Miscellaneous poisonings, acute; method of George H.W. Lucas and Robert J. Imrie

Lucas, George Herbert William
Miscellaneous poisonings

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1216

L77

Miscellaneous

rison antinarcotic act. Levallorphan does not
have this restriction. It is, therefore, more read-
ily available in the event of an emergency.

When opiate overdosage is suspected, 5 mg.
of nalorphine are given intravenously. As a rule,
if depression is due to a narcotic, some change
in the ventilatory pattern occurs. Usually there
is an increase in rate and some increase in the
over-all minute volume exchange within one
minute. An additional 5 mg. of nalorphine or 1
mg. of levallorphan enhances this efiFect. The
response, as a rule, is sustained for several
hours. Should the patient relapse after this time,
5 or 10 mg. of nalorphine or 1 or 2 mg. of
levallorphan should be repeated. In this respect
the behavior of these antinarcotics difiFers from
that of the analeptics used in the treatment of
overdosage of hynotics. The latter require re-
peated administration to maintain the arousal
efiFects and the return of reflex activity. As a
rule, if no response is evoked when a 10 mg.
dose of nalorphine is administered, one should
strongly suspect that the depression is due to
some other cause besides a narcotic. An addi-
tional 5 mg. may be added, but should this fail
to evoke a response this course of therapy
should be abandoned. The failure to respond is
presumptive evidence that the depression is not
due to a narcotic or that it is complicated by
some other factor. The use of excessive quanti-
ties of either levallorphan or nalorphine en-
hances the depression. Hypotension, if due to a
narcotic, is usually reversed. Nausea and vomit-
ing, excitement and other side actions charac-
teristic of the narcotics are not reversed or an-
tagonized by levallorphan or nalorphine. Sel-
dom is it necessary to give subsequent injec-
tions. If they are necessary they should be given
at intervals of not less than two to two and a
half hours.

Occasionally, several drugs have been used in
conjunction with the narcotics, as, for instance,
a barbiturate in combination with a narcotic.
Generally my experience has been that the anti-
narcotics elevates the rate of respiration only to

Poisonings, Acute

696215

4. ■^. r^j

655

a certain point, but not to that ordinarily con-
sidered normal. In this case one of the analep-
tics, such as megimide may be tried.

The doses for infants and children should be
scaled down according to body weight. Gen-
erally 0.1 mg. of nalorphine per pound suffices.
Apneic or depressed infants delivered from
mothers who have received narcotics during
labor should have the drug administered into
the umbilical or other vein. Usually 0.2 mg. as
the initial dose suffices. (Should levallorphan
be used, .04 mg. fractions may be given.) A
second 0.2 mg. may be given if the first is with-
out efi^ect. If a third 0.2 mg. fraction is ineffec-
tive, the apnea is due to some other cause and
not to a narcotic. It cannot be emphasized too
strongly that all apneic babies born of mothers
who have received narcotics are not necessarily
depressed from the narcotic. In pediatric prac-
tice, as in adult practice, it is preferable to ad-
minister the doses in small fractions until the
desired effect is obtained rather than to esti-
mate what the dose might be and administer it
in a single injection. The response is usually
apparent within a minute. Seldom are more
than two or three minutes required for fuU
establishment of respiratory stimulation. The re-
sults are nowhere near as dramatic when the
drug is given intramuscularly. It is advisable to
administer the drug intravenously at all times.
It is not necessary to administer a sustaining
dose after the initial intravenous injection has
caused reversal. No other stimulant is necessary
to augment that of the levallorphan.

OTHER THERAPEUTIC MEASURES

Other therapeutic measures which may be in-
dicated are aspiration of the stomach contents,
maintaining fluid balance, prevention of blad-
der distention from accumulation of urine by in-
serting an indwelling catheter, and prevention
of infection of the tracheal bronchial pulmonary
tree. Antibiotics may be necessary prophylac-
tically to avoid pulmonary infection.

MISCELLANEOUS POISONINGS, ACUTE

METHOD OF GEORGE H. W. LUCAS, Ph.D., University of Toronto, and
ROBERT J. IMRIE, M.D., Hyspitd for Sick Children, Toronto, Ontario,
Canada

FOREWORD

The authors, who form part of the person-
nel of The Poison Information Centre, The

Hospital for Sick Children, Toronto, wish to
draw the attention of all doctors to similar cen-
tres which are established in many large cities

656

Miscellaneous Poisonings, Acute — continued

in the United States and Canada by our federal
governments. All the available information on
the toxic ingredients in thousands of medicines,
insecticides, pesticides and other registered
commercial products has been placed in a con-
fidential manner by the government in these
Poison Information Centres, and as new drugs
and preparations are marketed, government in-
formation regarding the toxic ingredients is for-
warded to the centres. Each doctor should Hst
the telephone numbers of several of the nearest
centres so that he may telephone quickly for
up-to-date information on the identity of and
treatment for a poison.

It has been conservatively estimated that over
500,000 different household trade name sub-
stances are currently on the market and that
1500 new products are placed on the market
each month. Most of these products are harm-
less when used according to directions, but,
from tranquilizers to pesticides, each can be
harmful — if not fatal — when not used as di-
rected. It behooves the practicing physician,
therefore, to acquaint himself with the avail-
able literature on the methods of treatment.

Poisoning should always be suspected in any
otherwise unexplained acute illness, and more
particularly when acute gastroenteritis, convul-
sions or coma are the presenting symptoms.
There are no specific pathognomonic signs or
symptoms in acute poisoning; instead, we are
often presented with a bizarre clinical history
and inconclusive physical signs. With the poison
control concept persistently in mind, plus a lit-
tle detective work, the seemingly elusive diag-
nosis can be made. Early diagnosis leads to
prompt specific and supportive measures that
could be life-saving.

It is quite impossible for any one physician
to know all the signs and symptoms of the pos-
sible acute poisonings, but he can, and should,
be very familiar with basic principles in order
that he might treat a suspected case even
though he does not know the exact identity of
the poison.

Identification of an individual poison is often
slow, as signs and symptoms are often confus-
ing, histories may be unreliable or not available
and chemical tests usually require hours or
days. The initial vomitus or gastric lavage fluid,
urine and feces should be saved for analysis.

PREVENTION OF POISONING

It has been shown conclusively by various
investigators throughout the United States that
chemical poisoning is preventable if ordinary

safety precautions are employed in the handling
use and storage of drugs and toxic household
preparations. Much has been said about th(
proper labelling of toxic substances by theii
manufacturers. This might help. The famil)
physician, however, is the most important mem-
ber of the team fighting accidental chemical
poisoning. He alone knows the background, the
customs, the traditions and the attitudes of his
patients; he visits them frequently in their
own homes and can see at a glance any po-
tential hazards. This is a golden opportunity for
him to educate the parents to be accident- and
safety-conscious. He can make concrete sug-
gestions regarding storage and handling of all
potentially toxic substances: i.e., keep all drugs,
poisonous substances and household chemicals
in a locked cupboard, out of the reach of chil-
dren; never transfer poisonous products from
their original containers to pop bottles, coffee
tins or drinking glasses. If flavoured or brightly
coloured medications have been prescribed for
children, always refer to them as medicine, and
never as candy.

It is a dangerous habit to prescribe more
medication than is necessary to meet the im-
mediate need. Always caution adult members of
the family to keep medicaments out of the reach
of children — not on the television set, in the
refrigerator, in the night table drawer or in
grandmother's purse.

GENERAL PRINCIPLES OF TREATMENT

In response to a telephone call regarding ^
possible poisoning case, the physician must ba
cool, calm and collected. It is wise to give a
minimum of instructions over the 'phone in
order not to further confuse an already harassed
patient or parent of a child.

Ingested poisons are by far the most common
in accidental poisonings. If the victim has not
consumed a strong acid, alkali or other cor-
rosive, give instructions for him to drink three
to four glasses of milk, which is an excellent
nonoily demulcent, or a similar quantity of
water, and following this, to insert the index
finger deep in his mouth to make him vomit.
Time is often precious; therefore instruct the
patient to take only five minutes to produce
emesis. If this fails, the patient should be taken
immediately to hospital, clinic or office where
a more accurate appraisal of the poisoning may
be made and definitive treatment carried out.

When the patient arrives, a quick history and
physical examination should be done. If the

Miscellaneous Poisonings, Acute — continued

657

physical signs of overdosage are present, they
should be treated immediately.

Most patients should have a gastric lavage to
remove any of the unabsorbed poison — except,
of course, unconscious patients or those who
have swallowed an acid, alkali or other cor-
rosive. Gastric lavage is a simple, safe procedure
if performed correctly. In the case of a child, he
should be adequately restrained by being rolled
tightly in a cotton sheet. The head should al-
ways be lower than the stomach; therefore ele-
vate the foot of the bed. Never use a nasal tube,
but a gastric tube with the largest lumen that
can be passed orally. Gastric contents will easily
plug a small-bore tube. To remove the contents
from the stomach, use a large-bore metal ear
syringe — larger than the conventionally used 50
cc. glass syringe. Never instill fluid into the tube
until you are sure that the tube is in the stomach
and not in the main bronchus. Always aspirate a
small quantity of the thick, whitish, mucinous
gastric juice before proceeding with the wash-
ings. If there is a specific antidote, leave it in
the stomach before removing the lavage tube.
If the nature of the poison is unknown, the
patient should remain under close observation
for twenty-four hours for the development of
any latent signs or symptoms; any of the unused
poison should be sent to a centre so that identi-
fication of the material can be instituted.

SUPPORTIVE MEASURES

If the patient has been severely poisoned, the
maintenance of an airway is paramount. Use
extreme caution in administering sedatives to a
toxic patient. Remember that the simplest meas-
ures are the most eflFective. It is much easier
to overtreat a patient with unnecessary anti-
biotics, sedatives and stimulants than it is to use
scientific, skilfuU neglect.

Oxygen Therapy. In cases of respiratory de-
pression, unconsciousness, cyanosis or shock, oxy-
gen therapy is of extreme importance. It may be
administered by means of an intranasal catheter,
a tight-fitting B.L.B. face mask or one of the
newer complete, compact and highly eflBcient
oxygen tents. As a rule, every emergency unit has
oxygen available and this is most effectively ad-
ministered with a tight-fitting B.L.B. facial mask.
In cases where artificial respiration is necessary
an inhalator is most effective. Rarely are these
found in emergency units, but the fire or police
departments usually have one or know where
one can be located. It is preferable not to ad-
minister C©t with O2 in the poisons dealt with

in this article except in the case of carbon mon-
oxide.

Fluid Treatment. In the past few years we
have learned a good deal regarding electrolyte
replacement therapy. It is unwise to administer
intravenous fluids indiscriminately without the
aid of blood chemistries. It is better to use oral
or tube feedings than to give intravenous fluids
without adequate laboratory facihties in cases of
acute poisoning. A very good general intrave-
nous solution to use awaiting chemical labora-
tory reports on the patient's serum is a % 5%
glucose in water and ^ normal saline. Allow
this solution to run intravenously at approxi-
mately 75 cc. per hour. In acute salicylism poi-
sons, we are unable to tell cHnically whether the
patient is in a state of metaboUc acidosis or
respiratory alkalosis without the COa of the
serum and the pH of the blood. On more than
one occasion sodium lactate has been adminis-
tered intravenously when the patient was al-
ready in a state of respiratory alkalosis, with
severe tetany as a result.

Shock. The most efficacious treatment of shock
regardless of the cause is whole blood. It is
not uncommon to have a poisoned patient in
severe shock. One must bear in mind the
importance of adequate circulating blood vol-
ume— and to increase it when necessary. Keep
the patient in a shock position, that is, the head
low and the feet slightly elevated. These pa-
tients should be handled as little as possible
and should be kept warm with hot water bot-
tles or warmed blankets.

Convulsions. As many poisonous materials are
central nervous system excitants, the hazard of
convulsions is ever present. If intravenous pen-
tobarbital fails to stop convulsions due to
strychnine picrotoxin, nicotine or cocaine im-
mediately, then one must consider gas or ether
anesthetic.

Antibiotics. Intramuscular aqueous penicillin
still remains the antibiotic of choice in unknown
or prophylactic cases. It is wise to give this drug
foUowing the inhalation of any of the aromatic
or halogenated hydrocarbons or other volatile
irritants as a prophylaxis against pneumonitis,
mediastinitis or tracheitis. When the blood cul-
tures, nose and throat cultures reveal the causa-
tive agent, then appropriate specific antibiotic
therapy should be instituted.

Medicinal Charcoal (Activated Charcoal). This
is a specially prepared charcoal in extremely
small particle size intended to absorb certain
organic and inorganic materials from aqueous
solution. (The presence of water does not im-

658

Miscellaneous Poisonings, Acute — continued

pair the absorbing power.) It must not be con-
fused with animal charcoal or charcoal of other
forms — wood charcoal, burnt toast, etc., which
are useless in the treatment of poisons. When
administering it, 5 to 6 heaping teaspoonfuls
should be stirred in a glass of water to make a
very thin paste. Shortly after it has been swal-
lowed remove it with an emetic or gastric
lavage. Some fresh material may be left in the
stomach to pass into the intestine.

Universal Antidote. Universal antidote con-
sists of 1 part of magnesium oxide, 1 part of
tannic acid and 2 parts of activated charcoal.
The magnesium oxide neutralizes acids without
formation of gas; tannic acid reacts with many
substances to form insoluble salts (alkaloids,
metals); medicinal charcoal adsorbs dyes, tox-
ins, alkaloids and some salts of metals. The rec-
ommended dose is 15 grams ( 5 to 6 heaping tea-
spoonfuls) well stirred in a glass of water to
form a thin paste before being swallowed. Fol-
lowing its administration it should be removed
by an emetic or by gastric lavage; it is not
advisable to leave the universal antidote in the
stomach to pass into the intestines where the
toxic substance might be slowly absorbed, but
some fresh material may be left in the stomach
to pass into the intestines.

Methylene Blue. Methylene blue is employed
to reduce the amount of methemoglobin in the
blood stream when large quantities of it have
been formed by a poison. When the reduction of
methemoglobin is not urgent the drug may be
given orally in doses 60 to 300 mg. When rapid
reduction is essential a 1% solution (10 mg. per
ml.) may be injected intravenously slowly, 10
to 15 mg. per 22 lb. body weight. It is important
to recognize that when methylene blue is in-
jected rapidly into the bloodstream it oxidizes
hemoglobin to methemoglobin. Advantage of
this fact is taken in the treatment of cyanide
poisoning where methemoglobin reacts with cya-
nide to form cyanmethemoglobin, a relatively
nontoxic product. The doctor should appreciate
that this reaction of methylene blue with hemo-
globin and with methemoglobin is one in which
equilibrium is established and the relative
amounts of methemoglobin at any time will de-
pend on the state of equilibrium.

Demulcent Drinks and Milk. Milk, while not a
universal antidote, has an important place in the
treatment of certain types of poisoning. Where
there has been corrosion in the throat, oesopha-
gus and stomach, it is the liquid of choice to
swallow easily. If ingested poison reacts with
protein, milk provides protein on which it will

act, resulting in less injury to the tissues. After
the reaction has taken place the stomach con-
tent may be removed with gastric lavage or an
emetic. More milk may then be swallowed. De-
mulcents or mucilaginous materials may be pre-
pared from linseed meal, oatmeal (gruel), bar-
ley, or egg white beaten with water. These are
administered as soothing drinks where highly
irritant or corrosive poisons have damaged the
oesophagus or stomach.

Ascorbic Acid. Ascorbic acid in large quanti-
ties is employed for its detoxifying action on
lead, arsenic and some bacterial toxins. It is
useful also in decreasing cyanosis due to in-
creased methemoglobin. Doses up to 10 grams
have had no observable toxic eflPect. It is avail-
able in tablets and in ampules containing sodium
ascorbate for injection.

British Anti-Lewisite (B.A.L., Dimercaprol Injec-
tion). This drug has been used mainly to com-
bat severe arsenic and mercury poisoning. For
arsenic poisoning 30 mg. per 25 pounds of body
weight may be given every four hours (six in-
jections daily for two days); four injections are
given on the third day and two on each of the
following days until recovery. In mercury poi-
soning larger doses are indicated: 30 mg. per 15
pounds of body weight followed in one or two
hours by 30 mg. per 20 pounds of body weight. ,
Two more such doses may be given within thej
twelve-hour period after the first injection if
poisoning is severe. On the second day two
such doses may be given and on the third day
one dose; one dose daily may be continued until
recovery. The treatment with B.A.L. should be-
gin as soon as possible after the poisoning has
occurred.

Calcium Disodium Versenate. This is the calci-
um chelate of ethylene diamine tetra-acetic acid
(EDTA). It is employed in the deleading of
bone following lead poisoning and should be
employed only in a hospital.

Purgatives. Saline purgatives consist of mag-
nesium sulfate (Epsom salt), sodium sulfate
(Glauber's salt) and Rochelle salts (sodium po-
tassium tartrate). Since under some circum-
stances magnesium may be absorbed from the
intestine and produce some central depression,
sodium sulfate may be considered a more suit-
able purgative. In numerous poisonings large
doses of mineral oil (liquid paraffin, liquid pet-
rolatum) are administered. Liquid paraffin
is not considered as an oil cathartic. It has
the advantage that, although it may not cause
pmrgation rapidly, it may absorb certain toxic

Miscellaneous Poisonings, Acute — continued

659

materials and thus remove them from the gastro-
intestinal tract.

Emetics. In adults and older children emetics
may be used to advantage to remove relatively
large particles such as undissolved tablets, cap-
sules, pills and pieces of food from the stomach;
these might not pass through a stomach tube.
Recommended emetics are solutions made by
stirring 1 to 3 teaspoonfuls of mustard powder
in a glass of lukewarm water or a teaspoonful of
salt in 3 oz. of warm water. Soap suds may be
administered also. Emetics should not be ad-
ministered when the vomiting centre has been
depressed by narcotic substances or when a cor-
rosive acid or alkali has been ingested. During
the expulsion of vomitus, especially when vom-
iting occurs after the ingestion of volatile sub-
stances such as kerosene or gasoline, the head
of the patient should be lower than the hips.
The vomiting reflex can be more readily elicited
when the stomach is full. When vomiting does
not occur spontaneously after the ingestion of
an emetic, tickling the throat with a finger or
tongue depressor may be suflBcient to bring it
about.

Acid Burns. Acid burns, particularly in the
eye, should be treated immediately by placing
the injured person on the floor and pouring
gently on the eyeball several quarts of lukewarm
water. When all the corrosive material has been
washed away, some soothing antiseptic such as
boric acid solution or drops of castor oil may be
applied.

COMMON POISONS

1. ACONITE. (Monkshood, Wolfsbane, Blue

Rocket)

Give universal antidote or activated charcoal and
remove by emetic or gastric lavage using about 300
ml. 1:1000 potassium permanganate solution (a
0.3 gram [5 grainsl tablet dissolved in 10 fl. oz.
of water). Keep the patient warm and in bed,
massaging the extremities and placing a mustard
plaster over the heart. The pulse may be accelerated
by injecting 1 mg. (%o grain) of atropine sulfate.
Oxygen therapy (p. 657) may be required. Give
hot drinks of tea or coffee or inject subcutaneously
or intravenously 0.5 gram (7% grains) of caffeine
and sodium benzoate. Relieve cardiac depression by
injecting intravenously 0.3 mg. (^oo grain) of
strophanthin.

2. ALCOHOL, ETHYL (Ethanol, Grain Alcohol)

Acetone, Methyl Ethyl Ketone

Mild cases need no special care; in severe cases
keep the patient warm and in bed. Do not give

emetics. Remove the alcohol from the stomach by
gastric lavage. Oxygen therapy (p. 657) may be
necessary. Inject caffeine and sodium benzoate 0.5
gram (7% grains) intramuscularly. Control acidosis
as indicated for methyl alcohol. Strong respiratory
stimulants are contraindicated. ,

3. ALCOHOL, ISOPROPYL

Treat as for Ethyl Alcohol. • ■ "

4. ALCOHOL, METHYL (Wood Alcohol, Methyl

Hydrate, Methanol, Wood Naphtha, Wood
Spirit, Green Wood Spirit, Standard Wood
Spirit, Manhattan Spirit, Pyroxylic Spirit,
Colonial Spirit, Columbian Spirit, Eagle
Spirit, Carbonol, Carbinol, Methyl Hydrox-
ide, Lion d'Or, Canned Heat)

Keep the patient warm and in bed. Protect the
eyes from light. Control severe acidosis quickly by
injecting slowly intravenously 3 to 5 per cent sodium
bicarbonate solution (about 1000 ml. per hour) or
160 ml. of sodium lactate solution in 1000 ml.
physiologic saline. Depending on the severity of the
poisoning, 150 grams or more of sodium bicarbonate
may be necessary. Check the pH and the carbon
dioxide combining power of the blood, or administer
alkali until the urine is alkaline. Improvement in the
patient's respiration is a good clinical guide. The
patient must be watched closely as patients thus
treated with alkali soon become acidotic again. If
the patient's respiration is rapidly failing or he is in
shock, oxygen should be administered at once.
Nikethamide (3 ml. of a 25 per cent solution) may
be given intravenously slowly.

5. ALKALI SULFIDES AND POLYSULFIDES

Treat as for caustic soda (6). Oxygen therapy
may be necessary (p. 657). The source of the
sulfide, i.e., such as barium, must be removed unless
the damage to tissues is so extensive as to prevent
it. If barium is present, administer sulfate in solu-
tion (20).

6. ALKALIS, CAUSTIC (Sodium Hydroxide

[Caustic Soda, Lye, Gillett's Lye]; Potas-
sium Hydroxide [Caustic Potash]; Sodium
Carbonate [Washing Soda]; Potassium Car-
bonate; Soda Ash [Wood Ash, Lye]; Other
Alkalis)

Do not attempt gastric lavage or give an emetic.
External burns should be flooded with water and
finaUy washed with 1 per cent boric acid solution.
Give large drinks of water containing any one of
vinegar, citric acid, lemon juice or juice of other
citrus fruits. Give demulcent drinks or milk or tea-
spoonful doses of salad oil or olive oil. Pain may
be relieved by injections of morphine as required.
Watchful, careful nursing is essential. Administra-
tion of food may impose a problem. Special surgical

660

Miscellaneous Poisonings, Acute — continued

procedures for stricture of esophagus may be neces-
sary. Cortisone, 5 mg. per pound of body weight
per day administered in four divided doses, is rec-
ommended in severe cases to allay fibrosis.

7. ALUMINUM (Aluminum, Aluminum Sulfate,

Ammonium Alum [Ammonium Aluminum
Sulfate], Sodium Alum [Sodium Aluminum
Sulfate], Potassium Alum [Potassium Alumi-
num Sulfate], Alum)

Give protein material such as egg white beaten
in water, milk or cheese in finely ground state. This
will be vomited as a rule, but if not, remove it
with an emetic or gastric lavage (if corrosion is not
too severe). Universal antidote is also useful. Keep
the patient in bed and warm. CafiFeine and sodium
benzoate 0.5 gram (7^ grains) subcutaneously will
serve as a stimulant. Administer fluid therapy (p.
657) for dehydration, to control renal tubular dam-
age and central necrosis of the liver.

8. 3-AMINO-l,2,4,-TRIAZOLE (Actamer [Bithio-

nol], Hexachloraphene )

These herbicides or germicides are relatively non-
toxic, and treatment is symptomatic.

9. AMMONIA (Ammonium Hydroxide [Am-

monium Hydrate, Ammonia Water, Harts-
horn, Spirit of Hartshorn, Spirit of Am-
monia, Spirit of Bones, Solution of Am-
monia] )

The fumes, which are highly irritating, may cause
rapid loss of consciousness and death from shock.
The patient should be removed to fresh air at once
and oxygen therapy (p. 657) administered if res-
piration is difficult. Tracheotomy may be necessary
if there is much edema of the glottis following
inhalation or ingestion of the drug. If ingested, treat
quickly as for caustic soda (6). The physician must
use his own judgment in passing a stomach tube.
The patient will require careful nursing. If the eyes
are involved, place the patient on the floor and flush
the cornea gently with quarts of water, finally wash-
ing with very weak vinegar solution or boric acid
solution.

10. AMMONIUM, QUATERNARY, GERMICIDES
AND RELATED PRODUCTS

Alkyl aryl sulfonate
Alrosept M.B.C.
Alrosept MM.
Aralkonium chloride
Benzalkomium chloride

(Zephiran Chloride)
Benzethonium chloride

(Phemerol Chloride)
Cetab

Cetyl pyridinium chloride
(Cepryn Chloride)

Emulsept E670

Hyamine 1622

Hyamine 2389

Methyl benzethonium chlo-
ride (Diaparene Chlo-
ride)

Orolocide

Petronate

These substances are relatively harmless when
ingested in small doses; large doses may cause some
gastrointestinal distress which must be treated
symptomatically.

n. AMPHETAMINE SULFATE (Benzedrine; Dexe-
drine [Dextro- Amphetamine Sulfate]; Meth-
amphetamine hydrochloride [Desoxyephed-
rine Desoxyn, Norodin] )

If poisoning is due to medication, stop this im-
mediately. Oxygen therapy (p. 657) may be nec-
essary. Administer barbiturates for sedation. If in-
gested in large quantities, empty the stomach with
gastric lavage or an emetic and proceed as indi-
cated above.

12. AMYL ACETATE (Banana Oil)

If inhaled, remove the patient to fresh air.

If ingested, empty the stomach with gastric lavage g
or by an emetic and continue treatment as for ethyl f
alcohol (2).

13. ANESTHETICS, LOCAL (Novocain [Pro- |
caine]; Pontocaine [Amethocaine, Tetra-
caine]; Nupercaine [Cinchocaine, Dibu-
caine, Percaine]; Lidocaine [Xylocaine];
Benzocaine [Ethylaminobenzoate]; Buta-
caine [Butyn]; Monocaine [Butethamine] )

The treatment of acute poisoning by any mem-
ber of the local anesthetic group is so similar that
these poisons are considered under one heading;
only a few have been hsted. When it occurs follow-
ing ingestion of the drug, administer quickly uni-
versal antidote or activated charcoal suspended in
water and remove gastric content with an emetic or
by gastric lavage using potassium permanganate
1:1000 (a 0.3 gram (5 grains) tablet dissolved in
300 ml. [10 fl. oz.] of water). Leave about 60 ml.
(2 fl. oz.) of this solution in the stomach. Apply
artificial respiration with oxygen when respiration
fails, and restore circulation by injecting 0.5 to 1.0
ml. of 1:1000 epinephrine intravenously. Following
restoration of circulation, small doses of nikethamide
or Metrazol (pentylenetetrazol) may be adminis-
tered to stimulate respiration. Death has occurred
following small doses of local anesthetics; it is
beheved this is due to an idiosyncrasy to the drug. "

14. ANILINE (AMINOBENZENE, AMIDOBEN-
ZENE) (Nitrobenzene [Oil of Mirbane, Es-
sence of Mirbane]; Nitroglycerin [Trinitrin,
Glonin]; Azobenzene [Azobenzide] )

Administer universal antidote followed by an
emetic or gastric lavage. Keep the patient warm
and in bed. Give hot drinks of tea or coffee or 0.5
gram (7% grains) of caffeine and sodium benzoate
subcutaneously or intravenously. Reheve headache
by keeping an ice bag or cold cloths on the
head. Circulation may be maintained by injecting

Miscellaneous Poisonings, Acute — continued

661

intravenously 16 mg. or ephedrine hydrochloride or
sulfate. Oxygen therapy (p. 657) may be required.
For persistent cyanosis (due to methemoglobin) in-
ject 6 to 12 ml. of 1 per cent methylene blue
solution slowly intravenously or administer 60 to
300 mg. orally; 500 mg. of sodium ascorbate in 5 or
10 per cent solution may be given slowly intrave-
nously followed by another 500 mg. in divided
doses. Blood transfusion may be necessary.

15. ANTABUSE (Antabus, Disulfiram, Tetra-
ethylthiuram Disulfide)

Oxygen therapy (p. 657) may be needed
urgently. Improve circulation by administering 500
ml. of 5 per cent glucose; more may be necessary
unless there is danger of pulmonary edema. Give
an intravenous injection of 1 gram of sodium ascor-
bate. Keep the patient in bed and as quiet as pos-
sible. In very severe cases, a very slow intravenous
injection of a 2 per cent solution of saccharated
iron oxide (100 mg. in 5 ml.) has been beneficial;
similar amounts may be given daily or on alternate
days if the physician deems it advisable.

16. ANTIHISTAMINES

There are no specific antidotes.

Remove the drug from the stomach quickly with
an emetic or gastric lavage. Control drowsiness by
giving drinks of strong tea or coffee or by injec-
tions of caffeine and sodium benzoate 0.5 gram
(7% grains) intramuscularly or intravenously. Am-
phetamine sulfate or methamphetamine hychrochlo-
ride 20 mg. may be administered intravenously for
the same purpose; these may be repeated as neces-
sary. Employ sedatives for insomnia with great cau-
tion.

17. ANTU (Alpha naphthylthiourea)

No specific antidote and no human fatalities have
been reported; treatment is symptomatic.

18. ARSENIC (Arsenious Acid, White Arsenic,
Arsenious Anhydride, Ratsbane, Fowler's
Solution ) , See Antimony.

19. ANTIMONY (Tartarated Antimony, Tartar
Emetic, Antimony Trichloride [Butter of
Antimony] )

Treatment for these poisons is the same.

Administer quickly universal antidote and follow
by an emetic or gastric lavage using large volumes
of a 1 per cent sodium bicarbonate solution (3 level
teaspoonfuls per quart of water). Keep the patient
warm and in bed. Force fluids to combat dehydra-
tion (p. 657). Give mucilaginous drinks; morphine
sulfate 15 mg. (% grain) may be used to control
severe pain. Administer BAL quickly as directed
(p. 658).

20. BARIUM (Carbonate, Chloride, Hydrate,
Sulfide)

Give soluble sulfates in solution (Epsom salt,
Glauber's salt, potassium alum, magnesium sulfate,
sodium sulfate or milk of magnesia) to precipitate
the barium. Follow with an emetic or gastric lavage
with water. Oxygen therapy (p. 657) may be nec-
essary if respiration is depressed. Give 15 mg. (M
grain) of morphine sulfate to control severe pain;
0.1 to 0.3 gram (1^ to 4^/^ grains) of quinidine
sulfate to prevent ventricular fibrillation and 0.5
to 1 mg. (M20 to %4 grain) of nitroglycerine to re-
duce elevated blood pressure.

21. BELLADONNA ALKALOIDS (Atropme [Ra-
cemic Hyoscyamine] , Deadly Nightshade,
Henbane, Thorn Apple, Jimson Weed)

For ingestion, use universal antidote followed by
emetic or gastric lavage with water or normal saline
(2 level teaspoonfuls of salt per quart). Give sips
of ice water to relieve dryness in the mouth and
keep an ice cap on the head. Catheterization may
be necessary. Physostigmine salicylate 3 mg. (^0
grain) or pilocarpine nitrate 10 mg. (Vq grain) may
be employed to relieve peripheral symptoms or until
the mouth is moist. Persistent excitation may be
decreased by gas anesthesia or by cautious use of
short-acting barbiturates. Give tepid baths; careful
nursing is essential. Liquid petrolatum may be
sprayed in the nose or placed in the conjunctival
sac to relieve dryness. Eserine or pilocarpine drops
may be employed to decrease dilatation of the pu-
pil and relieve intraocular pressure. Protect the eyes
from light. Combat respiratory failure by giving
oxygen.

22. BENZENE (Benzol) (Toluene [Toluol], Xy-
lene [Xylol])

Benzene is the most toxic of these when inhaled.
All are equally toxic when ingested.

For inhalation, remove the patient to fresh air
promptly; give oxygen; artificial respiration may be
necessary.

For ingestion, swallow 1 per cent sodium bicar-
bonate solution (3 level teaspoonfuls per quart of
water) and follow with an emetic or employ this
solution in gastric lavage until the odor of the
drug is removed. Keep the patient in bed. Blood
transfusion may be necessary if there is much red
cell destruction. Keep the patient on a high calorie
diet; administer 15 mg. of folic acid intravenously
or 5 to 10 ml. of liver extract intramuscularly as
well as intramuscular penicillin.

23. BERYLLIUM

Keep the patient in bed and administer oxygen
when cyanosis appears. Recovery usually is slow;
months of treatment may be required. (See also
Berylliosis, p. 651.)

662

Miscellaneous Poisonings, Acute — continued

24. BISMUTH (Bismuth Subnitrate, Bismuth Ox-

ynitrate)
Administer an emetic or remove stomach con-
tents by gastric lavage. Leave 3 to 4 heaping tea-
spoonfuls of magnesium sulfate or sodium sulfate
dissolved in water in the stomach. Fluid therapy (p.
657) and BAL (p. 658) may be necessary. In case
of cyanosis due to nitrite, see 14.

25. BITTER ALMOND OIL (Essential Oil of Bitter
Almonds, Oil of Bitter Almonds )

See treatment for Cyanides (49).

26. BORIC ACID (Boracic Acid) (Borax [Sodium
Borate, Sodium Biborate], Sodium Tetra-
borate, Sodium Perborate)

Keep the patient warm and in bed. Administer
an emetic or perform gastric lavage if the drug has
been ingested, using ample 1 per cent sodium bi-
carbonate solution (3 level teaspoonfuls dissolved in
a quart of water). CaflFeine and sodium benzoate
0.5 gram (7^ grains) may be given intramuscu-
larly. Fluid therapy is important (p. 657).

27. BROMIDES (Sodium, Potassium, Ammonium,
Lithium, Strontium or Calcium Bromide)

Withdraw bromide medication if such is in prog-
ress. If large doses have been swallowed, remove
with gastric lavage using warm water. Increase
sodium chloride intake and employ barbiturates or
paraldehyde for sedation.

28. BROMINE

For ingestion, treat as for Iodine (77).

Following inhalation, remove the patient from
the fumes; keep him quiet and warm — rest is most
important. Oxygen therapy may be necessary (p.
657). Morphine in small doses may be injected to
check spasmodic cough, but such medication must
be used with discretion by the physician. Nebulized
5 per cent solution of sodium bicarbonate is said
to alleviate the irritation of the respiratory tract.

29. CADMIUM

There is no specific treatment.

If vomiting has not removed ingested material,
administer an emetic or perform gastric lavage.
Control restlessness by use of barbiturates or paral-
dehyde (5 to 15 ml. injected). Morphine may be
used if the respiration is not markedly depressed.
Keep the patient in bed and warm; give food rich
in protein and carbohydrates. Oxygen therapy (p.
657) and penicillin injection may be necessary if
bronchopneumonia threatens.

30. CAFFEINE (Caffeine Citrate)

Control tremors or excitement by use of barbitu-
rates given orally or by injection.

31. CAMPHOR (Gum Camphor, Laurel Cam-
phor, Camphorated Oil, 2-Camphanone)

Administer an emetic or perform gastric lavage
quickly. Convulsions may be controlled by gas in-
halation or ether or by 100 to 300 mg. of pento-
barbital intravenously; only short-acting barbitu-
rates may be used. Intramuscularly injected
paraldehyde 5 to 15 ml. is also valuable. Ephedrine
sulfate 45 mg. (% grain) or caffeine and sodium
benzoate 0.5 gram (7% grains) may be given to
support circulation. Keep the patient in bed. Avoid
the use of opiates.

32. CANTHARIDES (Cantharis, Spanish FHes,
Russian Flies, Blistering Beetle, Blistering
Fluid, Tincture of Cantharides [Essence of
Viper] )

Give universal antidote or activated charcoal
and follow with gastric lavage or an emetic. Give
demulcent drinks and milk, but avoid fatty foods.
Fluid therapy (p. 657) is advisable since renal im-
pairment is likely. Keep the patient warm and in
bed; an electric pad or hot water bottle may aid in
controlling pain. Morphine suffate 15 mg. {% grain)
may be injected when pain becomes severe.

33. CARBON DIOXIDE (Carbonic Acid Gas, Car-
bonic Anhydride, Choke Damp, After
Damp, Black Damp)

Remove the patient to fresh air and give oxygen 1
therapy (p. 657); artificial respiration may be nee-
essary. Drinks of tea or coffee or injection of caf-
feine and sodium benzoate 0.5 gram (7% grains)
subcutaneously may be used as stimulants. Recov-
ery is slow; keep the patient in bed for several
days.

34. CARBON DISULFIDE (Carbon Bisulfide)

Oxygen therapy (p. 657) may be required.
Keep the patient warm and in bed in a weU-venti-
lated room. Give drinks of tea or coffee or injec-
tions of caffeine and sodium benzoate 0.5 gram
(7% grains). Recovery is slow, and rest in bed for
several days is advisable.

35. CARBON MONOXIDE

Remove the patient to fresh air immediately;
apply artificial respiration if respiration has ceased.
Administer oxygen containing 7 per cent carbon
dioxide if possible. Nikethamide (5 to 10 ml. of a
25 per cent solution) may be given intravenously.
Inhalations of amyl nitrite may be beneficial. Do not
employ methylene blue. The patient needs good
nursing and constant care until all danger of men-
tal confusion or loss of memory is past.

36. CARBON TETRACHLORIDE AND RELATED
CHLOR-PRODUCTS (Carbon Tetrachloride
[Tetrachlormethane Chlorocarbon, Perchlor

Miscellaneous Poisonings, Acute — continued

663

Methane]; Ethyl Chloride [Chloroethyl,
Kelene]; Trichloroethylene [Ethylene Tri-
chloride]; Tetrachlorethylene)
These are considered together because they may
cause poisoning by inhalation or following ingestion.
Carbon tetrachloride is the most toxic.

7/ inhaled, remove the patient from the fumes and
treat symptomatically, keeping him under supervi-
sion for delayed toxic symptoms from kidney or
liver.

If ingested, swallow 4 fl. oz. of mineral oil and
perform gastric lavage or empty the stomach by
use of an emetic. Drinks of tea or coflFee or subcu-
taneous or intravenous injections of caffeine and
sodium benzoate 0.5 gram (7^ grains) may serve
as stimulants. Administer 5 to 10 grams of calcium
gluconate intramuscularly or intravenously. Give
methionine or choline 2 grams by mouth every two
hours if liver damage is evident. Feed a diet high
in carbohydrate, excluding fat. Fluid therapy (p.
657) or blood transfusion may be necessary.

37. CHLORAL (Chloral Hydrate)

Perform gastric lavage immediately. Administer
oxygen therapy (p. 657) for seriously depressed
respiration. Nikethamide 1 to 4 ml. of a 25 per
cent solution may be administered intramuscularly
or intravenously and repeated as necessary. Fluid
therapy may be employed to prevent shock and
promote diuresis (p. 657).

38. CHLORINE

Remove the patient prompdy to fresh air. Keep
him warm and as quiet as possible. A nebulized 5
per cent solution of sodium bicarbonate helps in
alleviating upper respiratory tract irritation. Oxy-
gen therapy is usually necessary (p. 657), and in-
travenous injection of 50 per cent glucose may be
valuable in relieving pulmonary edema. Admin-
istering oxygen bubbled through 50 per cent solu-
tion of ethyl alcohol in water lowers the surface
tension of the edema fluid in the alveoli and allows
the absorption of oxygen through this fluid. Ad-
minister for 10 minutes at a time and repeat treat-
ment every 20 to 30 minutes as required. Nebulized
epinephrine solution 1:100 or parenteral amino-
phylline is recommended to relieve respiratory dis-
tress.

39. CHLORINE ANTISEPTIC SOLUTIONS

Gastric lavage or an emetic; follow with demul-
cent drinks or milk. Sedation with Amytal (amo-
barbital) Sodium or other barbiturate if necessary.

40. CHLOROFORM

When inhaled, artificial respiration at once with
oxygen. Inject caffeine and sodium benzoate 0.5
gram (7% grains) or nikethamide 2 to 5 ml. (25
per cent solution) or Metrazol (pentylenetetrazol)

1 ml. 10 per cent solution intravenously. Strophan-
thin 0.5 mg. or other suitable glycoside may be
given intravenously. Treat symptomatically for Hver
damage.

When ingested, treat as for carbon tetrachloride
(36).

41. COLCHICUM (Meadow Saffron, Colchicum
[Seed, Corm, Root], Colchicine)

Give universal antidote or activated charcoal and
follow quickly by gastric lavage or an emetic. Oxy-
gen therapy may be required depending on the
depression of respiration (p. 657). Morphine sulfate
15 mg. (Vi grain) and atropine sulfate 0.6 mg.
(Moo grain) may be injected to relieve pain and
spasm. (Morphine must be used with caution.)
Keep the patient warm and in bed. Give demulcent
drinks and milk.

42. COPPER (Copper Acetate [Verdigris]; Cop-
per Sulfate [Blue Vitriol, Bluestone, Blue
Copperas]; Copper [Chloride, Nitrate, Ar-
senite]; Schweinfurt Green, Scheele's Green,
Brunswick Green; Bordeaux Mixture)

Administer potassium ferrocyanide 0.6 gram in
water as quickly as possible or give soap suds or
alkaline substances such as lime or weak sodium
carbonate (washing soda) to precipitate the cop-
per. Proteins such as white of egg beaten with
water, barley water, gruel or cheese in fine pieces
wfll also precipitate the metal. If the stomach con-
tent is not vomited, give an emetic or perform
gastric lavage. Keep the patient in bed and warm
— a heating pad may be necessary. Drinks of tea or
coffee may be given after removal of the stomach
content, or caffeine and sodium benzoate 0.5 gram
(7^ grains) may be injected subcutaneously or in-
tramuscularly. Morphine sulfate 15 mg. (M grain)
hypodermically may be used to control pain. Fluid
therapy (p. 657) may be necessary.

43. CORROSIVES (Mineral Acids and some Or-
ganic Acids — Sulfuric, Hydrochloric [Muri-
atic], Phosphoric, Trichloroacetic, Glacial
Acetic)

Do not give emetics. Have the patient swallow
quickly some alkali such as milk of magnesia, lime
water or aluminum oxide gel. Avoid carbonates if
possible in order to reduce gas formation in the
stomach. Give milk, linseed tea or white of egg
beaten with water. Morphine sulfate 15 mg. (Vi
grain) may be given to control pain. Food admin-
istration may present a problem; therefore, glu-
cose rectally or intravenously should be considered.
Surgical treatment may be necessary. Cortisone, 5
mg. per pound of body weight per day adminis-
tered in four divided doses, may be used in severe
cases to allay fibrosis.

664

Miscellaneous Poisonings, Acute — continued

44. COTTON ROOT BARK

Give universal antidote or activated charcoal and
follow with gastric lavage using 1:1000 potassium
permanganate solution (a 0.3 gram (5 grains)
tablet dissolved in 30 ml. [10 fl. oz.] of water), or
an emetic. Keep the patient warm and in bed.
Oxygen therapy (p. 657) may be necessary. Give
drinks of strong tea or coflFee or injections of caf-
feine and sodium benzoate 0.5 gram (7^ grains)
as stimulants.

45. CRAYONS (Chalk Crayons, Wax Crayons)

Chalk crayons are likely to contain lead, copper,
arsenic or chromium pigments. Wax crayons are
likely to contain toxic dyes.

Give universal antidote or activated charcoal
and follow by gastric lavage using water, normal
saline or 2 per cent sodium bicarbonate solution (3
heaping teaspoonfuls per quart) or by an emetic.
Methemoglobinemia or mild symptoms of aniline
poisoning require treatment as outlined for aniline
(14).

46. CROTON OIL (Oleum Tiglii, Karathane)

Give white of egg beaten with water or flour
mixed with water; follow by gastric lavage or an
emetic. Fluid therapy may be necessary to control
shock or dehydration (p. 657). Injections of mor-
phine sulfate 15 mg. {Vi grain) with atropine sulfate
0.6 mg. (%oo grain) will relieve pain and spasm.
Drinks of tea or coffee or aromatic spirit of am-
monia 4 ml. (a teaspoonful) ia a wineglassful of
water are recommended.

47. CUTICLE REMOVER (Cutex)

Give an emetic or perform gastric lavage. Fol-
low with a glass of milk or white of egg beaten
with water or a spoonful of olive oil. The material
may be caustic; if so, follow treatment as described
for caustic alkali (6).

48. CYANAMIDE (Calcium Cyanamide)

Spontaneous recovery occurs in a few hours if the
drug has been inhaled.

Following ingestion, empty the stomach by gas-
tric lavage or by an emetic. Do not administer caf-
feine, theobromine, chloral hydrate or alcohol as
medication.

49. CYANIDES (Hydrocyanic Acid [Hydrogen
Cyanide, Prussic Acid, Acid Borussicum];
Sodium and Potassium Cyanide; Cyanogen
Chloride; Acrylonitrile [Vinyl Cyanide])

Treatment must be rapid to be of any value at all.

If swallowed, drink quickly a glass of sodium
thiosulfate solution (a level teaspoonful in 3 fl. oz
of water). Remove with an emetic or by gastric
lavage. Give amyl nitrite by inhalation, using arti-

ficial respiration if necessary. Oxygen therapy (p.
657) may be required. Administer slowly intra-
venously (2.5 to 5 ml. per minute) 10 ml. of 3 per
cent (30 mg. per ml.) sodium nitrite solution as
soon as possible and follow by injecting intra-
venously 50 ml. of a 25 per cent solution of sodium
thiosulfate. Repeat these injections using half
quantities if symptoms reappear. As an alternative
to the nitrite solution administer intravenously 50
ml. of a solution of 1 per cent methylene blue in
1.8 per cent sodium sulfate.

50. 2,4-D (2-4 Dichlorophenoxyacetic acid)

This weed-killer is not very toxic to animals or
man. If quantities of it are swallowed they should
be removed with an emetic or gastric lavage as
described for Petroleum Distillates (98).

51. DEPILATORY PREPARATIONS

Treatment as for barium (20) or for hair waving
lotions (thioglycollic acid [66]).

52. DICHLOROBENZENE ( Paradichlorobenzene,
Dichloricide, P.D.B.)

This insecticide is the least toxic of moth re-
pellants. Keep the patient warm and in bed; re-
move gastric contents with an emetic or gastric
lavage, after which give drinks of tea or coffee or
give caffeine and sodium benzoate 0.5 gram (7^
grains) intramuscularly. Administer a saline purge.
Avoid oil cathartics or fatty foods. Give demulcent
drinks. Fluid therapy (p. 657) may be necessary.
The diet should be high in carbohydrate, vitamins
and protein.

53. DIETHYLENE GLYCOL (Diethylene Ether)

Empty the stomach with gastric lavage or with
an emetic immediately. Fluid therapy (p. 657) is
essential. Remove the patient to a hospital because
delayed and severe kidney damage may result.
This poison should not be confused with ethylene
glycol (antffreeze).

54. DIGITALIS AND RELATED GLYCOSIDES (Digi-
toxin, Digoxin, Lanatoside C, Ouabain,
Strophanthin )

Administer 5 to 6 heaping teaspoonfuls of uni-
versal antidote or activated charcoal and remove
the stomach content with an emetic or gastric
lavage. Keep the patient in bed and as quiet as
possible. Administer morphine sulfate 10 to 15 mg.
(Ye to Vi grain) to control pain of vomiting and
diarrhea. Although no specific antidote has been
suggested for this type of poisoning, it is recom-
mended that the loss of serum potassium which
occurs be replaced by giving Darrow's solution in-
travenously at a rate not in excess of 0.5 mEq. per
kg. per hour.

Miscellaneous Poisonings, Acute — continued

665

55. DINITROPHENOL

Mild cases require no treatment. In severe cases
perform gastric lavage vi^ith 5 per cent sodium bi-
carbonate solution (about 3 level teaspoonfuls in 8
fl. oz. of water) or with 1 : 1000 potassium perman-
ganate (a 5 grain tablet dissolved in 10 fl. oz. of
water). Fluid therapy (p. 657) may be necessary
and so may oxygen therapy (p. 657). The patient
should be hospitalized as soon as possible.

56. ECBOLIC AND VOLATILE OILS (Pennyroyal,
Savin, Rue, Tansy, Nutmeg, Apiol, Euca-
lyptus, Menthol)

Treatment as for turpentine ( 127) .

57. EPINEPHRINE (Adrenalin)

Intravenous injections of piperoxan (benzodi-
oxan, Benodaine) 10 to 20 mg. have been recom-
mended recently since it has fewer side effects and
appears effective. Administer supportive therapy.

58. ERGOT (Ergotoxine, Ergotamine Tartrate,
Ergometrine Maleate, Liquid Extract of Er-
got)

Give universal antidote or activated charcoal and
follow with gastric lavage or with an emetic. Leave
some activated charcoal and 3 to 4 heaping tea-
spoonfuls of Epsom salt in the stomach. Keep the
patient in bed and warm; an electric pad or hot
water bottles may be necessary. Oxygen therapy
(p. 657) may be required. Stimulants such as tea
or coffee or injections of caffeine and sodium benzo-
ate 0.5 gram (7^ grains) are useful. Morphine
sulfate 15 mg. (^ grain) may be injected to control
pain and quiet a patient in threatened abortion.
Watch for evidence of gangrene in the extremities.

59. ETHYLENE GLYCOL (Antifreeze)
Treat as for oxalic acid (93) .

60. ETHYLENE OXIDE

Blisters which appear several hours after ex-
posure to this fumigant should be treated with
sterile petrolatum pressure dressings.

If the material is ingested, remove gastric con-
tent with gastric lavage and administer supportive
measures.

61. FERN, MALE (Felix Mas, Male Fern, Aspid-
ium. Oleoresin, Oleoresin of Male Fern, Ex-
tract of Male Fern )

Administer an emetic or remove stomach content
with gastric lavage. Control convulsions by use of
phenobarbital or Amytal (amobarbital) Sodium.
Oxygen therapy (p. 657) may be necessary. Give
demulcent drinks but do not administer fats, oils
or alcohol. Caffeine and sodium benzoate 0.5 gram
(7y2 grains) intravenously or 1 to 4 ml. nikethamide

25 per cent solution or amphetamine sulfate 5 to 10
mg. may be used to combat collapse.

62. FINGER NAIL POLISH

The toxic ingredients are not known.

Give universal antidote or activated charcoal and
follow with gastric lavage or an emetic. Give drinks
of milk, white of egg beaten with water or a spoon-
ful of olive oil. Do not give castor oil. Keep the
patient quiet and under careful observation for
some hours for symptoms from absorbed drugs.

63. FLUORIDES (Sodium Fluoride, Potassium
Fluoride, Fluosilicates, Sodium Fluoroace-
tate. Sodium Fluoaluminate, DFDT)

Swallow quickly a solution of some soluble cal-
cium salt — lime water, calcium gluconate or cal-
cium lactate. Remove gastric content by means of
an emetic or with gastric lavage. Keep the patient
in bed, warm and as quiet as possible. Morphine
sulfate 15 mg. (M grain) may be used to control
pain if respiration is not too seriously depressed.
Oxygen therapy (p. 657) may be required. Give
demulcent drinks and olive or salad oil. Restore the
blood calcium by injections of 10 ml. of a 10 per
cent calcium gluconate solution intravenously. Bar-
biturates may be employed to control convulsions.

64. FOOD POISONING (Due to Fungi, Mush-
rooms, Toadstools, False Morels, etc.)

Since these poisons may resemble muscarine in
action, atropine sulfate 0.6 mg. (l^oo grain) may be
injected and repeated in an hour as a parasympa-
thetic depressant. Give universal antidote or acti-
vated charcoal and remove with an emetic or gastric
lavage using 1:1000 potassium permanganate solu-
tion (a 5 grain tablet dissolved in 10 fl. oz. of
water) if vomiting has not begun. Keep the pa-
tient warm and in bed. Hypodermic injections of
morphine sulfate or meperidine (Pethidine, Dem-
erol) with or without atropine may be given to
relieve pain. Flmd therapy (p. 657) may be neces-
sary when there is marked dehydration. Restrict
the diet to fruit juices, soups, tea and sugar for
twenty-four hours. Avoid meats. In cases of per-
sistent excitement, give barbiturates. A saline cathar-
tic may be given to clear the intestine of poisonous
material.

65. FORMALDEHYDE (Formalin, Trioxymethy-
lene. Paraformaldehyde)

Swallow quickly well diluted ammonia or solu-
tion of ammonium acetate or aromatic spirit of am-
monia or milk or white of egg beaten with water.
Remove the gastric content with an emetic or gas-
tric lavage with a diluted ammonia cal solution (see
above). Give demulcent drinks and control acidosis
by intravenous sodium bicarbonate solution or so-
dium r-lactate solution.

666

Miscellaneous Poisonings, Acute — continued

66. HAIR WAVING PREPARATIONS (Cold Wave,
Thioglycollic Acid, Perborates and Bro-
mates of Sodium and Potassium)

If the solution ingested is strongly alkaline due to
thioglycollic acid, treat for caustics (6). Perborates
will give rise to boric acid poisoning (26). Bromates
are as toxic as chlorates (109) and have greater
central depression. A marked dermatitis may accom-
pany the poisoning.

67. HEADACHE REMEDIES AND OTHER ANAL-
GESICS (1) (Acetanelid [Antifebrin]; Aceto-
phenetidin [Phenacetin]; Aminopyrine
[Amidopyrine, Pyramidon]; Phenazone [An-
tipyrine] )

Administer universal antidote or activated char-
coal and follow with an emetic or gastric lavage.
Keep the patient warm and in bed. Control de-
pressed respiration with oxygen therapy (p. 657)
and cyanosis by 6 to 10 ml. of a 1 per cent solu-
tion of methylene blue intravenously. Strophanthin
0.3 mg. (%oo grain) intravenously may be given at
half-hour intervals for a failing myocardium. Blood
transfusion may be necessary.

68. HEADACHE REMEDIES AND OTHER ANAL-
GESICS (II) (Acetyl SaJicylic Add [Aspirin],
Methyl Salicylate, Sodium Salicylate, Oil of
Wintergreen, Salicylic Acid, Salol, Salicyla-
mide)

Administer universal antidote or activated char-
coal and follow with an emetic or gastric lavage.
Determine first whether the patient is suflFering from
metabolic acidosis or respiratory alkalosis by deter-
mining the blood pH and the CO2 combining
power. Acidosis may be controlled by the intra-
venous use of 2.5 per cent solution of sodium bicar-
bonate. In a severe case 50 ml. of this solution
should be given stat. Further bicarbonate should be
given only after the pH has been rechecked. If the
pH reveals alkalosis the patient may be made to
rebreathe his own CO2 or he may be given 5 per
cent COi inhalation. If the alkalosis is severe and
the patient develops tetany, 10 per cent calcium
gluconate should be given intravenously. Short-act-
ing barbiturates may be given to control excite-
ment. Epinephrine solution (1:1000) 0.5 ml. may
be necessary to alleviate laryngeal spasm.

69. HEADACHE REMEDIES AND OTHER ANAL-
GESICS (III) (Cinchophen [Quinophan,
Atophan]; Neocinchophen [Novatophan,
Tolysin, Neoquinophan] )

Acute poisoning by these analgesics resembles
that of sahcylate (68). They may also cause hema-
turia and toxic hepatitis which may proceed to a
fulminating yellow atrophy of the liver.

70. HEMLOCK, POISON

Universal antidote or activated charcoal should
be given and followed with gastric lavage or an
emetic. Keep the patient warm and in bed; an elec-
tric pad or hot water bottle may be needed. Give
drinks of tea or coflEee or injections of caffeine and
sodium benzoate 0.5 gram (7% grains) or of am-
phetamine.

71. HEMLOCK, WATER

Universal antidote or activated charcoal should
be given and followed with gastric lavage or an
emetic. Control convulsions by injections of pento-
barbital or Amytal (amobarbital) Sodium. Intrave-
nous calcium gluconate may be necessary if liver
damage becomes apparent.

72. HYDROGEN SULFIDE

Death may be very sudden and is usually pre-
ceded by asphyxial collapse.

Remove the patient immediately from the poison-
ous atmosphere and give oxygen therapy (p. 657).
Nikethamide 1 to 2 ml. of a 25 per cent solution
or Metrazol (pentylenetetrazol) 100 to 400 mg. in
a 10 per cent solution (1 to 4 ml.) may be injected
intravenously. The nikethamide may be repeated in
a few minutes if necessary. Caffeine and sodium
benzoate 0.5 gram (7% grains) injected intrave-
nously is also recommended.

73. HYOSCINE (Scopolamine)

Treatment is mainly as for atropine (21), but if
there is a general depression it may be relieved by
the intravenous injection of 1 to 4 ml. of a 25 per
cent solution of nikethamide or 1 to 3 ml. of a 10
per cent solution of Metrazol (pentylenetetrazol).

74. INDALONE (Rutgers 6-1-2; 2-Ethyl Hexane-
diol-1,3; Dimethyl Phthalate, Endothal)

If these insect repellants have been ingested, per-
form gastric lavage as quickly as possible or give
an emetic. Keep tbe patient warm and in bed. Fluid
therapy (p. 657) may be necessary for renal dam-
age. Keep the diet high in protein and carbohy-
drate and low in fat.

75. INK AND INDELIBLE PENCIL

The dyes in these materials usually are not very
toxic. Give universal antidote or activated charcoal
and follow with an emetic or gastric lavage.

76. INSECT BITES (Ant Bites, Bee Stings, Spider
Bites [Black Widow Spider], Wasp Stings)

These cases are rarely fatal, but a severe anaphy-
lactic shock may require immediate energetic treat-
ment. Make the patient lie down. Urticaria may be
controlled by 0.5 ml. of 1:1000 epinephrine subcu-
taneously. Remove the stinger if it is present.
Cover wounds with a paste of baking soda or am-
monia or washing soda (any alkaline material made
into a paste). Injections of ACTH have proved

I

Miscellaneous Poisonings, Acute — continued

667

beneficial in cases of wasp sting and of black
widow spider bites. Sedatives may be administered
to control excitement. (See also pp. 689, 691.)

77. IODINE (Tincture of Iodine)

Give plenty of water with starch or flovir or, if
possible, 4 level teaspoonfuls of sodium thiosulfate
in water. Remove the gastric content with an emetic
or gastric lavage. Give drinks of water or white of
egg beaten with water. Inject morphine sulfate 15
mg. (^ grain) to relieve pain if necessary.

78. IRON SULFATE (Ferrous Sulfate)

Administer quickly sodium bicarbonate solution
(a level teaspoonful of baking soda in 3 fl. oz. of
water) . Induce vomiting or perform gastric lavage
with more bicarbonate solution. Give 0.2 gram (3
grains) bismuth carbonate every four hours. Main-
tain fluid balance (p. 657). For shock see p. 657.

79. LEAD (Lead Acetate [Sugar of Lead], Lead
Subacetate, Tetraethyl Lead)

Administer quickly some soluble sulfate in solu-
tion— Epsom salt, sodium sulfate or aluminum sul-
fate. Emesis usually occurs, but if it does not, re-
move the gastric contents by means of an emetic or
gastric lavage. Keep the patient warm and in bed.
Morphine sulfate 15 mg. i}A grain) may be used to
control pain. Oxygen therapy (p. 657) may be re-
quired. Removal of the lead from the tissues should
be carried out later in a hospital by means of cal-
cium EDTA. If tetraethyl lead is spilled on the skin
it should be washed off immediately with kerosene
or gasoline.

80. LETHANE 384 ( Beta-butoxy-beta-thiocyano-
diethylether, Thiocyano Diethyl Ether,
Lethane 60)

Refer to Cyanides (49).

81. LINDANE (B.H.C., Benzene Hexachloride,
Gammexane (the Gamma Isomer), Gamma
Benzene Hexachloride)

When skin contamination occurs, clean the area
well with soap and water; remove contaminated
clothing and clean it thoroughly. Remove ingested
material quickly by means of an emetic or gastric
lavage using dilute Epsom salt solution. Leave
about 3 to 4 heaping teaspoonfuls of Epsom salt
or Glauber's salt in solution in the stomach. Do
not use an oil cathartic or give injections of mor-
phine. Administer oxygen before pulmonary compH-
cations develop. Drinks of tea or coffee or injections
of caffeine and sodium benzoate 0.5 gram (7^
grains) subcutaneously or intramuscularly may be
given. If tremors develop, administer either pheno-
barbital or Amytal (amobarbital) Sodium orally or
by injection as required. Careful nursiQg may be
necessary for at least forty-eight hours. The diet
should be high in protein and low in fat. Give 2
grams of methionine or choline every two hours to

combat liver damage. Blood transfusion may be
necessary.

82. MEPERIDINE HYDROCHLORIDE (Pethidine
Hydrochloride, Isonipecaine, Demerol, Do-
lantin, Dolantol)

If the drug has been ingested, give universal
antidote or activated charcoal and follow with gas-
tric lavage or an emetic. Tremors or convulsions
may be controlled by N-allylnormorphine (Nalline)
in 5 to 10 mg. doses repeated after 10 to 15 min-
utes or by injections of Amytal (amobarbital)
Sodium.

83. MERCURY (Mercuric Oxycyanide, Mercuric
Chloride, Mercuric Nitrate, Mercury Bi-
chloride [Corrosive Sublimate], Mercuric
Cyanide, Mercuric Oxide, Mercuric Potas-
sium Iodide, Mercurous Chloride [Cal-
omel], Mercurous Oxide, Ammoniated Mer-
cury, Mercurial Diuretics [Mercurophyl-
line], Mercurochrome, Merthiolate [Thimer-
osal], Metaphen, Merbromin)

Metallic mercury ingested in small quantity (as
from a broken thermometer) is not toxic; it may
be removed by a saline cathartic.

Administer quickly universal antidote or acti-
vated charcoal or albuminous foods — white of egg
beaten with water, milk, gelatin, ground meat, etc.
Remove this material from the stomach with an
emetic or gastric lavage if it can be performed.
Wash the stomach with a sodium bicarbonate so-
lution made by dissolving a level teaspoonful of the
salt in 6 fl. oz. of water. Calcium gluconate, 10 ml.
of a 10 per cent solution, may be used intra-
venously or intramuscularly to control muscle
spasm. Administer BAL (p. 658).

84. METALDEHYDE (Meta)

Give universal antidote or activated charcoal and
empty the stomach with an emetic or gastric lavage.
Leave 3 or 4 heaping teaspoonfuls of Epsom salt
or sodium suffate dissolved in water in the stomach.
Keep the patient warm and in bed. Fluid therapy
may be required (p. 657). Calcium gluconate, 10
ml. of a 10 per cent solution may be needed to
arrest tetany. Amphetamine may be administered
orally or parenteraUy if a stimulant is needed. In
case of serious cardiac disturbance, injection of a
digitalis glycoside is recommended.

85. METAL FUME FEVER (Brass Founder's Ague,
Zinc Fever)

The fever, chills, etc., which occur several hours
after exposure to the fumes are serious but nonfatal;
the attack ends in twelve to twenty-four hours.

86. METHYL BROMIDE

Remove the patient from the fumes. Treat as for
methyl chloride (87).

668

Miscellaneous Poisonings, Acute — continued

87. METHYL CHLORIDE

Remove the patient from the fumes and adminis-
ter oxygen if respiration is depressed. Treat acido-
sis with 5 per cent sodium bicarbonate solution or
sodium r-lactate solution as for methyl alcohol (4).
Restlessness may be controlled by bromides or by
Amytal (amobarbital) Sodium. Convalescence is
slow,

88. NAPHTHALENE (Naphthaline, Naphthalene
Camphor, Tar Camphor, Albocarbon, Moth
Balls, Camphylene, Alabastine, Tetralene)

Keep tiie patient warm and in bed. Remove the
gastric content by an emetic or by gastric lavage.
Give drinks of tea or coffee or give caffeine and
sodium benzoate 0.5 gram (7% grains) intramuscu-
larly as a stimulant. Administer a saline purge;
avoid castor oil or fatty foods. Drinks made of egg
white beaten with water or of milk may be helpful.
Give fluid therapy (p. 657) as required. The
physician should bear in mind that acute hemolytic
anemia with a crisis may follow ingestion of even a
small quantity of naphthalene, requiring a blood
transfusion.

89. NICOTINE (Black Leaf 40, Tobacco)

Mild cases are not serious, and symptoms subside
as a rule in a few hours.

In acute poisoning, swallow quickly universal an-
tidote or activated charcoal suspended in water;
tannic acid or strong tea may serve as a substitute.
Remove the gastric content by gastric lavage using
1:1000 potassium permanganate solution (0.3
gram [5 grains] tablet dissolved in 300 ml. [10 fl.
oz.] of water); leave about two ounces of the per-
manganate solution in the stomach. Failing gastric
lavage, empty the stomach with an emetic. Keep
the patient in bed and warm with an electric pad.
Forty mg. of ephedrine sulfate may be used to
maintain circulation. Oxygen therapy (p. 657)
may be required. In mild poisoning excitement may
be relieved by pentobarbital sodium 100 mg. or
Amytal (amobarbital) Sodium 60 to 200 mg.

90. NIKETHAMIDE (Coramine)

If ingested, remove the stomach content with an
emetic or gastric lavage. Oxygen therapy may be
required (p. 657). Control tremors or convulsions
by use of suitable doses of Amytal (amobarbital)
Sodium or phenobarbital.

91. NITROCHLOROFORM

Remove the patient from the contaminated area
and give oxygen therapy (p. 657) if respiration is
diflBcult; artificial respiration may be necessary.
Wash the contaminated areas of the skin with an
alcohohc solution of sodium sulfate. Keep the pa-
tient in bed and warm and quiet. Respiratory stim-
ulants are not contraindicated.

92. OPIUM AND BARBITURATES

Not discussed in this section. See pp. 651, 653.

93. OXALIC ACID AND OXALATES (Oxalic Acid
[Essence of Sugar, Acid of Sugar]; Potas-
sium Oxalate; Potassium Binoxalate [Salt of
Sorrel]; Potassium Quadroxalate [Essential
Salts of Lemon]; Sodium Oxalate; Rhubarb
Leaves )

Promptly administer in water 5 to 6 heaping tea-
spoonfuls of calcium lactate or saccharated solu-
tion of lime or chalk or plaster to form insoluble
calcium oxalate. Lacking these, give milk or cheese
in large quantities or milk of magnesia or Epsom
salt. Potassium permanganate 300 ml. (10 fl. oz.)
1:1000 solution (a 0.3 gram [5 grains] tablet dis-
solved in 300 ml. [10 fl. oz.] of water) may be
swallowed or used as a gastric lavage. An emetic
may be employed to remove the stomach content.
Keep the patient in bed and warm. Give demulcent
drinks or mflk. Calcium gluconate by mouth is of
value in restoring the blood calcivmi. Fluid therapy
(p. 657) may be necessary to increase diuresis.

94. PARAPHENYLENEDIAMINE (ORSIN) AND RE-
LATED PHENYLENE DIAMINES

If ingested, administer an emetic or empty the
stomach with gastric lavage. Keep the patient in
bed and as quiet as possible. Oxygen therapy (p.
657) may be necessary to relieve asthma, or it may
be relieved by ephedrine, epinephrine or amino-
phyUine. For tremors and convulsions give Amytal
(amobarbital) Sodium or pentobarbital sodium.

95. PENTYLENETETRAZOL (Leptazol, ]VIetrazol
Cardiazol)

// ingested, administer universal antidote or ac-
tivated charcoal and remove stomach content with
an emetic or gastric lavage. Control convulsions by
use of ether or other gaseous anesthetic or by use of
barbiturates, chloral or paraldehyde.

96. PEST CONTROL POISONS (Insecticides, Pest-
icides, Herbicides) (I)

I

Calcium polysulfide
Chloro I.P.C. (isopropyl

N- ( 3-chlorophenyl )

carbamate )
C.M.U. (3-(p-chloro-

phenyl ) -1-dimethyl-

urea)
Crag Herbicide (sodium

2,4-dichlorophenoxy-

ethylsulf ate )
DDT
Dilan

Ethyl mercury chloride
Glyodin
Kiu-on
Maneb
Manzate

M.G.K. 264

Nabam

Ovotran

Penta

Perma

Permatox

Propham

Phygon

Sodium N-methyldithio-

carbamate dihydrate
Sodium trichloroacetate

(TCA)
Sulfenone
Sulfoxide
Thiram ( Tetramethylthi-

uramdisulfide )

Miscellaneous Poisonings, Acute — continued

669

No specific treatment has been recommended for
the poisons hsted above. With these, danger may
arise from contamination when the material is ab-
sorbed by the skin or is inhaled. If commercial
preparations contain petroleum distillates, see 98.
The solvent may increase the toxicity. When skin
contamination occm-s the areas should be washed
thoroughly with soap and water. If marked irrita-
tion develops in the eyes, they should be flushed
with water 10 to 15 minutes. When the drug has
been ingested, remove it from the stomach with
an emetic or with gastric lavage and follow by ad-
ministering demulcent drinks. The doctor must use
his own judgment in giving supportive therapy.

97. PEST CONTROL POISONS (Insecticides,
Pesticides, Herbicides) (II)

Actidione Neotran (bis(p-chloro-
Allethrin phenoxy) methane)

Ammate (ammonium sul- Piperonyl butoxide

f amate ) Piperonylcyclonone

Butyl carbityl ether Pyrethrum (pyrethrum
Butyl carbityl-6-( propyl- flowers)

piperonyl) Ricin

Captan Rotenone (derris root)

Castrix Ryania

Diazinon Sabadilla

Ferbam Sodium selenate
Isobomyl thiocyanoacetate

( Thanite )

For the above poisons, no specific treatment has
been recommended. When they have been ingested,
induce vomiting or remove gastric content by gastric
lavage. Fluids such as milk or demulcents may be
administered. Following the removal of the material,
the doctor must use his own judgment in giving
supportive therapy. Nembutal (pentobarbital) is
recommended to control convulsions when they oc-
cur.

98. PETROLEUM DISTILLATES (Kerosene, Gaso-
line, Naphtha, Petroleum Spirits, Petroleum
Ether, Petroleum Naphtha, Petroleum Ben-
zine, Benzine, Petrol)

If the drug has been ingested, swallow quickly 4
fl. oz. (120 ml.) of liquid parafiin (mineral oil) and
begin gastric lavage using sodium bicarbonate,
5 level teaspoonfuls in a quart of water. Gastric
lavage is preferable to removal of the gastric con-
tents by an emetic. In any event, the head must be
lower than the hips as the gastric content is re-
moved. Keep the patient in bed and warm. One to
4 ml. of nikethamide 25 per cent solution or caffeine
and sodium benzoate 0.5 gram (7% grains) may be
used as a stimulant if necessary. Use intramuscular
penicillin prophylactically. Pneumonia and kidney
comphcations may occiu- later.

99. PHENOLPHTHALEIN AND PODOPHYLLIN

About an ounce of propylene glycol in an ounce
of water is said to be a specific antidote. Administer

universal antidote and remove gastric contents with
an emetic or gastric lavage. iTiere is usually mild
to violent purging, but death does not occur. A rash
accompanied by severe itching may appear.

Podophyllin, which also acts as a purgative, may
be treated in a similar manner; fluid therapy (p.
657) may be necessary because of damage to the
kidneys.

100. PHENOLS (Phenol [Carbolic Acid]; Cresol
[Cresyl Hydrate Tricresol, Oxytoluene,
Methyl Phenol, CresyHc Acid]; Resorcinol
Metadihydroxybenzene] ; Hexyhresorcinol )

Medication must be prompt.

Swallow quickly about 7 fl. oz. (200 ml.) of 10
per cent alcohol or whisky diluted 1:3. If stronger
alcoholic solutions can be swallowed, all the better,
since alcohol is a solvent for phenol. Give any salt of
calcium to form calcium phenolate, or administer
Epsom salt, milk or white of egg beaten with water.
Remove the gastric content with gastric lavage
using a well lubricated tube. Continue lavage with
warm water until all odor of phenols has disap-
peared. Administer caffeine and sodium benzoate
0.5 gram (7^ grains) subcutaneously or intra-
venously. Wash burns on the skin with rubbing
alcohol. Oxygen therapy (p. 657) and fluid therapy
(p. 657) may be necessary.

101. PHENOTHIAZINE

Wash contaminated areas with plenty of water. If
the material has been ingested, induce vomiting or
remove it by gastric lavage. Oxygen therapy (p.
657) may be required, and blood transfusion may
be necessary if tiiere are signs of blood destruc-
tion. The poisoning is rarely fatal.

102. PHOSGENE (Carbonyl Chloride)

Remove the patient from the contaminated at-
mosphere and keep him in bed, as quiet as possible
and warm, using electric pads, etc., as necessary.
Oxygen therapy (p. 657) may be required. Cough-
ing may be controlled by codeine, Dilaudid (di-
hydromorphinone) or Metapon or some other cough
depressant.

103. PHOSPHATES, ORGANIC

Bis(dimethylamino) phos-
phorus anliydride

Chlorothion

EPN (o-ethyl-o-(p-nitro-
phenyl ) thionobenzene
phosphonate )

HETP (hexa-ethyltetra-
phosphate )

Malathion

Metacide ( di-methyl-p-
nitrophenylthiopnos-
phate )

Methyl parathion
Ompa ( octamethylpyro-

phosphorainide )
Para-oxon
Parathion ( di-ethylnitro-

phenylphosphate )
Schradan
Sulfotepp
Systox
TEPP (tetra-ethylpyro-

phosphate )
Tetraethyldithionopyro-

phosphate

670

Miscellaneous Poisonings, Acute — continued

The specific antidote for these poisons is atropine
sulfate in large doses, 1 to 2 mg. {Vao to %o grain)
administered quickly intravenously and repeated
every hour. Doses up to 20 mg. (Vs grain) may be
given daily. Postural drainage may be necessary if
secretions are excessive, and oxygen therapy should
be available. Morphine injections are contrain-
dicated.

104. PHOSPHORUS (Isopestox)

The best antidote for phosphorus is copper sulfate
0.3 gram (5 grains) in water swallowed quickly and
followed with gastric lavage using sodium bicarbo-
nate (12 level teaspoonfuls dissolved in a quart of
water). Potassium permanganate 1 per cent solu-
tion may be used in gastric lavage together with
5 to 6 heaping teaspoonfuls of activated charcoal
stirred to a thin paste. If these cannot be secured,
swallow 4 fl. oz. (120 ml.) of liquid paraflBn (min-
eral oil) and follow with gastric lavage. Treat for
Hver damage as indicated for carbon tetrachloride
(36).

105. PICRIC ACID (Trinitrophenol, Trinitrophen)

Administer quickly some protein material — white
of egg beaten with water, milk, finely ground
cheese, etc. Remove this material from the stomach
with an emetic or with gastric lavage. Fluid therapy
(p. 657) may be necessary if there is much dehy-
dration. Cathartics are not indicated.

106. PIPERAZINE CITRATE (Antepar)

Perform gastric lavage or give an emetic; symp-
tomatic therapy as indicated.

107. PIVAL (2-Pivalyl-l; 3-Indanedione)

Remove the drug from the stomach with an
emetic or with gastric lavage. Control hemorrhage
by intravenous injections of vitamin Kj. Blood trans-
fusions may be necessary.

108. PLANT POISONS (General)

Administer activated charcoal or universal anti-
dote to remove any toxic alkaloids or glycosides;
follow with gastric lavage or an emetic. Leave some
activated charcoal in the stomach. Give drinks of
tea or coflFee; children tolerate tea better than cofiFee.
Excitement, tremors or convulsions may be de-
creased by administering barbiturates orally or by
injections. If there is much vomiting or purging
give fluid therapy (p. 657) .

109. POTASSIUM CHLORATE AND POTASSIUM
BROMATE

Administer an emetic or perform gastric lavage
and leave 3 to 4 heaping teaspoonfuls of Epsom
salt dissolved in water in the stomach. Give copious
fluids by mouth; fluid therapy may be necessary as

well (p. 657). Authorities differ on the use of
methylene blue to combat cyanosis. Cardiac stimu-
lants may be required.

110. POTASSIUM NITRATE (Saltpeter, Niter)

Administer an emetic or perform gastric lavage.
Keep the patient warm and in bed; an electric pad
may be necessary; massage the hmbs. Caffeine and
sodium benzoate 0.5 gram (7% grains) subcu-
taneously or intravenously may be given as a stim-
ulant. Give mucilaginous drinks, white of egg
beaten with water or olive oil.

111. POTASSIUM NITRITE ( Sodium Nitrite)
Treat as for Aniline ( 14) .

112. POTASSIUM PERMANGANATE (Condy's
Crystals, Chameleon Mineral, Sodium Per-
manganate )

Administer activated charcoal and follow with an
emetic or gastric lavage. Leave 3 to 4 heaping
teaspoonfuls of Epsom salt dissolved in water in
the stomach. Give milk and demulcent drinks. Fluid
therapy may be necessary (p. 657) .

113. PROPENE NITRILE

The symptoms may resemble those of cyanide
poisoning, and treatment should be as described for
cyanides (49).

114. 2(3'PYRIDYL) PIPERIDINE

The symptoms usually resemble those arising
from nicotine poisoning, and treatment is as de-
scribed for nicotine (89) .

115. QUININE (Quinidine)

Administer universal antidote or activated char-
coal and remove stomach content with gastric lavage.
Keep the patient warm and in bed. Oxygen therapy
(p. 657) may be required. Caffeine and sodium
benzoate 0.5 gram (7^ grains) may be adminis-
tered subcutaneously or intravenously. Control
acidosis by intravenous sodium r-lactate solution or
by sodium bicarbonate orally. Barbiturates may be
injected hypodermically or intravenously if excite-
ment occurs. In extreme cases intracardiac injection
of epinephrine solution 1:1000 has been recom-
mended.

116. SILVER (Silver Nitrate [Lunar Caustic],
Silver Cyanide, Photographic Preparations,
Argyrol )

Lips and mucous membranes will be brown or
black. Give 3 to 4 teaspoonfuls of salt in water to
form insoluble silver chloride, which can be re-
moved with an emetic or with gastric lavage. Give
demulcent drinks and morphine sulfate 8 mg. {%
grain) by injection as necessary to control pain;

Miscellaneous Poisonings, Acute — continued

671

codeine 60 mg. (1 grain) orally may suflBce. Leave
4 heaping teaspoonfuls of saline purgative dissolved
in ample water in the stomach. Fluid therapy (p.
657) or treatment for shock (p. 657) may be neces-
sary.

117. SQUILL (Red or White)

Since the cardiac glycosides in squill resemble
those of digitalis, see (54).

118. STRYCHNINE (Nux Vomica)

Medication must be administered quickly. Give
universal antidote or activated charcoal in a thin
paste and remove the gastric content with gastric
lavage using 10 to 15 fl. ox. (300 to 450 ml.) of
1:1000 potassium permanganate solution (a 0.3
gram [5 grains] tablet dissolved in 300 ml. [10 fl.
oz.] of water) or an emetic. Convulsions may be
controlled quickly by ether or chloroform or nitrous
oxide. Intravenous pentobarbital sodium 0.1 gram
{IVz grains) or, better, Amytal (amobarbital)
Sodium 0.2 gram (3 grains) should be adminis-
tered and repeated as the occasion calls for it.
Emetics may be used only in the first few minutes
after the drug has been swallowed, as convulsions
will interfere with emesis; there is also only a lim-
ited time for use of gastric lavage unless ether, etc.,
is given. Leave ample activated charcoal in the
stomach after gastric lavage.

119. SULFONAMIDES (Sulfa Drugs)

Stop the administration of the drugs immedi-
ately. If large doses have been swallowed, give an
emetic or perform gastric lavage. Force fluids orally
or parenterally and alkalinize the urine by admin-
istering sodium bicarbonate orally or intravenously.
Hospitalize the patient to determine blood levels
of the drug and further treatment.

120. SULFUR DIOXIDE

Prompt removal of the patient from the gas is
important. Oxygen therapy (p. 657) and fluid
therapy (p. 657) may be required. Give drinks of
tea or coffee or an injection subcutaneously or in-
travenously of caffeine and sodium benzoate 0.5
gram (7% grains). Keep the patient at complete
rest in bed. To relieve bronchial spasm inject 0.5
ml. 1:1000 epinephrine subcutaneously. Acidosis
may be controlled by intravenous injections of so-
dium r-lactate or by giving sodium bicarbonate
orally.

121. THALLIUM

Administer a 1 per cent sodium iodide solution
and follow with drinks of milk. Remove gastric
contents with an emetic or gastric lavage. Shock
treatment (p. 657) may be necessary. Drinks of
tea or coffee or caffeine and sodium benzoate 0.5
gram (7^^ grains) intravenously or subcutaneously

may be used as stimulants. Hasten the excretion of
thallium by daily injections of 10 ml. of 50 per cent
sodium iodide solution or 10 ml. or more of 10 per
cent sodium thiosulfate solution. Frequent drinks of
tea or coffee to act as a diuretic and frequent
purging will also help to eliminate the thallium.

122. THEOPHYLLINE (Aminophylline, Soluphyl-
lin)

Discontinue use of the drug. Convulsions may be
controlled by suitable medication with pentobarbital
sodium or Amytal (amobarbital) Sodium. For dehy-
dration due to excessive vomiting see fluid therapy

(p. 657).

123. TIN COMPOUNDS

Remove the ingested material from the stomach
with an emetic or with gastric lavage. Give milk
and demulcent drinks. Control nervous symptoms
by suitable doses of Amytal (amobarbital) Sodium
or pentobarbital sodium.

124. TITANIUM OXIDE

This pigment in paints has so far not caused any
ill effects when ingested.

125. TOXAPHENE ( Octachlorocamphene, Chlori-
nated Hydrocarbons [I] )

If inhaled, recovery is usually rapid following
symptomatic treatment.

If ingested, administer an emetic or empty the
stomach with gastric lavage. Give a large dose of
mineral ofl. Control convulsions by use of intra-
venous or intramuscular injections of Amytal (amo-
barbital) Sodium or pentobarbital sodium.

Chlorinated Hydrocarbons (II)

Freon 11
Freon 12

HeptacMorocamphene
Methoxychlor
Pentachlorophenol ortho

dichlorobenzene
Perthane
Rothane (DDD)
Spergon

Aldrin

Aramite

l-Bromo-2-chloroethane

Chloranil

Chlordane

Chlorobenzilate

Dieldrin

Dipterex

Endrin

Ethylene dichloride

Since these may cause poisoning by contamina-
tion as well as when ingested, see Lindane (81).

126. TRANQUILIZERS ( Chlorpromazine [Lar-
gactil, Thorazine], Reserpine, Meprobamate
[Miltown, Equanil])

Perform gastric lavage as quickly as possible with
plenty of water. If tremors or convulsions develop,
as they may do with chlorpromazine (Largactil,
Thorazine) they may be controlled by barbiturates.
The hypotension following reserpine and meproba-

672

Miscellaneous Poisonings, Acute — continued

mate (Miltown, Equanil) may be treated with
ephedrine sulfate or arterenol. In the case of the
latter (meprobamate) catheterization, oxygen ther-
apy (p. 657) and fluid therapy (p. 657) may be
necessary.

127. TURPENTINE (Oil of Turpentine, Spirits of
Turpentine, Liniment of Turpentine, Ter-
pene Polychlorinate> Strobane)

Administer quickly about 4 fl. oz. (120 ml.) of
liquid paraffin (mineral oil, Hquid petrolatum) and
follow with an emetic or gastric lavage. Leave 3 to 4
heaping teaspoonfuls of Epsom salt or sodium sulfate
dissolved in plenty of water in the stomach if diar-
rhea has not occurred. Give milk, white of egg
beaten with water, gruel or barley water, with
drinks of strong tea or coffee if fluids can be toler-
ated. Keep the patient in bed and warm. Oxygen
therapy may be required (p. 657). Excitement may
be controlled by 100 mg. (1^ grains) of intrave-
nous pentobarbital sodium, and for intense pain
morphine sulfate 15 mg. (H grain) may be injected.

128. WARFARIN

Remove the ingested material with emetic or gas-
tric lavage as soon as possible after it has been
swallowed. The patient should be kept on a milk
diet and observed closely for a day or more. Vita-

min Ki should be employed to counteract bleeding
tendencies; a blood transfusion may be necessary.

129. ZINC COMPOUNDS (Zinc Chloride; Zinc]
Sulfate [White Vitriol, White Copperas];,
Zinc Undecylenate; Zinc Oxide)

For zinc arsenite and arsenate see Arsenic (18) .

For zinc silicofluoride see Fluorides (63).

Administer an emetic to remove all gastric con-
tent or employ gastric lavage. Give milk or egj
white beaten with water. Keep the patient in bee
and warm, applying heat to die abdomen. Drinks
of tea or coffee may be given. Morphine sulfate 15
mg. (Vi grain) may be injected intramuscularly to
control severe pain. Give injection of BAL (p.
658). Fluid therapy (p. 657) may be necessary.

130. ZINC PHOSPHIDE (Zineb, Zinc Ethylene-
bisdithio-carbamate, Zinc Dimethyldithio-
carbamate, Dithane)

If ingested administer an emetic or perform gas-
tric lavage with 1:1000 potassium permanganate
solution (a 0.3 gram [5 grains] tablet dissolved in
300 ml. [10 fl. oz.] of water). Clear the gastrointes-
tinal tract with a large dose of mineral oil. The
patient must be kept in bed and nursed carefully.

For skin contamination, wash the affected parts
thoroughly with water.

POISONOUS SUBSTANCES IN 48 HOUSEHOLD ITEMS

(Adapted from American Druggist)

Should a child swallow a product the label of which does not list ingredients, a glance at the table will show what poison the product
probably contains. Numbers in parentheses refer to appropriate paragraphs in the section on Miscellaneous Poisonings immediately
preceding this table.

Polishes and Waxes for Furniture and Floors

Petroleum Distillates

Kerosene (98)
Mineral seal oil (98)
Mineral spirits (98)

Naphtha, high boiling (98)
Spindle oil
Stoddard solvent
Summer black oil

Other Toxic Substances

Antimony chloride (19)
Caustic alkali (6)
Cellosolve

Isopropyl and butyl alcohols (3)
Nitrobenzene (14)
Oxalic acid (93)
Turpentine (127)

Paint Solvents and Related Products

Paint Brush Cleaners
and Preservatives

Acetone (2)

Caustic alkalis (6)

Cresols and higher phenols (100)

Dipentene (127)

Methanol (4)

Naphthalene (88)

Sodium chromate
Toluol (22)
Turpentine (127)

Paints, Putty, Varnishes

Arsenic (18) Lead (79)
Chromium Titanium (124)
Iron (78) Zinc (129)

Removers of Paint, Wax,
Lacquers, Grease Spots

Amyl acetate (12)

Alcohols — amyl, butyl, ethyl

(2) (3) (4)
Amylene dichloride
Benzene (22)
Butyl acetate

Carbon tetrachloride (36)
Caustic alkalis (6)
Ethyl acetate

Ethylene dichloride (13) (36)
Kerosene (98)
Methyl alcohol (4)
Methylene chloride (13) (36)
Toluene (22)

BiftMed

Lucas, George Herbert William
Miscellaneous poisonings

PLEASE DO NOT REMOVE
CARDS OR SLIPS FROM THIS POCKET

UNIVERSITY OF TORONTO LIBRARY