Poisoning is the harmful effect that occurs when a toxic substance is swallowed, is inhaled, or comes in contact with the skin, eyes, or mucous membranes, such as those of the mouth or nose.
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Possible poisonous substances include prescription and over-the-counter drugs, illicit drugs, gases, chemicals, vitamins, food, mushrooms, plants, and animal venom.
Some poisons cause no damage, whereas others can cause severe damage or death.
The diagnosis is based on symptoms, on information gleaned from the poisoned person and bystanders, and sometimes on blood and urine tests.
Drugs should always be stored in original child-proof containers and kept out of the reach of children.
Treatments include supporting the person's body functions, preventing additional absorption of the poison, increasing elimination of the poison, and sometimes giving a specific antidote.
More than 2 million people suffer some type of poisoning each year in the United States. Drugs—prescription, over-the-counter, and illicit—are a common source of serious poisonings and poisoning-related deaths (see Acetaminophen PoisoningAcetaminophen Poisoning and Aspirin PoisoningAspirin Poisoning). Other common poisons include gases (for example, carbon monoxide), household products (see Caustic Substances Poisoning), agricultural products, plants, heavy metals (for example, iron and lead), vitamins, animal venom, and foods (particularly certain species of mushroom and bony fish and shellfish). However, almost any substance ingested in sufficiently large quantities can be toxic (poisonous).
Accidental poisoning
Poisoning is the most common cause of nonfatal accidents in the home. Young children, because of curiosity and a tendency to explore, are particularly vulnerable to accidental poisoning in the home, as are older people, often due to confusion about their drugs. Because children often share found pills and substances, siblings and playmates may also have been poisoned. Also vulnerable to accidental poisoning are hospitalized people (by drug errors) and industrial workers (by exposure to toxic chemicals).
Deliberate poisoning
Poisoning may also be a deliberate attempt to commit murder or suicide. Most adults who attempt suicide by poisoning take more than one drug and also consume alcohol. Poisoning may be used to disable a person (for example, to rape or rob them). Rarely, parents with a psychiatric disorder poison their children to cause illness and thus gain medical attention (a disorder called factitious disorder imposed on another previously called Munchausen syndrome by proxy).
Symptoms of Poisoning
The symptoms caused by poisoning depend on the poison, the amount taken, and the age and underlying health of the person who takes it. Some poisons are not very potent and cause problems only with prolonged exposure or repeated ingestion of large amounts. Other poisons are so potent that just a drop on the skin can cause severe symptoms.
Some poisons cause symptoms within seconds, whereas others cause symptoms only after hours, days, or even years. Some poisons cause few obvious symptoms until they have damaged vital organs—such as the kidneys or liver—sometimes permanently.
Ingested and absorbed toxins generally cause bodywide symptoms, often because they deprive the body's cells of oxygen or activate or block enzymes and receptors. Symptoms may include changes in consciousness, body temperature, heart rate, and breathing and many others, depending on the organs affected.
Caustic or irritating substances injure the mucous membranes of the mouth, throat, gastrointestinal tract, and lungs, causing pain, coughing, vomiting, and shortness of breath.
Skin contact with toxins can cause various symptoms, for example, rashes, pain, and blistering. Prolonged exposures may cause dermatitis.
Eye contact with toxins may injure the eye, causing eye pain, redness, and loss of vision.
First Aid for Poisoning
The first priority in helping a poisoned person is for bystanders not to become poisoned themselves.
People exposed to a toxic gas should be removed from the source quickly, preferably out into fresh air, but rescue attempts should be done by professionals. Special training and precautions must be considered to avoid being overcome by the toxic gases or chemicals during rescue attempts. (See also Overview of Incidents Involving Mass-Casualty Weapons.)
In chemical spills, all contaminated clothing, including socks and shoes, and jewelry should be removed immediately. The skin should be thoroughly washed with soap and water. If the eyes have been exposed, they should be thoroughly flushed with water or saline. Rescuers must be careful to avoid contaminating themselves.
If the person appears very sick, emergency medical assistance (911 in most areas of the United States) should be called. Bystanders should do cardiopulmonary resuscitation (CPR) if needed. If the person does not appear very sick, bystanders can contact the nearest poison control center for advice. In the United States, the local poison center can be reached at 800-222-1222. More information is available at the American Association of Poison Control Centers web site (www.aapcc.org). If the caller knows or can find out the identity of the poison and the amount ingested, treatment can often be initiated on site if this is recommended by the poison center.
Containers of the poisons and all drugs that might have been taken by the poisoned person (including over-the-counter products) should be saved and given to the doctor or rescue personnel. The poison center may recommend giving the poisoned person activated charcoal before arrival at a hospital and, rarely, may recommend giving syrup of ipecac to induce vomiting, particularly if the person must travel far to reach the hospital. However, unless specifically instructed to, charcoal and syrup of ipecac should not be given in the home or by first responders (such as ambulance personnel). Syrup of ipecac has unpredictable effects, often causes prolonged vomiting, and may not remove substantial amounts of poison from the stomach. before arrival at a hospital and, rarely, may recommend giving syrup of ipecac to induce vomiting, particularly if the person must travel far to reach the hospital. However, unless specifically instructed to, charcoal and syrup of ipecac should not be given in the home or by first responders (such as ambulance personnel). Syrup of ipecac has unpredictable effects, often causes prolonged vomiting, and may not remove substantial amounts of poison from the stomach.
Diagnosis of Poisoning
Identification of the poison
Sometimes, urine and blood tests
Rarely, abdominal x-rays
Identifying the poison is helpful to treatment. Labels on bottles and other information from the person, family members, or coworkers best enable the doctor or the poison center to identify poisons. If labels are not available, drugs can often be identified by the markings and colors on the pill or capsule. Laboratory testing is much less likely to identify the poison, and many drugs and poisons cannot be readily identified or measured by the hospital. Sometimes, however, urine and blood tests may help in identification. Blood tests can sometimes reveal the severity of poisoning, but only with a very small number of poisons.
Doctors examine people to look for signs that suggest a certain type of substance. For example, doctors look for needle marks or track marks suggesting people have injected drugs (see Injection Drug Use). Doctors also examine people for symptoms characteristic of certain kinds of poisoning. Doctors look to see whether people have traces of a drug or substance on their skin or whether drug patches for drugs absorbed through the skin may be hidden in skin folds, on the roof of the mouth, or under the tongue.
For certain poisonings, abdominal x-rays may show the presence and location of the ingested substances. Poisons that may be visible on x-rays include iron, lead, arsenic, other metals, and large packets of cocaine or other illicit drugs swallowed by so-called body packers or drug mules (see For certain poisonings, abdominal x-rays may show the presence and location of the ingested substances. Poisons that may be visible on x-rays include iron, lead, arsenic, other metals, and large packets of cocaine or other illicit drugs swallowed by so-called body packers or drug mules (seeBody Packing and Body Stuffing). Batteries and magnets are also visible on x-rays, as are fangs, teeth, cartilaginous spines and other animal parts that may break off and remain embedded in the body after an animal attack or envenomation.
Drug testing
Kits to identify drugs in the urine can now be bought over the counter. The accuracy of these kits can vary significantly. Thus, results should not be regarded as proof that a certain drug has or has not been taken. Testing is best done in consultation with a professional. If done without a professional, results should be discussed with a professional who has experience with drug testing. The professional can help people interpret test results and draw the appropriate conclusions.
Prevention of Poisoning
In the United States, widespread use of child-resistant containers with safety caps has greatly reduced the number of poisoning deaths in children younger than age 5. To prevent accidental poisoning, drugs and other potentially dangerous substances should be kept in their original containers and the containers kept where children cannot get them. Toxic substances, such as insecticides and cleaning agents, should not be put in drink bottles or cups, even briefly. Other preventive measures include
Clearly labeling household products
Storing drugs (particularly opioids) and toxic or dangerous substances in cabinets that are locked and out of the reach of children
Using carbon monoxide detectors
Expired drugs should be disposed of by mixing them with cat litter or some other substance that is not tempting and putting them in a trash container that is inaccessible to children. People can also call a local pharmacy for advice on how to properly dispose of drugs. All labels should be read before taking or giving any drugs or using household products.
Limiting the amount of over-the-counter pain reliever in a single container reduces the severity of poisonings, particularly with acetaminophen, aspirin, or ibuprofen. The identifying marks printed on pills and capsules by the drug manufacturer can help prevent confusion and errors by pharmacists, health care practitioners, and others.Limiting the amount of over-the-counter pain reliever in a single container reduces the severity of poisonings, particularly with acetaminophen, aspirin, or ibuprofen. The identifying marks printed on pills and capsules by the drug manufacturer can help prevent confusion and errors by pharmacists, health care practitioners, and others.
Did You Know...
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Treatment of Poisoning
Some people who have been poisoned must be hospitalized. With prompt medical care, most recover fully.
The principles for the treatment of all poisonings are the same:
Support vital functions such as breathing, blood pressure, body temperature, and heart rate
Prevent additional absorption
Increase elimination of the poison
Give specific antidotes (substances that eliminate, inactivate, or counteract the effects of the poison), if available
Prevent reexposure
The usual goal of hospital treatment is to keep people alive until the poison disappears or is inactivated by the body. Eventually, most poisons are inactivated by the liver or are passed into the urine.
Provide supportive care
Poisoning often requires treatment, termed supportive care, to stabilize the heart, blood pressure, and breathing until the poison disappears or is inactivated. For example, a person who becomes very drowsy or comatose may need a breathing tube inserted into the windpipe. The tube is then attached to a mechanical ventilator, which supports the person’s breathing. The tube prevents vomit from entering the lungs, and the ventilator ensures adequate breathing.
Treatment also may be needed to control seizures, fever, or vomiting. If a poison causes a high fever, the person may need to be cooled, for example, with a cooling blanket, or sometimes by applying cool water or ice to the skin.
If the kidneys stop working, hemodialysis is necessary. If liver damage is extensive, treatment for liver failure may be necessary. If the liver or kidneys sustain permanent, severe damage, liver transplantation or kidney transplantation may be needed.
Remove poison from the eyes and skin
Poisons in the eyes or on the skin usually should be washed off with large amounts of salt (saline) solution, or tap water. Sometimes soap and water is used on the skin.
Prevent absorption of poison
Very few swallowed poisons are absorbed so quickly that measures cannot be tried to keep them out of the bloodstream. However, such measures are effective only for certain poisons and situations.
Stomach emptying (inducing vomiting or stomach pumping), once commonly done, is now usually avoided because it removes only a small amount of the poison and can cause serious complications. Stomach emptying rarely improves a person's outcome. However, stomach pumping may be done very rarely if an unusually dangerous poison is involved or if the person appears very sick.
In this procedure, a tube is inserted through the mouth into the stomach. Water is poured into the stomach through the tube and is then drained out (gastric lavage). This procedure is repeated several times. If people are drowsy because of the poison, doctors usually first put a plastic breathing tube through the mouth into the windpipe (endotracheal intubation). Endotracheal intubation helps keep the gastric lavage liquid from entering the lungs.
Doctors often used to give syrup of ipecac, a drug that causes vomiting, to children who swallowed poisonous substances. However, this treatment did not often remove significant amounts of the swallowed substance. Now doctors use ipecac only for substances that are highly toxic and when it would take a long time to get the person to the emergency department. In the hospital, doctors do not give syrup of ipecac to empty the stomach because its effects are inconsistent.Doctors often used to give syrup of ipecac, a drug that causes vomiting, to children who swallowed poisonous substances. However, this treatment did not often remove significant amounts of the swallowed substance. Now doctors use ipecac only for substances that are highly toxic and when it would take a long time to get the person to the emergency department. In the hospital, doctors do not give syrup of ipecac to empty the stomach because its effects are inconsistent.
Activated charcoal is sometimes given in hospital emergency departments to people who have swallowed poisons. Activated charcoal binds to the poison that is still in the digestive tract, preventing its absorption into the blood. Charcoal is usually taken by mouth if the person is alert and cooperative. Introducing activated charcoal through a tube placed in the nose or mouth in people who are either uncooperative or lethargic is not recommended. Sometimes doctors give charcoal every 4 to 6 hours to help cleanse the body of the poison. Not all poisons are inactivated by charcoal. For example, charcoal does not bind alcohol, iron, or many household chemicals.
Whole-bowel irrigation is a treatment method designed to flush a poison from the digestive tract. It is used only occasionally, for example, for serious poisoning caused by poisons that get stuck in the digestive tract or need to be moved physically (such as packets of hidden, smuggled drugs) or poisons that are absorbed slowly (such as some sustained-release drugs) or not absorbed by activated charcoal (such as iron and lead).
Increase elimination of poison
If a poison remains life threatening despite the use of charcoal and antidotes, more complicated treatments that remove the poison may be needed. The most common treatments are hemodialysis and charcoal hemoperfusion.
In hemodialysis, an artificial kidney (dialyzer) is used to filter the poisons directly from the bloodstream.
In charcoal hemoperfusion, a person's blood is passed over activated charcoal to help eliminate the poisons (see table Hemofiltration and Hemoperfusion: Other Ways of Filtering the Blood).
For either of these methods, small tubes (catheters) are inserted into blood vessels, one to drain blood from an artery and another to return blood to a vein. The blood is passed through special filters that remove the toxic substance before being returned to the body.
Alkaline diuresis is sometimes used. With this procedure, a solution containing sodium bicarbonate (the chemical in baking soda) is given by vein to make the urine more alkaline or basic (as opposed to acidic). This can increase the amount of certain drugs (such as aspirin and barbiturates) excreted in the urine.is sometimes used. With this procedure, a solution containing sodium bicarbonate (the chemical in baking soda) is given by vein to make the urine more alkaline or basic (as opposed to acidic). This can increase the amount of certain drugs (such as aspirin and barbiturates) excreted in the urine.
Antidotes
Although most poisons and drugs do not have specific antidotes (unlike the popular perception from TV and movies), some do. Some common drugs that might require specific antidotes include acetaminophen (Although most poisons and drugs do not have specific antidotes (unlike the popular perception from TV and movies), some do. Some common drugs that might require specific antidotes include acetaminophen (antidote is N-acetylcysteineantidote is N-acetylcysteine) and opioids such as heroin and fentanyl (antidote is naloxone). Some poisonous bites and stings also have antidotes (see ) and opioids such as heroin and fentanyl (antidote is naloxone). Some poisonous bites and stings also have antidotes (seeSnakebites). Not everyone who has been exposed to a poison requires its antidote. Many people recover on their own. But with severe poisoning, antidotes can be lifesaving.
Common Specific Antidotes
Toxin | Antidote |
|---|---|
AcetaminophenAcetaminophen | N-Acetylcysteine-Acetylcysteine |
Anticholinergic drugs | Physostigmine*Physostigmine* |
Anticoagulants, oral factor Xa inhibitors (apixaban, edoxaban, rivaroxaban)Anticoagulants, oral factor Xa inhibitors (apixaban, edoxaban, rivaroxaban) | Coagulation factor Xa [recombinant], inactivated Andexanet alfa |
Antifreeze (ethylene glycol type) | FomepizoleFomepizole Ethanol |
Benzodiazepines (such as diazepam and lorazepam)Benzodiazepines (such as diazepam and lorazepam) | Flumazenil*Flumazenil* |
Beta-blockers | GlucagonGlucagon IV lipid emulsion |
Lactrodectus antivenom | |
Botulism | Botulinum antitoxin |
Calcium channel blockers | Calcium IV insulin in high doses with IV glucoseIV insulin in high doses with IV glucose IV lipid emulsion |
Cyanide | HydroxocobalaminHydroxocobalamin Cyanide antidote kit (Nithiodote®, includes amyl nitrate, sodium nitrite and sodium thiosulfate)Cyanide antidote kit (Nithiodote®, includes amyl nitrate, sodium nitrite and sodium thiosulfate) |
DabigatranDabigatran | IdarucizumabIdarucizumab |
Digitalis, including drugs (digoxin) and plants (oleander, foxglove)Digitalis, including drugs (digoxin) and plants (oleander, foxglove) | Digoxin-specific antibodiesDigoxin-specific antibodies |
Heavy metals (such as arsenic, cadmium, lead, mercury, and zinc) | Drugs that remove heavy metals from the body (chelating drugs), such as dimercaprol, edetate calcium disodium, penicillamine, and succimer Drugs that remove heavy metals from the body (chelating drugs), such as dimercaprol, edetate calcium disodium, penicillamine, and succimer |
HeparinHeparin | ProtamineProtamine |
Insecticides† (many brands, which may contain carbamates and organophosphates)—ingredients should be checked) | AtropineAtropine Pralidoxime |
Iron | DeferoxamineDeferoxamine |
IsoniazidIsoniazid | Pyridoxine (vitamin B6)Pyridoxine (vitamin B6) |
Methanol (wood alcohol) | FomepizoleFomepizole Ethanol |
Methemoglobin‡-forming agents (such as aniline dyes, some local anesthetics, nitrates, nitrites, phenacetin, sulfonamides) | Methylene blueMethylene blue |
Opioids (such as morphine and heroin)(such as morphine and heroin) | NaloxoneNaloxone |
Scorpion sting (only the Centruroides species) | Centruroides immune fractionated antibodies |
Snakebites§ (rattlesnakes and copperheads in the United States) | Rattlesnake (Crotalinae) antivenom |
Sulfonylurea | OctreotideOctreotide |
Thallium | Prussian blue |
Tricyclic antidepressants | Sodium bicarbonateSodium bicarbonate |
Valproic acidValproic acid | L-Carnitine¶ |
WarfarinWarfarin | Vitamin K Fresh frozen plasma (FFP) Prothrombin complex concentrate (PCC) |
* Use is controversial. | |
† The antidotes cited are for carbamate and organophosphate insecticides only. | |
‡ Methemoglobin is an abnormal form of hemoglobin that is produced by certain poisons. Unlike normal hemoglobin, methemoglobin does not carry oxygen so the body's tissues do not get enough oxygen. | |
§ Antivenom is specific to the species of snake. There are many antivenoms, but rattlesnakes and copperheads cause most poisonous snakebites in the United States. | |
¶ There is limited evidence that L-carnitine is a good general antidote for acute valproic acid overdose. However, L-carnitine is likely to be safe, so it is a reasonable treatment in people who have a decreased level of consciousness. ¶ There is limited evidence that L-carnitine is a good general antidote for acute valproic acid overdose. However, L-carnitine is likely to be safe, so it is a reasonable treatment in people who have a decreased level of consciousness. | |
Mental health evaluation
People who attempt suicide by poisoning need mental health evaluation and appropriate treatment.
More Information
The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
American Association of Poison Control Centers: Represents the US-based poison centers that provide free, confidential services (24/7) through the Poison Help Line (1-800-222-1222)
Disposal of Unused Medicines: What You Should Know: Information on how to safely dispose of unused medicines
PoisonHelp.org: For free, confidential online help about specific poisons.
