1984
(16) The Sigma-Aldrich library of chemical safety data. Edition II. Volume 1. Sigma-Aldrich Corporation, 1988. p. 667B
(17) Fire protection guide to hazardous materials. 11th edition. National Fire Protection Association, 1994. NFPA 491
(18) Corrosion data survey: metals section. 6th edition. National Association of Corrosion Engineers, 1985. p. 30-1 to 31-1
(19) NIOSH pocket guide to chemical hazards. National Institute for Occupational Safety and Health, June 1994. p. 46-47
(20) Forsberg, K., et al. Quick selection guide to chemical protective clothing. 4th ed. Van Nostrand Reinhold, 2002
(21) Occupational Safety and Health Administration (OSHA). Metal and Metalloid Particulates in Workplace Atmospheres. In: OSHA Analytical Methods Manual. Revision Date: Oct. 31, 2001. Available at: 
(22) National Institute for Occupational Safety and Health (NIOSH). Calcium and compounds as Ca. In: NIOSH Manual of Analytical Methods (NMAM(R)). 4th ed. Edited by M.E. Cassinelli, et al. DHHS (NIOSH) Publication 94-113. Aug. 1994. Available at: 
Information on chemicals reviewed in the CHEMINFO database is drawn from a number of publicly available sources. A list of general references used to compile CHEMINFO records is available in the database Help.

Review/Preparation Date: 1996-11-08

Revision Indicators:
Resistance of material    1998-05-01
Bibliography    1998-05-01
PEL-TWA final    2003-12-04
PEL final comments    2003-12-04
PEL-TWA transitional    2003-12-04
PEL transitional comments    2003-12-04
Resistance of materials for PPE    2004-04-05
Bibliography    2004-04-05
Bibliography    2005-03-09
Sampling/analysis    2005-03-09
Sampling/analysis    2005-03-28





        
The following information has been extracted from our CHEMINFO database, which also contains hazard control and regulatory information. [More about...] [Sample Record]

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SECTION 1. CHEMICAL IDENTIFICATION

CHEMINFO Record Number:    77
CCOHS Chemical Name:    Hydrogen peroxide solutions less than 8%
Synonyms:
Dihydrogen dioxide
Hydrogen dioxide
Hydroperoxide
Peroxide
Hydrogen peroxide
Chemical Name French:    Peroxyde d'hydrogène
Chemical Name Spanish:    Peróxido de hidrógeno
Trade Name(s):
Albone
Kastone
Perone
Tysul
CAS Registry Number:    7722-84-1
RTECS Number(s):    MX0887000
EU EINECS/ELINCS Number:    231-765-0
Chemical Family:    Inorganic peroxide / hydrogen oxide / hydrogen peroxide
Molecular Formula:    H2-O2
Structural Formula:    H-O-O-H

SECTION 2. DESCRIPTION

Appearance and Odour:
Colourless liquid; odourless or having an odour resembling ozone (18); vapour is not irritating except at high concentrations.
Odour Threshold:
Not available
Warning Properties:
Insufficient information for evaluation.
Composition/Purity:
All information given is for hydrogen peroxide solutions in water because this is the only form in which hydrogen peroxide is commercially available. Hydrogen peroxide is available in grades ranging from 3 to 90 wt.%. The most common industrial grades are 35, 50, and 70 wt.%. Less concentrated solutions, such as 3-6%, are obtained by dilution of more concentrated ones, such as 35%, with water, usually with the addition of extra stabilizer.(4,19) Commercial solutions almost always contain very small amounts of impurities, such as iron or copper, which can cause decomposition. Therefore, stabilizers are often added to prevent decomposition into oxygen and water. Common stabilizers include sodium pyrophosphate and sodium stannate trihydrate, phosphoric or other mineral acids and organic stabilizers such as 8- hydroxyquinoline, pyridine carboxylic acids, tartaric and benzoic acids, acetanilide and acetophenetidin.(4,19,20)
Uses and Occurrences:
Hydrogen peroxide solutions of less than 8% are used in pharmaceutical preparations such as mouth wash, dentifrices, and sanitary lotions; as a disinfectant for cleansing wounds and ulcers; in ear drops; in cosmetic preparations such as hair bleaches, skin care and nail hardeners; for bleaching delicate fabrics; and for artificially aging wines and liquors.(4,18)

SECTION 3. HAZARDS IDENTIFICATION


    
EMERGENCY OVERVIEW:
Clear, colourless liquid. Will not burn. Essentially non-toxic following short-term exposure. Solutions of greater than 5% may cause eye irritation.




POTENTIAL HEALTH EFFECTS

Effects of Short-Term (Acute) Exposure

Inhalation:
Hydrogen peroxide does not readily form a vapour at room temperature. If heated or misted, it is irritating to the nose, throat and respiratory tract, based on limited human and animal information.
Throat irritation has been reported in employees exposed to aerosol concentrations of 12 to 41 mg/m3.(1) No effect on airways resistance was observed in volunteers exposed to 0.3 mg/m3 of hydrogen peroxide aerosol for 5 minutes.(2) In volunteers exposed to the aerosol for 4 hours, the threshold for respiratory tract irritation was 10 mg/m3.(3)
Skin Contact:
Hydrogen peroxide solutions of less than 8% are not irritating, based on animal information. Whitening or bleaching of the skin has been observed in humans.(4,5,6)
Eye Contact:
Hydrogen peroxide solutions of 5% are minimally irritating based on animal information. No reliable information was located for solutions greater than 5% and less than 8%, but this concentration range may be irritating to the eyes. In humans, application of 1-3% solutions has caused severe pain which soon subsided. Use of contact lenses which had been soaked in 3% hydrogen peroxide produced immediate pain, tearing and spasm of the eyelids in one case, but not another. Permanent damage did not result.(7, unconfirmed)
Ingestion:
Case reports of non-occupational ingestion of hydrogen peroxide describe symptoms such as sharp pains in the abdomen, foaming at the mouth, vomiting, temporary unconsciousness and fever. Sensory and motor impairment have also been described. Hydrogen peroxide reacts in the stomach releasing large amounts of oxygen.(4,5) Ingestion is not a typical route of occupational exposure.
Effects of Long-Term (Chronic) Exposure

INHALATION EXPOSURE: No firm conclusions can be drawn from one case report. This report described reversible lung disease in an employee exposed to 12 to 41 mg/m3 of hydrogen peroxide aerosols for 1 year. This individual was also a heavy smoker which may have contributed to him developing lung disease. Six other employees similarly exposed did not show evidence of lung disease. All 7 employees reported eye and throat irritation and gradual bleaching of their hair since the machine which generated hydrogen peroxide was in use.(1)

SKIN SENSITIZATION: There is one occupational case report of a hairdresser who developed an intensely itchy rash. She later tested positive to a 3% solution of hydrogen peroxide, as well as nickel sulfate and 4-aminophenol. She had no previous history of allergies. This authors indicate that 156 other hairdressers tested negative to 3% hydrogen peroxide.(8) Negative results were also reported for hydrogen peroxide in another study of employees exposed to several chemicals in a hydrogen peroxide production unit.(9)
Carcinogenicity:
In a limited human population study, there was no indication of an increased risk of cancer due to hydrogen peroxide exposure. This study is limited by the small number of people studied and possibly low exposure levels.(34) Animal studies have shown that long-term oral administration of 0.1-0.15% hydrogen peroxide causes an inflammatory response in the gastro-duodenal tissue of mice. This inflammatory response may progress to carcinogenic changes.(4,10) The International Agency for Research on Cancer (IARC) has concluded that there is inadequate evidence for the carcinogenicity of hydrogen peroxide to humans. There is limited evidence of the carcinogenicity of hydrogen peroxide in experimental animals.(34).
The International Agency for Research on Cancer (IARC) has concluded that this chemical is not classifiable as to its carcinogenicity to humans (Group 3).
The American Conference of Governmental Industrial Hygienists (ACGIH) has designated this chemical as an animal carcinogen (A3).
The US National Toxicology Program (NTP) has not listed this chemical in its report on carcinogens.
Teratogenicity and Embryotoxicity:
There is no human information available. No conclusions can be drawn based on the limited animal information available.
Reproductive Toxicity:
There is no human information available. No conclusions can be drawn based on the limited animal information available.
Mutagenicity:
It is not possible to conclude that hydrogen peroxide is mutagenic. Positive results have been obtained in cultured humans cells.(34) Negative results have been obtained in relevant studies using live animals. Positive results have been obtained in short-term mutagenicity tests.
Toxicologically Synergistic Materials:
Increased airways resistance was observed in volunteers exposed to hydrogen peroxide and sulfur dioxide aerosols at the same time.(2) Exposure to hydrogen peroxide increased the toxicity of ozone in animals.(11)
Potential for Accumulation:
Some hydrogen peroxide undergoes decomposition to oxygen and water when in contact with mammalian tissues, such as skin and the tongue, before absorption. In the body, hydrogen peroxide is readily metabolized to oxygen and water, by one route, or to water alone by another. It does not accumulate in the body.(4)

SECTION 4. FIRST AID MEASURES


    
Inhalation:
If symptoms are experienced, remove source of contamination or have victim move to fresh air and obtain medical advice.
Skin Contact:
As quickly as possible, flush with lukewarm, gently flowing water for at least 5 minutes or until the chemical is removed. If irritation persists, obtain medical advice immediately. Completely decontaminate clothing before re-use or discard.
Eye Contact:
Immediately flush the contaminated eye(s) with lukewarm, gently flowing water for 15-20 minutes, while holding the eyelid(s) open. If a contact lens is present, DO NOT delay irrigation or attempt to remove the lens until flushing is done. If irritation persists, obtain medical attention.
Ingestion:
If irritation or discomfort occur, obtain medical advice immediately.
First Aid Comments:
All first aid procedures should be periodically reviewed by a doctor familiar with the material and its condition of use in the workplace.




SECTION 5. FIRE FIGHTING MEASURES

Flash Point:
Does not burn
Lower Flammable (Explosive) Limit (LFL/LEL):
Not applicable
Upper Flammable (Explosive) Limit (UFL/UEL):
Not applicable
Autoignition (Ignition) Temperature:
Not applicable
Sensitivity to Mechanical Impact:
Very dilute hydrogen peroxide solutions are not shock sensitive.
Sensitivity to Static Charge:
Not sensitive
Combustion and Thermal Decomposition Products:
Molecular oxygen
Fire Hazard Summary:
Does not burn. Hydrogen peroxide (solutions less than 8%) is a very weak oxidizing agent. In a fire, it may release oxygen which can increase the burning rate of flammable materials.(19-22)
Extinguishing Media:
Hydrogen peroxide does not burn. Use large quantities of water as fog to fight fires in which this material is involved.(23) Some chemical extinguishing agents may accelerate decomposition. Carbon dioxide or other extinguishing agents that smother flames are not effective in extinguishing fires involving oxidizers.(22)

    
Fire Fighting Instructions:
Evacuate area and fight fire from a safe distance or a protected explosion-resistant location or maximum possible distance. Approach fire from upwind to avoid hazardous vapours and decomposition products.
Move containers from the fire area if this can be done without risk. Explosive decomposition may occur under fire conditions. Use extreme caution since heat may cause rupture of containers and release large amounts of oxygen. Otherwise, apply water from as far a distance as possible, in flooding quantities as a spray or fog to keep fire-exposed containers or equipment cool and absorb heat, until well after the fire is out.
Remove all flammable and combustible materials from the vicinity, especially oil and grease. Do not direct water directly on leak as this may cause leak to increase. Stay away from ends of tanks, but realize that shrapnel may travel in any direction. Withdraw immediately in case of rising sound from venting safety device or any discolouration of tanks due to fire. In an advanced or massive fire, the area should be evacuated; use unmanned hoseholders or monitor nozzles.
Firefighters may enter the area if positive pressure self-contained breathing apparatus (MSHA/NIOSH approved or equivalent) and full Bunker Gear is worn.




NATIONAL FIRE PROTECTION ASSOCIATION (NFPA) HAZARD IDENTIFICATION

NFPA - Comments:
NFPA has no listing for this chemical in Codes 49 or 325.

SECTION 9. PHYSICAL AND CHEMICAL PROPERTIES

Molecular Weight:    34.02
Conversion Factor:
1 ppm = 1.39 mg/m3; 1 mg/m3 = 0.72 ppm at 25 deg C (calculated)
Physical State:    Liquid
Melting Point:    No information available
Boiling Point:    No specific information available; probably close to 100 deg C (212 deg F)
Relative Density (Specific Gravity):    No specific information available; probably close to 1 at 20-25 deg C (water = 1)
Solubility in Water:    Soluble in all proportions.(4,19,20)
Solubility in Other Liquids:    Soluble in all proportions in many polar solvents, e.g. low molecular weight alcohols, glycols and ketones; insoluble in petroleum ether.(4,20,24)
Coefficient of Oil/Water Distribution (Partition Coefficient):    Log P(oct) = -0.70 to -1.33 (estimated) (25)
pH Value:    Very slightly acid to litmus paper.
Acidity:    Weak acid; pKa = 11.75 at 20 deg C (Ka = 1.78 X 10(-12) at 20 deg C).(19,20)
Viscosity-Dynamic:    Approximately 1 mPa.s (1 centipoise) at 20 deg C.(4)
Surface Tension:    Approximately 73 mN/m (73 dynes/cm) at 20 deg C.(4)
Vapour Density:    1.2 (air = 1)
Vapour Pressure:    Not available
Saturation Vapour Concentration:    Not available
Evaporation Rate:    Not available

SECTION 10. STABILITY AND REACTIVITY

Stability:
Solutions which are completely free of contamination are relatively stable. Alkaline solutions are less stable than acidic ones (the optimum pH is 3.5-4.5). It can decompose in sunlight. Hydrogen peroxide can liberate oxygen, water and heat.(4,19)
Hazardous Polymerization:
Does not occur
Incompatibility - Materials to Avoid:
NOTE: Chemical reactions that could result in a hazardous situation (e.g. generation of flammable or toxic chemicals, fire or detonation) are listed here. Many of these reactions can be done safely if specific control measures (e.g. cooling of the reaction) are in place. Although not intended to be complete, an overview of important reactions involving common chemicals is provided to assist in the development of safe work practices.


Dilute hydrogen peroxide solutions (less than 8%) are incompatible with reducing agents, including organic matter and oxidizable substances, alkalies, iodides, permanganates and other stronger oxidizing agents (e.g. nitric acid, perchloric acid). Its decomposition is increased by contact with powdered metals or their salts (e.g. iron, copper).(18)
More concentrated hydrogen peroxide solutions (30% or greater) are strong oxidizing agents and are capable of reacting explosively with many substances. For a review of the many substances with which hydrogen peroxide can react, consult references 23, 26 and 27.
Hazardous Decomposition Products:
Oxygen
Conditions to Avoid:
Temperatures greater than 100 deg C, depletion of stabilizers, pH greater than 4.5.
Corrosivity to Metals:
Hydrogen peroxide solutions less than 8% are corrosive (corrosion rate greater than 1.27 mm/year) to carbon steel (types 1010 and 1020), ductile cast iron, copper, nickel-copper alloy, brass, cartridge brass, naval brass, bronze, aluminum bronze, naval bronze, silicon bronze, and lead at room temperature.(28,35,36) Hydrogen peroxide solutions attack types 1010 and 1020 carbon steel at any concentration and temperature.(35) Hydrogen peroxide solutions less than 8% are not corrosive (corrosion rate less than 0.5 mm/year) to stainless steel (e.g. types 304, 316, 403, 410, 430, Carpenter 20Cb-3), aluminum (99.5%), certain aluminum alloys (types 1060, 3003, 5052, 6063, Cast B-356 and aluminum-magnesium alloys), nickel, the nickel-base alloys, Monel, Hastelloy C, Inconel and Incoloy, tantalum, titanium and zirconium.(35,36,37) Both stainless steel and aluminum surfaces must be passivated (formation of a protective film by chemical treatment) before use.(19,20)
Stability and Reactivity Comments:
The degree of hazard associated with hydrogen peroxide depends on concentration. It may attack some forms of plastics, rubber, or coatings.(30)

SECTION 11. TOXICOLOGICAL INFORMATION

LC50 (rat): 2000 mg/m3 (4-hour exposure; whole body exposure) (concentration not specified) (3)
NOTE: This value is not considered reliable since a whole body exposure was used and the study was poorly reported.
LD50 (oral, male rat): 1517 mg/kg (9.6% solution) (4,12)
Eye Irritation:
Hydrogen peroxide solutions of 5% have caused minimal irritation. No reliable information was located for solutions of greater than 5 and less than 8%.
Application of 0.1 mL of a 5% solution caused minimal irritation in washed and unwashed eyes (maximum score 3/110) in rabbits.(13) Repeated instillation of a drop of a 1% solution caused severe irritation and clouding of the cornea.(4, unconfirmed) Other unpublished studies have shown no effects following application of a 3% solution.(4, unconfirmed) A drop of 5-30% solution caused severe damage, which was persistent when concentrations were greater than 10%. Even a 5% solution resulted in severe irritation, which only improved partially over 4-5 months.(7, unconfirmed)
Skin Irritation:
Hydrogen peroxide solutions of less than 8% are not irritating.
In unpublished studies, application of a 3, 6 or 8% hydrogen peroxide solution, under a cover to intact skin for 24 hours, caused no irritation in rabbits (all scores for erythema and edema were 0/4).(4, unconfirmed)
Effects of Short-Term (Acute) Exposure:
Inhalation:
Interpretation of the available inhalation exposure information is complicated because the form of hydrogen peroxide (vapour or aerosol) is not always specified. In general, studies have shown that airborne hydrogen peroxide is irritating to the respiratory tract. Symptoms have included nose irritation and discharge, fluid accumulation in the lungs and necrosis of bronchial tissue. Deaths have been reported.(4,14,15)
Ingestion:
Male mice showed a decrease in body weight and died within 2 weeks when their drinking water contained greater than 1% hydrogen peroxide. Significant decreases in body weight gain were observed after administration of 0.6% but not 0.3% for 3 weeks.(4,5) In another study, decreased fluid intake and body weight were observed in male rats exposed to 0.45% for 3 weeks.(16)
Effects of Long-Term (Chronic) Exposure:
Inhalation:
There is no specific information available for vapours or aerosols generated from solutions of less than 20%. A study which examined rats exposed to 67 ppm (93 mg/m3) of an aerosol/vapour mixture generated from 90% hydrogen peroxide over a 7 week period showed irritation of the respiratory tract and lung congestion in all animals. In the same study, two dogs were exposed to 7 ppm (10 mg/m3) of an aerosol/vapour mixture generated from 90% hydrogen peroxide for 6 months. There were no signs of toxicity by 14 weeks except for bleaching and loss of hair. Autopsy showed signs of lung irritation, as well as loss of hair and thickening of the skin.(14)
Ingestion:
Several studies have investigated the effects of long-term oral administration of hydrogen peroxide. In general, decreases in body weight gain and biochemical changes have been observed with exposure to lower doses or with exposures of longer durations. Deaths have occurred in animals exposed to doses of 1.5% and higher for 8 weeks or longer. Liver damage and thickening of the stomach wall has been observed in mice administered 0.15% hydrogen peroxide (approximately 230 mg/kg/day) in their drinking water for 16 weeks. This study continued for 35 weeks during which harmful changes in the kidneys, gastrointestinal tract and spleen were also observed.(4,5)
Skin Sensitization:
Negative results were obtained in guinea pigs exposed to 3 or 6% solutions.(4, unconfirmed)
Carcinogenicity:
The International Agency for Research on Cancer (IARC) has concluded that there is limited evidence of the carcinogenicity of hydrogen peroxide in experimental animals.(5,34) The American Conference of Governmental Industrial Hygienists (ACGIH) has designated hydrogen peroxide as an A3 (animal carcinogen).
Several studies have shown that long-term oral administration of 0.1-0.15% hydrogen peroxide causes an inflammatory response in the gastro-duodenal tissue of mice. This inflammatory response may progress to carcinogenic changes. In rats, hydrogen peroxide only induced benign tumours, not malignant tumours, even at nearly lethal concentrations (1-1.5%).(4,10) No neoplasms were observed in hamsters administered 0.75% hydrogen peroxide in dentrifice 5 times/week for 20 weeks. This study is limited by its short duration and the unknown effect of using dentrifice as the vehicle.(34) Hydrogen peroxide did not act as a tumour promoter when administered to rats or hamsters with a known carcinogen.(10,34)
Teratogenicity, Embryotoxicity and/or Fetotoxicity:
No conclusions can be drawn based on the available information.
One historical study which lacks details reported that normal litters were born to 3 female rats exposed to 0.45% in drinking water for 5 months and then mated with unexposed males.(16) No conclusions can be drawn from another poorly conducted study (4, unconfirmed).
Reproductive Toxicity:
No conclusions can be drawn based on the limited information available.
Male mice were given 0.33% or 1.0% hydrogen peroxide solutions in place of drinking water. The mice were mated after days 7 and 28 or day 21 of exposure. No significant effects on fertility were observed. The concentration, morphology and motility of sperm of mice and rabbits receiving hydrogen peroxide in their drinking water over 3 and 6 weeks remained normal.(17) This study is limited by the small number of animals used and the fact that a control group was not used. Rats were orally administered doses of up to 50 mg/kg orally for 6 months. At the high dose, altered fertility cycles were observed in the females and decreased sperm mobility in males. Treated animals were mated. High dose females produced fewer litters.(4, unconfirmed) There is insufficient information available to evaluate this report.
Mutagenicity:
Negative results have been obtained in most studies using live animals. However, positive results have been obtained in host-mediated assays. In these studies, mutagenicity was observed in bacteria and tumour cells injected into live animals.(4,5,34)
Positive results were obtained in cultured mammalian cells, including human cells, and in bacteria and yeast.(4,5,34)
Negative results were obtained in fruit flies.(4,5,34)

SECTION 16. OTHER INFORMATION

Selected Bibliography:
(1) Kaelin, R.M.. Diffuse interstitial lung disease associated with hydrogen peroxide inhalation in a dairy worker. American Review of Respiratory Diseases. Vol. 137, no. 5 (May 1988). p. 1233-1235
(2) Toyama, T., et al. Synergistic response to hydrogen peroxide aerosols and sulfur dioxide to pulmonary airway resistance. Industrial Health. Vol. 2 (1964). p. 35-45
(3) Kondrashov, V.A. Comparative toxicity of hydrogen peroxide vapour on inhalation and dermal exposure. [English translation]. Gigiena Truda i Professionalnye Zabolevaniya. Vol. 21, no. 10 (1977). p. 22-25. (HSE Translation No. 14391A)
(4) Hydrogen peroxide CAS No. 7722-84-1. Joint assessment of commodity chemicals no. 22. European Centre for Ecotoxicology and Toxicology of Chemicals (ECETOC), Sept. 1992
(5) International Agency for Research on Cancer (IARC). Hydrogen peroxide. In: IARC monographs on the evaluation of the carcinogenic risk of chemicals to humans. Vol. 36. Allyl compounds, aldehydes, epoxides and peroxides. World Health Organization, Feb. 1985. p. 285-314
(6) Goette, D.K., et al. Skin blanching induced by hydrogen peroxide. Case reports. Southern Medical Journal. Vol. 70, no. 5 (May 1977). p. 620-622
(7) Grant, W.M., et al. Toxicology of the Eye. 4th ed. Charles C. Thomas, 1993. p. 791-797
(8) Aguirre, A., et al. Positive patch tests to hydrogen peroxide in 2 cases. Contact Dermatitis. Vol. 30, no. 2 (Feb. 1994). p. 113
(9) Barsotti, M., et al. Symptoms of bronchial asthma and eczema in workers assigned to hydrogen peroxide production units. English summary. Medicina del Lavoro. Vol. 42, no. 2 (1951). p. 68
(10) Takahashi, M., et al. Effects of ethanol, potassium metabisulfite, formaldehyde and hydrogen peroxide on gastric carcinogenesis in rats after initiation with N-methyl-N'-nitro-N-nitrosoguanidine. Japanese Journal of Cancer Research. Vol. 77, no. 2 (Feb. 1986). p. 118-124
(11) Svirbely, J.L., et al. Enhanced toxicity of ozone-hydrogen peroxide mixture. American Industrial Hygiene Association Journal. Vol. 22, no. 1 (Feb. 1961). p. 21-26
(12) RTECS database record for hydrogen peroxide, 8% to 20%. Last updated: 1997/10
(13) Weiner, M., et al. Eye irritation studies on three concentrations of hydrogen peroxide. Journal of the American College of Toxicology. Part B (1990). p. 49-50
(14) Oberst, F.W., et al. Inhalation toxicity of ninety percent hydrogen peroxide vapor. A.M.A. Archives of Industrial Hygiene and Occupational Medicine. Vol. 10 (Oct. 1954). p. 319-327
(15) Punte, C.L., et al. The inhalation toxicity of aerosols of 90% hydrogen peroxide. Medical Laboratories Research Report No. 189. Chemical Corps Medical Laboratories. Army Chemical Center, Maryland, May 1953. (NIOSHTIC Control Number: 00068230)
(16) Hankin, L. Hydrogen peroxide ingestion and the growth of rats. Nature. No. 4647 (Nov. 22, 1958). p. 1453
(17) Wales, R.G., et al. The spermicidal activity of hydrogen peroxide in vitro and in vivo. Journal of Endocrinology. Vol. 18 (1959). p. 236-244
(18) Reynolds, J.E.F., ed. Martindale; the extra pharmacopoeia. 29th ed. The Pharmaceutical Press, 1989. p. 1578-1579
(19) Eul, W.E., et al. Hydrogen peroxide. In: Kirk-Othmer encyclopedia of chemical technology. John Wiley and Sons, 2005. Available at:  {Subscription required}
(20) Goor, G., et al. Hydrogen Peroxide. In: Ullmann's encyclopedia of industrial chemistry. 7th ed. John Wiley and Sons, 2005. Available at:  {Subscription required}
(21) Chemical safety sheets: working safely with hazardous chemicals. Kluwer Academic Publishers, 1991
(22) NFPA 430. Code for the storage of liquid and solid oxidizers. 1995 ed. National Protection Association, 1995. p. 430-1 to 430-16
(23) Fire protection guide to hazardous materials. 11th ed. National Fire Protection Association, 1994
(24) HSDB database record for hydrogen peroxide. Last revision date: 97/05/01
(25) Leo, A., et al. Partition coefficients and their uses. Chemical Reviews. Vol. 71, no. 6 (Dec. 1971). p. 555
(26) Urben, P.G., ed. Bretherick's handbook of reactive chemical hazards. 5th ed. Vol. 1. Butterworth-Heinemann Ltd., 1995
(27) Sigma-Aldrich library of chemical safety data. Ed. II. Vol. 1. Sigma-Aldrich Corporation, 1988
(28) Corrosion data survey: metals section. 6th ed. National Association of Corrosion Engineers, 1985
(29) Merrifield, R. Fire and explosion hazards associated with the storage and handling of hydrogen peroxide. Specialist Inspector Report no. 19. Health and Safety Executive, Technology Division, Oct. 1988
(30) Emergency action guide for hydrogen peroxide. Association of American Railroads, Jan. 1990
(31) NIOSH pocket guide to chemical hazards. National Institute for Occupational Safety and Health, June 1997
(32) Forsberg, K., et al. Quick selection guide to chemical protective clothing. 4th ed. Van Nostrand Reinhold, 2002
(33) European Communities (EC). Commission Directive 2004/73/EC. Apr 29, 2004
(34) International Agency for Research on Cancer (IARC). IARC monographs on the evaluation of carcinogenic risks to humans. Vol. 71, parts 1, 2 and 3. Re-evaluation of some organic chemicals, hydrazine and hydrogen peroxide. IARC, 1999
(35) Pruett, K.M. Hydrogen peroxide. In: Chemical resistance guide to metals and alloys: a guide to chemical resistance of metals and alloys. Compass Publications, 1995. p. 170-181
(36) Schweitzer, P.A. Hydrogen peroxide. In: Corrosion resistance tables: metals, nonmetals, coatings, mortars, plastics, elastomers and linings, and fabrics. 4th ed. Part B, E-O Marcel Dekker, Inc., 1995. p. 1553-1556
(37) Hydrogen peroxide. In: Handbook of corrosion. 2nd ed. Edited by B.D. Craig, et al. ASM International, 1997. p. 468-470
Information on chemicals reviewed in the CHEMINFO database is drawn from a number of publicly available sources. A list of general references used to compile CHEMINFO records is available in the database Help.

Review/Preparation Date: 1998-05-05

Revision Indicators:
WHMIS (disclosure list)    1999-03-01
Carcinogenicity    1999-12-01
Mutagenicity    1999-12-01
ERPG    2001-03-01
PEL-TWA final    2003-12-19
PEL transitional comments    2003-12-19
Resistance of materials for PPE    2004-04-06
EU classification    2004-11-18
EU risks    2004-11-18
EU safety    2004-11-18
EU comments    2004-11-18
Toxicological info    2006-03-27
Short-term eye contact    2006-03-27
Emergency overview    2006-03-27
WHMIS health effects    2006-03-27
WHMIS proposed classification    2006-03-27
OSHA hazcom    2006-03-27
Corrosivity to metals    2006-04-04
WHMIS detailed classification    2006-04-04
Bibliography    2006-04-04
Eye/face protection    2006-04-04
Resistance of materials for PPE    2006-04-04
Skin protection    2006-04-04
Handling    2006-04-04






        
The following information has been extracted from our CHEMINFO database, which also contains hazard control and regulatory information. [More about...] [Sample Record]

Access the complete CHEMINFO database by contacting CCOHS Client Services.

             
        
SECTION 1. CHEMICAL IDENTIFICATION

CHEMINFO Record Number:    780
CCOHS Chemical Name:    Bisphenol A diglycidyl ether
Synonyms:
2,2-Bis(4-(2,3-epoxypropoxy)phenyl)-propane
2,2-Bis(4-hydroxyphenyl)propane diglycidyl ether
4,4'-Bis(2,3-epoxypropoxy)diphenyldimethylmethane

DGEBPA
4,4'-Isopropylidenebis(1-(2,3-epoxypropoxy)benzene)
4,4'-Isopropylidenediphenol diglycidyl ether
Bis(4-glycidyloxyphenyl)dimethylmethane
Bis(4-hydroxyphenyl)dimethylmethane diglycidyl ether
Diglycidyl bisphenol A ether
2,2'-[(1-Methylethylidene)bis(4,1-phenyleneoxymethylene)]bis[oxirane]
CAS Registry Number:    1675-54-3
RTECS Number(s):    TX3800000
EU EINECS/ELINCS Number:    216-823-5
Chemical Family:    Aromatic glycidyl ether / aromatic diglycidyl ether / bisphenol A ether / epoxy resin / epichlorohydrin resin
Molecular Formula:    C21-H24-O4
Structural Formula:    H2C-(O)-CH-CH2-O-C6H4-C[(CH3)2]-C6H4-O-CH2-CH-(O)-CH2

SECTION 2. DESCRIPTION

Appearance and Odour:
Colourless, crystalline solid.(32)
Odour Threshold:
Not available
Warning Properties:
Information not available for evaluation
Composition/Purity:
Diglycidyl ether of bisphenol A (DGEBPA) is made by reacting epichlorohydrin and bisphenol A. DGEBPA is not generally produced as a pure monomer, but occurs as a component of a resin mixture containing varying amounts of the low molecular weight polymers (monomer, dimers, trimers and tetramers) (CAS 25068-38-6); as a homopolymer of DGEBPA (CAS 25085-99-8); or as a higher molecular weight polymer of DGEBPA (CAS 25036-25-3). It is unlikely that many commercial products are pure DGEBPA monomer (CAS 1675-54-3).(9,32-35) Nevertheless, some suppliers/manufacturers do use the monomer CAS Registry Number (1675-54-3) for products that are actually complex DGEBPA-based epoxy resin mixtures. Interpretation and evaluation of the information on DGEBPA and DGEBPA-based epoxy resins is complicated by the fact that these materials are complex mixtures; it is not always clear exactly which material is being studied; and the CAS Registry Numbers and names of the materials are, at times, used interchangeably. This CHEMINFO profile reviews information available for pure DGEBPA monomer (CAS 1675-54-3). For information on low molecular weight liquid DGEBPA-based epoxy resin mixtures (CAS 25068-38-6 or 25085-99-8), low molecular weight solid DGEBPA-based epoxy resin mixtures (CAS 25068-38-6 or 25085-99-8), or medium to high molecular weight solid DGEBPA-based epoxy resin mixtures (CAS 25036-25-3) refer to the relevant CHEMINFO reviews.
Uses and Occurrences:
Epoxy resins based on glycidyl ethers are used in protective coatings, including waterborne coatings, solventless coatings, high solids coatings and powder coatings, decorative and protective coatings for automobiles, coal tar pitch modified coatings, reinforced plastics, structural composites, including pipes, vessels, electrical, aerospace and sporting goods applications; electrical laminates, moulding components, bonding materials and adhesives, sealants, patching compounds, flooring, paving and aggregates, tins and closures, boats and ships, appliances, piping and miscellaneous metal decoration, fibre-reinforced laminates, encapsulants and grouting compounds, tooling, casting and moulding resins.(9,32)

SECTION 3. HAZARDS IDENTIFICATION


    
EMERGENCY OVERVIEW:
Colourless, crystalline solid. POTENTIAL COMBUSTIBLE DUST HAZARD. Powdered material may form explosive dust-air mixtures. SKIN SENSITIZER. May cause severe allergic skin reaction.




POTENTIAL HEALTH EFFECTS

Effects of Short-Term (Acute) Exposure

Inhalation:
For most workers, exposure to DGEBPA is probably not harmful following short-term exposure, based on animal information for DGEBPA and related compounds. High concentrations of DGEBPA dust may cause coughing and mild, temporary irritation. In very rare cases, DGEBPA may cause an allergic respiratory reaction like asthma, based on limited human information for low molecular weight DGEBPA-based epoxy resins which contain a high percentage of pure DGEBPA. Refer to "Effects of Long-term (Chronic) Exposure" for more information.
Skin Contact:
Pure DGEBPA is a mild skin irritant, based on animal information. DGEBPA is a well known skin sensitizer, based on animal and human information. It can cause a severe allergic skin reaction in sensitized individuals, even following very brief contact. Refer to "Effects of Long-term (Chronic) Exposure" for more information.
Animal toxicity information suggests that DGEBPA is not absorbed through the skin in harmful amounts.
Eye Contact:
Pure DGEBPA dust is a mild eye irritant, based on animal information for low molecular weight DGEBPA-based epoxy resins, which contain a large percentage of pure DGEBPA. Some tearing, blinking and mild, temporary pain may occur as the solid material is rinsed from the eye by tears.
Ingestion:
There is no human information available. Animal toxicity information suggests that pure DGEBPA would not cause significant harmful effects following ingestion. Ingestion is not a typical route of occupational exposure.
Effects of Long-Term (Chronic) Exposure

Respiratory Sensitization:
It is not possible to conclude that DGEBPA is a respiratory sensitizer, based on the available information.
In a very small number of cases (three people), low molecular weight DGEBPA-based epoxy resins have caused respiratory sensitization in humans occupationally exposed to these compounds.(4,17,57) Pure DGEBPA is normally a significant component of low molecular weight resins and may, therefore, also cause this effect. Sensitized people can experience symptoms of bronchial asthma such as wheezing, difficult breathing, sneezing and runny or blocked nose at low airborne concentrations that have no effect on unsensitized people.
Skin:
Repeated or prolonged contact may result in dermatitis (dry, red, cracked skin), based on animal information.
Skin Sensitization:
Repeated skin contact can cause allergic skin sensitization in some individuals. Once a person is sensitized to DGEBPA, contact with even a small amount causes outbreaks of dermatitis with symptoms such as skin redness, itching, rash and swelling. This reaction can spread from the point of contact (usually the hands or arms) to other parts of the body.
Numerous cases of allergic skin reactions have been reported in people occupationally exposed to DGEBPA-based epoxy resins (13-19,27,50-56) and in animal studies following exposure to pure DGEBPA and DGEBPA-based epoxy resins (1,2,12,21,22,26). Low molecular weight resins, which contain a high percentage of pure DGEBPA, appear to be the true sensitizers.
Endocrine System:
Firm conclusions cannot be drawn from one study that also involved exposure to organic solvents. In this study, 42 male epoxy sprayers who worked with hardening agents containing 10-30% DGEBPA for at least 3 hrs/day (duration unspecified) were compared to 82 unexposed controls. Exposure was to DGEBPA with mixed organic solvents including toluene, xylene, 2-ethoxyethanol, 2-butoxyethanol and methyl isobutyl ketone. Urinary concentrations of bisphenol A (a metabolite of DGEBPA) were increased and plasma FSH (Follicle Stimulating Hormone) concentrations were decreased, but still within the normal range. Plasma testosterone and LH (Luteinizing Hormone) levels were normal. The authors speculated that bisphenol A may interfere with pituitary FSH secretion, but the clinical importance of the reported findings remains unclear.(37)
OTHER EFFECTS: Skin irritation and rashes, muscle and joint disorders and central nervous system and respiratory disturbances have been reported in workers exposed to DGEBPA-based epoxy resins, as well as several other potentially harmful chemicals.(10,11,27,28) It is not possible to say that DGEBPA alone caused any of these effects because of the exposures to other potentially harmful chemicals at the same time.
Carcinogenicity:
There is no human information available. The International Agency for Research on Cancer (IARC) has determined that there is limited evidence for the carcinogenicity of DGEBPA in experimental animals.(9,43)
The International Agency for Research on Cancer (IARC) has concluded that this chemical is not classifiable as to its carcinogenicity to humans (Group 3).
The American Conference of Governmental Industrial Hygienists (ACGIH) has no listing for this chemical.
The US National Toxicology Program (NTP) has not listed this chemical in its report on carcinogens.
Teratogenicity and Embryotoxicity:
There is no human information available. No significant effects have been observed in animal studies following oral or skin exposure, even in the presence of significant toxicity in the mothers.
Reproductive Toxicity:
There is no human information available. No reproductive effects were observed in one animal study following oral exposure to low molecular weight DGEBPA-based epoxy resins which contain a high percentage of pure DGEBPA.
Mutagenicity:
It is not possible to conclude that DGEBPA is mutagenic. Negative results were obtained in two studies of a small number of workers exposed to DGEBPA-based epoxy resins.(24,25) One other study cannot be evaluated because of insufficient information.(2) Positive results (DNA adducts) were obtained in a limited test using live mice. Positive results were also obtained in cultured mammalian cells. Positive and negative results were obtained in tests using bacteria.
Toxicologically Synergistic Materials:
There is no human or animal information available.
Potential for Accumulation:
In animals, DGEBPA is rapidly excreted as metabolites in the urine and feces.(2,12)

SECTION 4. FIRST AID MEASURES


    
Inhalation:
If symptoms develop, remove source of contamination or have victim move to fresh air and obtain medical advice immediately.
Skin Contact:
This material is a skin sensitizer. Avoid direct contact. Wear chemical protective clothing, if necessary. As quickly as possible, remove contaminated clothing, shoes and leather goods (e.g. watchbands, belts). Quickly and gently blot or brush away excess chemical. Wash gently and thoroughly with water and non-abrasive soap for 20 minutes or until the chemical is removed. Obtain medical advice immediately. Discard contaminated clothing, shoes and leather goods. Do not re-use.
Eye Contact:
Avoid direct contact. Wear chemical protective gloves, if necessary. Quickly and gently blot or brush away excess chemical. Do not allow victim to rub eye(s). Let the eye(s) water naturally for a few minutes. Have victim look right and left, and then up and down. If particle/dust does not dislodge, flush with lukewarm, gently flowing water for 5 minutes or until particle/dust is removed, while holding the eyelid(s) open. If irritation persists, obtain medical attention. DO NOT attempt to manually remove anything stuck to the eyes.
Ingestion:
If irritation or discomfort occurs, obtain medical attention immediately.
First Aid Comments:
Provide general supportive measures (comfort, warmth, rest).
Consult a doctor and/or the nearest Poison Control Centre for all exposures except minor instances of inhalation or skin contact.
All first aid procedures should be periodically reviewed by a doctor familiar with the material and its conditions of use in the workplace.




SECTION 5. FIRE FIGHTING MEASURES

Flash Point:
Approximately 250 deg C (485 deg F) (closed cup) (36)
Lower Flammable (Explosive) Limit (LFL/LEL):
Not available
Upper Flammable (Explosive) Limit (UFL/UEL):
Not available
Autoignition (Ignition) Temperature:
Not available
Sensitivity to Mechanical Impact:
Not sensitive. Stable material.
Electrical Conductivity:
Not available
Minimum Ignition Energy:
Not available
Combustion and Thermal Decomposition Products:
Incomplete combustion may produce phenolics and possibly also aldehydes, acids and other unidentified toxic organic compounds.(36)
Flammable Properties:
Specific Hazards Arising from the Chemical:
During a fire, toxic, irritating compounds may be formed. Decomposition may occur under fire conditions and closed containers can explode and rupture violently if heated.
Fire Hazard Summary:
Extinguishing Media:
Carbon dioxide, dry chemical powder and foam. Water may be ineffective for fires involving DGEBPA.(36)

    
Fire Fighting Instructions:
Evacuate area and fight fire from a safe distance or a protected location. Approach fire from upwind to avoid DGEBPA and its toxic decomposition products.
Avoid generating dust to minimize risk of explosion. Water or foam may cause frothing. The frothing may be violent and could endanger personnel close to the fire. However, a water spray or fog that is carefully applied to the surface of the burning material, preferably with a fine spray or fog nozzle, will cause frothing that will blanket , prevent dust formation and extinguish the fire.
Closed containers may rupture violently when exposed to the heat of the fire and suddenly release large amounts of products. Stay away from ends of tanks, involved in fire, but be aware that flying material from ruptured tanks may travel in any direction.
If possible, isolate materials not yet involved in the fire, and move containers from the fire area if this can be done without risk, and protect personnel. Otherwise, fire-exposed containers, tanks, equipment or pipelines should be cooled by application of hose streams. Application should begin as soon as possible (within the first several minutes) and should concentrate on any unwetted portions of the container. Apply water from the side and from a safe distance until well after the fire is out. Cooling should continue until well after the fire is out. If this is not possible, use unmanned monitor nozzles and immediately evacuate the area.
If a leak or spill has not ignited, use water spray in large quantities to disperse the vapours and to protect personnel attempting to stop the leak. Water spray can be used to flush spills away from ignition sources and prevent dust clouds. Solid streams of water may be ineffective and spread material.
For an advanced or massive fire in a large area, it may be prudent to use unmanned hose holders or monitor nozzles; if this is not possible withdraw from fire area and allow fire to burn. Withdraw immediately in case of rising sound from venting safety device or any discolouration of tank.
Protection of Fire Fighters:
DGEBPA and its thermal decomposition products are hazardous to health. Do not enter without wearing specialized equipment suitable for the situation. Firefighter's normal protective clothing (Bunker Gear) will not provide adequate protection. Chemical protective clothing (e.g. chemical splash suit) and positive pressure self-contained breathing apparatus (NIOSH approved or equivalent) may be necessary.




NATIONAL FIRE PROTECTION ASSOCIATION (NFPA) HAZARD IDENTIFICATION

NFPA - Comments:
NFPA has no listing for this chemical in Codes 49 or 325.

SECTION 9. PHYSICAL AND CHEMICAL PROPERTIES

Molecular Weight:    340.45
Conversion Factor:
Not applicable
Physical State:    Solid
Melting Point:    43 deg C (109.4 deg F) (32,33)
Boiling Point:    Not available
Relative Density (Specific Gravity):    1.16 at 25 deg C (water = 1) (34)
Solubility in Water:    Negligible
Solubility in Other Liquids:    Soluble in acetone and aromatic solvents such as benzene.
Coefficient of Oil/Water Distribution (Partition Coefficient):    Not available
pH Value:    Not applicable
Viscosity-Dynamic:    Not applicable
Surface Tension:    Not applicable
Vapour Density:    Not applicable
Vapour Pressure:    Not applicable. Does not form a vapour.
Saturation Vapour Concentration:    Not applicable
Evaporation Rate:    Probably very low
Henry's Law Constant:    Not available
Other Physical Properties:
METTLER SOFTENING POINT: Less than 25 deg C (77 deg F) (34)

SECTION 10. STABILITY AND REACTIVITY

Stability:
Normally stable.
Hazardous Polymerization:
Information not available.
Incompatibility - Materials to Avoid:
NOTE: Chemical reactions that could result in a hazardous situation (e.g. generation of flammable or toxic chemicals, fire or detonation) are listed here. Many of these reactions can be done safely if specific control measures (e.g. cooling of the reaction) are in place. Although not intended to be complete, an overview of important reactions involving common chemicals is provided to assist in the development of safe work practices.


STRONG OXIDIZING AGENTS (e.g. peroxides, nitric acid, permanganates) - reaction may be violent. Risk of fire and explosion.
STRONG MINERAL ACIDS (e.g. sulfuric acid) or BASES (e.g. sodium hydroxide) - may react vigorously with the evolution of heat.
LEWIS ACIDS (e.g. boron trifluoride) or LEWIS BASES (e.g. N,N-dimethylbenzylamine) - may cause homopolymerization, with the evolution of heat.(34)
AMINES (e.g. diethylenetriamine, triethylenetetramine) - reactive curing agents.(33,34)
Hazardous Decomposition Products:
None reported.
Conditions to Avoid:
Generation of dust, heat, open flames, electrostatic discharge, sparks, and other ignition sources.
Corrosivity to Metals:
No information available. Probably not corrosive to metals.
Corrosivity to Non-Metals:
No information available.
Stability and Reactivity Comments:
In reactions with many curing agents, considerable heat is released. Smoke or toxic fumes may be evolved if the heat of reaction becomes excessive due to high curing temperatures or the curing of large amounts of material.(36)

SECTION 11. TOXICOLOGICAL INFORMATION

LD50 (oral, rat): greater than 500 mg/kg (no deaths) (purified DGEBPA; 20% w/v solution in toluene or acetone) (21)
LD50 (oral, mouse): greater than 500 mg/kg (no deaths) (purified DGEBPA; 20% w/v solution in toluene or acetone) (21)
LD50 (dermal, rat): greater than 800 mg/kg (no deaths) (purified DGEBPA 20% w/v in acetone) (21)
LD50 (dermal, mouse): greater than 1600 mg/kg (0-1/8 deaths) (purified DGEBPA 20% w/v in acetone or toluene) (21)
Eye Irritation:
There is no specific information available for pure DGEBPA. Low molecular weight liquid DGEBPA-based epoxy resins, which contain a high percentage of pure DGEBPA, are mild eye irritants.
Skin Irritation:
DGEBPA is a mild irritant.
A 24-hour application of undiluted purified DGEBPA to both abraded and intact skin produced mild, temporary redness and swelling in rabbits.(21) Daily application of 100 or 300 mg/kg 99.1% pure DGEBPA for 13 days produced a dose-related increase in redness, bleeding and swelling at the application site.(23) Low molecular weight liquid DGEBPA-based epoxy resins, which contain a high percentage of pure DGEBPA, have also only produced mild to moderate irritation following prolonged application.
Effects of Short-Term (Acute) Exposure:
Ingestion:
There is no specific information for pure DGEBPA. Low molecular weight liquid DGEBPA-based epoxy resins, which contain a large percentage of pure DGEBPA, have caused moderate depression, slight difficulty breathing, diarrhea and weight loss following the oral administration of very high doses (up to 13600 mg/kg). Lower doses (1000 mg/kg) have produced no effects.
Effects of Long-Term (Chronic) Exposure:
Long-term dermal application has produced dermatitis at the site of application in mice and rats. Liver injury has been observed in female rats exposed dermally to high doses for 2 years, but there was potential for ingestion exposure.
Skin Contact:
Rats and mice were dermally exposed to DGEBPA (99.65 ± 0.04% pure) in acetone for 13 weeks. Approximate doses were 0, 10, 100 or 1000 mg/kg/application for rats (0, 0.9, 9 or 90% w/v for males; 0, 0.6, 6 or 60% w/v for females) and 0, 1, 10 or 100 mg/kg/application for mice (0, 0.05, 0.5 or 5.0% w/v). Applications were made to rats 5 times/week and mice 3 times/week. There was potential for ingestion exposure. No systemic toxicity was observed, with the exception of a statistically significant decrease in body weight and body weight gain in rats exposed to the high dose. This effect may have been due to reduced food consumption. Chronic active dermatitis (increased cell growth with chronic inflammation) was observed at the site of application in both rats and mice.(44,45) Male mice and female rats were dermally exposed to DGEBPA (99.32 ± 0.11% pure) in acetone for 2 years. Approximate doses were 0, 0.1, 10 or 100 mg/kg/application for the male mice (0, 0.005, 0.5 or 5.0% w/v) and 0, 1, 100 or 100 mg/kg/application for female rats (0, 0.6, 6.0 or 60% w/v). Applications were made to mice 3 times/week and rats 5 times/week. There was potential for ingestion exposure. There was no evident systemic toxicity in mice. Body weights of high dose rat were significantly lower than controls for most of the study. Chronic dermatitis (increased cell growth and inflammation) was observed at the site of application in mice exposed to 10 or 100 mg/kg/application and rats exposed to 100 or 1000 mg/kg/application. Signs of liver injury (centrilobular hepatocyte hypertrophy and alterations in clinical chemistry results) were observed in high dose rats.(46,47) No significant nervous system effects were observed in rats dermally exposed to DGEBPA (99.65 ± 0.04% pure) in acetone for approximately 13 weeks. Approximate doses were 10, 100 or 1000 mg/kg/application (0, 0.9, 9 or 90% w/v for males; 0, 0.6, 6 or 60% w/v for females) for 5 days/week. (48)
Skin Sensitization:
Several studies have shown that the monomer (molecular weight 340) is a strong skin sensitizer in guinea pigs.(2,12,21,22,26)
Carcinogenicity:
The International Agency for Research on Cancer (IARC) has reviewed the available studies and determined that there is limited evidence for the carcinogenicity of DGEBPA in experimental animals.(9,43)
In one study with pure DGEBPA, application of 75 mg/week accelerated mortality in female, but not male mice. No other significant effects or treatment- related neoplasms were observed.(20) Other studies with dermal or oral exposure to DGEBPA-based epoxy resins have either produced negative results or there were limitations with the studies which do not allow conclusions to be drawn.(1,2,5-8,12)
Teratogenicity, Embryotoxicity and/or Fetotoxicity:
Developmental effects have not been observed in dermal and oral studies.
Rabbits were dermally exposed, under cover, to 0, 30, 100, or 300 mg/kg/day of 99.1% pure DGEBPA dissolved in polyethylene glycol 400 on days 6-18 of pregnancy. A polyethylene glycol 400 control was used. There was no evidence of embryotoxicity, teratogenicity or fetotoxicity. A decrease in the pregnancy rate and the ratio of males/females was observed at 30 mg/kg/day, but these effect were not dose-related and were considered to be random events. Maternal toxicity, as evidenced by bleeding, cracking, swelling and redness of the skin at the test site, was observed at the two highest doses.(23) No developmental effects were observed in rats orally administered 0, 50, 540 or 750 mg/kg/day DGEBPA (99.65% pure) in a 2-generation study. Body weights were significantly decreased in mid and high dose adult males and high dose adult females in both the P1 and P2 generations.(49) Studies with low molecular weight DGEBPA-based epoxy resin have not shown teratogenicity or embryotoxicity in rats or rabbits following oral exposure, despite maternal toxicity.(2,12)
Reproductive Toxicity:
DGEBPA is not expected to cause harmful reproductive effects based on the information available.
No effects on reproductive performance were observed in rats orally administered 0, 50, 540 or 750 mg/kg/day DGEBPA (99.65% pure) in a 2-generation study. Body weights were significantly decreased in mid and high dose adult males and high dose adult females in both the P1 and P2 generations.(49) No reproductive effects have been observed in rats following oral exposure to low molecular weight DGEBPA-based epoxy resins which contain a high percentage of pure DGEBPA.(2,12)
Mutagenicity:
It is not possible to conclude that DGEBPA is mutagenic, based on the available information. Positive results were obtained in a limited test using live mice. Positive results were also obtained in cultured mammalian cells. Positive and negative results were obtained in tests using bacteria.
Positive results (DNA adduct formation) were obtained in male mice after single dermal exposures to 2 mg DGEBPA in acetone for 48, 96 or 192 hours. Three mice were tested in each group, but results were reported for only 1 or 2 mice/group. There was no exposure-response relationship. Similar amounts of adducts were observed regardless of the exposure duration.(59)
Pure DGEBPA has produced positive results in cultured mammalian cells (chromosome damage in cultured rat liver cells and neoplastic transformation in cultured baby hamster kidney cells).(3) Positive results (micronuclei induction) were also obtained following treatment of human lymphocytes for 48 hours (without metabolic activation) or for 3 hours (with or without metabolic activation) with 12.50-62.50 microg/mL. These concentrations were also cytotoxic.(58) Negative results were obtained in cultured human lymphocytes tested with an unspecified DGEBPA-based epoxy resin and "distilled" DGEBPA.(29) Positive and negative results have been obtained for pure DGEBPA in bacteria, both with and without metabolic activation.(3,30,31,57)

SECTION 16. OTHER INFORMATION

Selected Bibliography:
(1) Weil, C.S., et al. Experimental carcinogenicity and acute toxicity of representative epoxides. American Industrial Hygiene Journal. Vol. 24 (July-Aug., 1963). p. 305-325
(2) Gardiner, T.H., et al. Glycidyloxy compounds used in epoxy resin systems: a toxicology review. Regulatory Toxicology and Pharmacology. Vol. 15, no. 2 (Apr. 1992). Part 2 of 2. p. S1-S77
(3) Shell Oil Co. Toxicity studies with epoxy resins: in vitro genotoxicity studies with and diglycidyl ether of bisphenol A, EPIKOTE 828, EPIKOTE 1001 AND EPIKOTE 1007. EPA/OTS 87-8210037. NTIS/OTS844003A.
(4) Kanerva, L., et al. Immediate and delayed allergy from epoxy resins based on diglycidyl ether of bisphenol A. Scandinavian Journal of Work, Environment and Health. Vol. 17, no. 3 (Mar. 1991). p. 208-215
(5) Hine, C.H., et al. An investigation of the oncogenic activity of two representative epoxy resins. Cancer Research. Vol. 18 (Jan. 1958). p. 20-26
(6) Holland, J.M., et al. Epidermal carcinogenicity of bis(2,3-epoxycyclopentyl)ether, 2,2-bis(p-glycidyloxyphenyl)propane, and m-phenylenediamine in male and female C3H and C57BL/6 mice. Cancer Research. Vol. 39 (May 1979). p. 1718-1725
(7) Peristianis, G.C., et al. Two-year carcinogenicity study on three aromatic epoxy resins applied cutaneously to CF1 mice. Food and Chemical Toxicology. Vol. 26, no. 7 (1988). p. 611-624
(8) Zakova, N., et al. Evaluation of skin carcinogenicity of technical 2,2- bis-(p-glycidyloxyphenyl)-propane in CF1 mice. Food and Chemical Toxicology. Vol. 23, no. 12 (1985). p. 1081-1089
(9) International Agency for Research on Cancer (IARC). Some glycidyl ethers. In: IARC monographs on the evaluation of carcinogenic risks to humans: some organic solvents, resin monomers and related compounds, pigments and occupational exposures in paint manufacture and painting. Vol. 47. World Health Organization, 1989. p. 237-261
(10) Tomizawa, T., et al. Scleroderma-like skin changes observed among workers handling epoxy resins. Proceeding of the XV International Congress of Dermatology, Mexico City, Oct. 16-21, 1977. p. 271-275
(11) Cragle, D., et al. An occupational morbidity study of a population potentially exposed to epoxy resins, hardeners and solvents. Applied Occupational and Environmental Hygiene. Vol. 7, no. 12 (Dec. 1992). p. 826-834
(12) Waechter, J.M., Jr., et al. Epoxy compounds - aromatic diglycidyl ethers, polyglycidyl ethers, glycidyl esters, and miscellaneous epoxy compounds. In: Patty's toxicology. 5th ed. Edited by E. Bingham, et al. Vol. 6. John Wiley and Sons, 2001. p. 1087-1145
(13) Jolanki, R., et al. Occupational dermatoses from epoxy resin compounds. Contact Dermatitis. Vol. 23, no. 3 (1990). p. 172-183
(14) Jolanki, R. Occupational skin diseases from epoxy compounds: epoxy resin compounds, epoxy acrylates, and 2,3-epoxypropyl trimethyl ammonium chloride. Acta Dermato-Venereologica. Suppl. 159 (1991). p. 1-80
(15) Niinimaki, A., et al. An outbreak of epoxy dermatitis in insulation workers at an electrical power station. Dermatosen. Vol. 31, no. 1 (1983). p. 23-25
(16) Fregert, S., et al. Patch testing with low molecular oligomers of epoxy resins in humans. Contact Dermatitis. Vol. 3 (1977). p. 301-303
(17) Kanerva, L., et al. A single accidental exposure may result in a chemical burn, primary sensitization and allergic contact dermatitis. Contact Dermatitis. Vol. 31, no. 4 (Oct. 1994). p. 229-235
(18) Burrows, D., et al. Contact dermatitis from epoxy resins, tetraglycidal-4,4'-methylene dianiline and o-diglycidyl phthalate in composite material. Contact Dermatitis. Vol. 11, no. 2 (Aug. 1984). p. 80-82
(19) Bokelund, F., et al. Sensitization from epoxy resin powder of high molecular weight. Contact Dermatitis. Vol. 6, no. 2 (1980). p. 144
(20) Holland, J.M., et al. Chronic dermal toxicity of epoxy resins. I. Skin carcinogenic potency and general toxicity (draft) with cover letter dated 041381. Union Carbide Corporation, June 1981. EPA/OTS 88-8100212. NTIS/OTS0204933.
(21) Hend, R.W., et al. Toxicity of purified diglycidyl ether of bisphenol A: results of preliminary studies. Shell Oil Company, Feb. 1978. EPA/OTS 87-8214186. NTIS/OTS0206488.
(22) Thorgeirsson, A., et al. Allergenicity of epoxy resins in the guinea pig. Acta Dermato-Venereologica. Vol. 57, no. 3 (1977). p. 253-256
(23) Breslin, W.J., et al. Teratogenic evaluation of diglycidyl ether of bisphenol A (DGEBPA) in New Zealand white rabbits following dermal exposure. Fundamental and Applied Toxicology. Vol. 10, no. 4 (May 1988). p. 736-743
(24) Mitelman, F., et al. Occupational exposure to epoxy resins has no cytogenetic effect. Mutation Research. Vol. 77, no. 4 (1980). p. 345-348
(25) de Jong, G., et al. Cytogenetic monitoring of industrial populations potentially exposed to genotoxic chemicals and of control populations. Mutation Research. Vol. 204 (1988). p. 451-464
(26) Thorgeirsson, A., et al. Sensitization capacity of epoxy resin oligomers in the guinea pig. Acta Dermato-Venereologica. Vol. 58 (1978). p. 17-21
(27) Grandjean, E. The danger of dermatoses due to cold-setting ethoxyline resins (epoxide resins). British Journal of Industrial Medicine. Vol. 14 (1957). p. 1-4
(28) Hine, C.H., et al. The toxicology of epoxy resins. American Medical Association Archives of Industrial Health. Vol. 17 (Feb. 1958). p. 129- 144
(29) Pullen, T.G. Integrated mutagenicity testing program on several epoxy compounds. Dow Chemical Company, Dec. 28, 1977. EPA/OTS 87-8214859. NTIS/OTS0206671.
(30) Canter, D.A., et al. Comparative mutagenicity of aliphatic epoxides in Salmonella. Mutation Research. Vol. 172 (1986). p. 105-138
(31) Wade, M.J., et al. Mutagenic action of a series of epoxides. Mutation Research. Vol. 66 (1979). p. 367-371
(32) Gannon, J. Epoxy resins. In: Kirk-Othmer encyclopedia of chemical technology. 4th ed. Vol. 9. John Wiley and Sons, 1994. p. 730-755
(33) McAdams, L.V., et al. Epoxy resins. In: Encyclopedia of polymer science and engineering. Vol. 6. John Wiley and Sons, 1986. p. 322-382
(34) Muskopf, J.W., et al. Epoxy resins. In: Ullmann's encyclopedia of industrial chemistry. Vol. A 9. VCH Verlagsgesellschaft, 1987. p. 547-563
(35) Gempler, H., et al. Paints and coatings. In: Ullman's encyclopedia of industrial chemistry. Vol. A 18. VCH Verlagsgesellschaft, 1991. p. 359-544
(36) Dow epoxy resins: product stewardship manual: safe handling and storage. The Dow Chemical Company, 1994
(37) Hanaoka, T., et al. Urinary bisphenol A and plasma hormone concentrations in male workers exposed to bisphenol A diglycidyl ether and mixed organic solvents. Occupational and Environmental Medicine. Vol. 59, no. 9 (Sept. 2002). p. 635-628
(38) Fire protection handbook. 17th ed. National Fire Protection Association, 1991
(39) Grossel, S.S. Safety considerations in conveying of bulk solids and powders. Journal of Loss Prevention in the Process Industries. Vol. 1 (Apr. 1988). p. 62-74
(40) Field, P. Explosibility assessment of industrial powders and dusts. Building Research Establishment, 1983
(41) European Economic Community. Commission Directive 93/72/EEC. Sept. 1, 1993
(42) Forsberg, K., et al. Quick selection guide to chemical protective clothing. 4th ed. Van Nostrand Reinhold, 2002
(43) International Agency for Research on Cancer (IARC). IARC monographs on the evaluation of carcinogenic risks to humans. Vol. 71, parts 1, 2 and 3. Re-evaluation of some organic chemicals, hydrazine and hydrogen peroxide. IARC, 1999
(44) Dow Chemical Co. DGEBPA - 13-week dermal toxicity study in the Fischer 344 rat, with cover letter dated 5/31/96. May 29, 1996. EPA/OTS 44628. NTIS/OTS0558862.
(45) Dow Chemical Co. DGEBPA - 13-week repeated dose dermal toxicity in the male mouse, with cover letter dated 4/18/96. Mar. 21, 1996. EPA/OTS 44626. NTIS/OTS0558858.
(46) Dow Chemical Co. Final report, DGEBPA: Two-year dermal chronic toxicity/oncogenicity study in the male B6C3F1 mouse, with TSCA notice of receipt of test data (63 FR 67087) and cvr ltr dated 9/24/98. Aug. 26, 1998. EPA/OTS 44650. NTIS/OTS0559599.
(47) Dow Chemical Co. Final report, DGEBPA: Two-year dermal chronic toxicity/oncogenicity study in female Fischer 344 rats, w/TSCA notice of receipt of test data (63 FR 67087) and cvr ltr dated 9/24/98. Sept. 22, 1998. EPA/OTS 40980000021. NTIS/OTS0559600.
(48) Dow Chemical Co. Diglycidyl ether of bisphenol A - 13-week dermal neurotoxicity study in Fischer 344 rats, with cover letter dated 5/31/96. May 29, 1996. EPA/OTS 44628. NTIS/OTS0558863.
(49) Dow Chemical Co. DGEBPA - Two-generation oral gavage reproduction study in Sprague-Dawley rats, with cover letter dated 4/16/96. EPA/OTS 44626. NTIS/OTS0558859.
(50) Dutch Expert Committee on Occupational Standards (DECOS). Bisphenol A and its diglycidylether. Publication No. 1996/02WGD. Health Council of the Netherlands, 1996
(51) Bruze, M., et al. Occupational dermatoses in a Swedish aircraft plant. Contact Dermatitis. Vol. 34 (1996). p. 336-340
(52) Kanerva, L., et al. Patch-test reactions to plastic and glue allergens. Acta Derm Venereol. Vol. 79 (1999). p. 296-300
(53) Le Coz, C.-J., et al. An epidemic of occupational contact dermatitis from an immersion oil for microscopy in laboratory personnel. Contact Dermatitis. Vol. 40 (1999). p. 77-83
(54) Kanerva, L., et al. Latent (subclinical) contact dermatitis evolving into occupational allergic contact dermatitis from extremely small amounts of epoxy resin. Contact Dermatitis. Vol. 43 (2000). p. 47-49
(55) Lee, Y.-C., et al. Epoxy resin allergy from microscopy immersion oil. Australian Journal of Dermatology. Vol. 40 (1999). p. 228-229
(56) Jolanki, R., et al. 182 patients with occupational allergic epoxy contact dermatitis over 22 years. Contact Dermatitis. Vol. 44, no. 2 (Feb. 2001). p. 121-123
(57) Kanerva, L., et al. Occupational allergic airborne contact dermatitis and delayed bronchial asthma from epoxy resin revealed by bronchial provocation test. Eur. J. Dermatol. Vol. 10 (2000). p. 475-477
(56) Occupational Safety and Health Administration (OSHA). Diglycidyl Ether of Bisphenol A. In: OSHA Chemical Sampling Information. Revision Date: Nov. 7, 2002. Available at: 
(57) Sueiro, R.A., et al. Mutagenic potential of bisphenol A diglycidyl ether (BADGE) and its hydrolysis-derived products in the Ames Salmonella assay. Mutagenesis. Vol. 16, no. 4 (July 2001). p. 303-307
(58) Suarez, S., et al. Genotoxicity of the coating lacquer on food cans, bisphenol A diglycidyl ether (BADGE), its hydrolysis products and a chlorohydrin of BADGE. Mutation Research. Vol. 470, no. 2 (Oct. 2000). p. 221-228
(59) Steiner, S., et al. Molecular dosimetry of DNA adducts in C3H mice treated with bisphenol A diglycidylether. Carcinogenesis. Vol. 13, no. 6 (June 1992). p. 969-972
Information on chemicals reviewed in the CHEMINFO database is drawn from a number of publicly available sources. A list of general references used to compile CHEMINFO records is available in the database Help.

Review/Preparation Date: 2004-06-18