Poisoning is when a person is exposed to a substance that can damage their health or endanger their life. Most poisons are swallowed or inhaled; however, they can also be absorbed through the skin. Many poisonous substances are found in homes and workplaces, including some cleaning products, illicit drugs, medications, and even some plants. International organisations are working to remove toxins such as lead, mercury and asbestos from paint and other building supplies.
Guidelines
- For a person who has swallowed a poisonous substance, the first aid provider should consider laying them on their left side. *
Good practice points
- The first aid provider should stop or limit further effects of the poison by stopping continued exposure. In the case of inhalation of toxic gas, the person should be removed from the area, but only if it is safe for the first aid provider to do so.
- In rooms which are potentially filled with carbon monoxide, exposure to all sources of ignition such as naked flames, electrical equipment, oxidizing chemicals and the smoking of tobacco products should be prevented.
- The nature and time of exposure and the name of the product or toxic substance should be described to the poison control centre, or local equivalent, or emergency medical services (EMS). All bottles, packages or containers with labels or any other information about the poison should be given to EMS.
- If life-threatening conditions are present (e.g., unresponsiveness or breathing difficulties) the first aid provider should access EMS. The first aid provider should start CPR or provide other first aid as necessary.
- If non-life-threatening conditions are present, the first aider should access and follow the instructions of the poison control centre (or local equivalent) or EMS.
- Rescue breaths should be avoided if poisoning by toxins such as cyanide, hydrogen sulphide, corrosives or organophosphates is suspected. The bag-valve-mask device may be used by those who are trained to do so.
- If the person is responsive, the first aid provider should remove any poisonous liquid remaining in the person’s mouth by allowing the person to use water to rinse and spit out any remaining toxin.
- First aid providers should not give any diluents such as milk, water or activated charcoal to a person who has swallowed a poisonous substance unless they are instructed to do so by the poison control centre or equivalent poison expert.
- The person should NOT be encouraged to vomit as this may damage their throat.
- Button-sized batteries contain poisonous chemicals which may leak into the body. If they are swallowed this should be treated as poisoning.
- First aid providers with appropriate training may administer oxygen to people who have carbon monoxide or carbon dioxide poisoning.
Chain of survival behaviours
Prevent and prepare
- Ensure that any poisonous substances (such as cleaning products and medicines) are locked away and inaccessible to children. This particularly includes brightly coloured or scented chemicals such as washing machine tablets or e-cigarette liquids.
- Carefully read the information leaflet that comes with new medication to avoid an overdose.
- Regularly service cooking and heating appliances that use fossil fuels and install a carbon monoxide detector.
- Store chemicals out of access to any person who may accidentally or purposefully swallow or sniff them and ensure they have child-resistant lids.
- Depending on the type of work or hobbies, learn how to prevent direct contact with poisonous substances. This may include contacting the person who is responsible for workplace safety to teach specific safety-regulations.
Early recognition
Upon entering an environment where there may be poisonous substances, assess the area. There may be open packaging near the person (e.g., a packet of tablets) or spilled chemicals. A confined space may smell of gas (note that carbon monoxide is odourless, as well as colourless and tasteless). The person may also be able to tell you that they have had contact with a poisonous substance.
Poisoning signs and symptoms can include:
- burns around the mouth and lips
- the breath may smell like chemicals, such as gasoline or paint thinner
- vomiting
- drowsiness
- difficulty breathing
- confusion or other altered mental status.
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NOTE
Poisoning signs and symptoms can mimic other conditions, such as Seizure, Stroke or an insulin reaction.
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First aid steps
- Help the person to reduce or stop further exposure to the poison.
- Try to identify the poisonous substance, the amount and when (or how long) the person was exposed to it. Only touch the packaging if it is safe to do so. If not, wait for EMS.
- Access the poison control centre (or local equivalent) or EMS and tell them as much as you can. Follow their instructions.
- Help the person into a position of comfort, on their left side if possible, and monitor them for any change in their breathing or level of response.
- Gather any bottles, packages or containers with labels and any other information about the poison to give to the EMS.
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SPECIAL CASES
- If the person is unresponsive, open their airway and check for breathing. See Unresponsiveness.
- If the person has a caustic substance in their eye or around their mouth, see Burns.
- If the person is having an opioid overdose, see Unresponsive and abnormal breathing with suspected opioid overdose.
- If the person has been bitten by a snake or stung by a jellyfish, see Snakebites or Aquatic animal injuries.
- If the person vomits while lying on the ground, turn them on their side to prevent choking.
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CAUTION
- If a toxic substance is suspected, the first aid provider may need to wear personal protective equipment such as a mask or gloves. If a harmful substance is suspected in or around the mouth, providers should use chest compression-only CPR to avoid contact.
- Do not make the person vomit as this may damage their throat.
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Access help
- It is important to tell the poison control centre (or equivalent) or EMS as much as you can about the type of poison the person may have been exposed to. This allows the professionals to give the most appropriate help based on the person’s needs.
Education considerations
Context considerations
- Establish with learners what substances and sources are most likely to lead to poisoning in their context and discuss ways to reduce the likelihood of poisoning. For example, discuss living or work conditions and how to store harmful substances.
- Give learners opportunities to assess danger through photos or scenarios, for example of a chemical spill or a gas-filled room. Discuss what signs they should look for. Explore how they can keep themselves safe. This may be particularly relevant to some workplaces.
- Inform learners of any local, regional or national carbon monoxide detector schemes such as free detectors from a local rescue service, regulated charity or commercial providers. These can be professionally fitted and tested.
Learner considerations
- Tailor education to specific learning needs. For example, child first aid courses aimed at parents and care providers may require more time around prevention.
- Decide if first aid education should include whether it is preferable to lay a person who has swallowed poison, on their left side. If including this, reassure learners that if they forget which side to lay the person on, first aid principles remain, and the key is to move the person into a safe position that will maintain an open airway.
- Children younger than five years of age are the most likely to ingest a button battery. Most ingested batteries are from hearing aids, watches, games, toys, and calculators (Ikenberry et al., 2011).
- In adults, the swallowing of caustic substances is frequently intentional, involves large amounts, and is life-threatening.
Facilitation tips and tools
- Make use of visual resources such as danger labels and signs, as well as photographs of the impact of poisoning to help learners identify what to look for.
- Help learners to identify a poison control centre (or equivalent) and how to call them.
- Use audio-visual resources to support facilitation and connect key first aid principles. For example, when covering carbon monoxide poisoning, this teaching clip may be helpful.
- Use information from official organisations when educating specific audiences and tailor the content accordingly. For example, the National Health Service in the United Kingdom provides clear guidance on what to do if you think a child may have swallowed a button-sized battery.
- Suggest reading leaflets distributed by authorities on the specific poisoning risks in the region.
Learning connections
- Make connections to Snakebites, Aquatic animal injuries (e.g., jellyfish stings) and Insect bites and stings.
- Connect to learning about a person who is Unresponsive with abnormal breathing with suspected opioid overdose.
- The approaches of Psychological first aid or topic of Suicidal ideation may be useful for this topic.
Scientific foundation
The Consensus on Science reviewed this subject in 2010. The Centre for Evidence-Based Practice (CEBaP) re-evaluated the available literature for this edition of the guidelines. This literature is available as two published systematic reviews (Avau et al., 2019; Borra et al., 2019). Carbon monoxide and carbon dioxide intoxication were not scientifically evaluated in the Consensus on Science in 2010 nor 2015. CEBaP, however, developed an evidence summary on the use of carbon monoxide detectors for the prevention of carbon monoxide intoxication, as well as an evidence summary on safe storage for the prevention of poisoning in general. The United Kingdom Public Health Authority, the Canadian Centre and the Dutch National Poisons Information Centre provided additional sources of information.
Systematic reviews
Body position
There is limited evidence of very low certainty in favour of lying on the left side. A CEBaP systematic review (Borra et al., 2019) of nine randomised cross-over studies in adult volunteers showed that lying down on the left side resulted in a statistically significant decreased uptake of several drugs (acetaminophen, nifedipine, nitropyridine), compared to other body positions.
Dilution with milk or water
There are no human studies on the effect of treating oral caustic exposure with dilution therapy.
Induced vomiting – Ipecac
A CEBaP Cochrane systematic review (Avau, Cochrane 2019) identified five studies investigating the effectiveness of ipecac syrup as a first aid intervention. None of the evidence on the use of syrup of ipecac as a first aid intervention shows any benefit, and it may even cause harm.
One study provided evidence of low certainty on the use of ipecac versus no intervention in asymptomatic participants with toxic berry ingestion. This study took place in a pre-hospital setting and reported no clinical outcomes. While there may be little or no difference in emergency department referral, there may be an increase in adverse events.
Four studies assessed the addition of ipecac syrup to single dose activated charcoal plus a cathartic (a medication that increases the passage of stool). All studies either did not specify or included multiple types of overdose. Low-certainty evidence suggests there may be little or no difference in the incidence of clinical improvement. On the other hand, we are uncertain about any effect on the incidence of mortality, adverse events, clinical deterioration, hospitalisation or intensive care unit admission.
Activated charcoal
A CEBaP Cochrane systematic review (Avau, Cochrane 2019) shows there is limited evidence with harm for single dose activated charcoal ingestion after poisoning.
It was shown that single dose activated charcoal and a hospital intervention (mostly gastric lavage) resulted in a statistically significant increase in several symptomatic features of poisoning (hospitalisation rate, intensive care unit admission rate, need for intubation rate), compared to hospital intervention alone. However, a statistically significant increase in mortality, convulsion rate, drug absorption (AUC, Cmax or Tmax), or the occurrence of adverse events (vomiting, absence of bowel sounds), using single-dose activated charcoal and a hospital intervention, compared to hospital treatment alone, could not be demonstrated. Furthermore, a statistically significant increase in mortality or the occurrence of adverse events, using single dose activated charcoal compared to no intervention, could not be demonstrated. Evidence is of very low certainty and results cannot be considered precise due to limited sample size, the low number of events, and/or large variability of results.
In addition, there is limited evidence neither in favour of multiple doses of activated charcoal nor no intervention. A statistically significant decrease in mortality, symptomatic features of poisoning (need for intubation, length of intubation, seizures, need for cardiac pacing or antitoxin treatment), drug absorption (AUC, Cmax or Tmax), or the occurrence of adverse events (absent bowel sounds), using multiple doses of activated charcoal and a hospital intervention compared to hospital treatment alone, could not be demonstrated. Evidence is of very low certainty and results cannot be considered precise due to limited sample size, the low number of events, and/or large variability of results.
Non-systematic reviews
Prevention
The unsafe storage of chemicals and medicine, household poisons, kerosene and petroleum, and lack of child-resistant lids on bathroom bottles are risk factors that resulted in a statistically increased risk of unintentional poisoning. However, the following risk factors could not demonstrate a statistically significant increased risk of unintentional poisoning: no child-resistant lids on household cleaning supplies, easy access to bathroom beauty supplies and medications, easy access to cleaning supplies and the use of unsafe product packaging. Evidence is of very low quality, and results cannot be considered precise due to lack of data and large variability of results.
There is evidence in favour of using child-resistant containers for paraffin. It was shown that using child-resistant containers resulted in a statistically significant decreased incidence of paraffin ingestion, compared to not using these. Evidence is of moderate quality.
CEBaP’s review showed from two observational studies that not having a carbon monoxide detector resulted in a statistically significant increased risk of poisoning or hospitalisation. Evidence is of very low certainty and results cannot be considered precise due to a low number of events.
Despite their utility, the effectiveness of carbon monoxide alarms or smoke alarms is limited by human awareness of the appropriate actions to take when an alarm sounds. (Wheeler-Martin et al., 2015). Messaging around the importance and timing of battery replacement needs improvement. A properly installed and functioning carbon monoxide detector is an effective tool to protect household occupants from residential, non-fire-related carbon monoxide poisoning (McKenzie et al., 2017).
Water irrigation
Irrigation of the skin and eye after exposure to caustic agents can reduce the severity of tissue damage and has been a mainstay of first aid treatment. Evidence from multiple studies examining alkali and acid exposure of both the eye and skin showed that outcomes were improved when water irrigation was rapidly administered in first aid treatment. In one non-random case series of immediate (first aid) versus delayed (healthcare provider) skin irrigation, the incidence of full-thickness burns was lower, and length of hospital stay was decreased by 50% with immediate and copious irrigation of skin chemical burns. Evidence-based on animal studies also supports water irrigation to reduce exposure of the skin and eye to acid. In a study of rats with acid skin burns, water irrigation within one minute of burn prevented any drop-in tissue pH, whereas delayed irrigation allowed a progressively more significant fall in tissue pH (Markenson et al., 2010).
Danger of vomiting
Because caustic substances can cause as much damage when returning up the oesophagus as they did when swallowed, a person who has swallowed a caustic substance should not be made to vomit (Weigert, 2005).
Dry cell battery poisoning
Children younger than five years of age are the most likely to ingest a button battery, and most ingested batteries are from hearing aids, watches, games, toys, and calculators. The electrical current from a battery lodged in the oesophagus rapidly burns and damages surrounding tissue, leading to severe and potentially fatal complications. (Ikenberry et al., 2011). Although hearing aid batteries are not the riskiest of ingested batteries (<1%), larger button cells, such as the popular lithium coin cells, can cause life-threatening damage in just two hours. If the battery is in the oesophagus, it will have to be removed. Burns to the oesophagus may lead to perforations, massive bleeding and complications from scarring, as well as months to years of impaired feeding (Cevik and Boleken, 2013; Martin, 2009). If the battery has passed into the stomach, it is usually safe to allow it to pass on through the intestinal tract.
Fatal complications after button battery ingestion are increasing worldwide. As soon as they suspect a button cell has been ingested, people should contact their general practitioner or another professional caregiver for medical guidance, regardless of the battery’s diameter. An X-Ray should be made for every child after battery ingestion. If they are showing signs of being seriously ill, such as vomiting or active bleeding, the emergency services should be called. A battery lodged in the oesophagus of a child may go undetected if parents or caretakers are unaware of it, as the symptoms can appear the same as other conditions such as viral infections (Krom et al., 2018).
Carbon dioxide
Large amounts of carbon dioxide are produced during the fermentation process in wine cellars, silos or cesspools, especially if they are not properly ventilated. It is heavier than air and floods the cellar or confined spaces and can dilute the oxygen concentration in air below the level necessary to support life. In the United States, carbon dioxide is responsible for more than 2700 deaths annually (Wheeler-Martin et al., 2015).
Low concentrations of carbon dioxide can cause increased respiration and headache. In high concentrations, people may die due to the lack of oxygen in the carbon dioxide filled atmosphere. Symptoms may include loss of mobility or consciousness, dizziness, drowsiness and nausea. Additionally, skin contact with frozen carbon dioxide (dry ice) may cause frostbite (IFRC, 2016).
Carbon monoxide
Carbon monoxide is a non-irritating, colourless and odourless gas and may be difficult to detect. It is a flammable gas and it may react violently with other substances and sources of energy, which might also cause explosions. Frequent sources of carbon monoxide are gas combustion engines, fires, furnaces and space heaters, especially in poorly ventilated spaces. Carbon monoxide binds to red blood cells more strongly than oxygen can, thus reducing the amount of oxygen that can be carried by the blood to reach important organs such as the heart and brain. Typical symptoms of carbon monoxide poisoning are headache, nausea, vomiting, muscle weakness (especially in lower limbs), unconsciousness and seizures. Unlike other conditions that decrease oxygen in the blood the person poisoned by carbon monoxide is rarely paler or showing bluish skin colouring around their fingers, lips or nails (cyanotic) (IFRC, 2016).
References
Systematic reviews
Avau, B., Borra, V., Vanhove, A. C., Vandekerckhove, P., De Paepe, P., & De Buck, E. (2018). First aid interventions by laypeople for acute oral poisoning. Cochrane database of systematic reviews, (12).
Borra, V., Avau, B., De Paepe, P., Vandekerckhove, P., & De Buck, E. (2019). Is placing a victim in the left lateral decubitus position an effective first aid intervention for acute oral poisoning? A systematic review. Clinical Toxicology, 57(7), 603-616.
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summaries to support First Aid Guidelines. Poisoning – Left lateral position. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summaries to support First Aid Guidelines. Poisoning – Safe storage (prevention). Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summaries to support First Aid Guidelines. Poisoning – CO detector (prevention). Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Non-systematic reviews
Canadian Centre for Occupational Health and Safety (2017). OSH Answers Fact Sheets. Carbon Monoxide. Retrieved from:
https://www.ccohs.ca/oshanswers/chemicals/chem_profiles/carbon_monoxide.html
Çevik, M., & Boleken, M. E. (2013). The Outcomes of Injuries Due To Button Batteries Becoming Lodged in the Esophagus in Children. Türkiye Klinikleri Tıp Bilimleri Dergisi, 33(3), 792-796.
Department of Health and Social Care and Public Health England. (2013)., Carbon Monoxide poisoning for healthcare professionals. Retrieved from: https://www.gov.uk/government/publications/carbon-monoxide-poisoning
International Federation of Red Cross and Red Crescent Societies. (2016). International first aid and resuscitation guidelines 2016, 8, 50-54.
Ikenberry, S. O., Jue, T. L., Anderson, M. A., Appalaneni, V., Banerjee, S., Ben-Menachem, T., … & Harrison, M. E. (2011). Management of ingested foreign bodies and food impactions. Gastrointestinal endoscopy, 73(6), 1085-1091.
Krom, H., Visser, M., Hulst, J. M., Wolters, V. M., Van den Neucker, A. M., De Meij, T., … & Kindermann, A. (2018). Serious complications after button battery ingestion in children. European journal of pediatrics, 177(7), 1063-1070.
Luiz, O. (2009). Advice and Guidance on Carbon Monoxide (CO), and the Prevention, Diagnosis and Treatment of CO Poisoning; Publications Gateway Number: 2015496. Public Health England: London, UK. Retrieved from: https://www.gov.uk/government/collections/carbon-monoxide-co
Markenson, D., Ferguson, J. D., Chameides, L., Cassan, P., Chung, K. L., Epstein, J., … & Singer, A. (2010). Part 17: first aid: 2010 American Heart Association and American Red Cross guidelines for first aid. Circulation, 122(18_suppl_3), S934-S946.
Martin, R. L. (2009). In case of battery ingestion, act fast!. The Hearing Journal, 62(3), 64.
McKenzie, L. B., Roberts, K. J., Shields, W. C., McDonald, E., Omaki, E., Abdel-Rasoul, M., & Gielen, A. C. (2017). Distribution and evaluation of a carbon monoxide detector intervention in two settings: emergency department and urban community. Journal of environmental health, 79(9), 24.
Weigert, A., & Black, A. (2005). Caustic ingestion in children. Continuing Education in Anaesthesia, Critical Care & Pain, 5(1), 5-8.
Wheeler-Martin, K., Soghoian, S., Prosser, J. M., Manini, A. F., Marker, E., Stajic, M., … & Hoffman, R. S. (2015). Impact of mandatory carbon monoxide alarms: An investigation of the effects on detection and poisoning rates in New York City. American journal of public health, 105(8), 1623-1629.
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