10. POISONING

POISONING AND POISON INFORMATION CENTRES: A TEACHER’S COMPREHENSIVE GUIDE

Welcome, future clinical pharmacists and healthcare professionals!

Poisoning is the term used to describe the adverse effects on the human body caused by exposure to poisonous amounts of any substance, whether by accident or on purpose. A poison is any substance that, when consumed, inhaled, absorbed, applied to the skin, or created in relatively small amounts within the body, causes harm to the organism by its chemical activity.

As a pharmacy educator with years of experience teaching clinical toxicology, I have observed that students often find poisoning management challenging due to the wide variety of poisons and their diverse mechanisms of action. The ability to recognise poisoning symptoms, identify the causative agent, and administer appropriate antidotes can mean the difference between life and death. Poisons cause injury by causing damaging or destructive changes in cellular metabolism. They can act rapidly in case of a heroin overdose or over a period of time in case of chronic alcohol consumption. The majority of poisoned individuals have minor morbidity and recover completely in a short period of time.

In this comprehensive guide, I will walk you through the types of poisoning, clinical manifestations, treatment protocols, and the role of Poison Information Centres. By the end of this article, you will have a thorough understanding of poisoning management and the resources available to healthcare professionals. Let us begin our journey into the critical field of clinical toxicology.

Dpharmguru’s exam insights:

Poisoning is a frequently tested topic in pharmacy exams. Remember: The principles of poisoning management include removal of unabsorbed poison, removal of absorbed poison, and administration of antidotes. Key concepts include: gastric lavage, emetics, activated charcoal, and specific antidotes for different poisons. Pay special attention to the antidotes for common poisons—this is frequently tested in exams!

10.1. TYPES OF POISONING

Poisons are comprised of a wide variety of highly toxic chemical substances that are prohibited for human ingestion or consumption—for example, cyanides, paint thinners, household cleaning products, etc. However, some substances that are suitable for human consumption—for example, foods and medicines—are also included in poisons. The type of poisoning caused by these substances is differentiated into the following types:

• Ingested poisoning
• Inhaled poisoning
• Food poisoning
• Injected poisoning
• Insecticide poisoning
• Heavy Metal poisoning
• Narcotic Drug poisoning
• Barbiturate poisoning
• Organophosphorus poisoning

10.1.1. Ingested Poisoning

Any substance that is damaging the body when consumed, whether intentionally or unintentionally, is considered an ingested poison. Any substance can be toxic if eaten in large quantities. Chemicals, fungi, and berries are examples of ingested toxins. Household items like bleach, which can poison or burn if consumed, are examples of hazardous chemicals. Poisonous plants include foxgloves and certain species of mushrooms. Drugs, both prescribed and over-the-counter, can be hazardous if used in excess.

Causes:

• Harmful household and personal care products
• Detergents and cleaning products
• Paint thinner and pesticides
• Herbicides, fertilizers, and fungicides
• Lead, mercury, and other metals
• Prescription and OTC medications (when taken incorrectly)
• Illegal substances and carbon monoxide
• Spoiled food and poisonous plants

Clinical Manifestations: Nausea, vomiting, diarrhoea, rash, redness or sores around the lips, dry mouth, drooling, breathing difficulties, dilated or constricted pupils, dizziness, and fainting.

Treatment: Antidotes, sedatives, ventilators, anti-epileptics, and activated charcoal.

10.1.2. Inhaled Poisoning

When a person breathes in carbon monoxide-containing vapours, he/she inhales poison. If a person breathes excessive levels of carbon monoxide for even a few minutes, he/she can become severely sick or possibly die.

Causes: Car and truck engines, gasoline engines, fuel-burning space heaters, gas stoves, lanterns, furnaces, and burning charcoal, kerosene, propane, or wood.

Clinical Manifestations: Dull headache, weakness, nausea, vomiting, confusion, dizziness, and trouble breathing.

Treatment: Oxygen treatment (inhaling pure oxygen) and hyperbaric oxygen chamber for severe cases.

10.1.3. Food Poisoning

Food poisoning is a condition brought on by consuming contaminated food. The most prevalent causes are infectious organisms—bacteria, viruses, and parasites—or their toxins.

Causes: Raw or undercooked meat or poultry, unpasteurised dairy products, raw shellfish, unwashed fruits and vegetables.

Clinical Manifestations: Stomach cramping, constipation, nausea, vomiting, loss of appetite, mild fever, fatigue, and headache. Severe symptoms include diarrhoea lasting more than 3 days, fever over 102°F, difficulty seeing or speaking, severe dehydration, and bloody urine.

Treatment: Replacement of lost fluids and electrolytes, antibiotics for bacterial infections, and anti-diarrhoeal agents like loperamide or bismuth subsalicylate.

10.1.4. Injected Poisoning

Injected poison seeps into the body through a skin wound caused by chemicals, illegal narcotics, some animal bites, and some bug stings. These usually result in an instant reaction at the injection location.

Stinging Insects: Bee, wasp, hornet stings, and fire ant bites are usually painful. Venom reactions from insect and spider bites cause more deaths compared to snake bites.

Clinical Manifestations: Pain, swelling, redness, itching, warmth, hives. Severe reactions include coughing, throat tightness, breathing problems, nausea, dizziness, sweating, and anxiety.

Treatment: First aid includes scraping the stinger, cleaning the area, applying ice packs, and elevating the limb. Emergency treatment includes IV antihistamines, epinephrine, corticosteroids, and breathing support.

Snake Bites: Snakes have poisonous parotid glands containing venom—a complex mixture of neurotoxins and enzymes.

Clinical Manifestations: Two puncture wounds, swelling, pain, redness, bruising, facial numbness, increased heart rate, difficulty breathing, dizziness, weakness, headaches, blurred vision, excessive sweating, and fever.

Treatment: Immediate medical help, recalling the snake’s appearance, remaining calm and still, cleaning the bite, and administering anti-snake venom (ASV).

10.1.5. Insecticide Poisoning

Insecticides are used for destroying insects but also cause toxicity in humans. Exposure has increased due to widespread use. Toxicity also occurs on consuming food with insecticide residue.

Types:

• DDT: Most widely used, produces toxic action in the brain. Causes paraesthesia, apprehension, irritability, dizziness, tremor, and convulsions.
• Methoxychlor: Less toxic alternative to DDT, non-carcinogenic, does not remain in the body long.
• Chlorinated Cyclodienes: Cause CNS stimulation with convulsions and fatalities.
• Organophosphorus Insecticides: Lower persistence but severe acute toxicity. Occurs via dermal, pulmonary, or oral routes.
• Carbamates: Similar symptoms but shorter duration and lower toxicity.

Treatment: Remove poison from skin with soap and water; prevent further inhalation; GIT decontamination with activated charcoal; atropine in large doses; pralidoxime for organophosphorus poisoning.

10.1.6. Heavy Metal Poisoning

Heavy metal poisoning occurs when certain metals accumulate in the body through food, water, industrial chemicals, or other sources. The most common are arsenic, lead, and mercury poisoning.

Arsenic Poisoning:

• Acute: Burning sensation, thirst, difficulty swallowing, abdominal pain, vomiting, diarrhoea, cyanosis, weakness, rapid pulse, unconsciousness, and death due to cardiac failure.
• Chronic: Skin rashes, hair loss, weakness, weight loss, sore gums, garlic breath, vomiting, abdominal pain.

Treatment: Remove from source, emesis, gastric lavage with potassium permanganate, dimercaprol injection, and symptomatic treatment.

Lead Poisoning (Plumbism):

• Acute: Loss of appetite and sleep, severe abdominal pain, joint and muscle pain, lead encephalopathy, anaemia, haemolysis.
• Chronic: Vomiting, abdominal pain, metallic taste, blue line on gums, chronic constipation, lead palsies, anaemia, basophilia, hypertension, nephritis.

Treatment: Emesis, gastric lavage with sodium or magnesium sulphate, chelating agents like EDTA, penicillamine, calcium gluconate.

Mercury Poisoning:

• Acute: Metallic taste, choking throat, burning abdomen, diarrhoea, thrombocytopenia, bone marrow depression, renal failure.
• Chronic: Nausea, appetite loss, abdominal pain, inflamed gums, skin eruptions, speech muscle paralysis.

Treatment: White albumin of eggs, glucose, sodium bicarbonate, dimercaprol injection, penicillamine, symptomatic treatment.

10.1.7. Narcotic Drug Poisoning

Opium Poisoning: Occurs on taking an opioid drug in large amounts.

Stages:

• Stage of Excitement: Restlessness, hallucination, flushing, rapid heart rate.
• Stage of Stupor: Headache, fatigue, drowsiness, contracted pupils, cyanosed face and lips.
• Stage of Coma: Unresponsiveness, muscle relaxation, lost reflexes, depressed respiration, slow pulse.

Treatment: KMnO₄ stomach wash, endotracheal tube, artificial respiration, keep body warm, nalorphine injection, purgatives.

Cannabis Poisoning: Contains tetrahydrocannabinol. Causes excitement, hallucination, laughing, singing, giddiness, muscle weakness, pupil dilation.

Treatment: Stomach wash, stimulants, artificial respiration, oxygen inhalation.

Cocaine Poisoning: Stimulant, aphrodisiac. Causes sense of well-being, restlessness, talkativeness, dryness of throat, dilated pupils, convulsions, coma, respiratory failure.

Treatment: Demulcent drinks, parenteral stimulants, artificial respiration, oxygen inhalation.

10.1.8. Barbiturate Poisoning

Barbiturate poisoning causes coma with respiratory depression, hypotension, oliguria, renal shutdown, hypothermia, and pneumonia. Death may occur due to respiratory failure.

Treatment: KMnO₄ and sodium bicarbonate stomach wash, universal antidote, magnesium sulphate purgation, picrotoxin injection, CNS stimulants (bemegride, nikethamide, leptazol), glucose IV drip, artificial respiration with 95% oxygen and 5% carbon dioxide.

10.1.9. Organophosphorus Poisoning

Malathion, OMPA, and TEPP are organophosphorus poisons that get absorbed from all routes.

Clinical Manifestations: Headache, nausea, vomiting, chest tightness, reduced vision, sweating, paleness, incoordination, confusion, diarrhoea, delirium, respiratory muscle paralysis, bronchospasm, pulmonary oedema, coma, and death.

Treatment: KMnO₄ stomach wash, atropine sulphate injection, cholinesterase reactivators (pralidoxime chloride), phenobarbitone for convulsions, artificial respiration or tracheostomy.

10.2. PRINCIPLES OF GENERAL TREATMENT OF POISONING

The principles of general treatment of poisoning include:

• Removal of unabsorbed poison
• Removal of absorbed poison
• Antidotes

10.2.1. Removal of Unabsorbed Poison

Emetics: Sodium chloride (15g in a glass of water), mustard powder (2 teaspoonfuls in a glass of water), ipecacuanha powder (1-2g), or apomorphine hydrochloride injection.

Gastric Lavage: Removes unabsorbed poison from the stomach using saline solution, alkaline wash (5% sodium bicarbonate), or sodium thiosulphate and dimercaprol for metallic poisoning.

Miscellaneous: Washing with plain water for skin/eye exposure, incision and suction for injected poisons, and fresh air or artificial respiration for inhaled poisons.

10.2.2. Removal of Absorbed Poison

Diuretics (mannitol or furosemide) increase urine output. Altering urine pH can accelerate excretion—acidic drugs are excreted faster in alkaline urine and vice versa. Peritoneal dialysis can also remove absorbed poison.

10.2.3. Antidotes

An antidote neutralises a poison and can be classified as:

• Physiological Antidote: Produces opposite effects (e.g., bemegride for barbiturate poisoning, caffeine for morphine poisoning).
• Chemical Antidote: Changes the poison’s chemical nature (e.g., sodium thiosulphate for cyanide poisoning).
• Mechanical Antidote: Hinders poison absorption (e.g., kaolin, charcoal, fats, oil, egg albumin).

Systemic Antidotes

Specific Antidotes:

• Nalorphine: Used in morphine poisoning.
• Dimercaprol (BAL): Used in heavy metal (arsenic and mercury) poisoning. Contains –SH groups that combine with metals and protect enzymes.
• EDTA: Used in lead poisoning. Forms stable, non-toxic, soluble lead-EDTA complex.
• Penicillamine (Cuprimine): Used in copper, lead, and mercury poisoning. Acts due to –SH group chelating effect.
• Desferrioxamine: Used for iron poisoning.
• Atropine: Used in physostigmine poisoning.

Universal Antidote: Activated charcoal (2 parts), Tannic acid (1 part), Magnesium oxide (1 part) suspended in warm water.

Dpharmguru’s exam insights:

Antidotes are frequently tested in exams. Remember the key ones: Naloxone for narcotics, Atropine for organophosphates, Dimercaprol for heavy metals, EDTA for lead, Acetylcysteine for paracetamol. The Universal Antidote contains activated charcoal, tannic acid, and magnesium oxide. Also, remember that gastric lavage should be done within 4-6 hours of ingestion!

10.3. DRUG INFORMATION CENTRE (DIC) AND SERVICES

10.3.1. Definition of DIC

Written and/or verbal information given about drugs and drug therapy in response to a request from another healthcare provider, organisations, committees, patients, public, or community is called Drug Information Service (DIS). Drug information service also includes the activities performed by pharmacists in providing information for the optimised use of drugs.

The Drug Information Service (DIS) or Drug Information Centre (DIC) aims to document drugs by extracting information about them. Drug information is the knowledge about drugs assembled in written forms or transmitted by oral communication or by electronic device of the physical, chemical, biological, and health care sciences.

10.3.2. Objectives of DIC

• Provides minimum resources needed to establish DIC at different levels.
• Recognises the importance of monitoring and evaluation necessary to maintain quality.
• Acts as a guide for the hospital.
• Maintains an organised database of drugs and drug therapies.
• Provides accurate and unbiased information about drugs, drug therapy, and other health-related services.
• Provides education to pharmacy students for effective drug information provision.
• Promotes rational use of medicines among patients and their caretakers.

10.3.3. Information Resources of DIC

1. Primary Sources: Original research written by authors. Include research studies, case reports, editorials, and letters. Examples: British Medical Journal, New England Journal of Medicine, Lancet, Indian Medical Journal.

Advantages: Updated information, peer-reviewed.

Disadvantages: May have inaccurate results, require scientific knowledge, time-consuming to assess.

2. Secondary Sources: Compiled by indexing and abstracting services. Examples: Medline (PubMed), International Pharmaceutical Abstracts, Embase, Scopus, Toxline.

Advantages: Easy access, precise information, standard quality.

Disadvantages: Prolonged lag-time, large amount of information to examine, special technical skills required.

3. Tertiary Sources: Provide core knowledge established via primary sources. Include textbooks, compendia, and online full-text databases. Examples: Remington’s Text Book, Martindale Drug Reference, Lexi Comp, Micromedex, UpToDate.

Advantages: Easily accessible, information on specific subjects, widely accepted in medical practice.

Disadvantages: Increased lag-time, may not be suitably referenced, potential inaccuracy, time-consuming updates.

10.4. POISON INFORMATION CENTRE (PIC)

10.4.1. Definition of PIC

Poison Information Centre or Poison Control Centre (PCC) is a specialised unit which gives information on poisoning management and immediate information on early diagnosis, treatment, management, prevention and hazard management of poisoning. These services are provided by well-trained poison information specialists.

10.4.2. Objectives of PIC

• Reduces the rate of morbidity and mortality due to poisoning.
• Improves the health and life quality of patients.
• Reduces treatment cost by preventing excessive visits to healthcare facilities, hospital admission, and extended hospitalisation.

10.4.3. Information Resources of PIC

Primary Sources: Online journal scanning services (AMEDEO), Clinical Toxicology, Indian Journal of Toxicology.

Secondary Sources: Poisindex, Hypertox, Toxbase, Intox, Toxinz.

Advantages: Provide prepared manuals and leaflets, reduce morbidity and mortality, aid in significant financial savings.

Disadvantages: Single staff involvement puts the director under work pressure.

10.4.4. Services under PIC

• Provides poison information services.
• Helps in treatment and management of poisoning cases.
• Performs toxicological analysis.
• Aids the study of toxicovigilance.
• Conducts education and training programmes for healthcare professionals.
• Conducts awareness programmes for prevention of accidental poisoning for the public.
• Develops treatment protocols for poison management.

Dpharmguru’s exam insights:

Drug Information Centres and Poison Information Centres are important topics in hospital pharmacy. Remember: DIC provides drug information to healthcare professionals, while PIC provides poison information and management guidance. Key resources include: Primary (original research), Secondary (indexing/abstracting), and Tertiary (textbooks, compendia). Know the difference between Poisindex (PIC) and Medline (DIC)—this is frequently tested!

COMPARISON: DRUG INFORMATION CENTRE VS POISON INFORMATION CENTRE

FREQUENTLY ASKED QUESTIONS (FAQs)

1. What is the difference between a poison and a toxin?

A poison is any substance that causes harm to the organism by its chemical activity. A toxin is a specific type of poison produced by a living organism (e.g., snake venom, bacterial toxins). All toxins are poisons, but not all poisons are toxins.

2. What is the first step in managing a poisoning case?

The first step is to remove the patient from the source of poison and assess ABCs (Airway, Breathing, Circulation). Then, remove unabsorbed poison (emesis, gastric lavage), remove absorbed poison (diuretics, dialysis), and administer specific antidotes.

3. What is the universal antidote and what does it contain?

The Universal Antidote contains Activated charcoal (2 parts), Tannic acid (1 part), and Magnesium oxide (1 part) suspended in warm water. It was discovered to be effective against a variety of poisonous substances.

4. What is the antidote for acetaminophen poisoning?

The antidote for acetaminophen poisoning is Acetylcysteine (N-acetylcysteine). The loading dose is 140mg/kg, followed by 70mg/kg orally every 4 hours for 17 doses or until serum acetaminophen levels become zero.

5. What are the three stages of opium poisoning?

Opium poisoning has three stages: (1) Stage of Excitement—restlessness, hallucination, flushing; (2) Stage of Stupor—headache, fatigue, drowsiness, contracted pupils; (3) Stage of Coma—unresponsiveness, muscle relaxation, lost reflexes, depressed respiration, slow pulse.

6. What is the difference between DIC and PIC?

Drug Information Centre (DIC) provides information about drugs and drug therapy to healthcare professionals and patients. Poison Information Centre (PIC) provides information on poisoning management, early diagnosis, treatment, and prevention of poisoning. PIC deals specifically with poisons and toxic substances.

SUMMARY

Poisoning is a serious medical emergency that requires prompt recognition, accurate diagnosis, and appropriate management. Understanding the types of poisoning, clinical manifestations, and treatment protocols is essential for every healthcare professional.

The principles of poisoning management include removal of unabsorbed poison (emesis, gastric lavage), removal of absorbed poison (diuretics, dialysis), and administration of specific antidotes. Key antidotes include Naloxone for narcotics, Atropine for organophosphates, Dimercaprol for heavy metals, EDTA for lead, and Acetylcysteine for acetaminophen.

Drug Information Centres (DIC) and Poison Information Centres (PIC) provide vital support to healthcare professionals. DIC offers drug information, while PIC offers poisoning management guidance. Understanding the primary, secondary, and tertiary sources of information is essential for effective drug information provision.

As I always tell my students: “Poisoning is a race against time. Every minute counts. The right antidote at the right time can save a life. Study toxicology seriously—it will make you a better pharmacist and a potential lifesaver.”

REFERENCES AND FURTHER READING

• Pharmacy Council of India (PCI). (2022). Clinical Toxicology Guidelines. New Delhi: PCI.
• World Health Organization (WHO). (2022). Management of Poisoning: Guidelines and Protocols. Retrieved from https://www.who.int.
• International Programme on Chemical Safety (IPCS). (2022). Poison Information Centres: Guidelines. Retrieved from https://www.who.int/ipcs.
• American Academy of Clinical Toxicology (AACT). (2022). Poisoning Management Standards. Retrieved from https://www.clintox.org.
• Goldfrank, L. R., et al. (2021). Goldfrank’s Toxicologic Emergencies (11th ed.). McGraw-Hill.
• National Poison Control Centre. (2022). Guidelines for Poison Information Services. Government of India.

Disclaimer: This article is for educational purposes only and does not constitute medical advice. Always consult qualified healthcare professionals and poison information centres for poisoning emergencies. Treatment protocols and antidote dosages may vary—always refer to current guidelines and local protocols.

written by:
Dr. N. Sujith Kumar

Dr. N. Sujith Kumar is a pharmacy educator, Pharm.D graduate, and academic content creator from Jawaharlal Nehru Technological University Kakinada (JNTUK), where he completed his Doctor of Pharmacy (Pharm.D) degree between 2015 and 2021. He has more than 7 years of experience creating pharmacy educational content, writing study materials, and reviewing academic articles for pharmacy students. He has also contributed guest articles to pharmacy education platforms, including PharmD Guru. At D.PharmGuru, his work focuses on simplifying complex Diploma in Pharmacy (D.Pharmacy) subjects into easy-to-understand notes, practical explanations, and exam-oriented educational resources for students across India. His areas of focus include Human Anatomy and Physiology, Pharmaceutics, Pharmacology, Pharmaceutical Chemistry, Hospital and Clinical Pharmacy, and other core D.Pharmacy subjects.

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