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

Lucas, George Herbert William 
Miscellaneous poisonings 



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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