- In 2012, 110,960 self-harm cases were admitted to NHS hospitals in Englnd in the 12 months to August 2012 - a 0.4 per cent increase on the previous 12-month period (110,490).
- In England and Wales, between 2013 and 2014, accidental poisonings represented 79% of all drug misuse deaths in males and 69% in females. The number of accidental poisoning deaths increased between 2013 and 2014 from 1,087 to 1,291 deaths in males and from 332 deaths to 429 deaths in females.
- The incidence of acute poisoning in children under the age of 5 is reducing due to the introduction of initiatives such as blister packs and other safety measures.
- The number of female suicides related to drug misuse increased from 155 deaths in 2013 to 168 deaths in 2014. In contrast, the number of male suicides related to drug misuse decreased from 271 deaths in 2013 to 246 deaths in 2014.
- The most common type of toxin ingested varies geographically, being prescribed medication in the developed countries and agricultural chemicals, hydrocarbons or traditional medicines in the developing nations.
Most of the discussion below is confined to drug and chemical poisoning.
Types of poisoning
- Overdose as self-harm or suicide attempt.
- Child abuse ± fabricated or induced illness by carers (formerly referred to as Münchhausen's syndrome by proxy).
- Third party (attempted homicide, terrorist, warfare).
- Most episodes of paediatric poisoning.
- Dosage error:
- Patient error
- Recreational use.
- Venomous stings/bites
- Industrial exposures.
See specific management dependent on drug(s) involved (contact poisons centre or Toxbase® for current specific advice).
- Open, suction, maintain and intubate as necessary.
- Assess work and effectiveness of ventilation.
- Give oxygen ± assisted ventilation (avoid mouth-to-mouth).
- Respiratory depression - consider opiates, benzodiazepines.
- Tachypnoea - consider metabolic acidosis - eg, salicylates, methanol.
- Attach a cardiac monitor, assess pulse, blood pressure and perfusion. Establish intravenous (IV) access.
- Tachycardia/irregular pulse - consider overdose of salbutamol, antimuscarinics, tricyclics, quinine, phenothiazine, chloral hydrate, cardiac glycosides, amfetamines and theophylline poisoning.
- If hypotensive, consider giving fluid bolus (colloid) or, if necessary, inotropes.
- Assess consciousness level - Glasgow Coma Scale or AVPU (= Alert, Voice, Pain, Unresponsive).
- Coma may suggest benzodiazepines, alcohol, opiates, tricyclics, or barbiturates.
- Check pupils and eye movements:
- Large - consider anticholinergics, sympathomimetics, tricyclics.
- Small - consider opiates or cholinergics.
- If opiates are suspected, give 0.8-2 mg naloxone IV/intramuscularly (IM) every 2-3 minutes up to 10 mg until response (children: 10 micrograms/kg IV/IM repeated up to 0.2 mg/kg); repeated doses may be required thereafter, as it has a shorter half-life than most opiates.
- Unreactive - causes include barbiturates, carbon monoxide, hydrogen sulphide, cyanide/cyanogens, head injury/hypoxia.
- Unequal - slight variation can be normal - but consider head injury.
- Strabismus - can be seen with carbamazepine overdose.
- Papilloedema - associated with methanol, carbon monoxide and glutethimide.
- Nystagmus - seen with CNS acting agents (eg, phenytoin).
- Check blood glucose - if hypoglycaemic, give 50 ml 50% dextrose IV (children: 5 ml/kg of 10% dextrose IV):
- Hyperglycaemia - organophosphates, theophyllines, monoamine-oxidase inhibitors (MAOIs) or salicylate.
- Hypoglycaemia - insulin, oral hypoglycaemics, alcohol or salicylate.
- Seizures - if prolonged/recurrent, initially give diazepam 5-10 mg IV (children: 0.25-0.4 mg/kg IV or PR) or midazolam (0.15 mg/kg) IM/IV. Many drugs can induce seizures, including tricyclics, theophylline, opiates, cocaine and amfetamines.
This may be unreliable but include the following:
- Ascertain what was taken, how much, when and by what route.
- Ask whether alcohol was consumed too.
- Establish whether there has been any vomiting since ingestion.
- Establish past medical history, current medications and allergies.
- Ascertain whether a suicide note was left.
- Ask whether the patient is pregnant.
- Histories from others, including family, friends, paramedics, police and observers.
Obtain the patient's past medical notes if possible.
- Directed cardiovascular, respiratory, abdominal and neurological examination.
- Vital signs, pupils, etc, mentioned in 'Resuscitation' section, above.
- Temperature - hypothermia (phenothiazines, barbiturates, or tricyclics) or hyperthermia (amfetamines, ecstasy, MAOIs, cocaine, antimuscarinics, theophylline, serotonin syndrome).
- Muscle rigidity (ecstasy, amfetamines).
- Skin - cyanosis (methaemoglobinaemia), very pink (carboxyhaemoglobinaemia, cyanide, hydrogen sulphide), blisters (barbiturates, tricyclic antidepressants (TCAs), benzodiazepines), needle tracks, hot/flushed (anticholinergics).
- Breath - ketones (diabetic/alcoholic ketoacidosis), 'bitter almonds' (cyanide), 'garlic-like' (organophosphates, arsenic), 'rotten eggs' (hydrogen sulphide), organic solvents.
- Mouth - perioral acneiform lesions (solvent abuse), dry mouth (anticholinergics), hypersalivation (parasympathomimetics).
- 12-lead electrocardiogram.
- U&E, laboratory glucose, anion gap ± lactate and osmolal gap.
- LFTs and clotting.
- Arterial blood gases.
- Paracetamol level (also salicylates, theophylline, digoxin, lithium, antiepileptics - if it was likely that they had been taken).
- Comprehensive toxicology screens not normally indicated in the emergency treatment.
- Carboxyhaemoglobin levels if carbon monoxide poisoning is suspected.
- Urinalysis - query rhabdomyolysis; save sample for possible toxicological analysis.
- CXR if there is suspected pulmonary oedema/aspiration.
- CT scan of the brain may be needed to exclude other causes of alterations in conscious level.
- Head trauma (especially, in the ethanol-intoxicated patient).
- Stroke/subarachnoid haemorrhage.
- Metabolic abnormalities (such as hypoglycaemia, hyponatraemia, or hypoxaemia).
- Liver disease.
- Post-ictal state
Obtain more information
- UK National Poisons Information Centres 0344 892 0111 (automatically routed to the nearest centre - available to health professionals but not the general public).
- Toxbase®: NHS intranet and internet-based information from the National Poisons Information Centre (registration free to NHS GPs and hospitals).
- MIMS Colour Index or TICTAC (a computer-aided tablet and capsule identification system available to authorised users, including Regional Drug Information Centres and Poisons Information Centres): to aid pill identification.
- British National Formulary (BNF)/Data Sheet Compendium.
Decontamination if appropriate
- Avoid contaminating yourself and wear protective clothing.
- Ensure the area is well ventilated.
- The patient should remove soiled clothing and wash himself/herself if possible.
- Put soiled clothing in a sealed container.
- Wash all contaminated skin/hair with liberal amounts of warm water ± soap.
- Single-dose activated charcoal is the preferred method of decontamination in many cases. Patients should have had a significant overdose, be co-operative, without impairment of consciousness and not thought to be likely to fit imminently. Ideally it is used in a 10:1 ratio with the ingested drug - the usual dose is 50 g for an adult (children: 1 g/kg). It may be repeated in one hour if necessary (oral, nasogastric tube). Its large surface area adsorbs many drugs but has its limitations. It may not be be effective if given after the first hour or in cases of poisoning with iron, lithium, boric acid, cyanide, ethanol, ethylene glycol, methanol, malathion, DDT, carbamate, hydrocarbon or strong acids or alkalis.
Any oral antidotes given after charcoal may be rendered ineffective.
- Gastric emptying is contra-indicated if the airway is unprotected or an overdose of corrosives or hydrocarbons has been taken. Complications include pulmonary aspiration and oesophageal perforation. Only 30% of gastric contents are returned and it is proven to be effective if within one hour of ingestion (so this is only generally done if patients present early having taken a potentially fatal dose of drug). Controversially, this is sometimes extended if delayed gastric emptying (eg, presence of coma or overdose of tricyclics or salicylates) is thought likely:
- Emesis is no longer recommended.
- Gastric lavage is used in cases where medications have been ingested that activated charcoal would absorb poorly (eg, iron, lithium) and for sustained-release formulations or enteric-coated tablets. It is carried out by placing the patient in the left lateral head-down (20°) position, inserting a large (36-40F) bore tube (children: 16-28F) into the stomach. Remove contents with sequential administration and aspiration of small (200-300 ml) quantities of warm water or saline (children: 10-20 ml/kg preferably saline). Alternatively, the stomach contents can just be aspirated.
- Whole bowel irrigation is also useful in cases where poisoning is due to substances which would not be absorbed by activated charcoal. It uses a large volume of an osmotically balanced, non-absorbable polyethylene glycol electrolyte solution (eg, Klean-Prep®, GoLYTELY®). Used with iron and other heavy metals, lithium, sustained-release or enteric-coated products, large ingestions and ingested drug packets. Administer at 1-2 L per hour PO or NG (children: 30 ml/kg/hour); antiemetics may be required; continue until rectal effluent is clear (approximately 3-6 hours). This is rarely used.
- Multiple doses of activated charcoal - interrupts enterohepatic or enteroenteric recirculation. Use 50 g four-hourly (children 1 g/kg) or 12.5 g hourly (children 0.25 g/kg) to reduce vomiting but beware severe constipation and fluid depletion. Used with carbamazepine, dapsone, phenobarbital, quinine, salicylate, colchicine, dextropropoxyphene, digoxin, verapamil and theophylline overdoses.
- Forced diuresis - no longer recommended.
- Haemoperfusion and acid/alkaline diuresis - rarely used now.
- Haemodialysis - severe salicylate, ethylene glycol, methanol, lithium, phenobarbital and chlorate poisonings.
- Maintain ABCDs.
- Observation and treatment of late complications - eg, liver failure, rhabdomyolysis.
See individual articles for relevant antidotes and antagonists.
- Medical/paediatric - for continued support/antidote administration, observation, cardiac monitoring.
- Psychiatric - for all deliberate self-poisonings, those with suicidal ideation and if the country's Mental Health Act has been employed to detain/treat.
Be sympathetic despite the hour! Interview relatives and friends if possible.
Aim to establish:
- Intentions at the time - ask:
- Was the act planned?
- What precautions were taken against being found?
- Did the patient seek help afterwards?
- Does the patient think the method was dangerous?
- Was there a final act (eg, a suicide note)?
- Problems which led to the act - ask:
- Do they still exist?
- Was the act aimed at someone?
- Is there a psychiatric disorder (depression, alcoholism, personalty disorder, schizophrenia, dementia)?
- What his/her resources are - in terms of:
- Present intentions and suicide risk. The following factors increase the chance of future suicide:
- Original intention was to die.
- Present intention is to die.
- Presence of psychiatric disorder.
- Poor resources.
- Previous suicide attempts.
- Socially isolated.
- Age over 50 years.
- Adult education.
- Double-check dosage before administration.
- Vigilance by health professionals to recognise the early signs of abuse and potential suicide.
- Put all medicines and household chemicals in a locked child-proof cupboard >1.5 metres off the ground.
- Safely dispose of medicines and chemicals which are not needed or are out of date.
- Keep all medicines and chemicals in their original containers with clear labels.
Further reading and references
Self harm: hospital admission rate per 100,000 population in North East almost triple the rate in London; Health and Social Care Information Centre, 2013
Deaths Related to Drug Poisoning in England and Wales: 2014 registrations; Office for National Statistics
Development of a UK Children's Environment and Health Strategy; Health Protection Agency, 2008 (archived content)
Frithsen IL, Simpson WM Jr; Recognition and management of acute medication poisoning. Am Fam Physician. 2010 Feb 181(3):316-23.
McGregor T, Parkar M, Rao S; Evaluation and management of common childhood poisonings. Am Fam Physician. 2009 Mar 179(5):397-403.
Guidelines for Resuscitation 2015 Section 2. Adult basic life support and automated external defibrillation; European Resuscitation Council
Guidelines for Resuscitation 2015 Section 6. Paediatric life support; European Resuscitation Council
Meyers L; Is there a need to check salicylate levels in overdose patients who deny having ingested salicylates? BestBETs, 2008