Guideline 9.5.1 – First Aid Management of Poisoning

Summary

Who does this guideline apply to?

This guideline applies to adults, children and infants.

Who is the audience for this guideline?

This guideline is for use by bystanders, first aiders and first aid training providers.

Recommendations

The Australian and New Zealand Committee on Resuscitation (ANZCOR) make the following recommendations for managing those that have or may have been exposed to poison:

Take active steps at home and in the workplace to prevent exposure to poisons. [Good Practice Statement]
Recognise potential risks and send for an ambulance early. [Good Practice Statement]

Remove the person who has been poisoned from the source or remove the source from the person if it is safe to do so. [Good Practice Statement]
If the person is not responding and is not breathing normally, commence resuscitation if safe to do so, following the ANZCOR Basic Life Support Flowchart [Refer to ANZCOR Guideline 8].
If the person is unresponsive and breathing normally, position them in a lateral, side-lying recovery (lateral recumbent) position ([Refer to ANZCOR Guideline 3 ].
Contact the National Poisons Centre for specific advice (available 24 hours)

Australian Poisons Information Centre call 13 11 26
New Zealand Poisons Centre call 0800 764 766 (0800 POISON)

Decontaminate only if it is safe to do so. [Good Practice Statement]
Ensure the poison is secured and ambulance personnel are advised of any information on poison. [Good Practice Statement]

Abbreviations

Abbreviation	Meaning/Phrase
ANZCOR	Australian and New Zealand Committee on Resuscitation
CPR	Cardiopulmonary Resuscitation
PPE	Personal Protective Equipment
CoSTR	Consensus on Science with Treatment Recommendations (from International Liaison Committee on Resuscitation - ILCOR)
HAZMAT	Hazardous Materials

Introduction

A poison is a substance (other than an infectious substance) that is harmful if ingested, inhaled, injected, or absorbed through the skin. Substances that have no effect or may be therapeutic at low levels (for example, medicines and herbal remedies) may be poisonous at higher concentrations. Toxins are poisons that are produced by living organisms. Venoms are toxins that are injected by an organism. For information on Bites and Stings go to ANZCOR Guideline 9.4.3 - First Aid Management of Envenomation from Tick Bites and Bee, Wasp and Ant Stings.

Poisoning is a common problem with many events reported in Australia and New Zealand. Most cases are unintentional and one third are children aged 1 to 4 years.¹The best treatment for poisoning is constantly evolving. Advice you may have received in the past may no longer be the recommended treatment, hence the advice to call the Poisons Information Centre in your country.

2.0

Prevention

Many poisons are substances that also have a useful purpose. Poisoning is particularly common in children and vulnerable adults so ensuring poisons are only accessible to those who need and know how to use them reduces their risk of harm.
It is useful to make a survey of the home or workplace and identify all poisonous substances.
The amount of poisonous substances stored in a home should be kept to a minimum.
Unwanted poisons or medicines should be removed. Chemicals should be disposed of safely using the accompanying directions for guidance. Medicines should be returned to a pharmacy for safe and environmentally friendly disposal. The National Poisons Information Centre can also advise on methods of safe disposal.
Poisonous substances must be stored in their original containers in locked or child-resistant cupboards or containers out of reach of children. Medicines should not be stored in the refrigerator unless advised to do so by a pharmacist.
Non-poisonous cleaning products and insecticides should be used where possible.
When possible, choose substances available in child-resistant packaging. However, do not rely on child-resistant packaging to prevent a child’s access to a poison, because child-resistant containers are not completely child proof.
Closely supervise children around the home.
Don't call medicines 'lollies' when giving medicine to children
Do NOT decant chemicals into drink bottles
Read medicine labels and use according to the directions. When medicines are taken ensure the right:
- medication
- person
- dose
- route of administration
- reason for administration
- time and frequency of administration
The recommended personal protective equipment (PPE) should be used when using toxic or caustic chemicals, for example spraying, painting, or oven cleaning. For industrial or commercial products this information can be found in the Safety Data Sheet for the product. For many non-commercial consumer products, the labeling may contain first aid instructions and safety directions, including recommended PPE.

Eating and drinking should be avoided near poisons.

3.0

Recognition

Poisons can cause harm by a wide range of mechanisms and can cause a wide range of symptoms including reduced levels of responsiveness, difficulty breathing, cardiac arrest, nausea, vomiting, burning pain in the mouth or throat, headache, blurred vision, seizures and burns to skin, eyes, mouth, nose and throat.
The circumstances of the incident may give an indication that poisoning has occurred. A person may complain of physical symptoms without realising these are due to a poison. Alternatively, they may exhibit abnormal behaviour, which may be misinterpreted as confusion or mental health disturbance.
Most medicines are poisonous in overdose. The point at which overdose becomes harmful is substance/medicine specific and varies greatly, but many medicines are lethal if less than a single pack is taken simultaneously.
The speed of effect of a poison is determined by the chemical and physical properties of the toxic material, the concentration of the toxic material, the route of exposure (oral, skin, eyes, inhalation, injection), and the length of time of exposure. The effects may be rapid, but they may also be delayed.
It is important to seek medical assessment after exposure to a poison, even if symptoms are initially mild or absent.
Poisoning can mimic other conditions such as intoxication, seizures, stroke
If poisoning is suspected, look for clues – empty pill bottles/packets, scattered pills
With children, consider the possibility of swallowed button battery or medicinal patches (normally applied to the skin)

4.0

Management

The principles of managing a person who has been poisoned are:

Recognise Danger, maintain safety and prevent poisoning of the first aid provider.
Send for an ambulance and possibly fire services for containment and decontamination where necessary
Resuscitation and supportive care, using the ANZCOR Basic Life Support Flowchart (Guideline 8]. If unresponsive and breathing normally, position in a lateral, side-lying recovery (lateral recumbent) position and ensure airway is clear [Refer to ANZCOR Guideline 3]. If not responding and not breathing normally, commence resuscitation if safe to do so, following the ANZCOR Basic Life Support Flowchart [Refer to ANZCORGuideline 8].
Decontamination of the skin or eyes if they have been exposed to poison and if it is possible and safe to do so. (Refer to section 4.3 below)
If possible, ascertain what poison or medicine has been taken, how much, and when.
ANZCOR recommends specific management of particular poisons including antidotes, techniques to remove the poison from the body, and the treatment of complications of the poison which is most commonly undertaken in the hospital setting. [Good Practice Statement]

4.1

Recognising Danger, maintaining safety

During first aid and subsequent treatment, the suspected poison should be identified and safely handled to minimise further exposure. The person exposed to a poison may pose a danger if the poisonous substance can be transferred to the rescuer for example, by contact with contaminated clothing.

If the poisoning occurs in an industrial, farm or laboratory setting suspect particularly dangerous agents and take precautions to avoid accidental injury. Attempt to identify the area that is contaminated, limit spread of contaminated material, and establish a cordon around this area using any practical means such as tape, markers, or control points on access roads.
If more than one person simultaneously appears affected by a poison, there is a high possibility of dangerous environmental contamination.
The rescuer may need to wear personal protective equipment (PPE) during decontamination and resuscitation. The need for PPE will be guided by knowledge of the likely poison. If equipment is not available to decontaminate and treat a person safely, rescue might not be possible.
The rescuer should approach the poisoned person from upwind, particularly for poisons in a gaseous state.

4.2

Sending for an ambulance and other assistance

Send for an ambulance promptly. The ambulance service will be able to offer advice on management of the person before the ambulance arrives. The National Poisons Information Centre (Australian call 13 11 26, New Zealand call 0800 764 766 or 0800 POISON) is available 24 hours and can also offer advice before an ambulance arrives. If suspected area/environmental contamination consider sending for fire service attendance to contain the agent and decontaminate the area and affected people. If possible, ascertain what poison or medicine has been taken, how much, and when.

4.3

Decontamination

Separate the person from the poisonous substance. How this is done will depend on the type of the poison. Examples are listed below.

If the poison is SWALLOWED
- Get the person who has swallowed the poison to wash out their mouth with water
- ANZCOR recommends to NOT try to make them vomit or give syrups or solutions that induce vomiting^2,3,4[Good Practice Statement]
- Do not attempt to get the person to ingest any substance to try to neutralise acids or alkalis.

If the poison is INHALED
- Immediately get the person to fresh air, without placing yourself at risk.
- Avoid breathing fumes. Special breathing apparatus may be required in the presence of poisonous gas or chemicals.
- If it is safe to do so, vent the area by opening doors and windows wide.
- Avoid using electrical appliances or turning on light switches if inflammable gases are suspected

If the poison enters the EYE
- Flood the eye with 0.9% sodium chloride, contact lens solution or cold water, continuing to flush for 15 minutes, holding the eyelids open.

If the poison contacts the SKIN
- Remove contaminated clothing, taking care to avoid contact with the poison. Place the clothing in a plastic bag, using caution to contain the poison unless certain of the type of poison, type of plastic, and the interaction of the two.
- Do not attempt to neutralise acids or alkalis on the skin. Flood the skin with running water ensuring to keep the person warm or irrigate with copious amounts of water or 0.9% sodium chloride.
- Wash gently with soap and water and rinse well. Having the person do this themselves reduces the risk to rescuers.

Those poisoned by environmental contamination will have to be removed from the environment. Once trained personnel arrive, a management plan defining three zones will allow this to be done safely.

The “hot” zone contains the environmental contaminant.
The “warm” zone is where contaminated persons are taken to be decontaminated. Rescuers and health care workers will require PPE in the warm zone. The poisonous material is present here, but it is contained.
The “cold” zone is where people are taken once they have been decontaminated and pose no risk.

4.4

Resuscitation and supportive care

Send for an ambulance (Refer to section 4.2 above).
If unresponsive and breathing normally, position the person in a lateral, side-lying recovery (lateral recumbent) position [Refer to ANZCOR Guideline 3] and ensure the airway is clear.
Rescuers should perform chest compressions for all those who are unresponsive and not breathing normally [Refer to ANZCORGuideline 8].¹⁹ [CoSTR 2015, strong recommendation, very-low-quality evidence].
For those trained in their use, a self-inflating bag-mask apparatus is the safest way for the rescuer to provide ventilation.
If there is poison remaining on the person’s lips, if corrosive chemicals have burnt the lips and chin, or if the rescuer is unsure of the nature of the poison, continue to perform chest compressions without providing any ventilation.
Inhaled poisons are unlikely to pose a risk during mouth-to-mouth ventilation unless the person is contaminated with the liquid form of the inhaled poison.

4.5

Specific Management of particular poisons

If possible, ascertain what poison or pharmaceutical has been taken, how much, and when.
Check for opened packets of medications in cases of suspected self-poisoning and try to collect vomitus, if any, in a plastic container, and send them to hospital with the person.
Look for signage (HAZMAT placards) on the fences or doors to industrial sites or laboratories or on the rear of trucks. This signage can provide information about hazardous materials that are classed, categorised and colour coded. When calling the emergency services, they may ask for this information to determine the response.
Obtain advice from the ambulance service (000 in Australia or 111 in New Zealand) promptly. Other sources of medical advice will depend on the situation but may include:
- National Poisons Information Centre (available 24 hours)
- Australian Poisons Information Centre call 13 11 26
- New Zealand Poisons Centre call 0800 764 766 (0800 POISON)
- Occupational health facilities
- A general practitioner or urgent care medical centre
- A hospital emergency department

Some poisons have specific antidotes. With some exceptions these are rarely used outside of a hospital. However, accurate identification of the poison will help treatment. If there are packets or bottles, they should be secured and go with the person to hospital.
Industries that have an increased risk of exposure to particular poisons may stock specific antidotes. Those working in these environments may have specialised training and protocols for the administration of these antidotes. Hospitals may not always stock specific antidotes to poisons so a supply of the antidote should accompany the poisoned person to hospital.

4.6

If unable to get advice, or while waiting for help to arrive:

ANZCOR recommends to monitor the person, especially their airway, level of response and breathing, and manage according to the ANZCOR Basic Life Support Flowchart [Refer to ANZCOR Guideline 8]. [Good Practice Statement]

References

Huynh A, Cairns R, Brown JA, Lynch AM, Robinson J, Wylie C, Buckley NA, Dawson AH; Synthesis of the Network of Australian Poisons Services' Health Outcomes and Treatment (SNAPSHOT) investigators. Patterns of poisoning exposure at different ages: the 2015 annual report of the Australian Poisons Information Centres Med J Aust. 2018 Jul 16;209(2):74-79.
Heard K: The changing indications of gastrointestinal decontamination in poisonings. Clin.Lab Med. 2006; 26: 1-12, vii
Greene SL, Dargan PI, Jones AL: Acute poisoning: understanding 90% of cases in a nutshell. Postgrad.Med.J. 2005; 81: 204-16
Pond SM, Lewis-Driver DJ, Williams GM, Green AC, Stevenson NW; Gastric emptying in acute overdose: a prospective randomised controlled trial. Med J Aust. 1995; 163 (7): 345-349
Daly FF, Fountain JS, Murray L, Graudins A, Buckley NA: Guidelines for the management of paracetamol poisoning in Australia and New Zealand--explanation and elaboration. A consensus statement from clinical toxicologists consulting to the Australasian poisons information centres. Med.J.Aust. 2008; 188: 296-301
Lam LT: Childhood and adolescence poisoning in NSW, Australia: an analysis of age, sex, geographic, and poison types. Inj.Prev. 2003; 9: 338-42
Turner A, Robinson P: Respiratory and gastrointestinal complications of caustic ingestion in children. Emerg.Med.J. 2005; 22: 359-61
Fungi poisoning. 1999. Melbourne, State of Victoria.
7. Uhl W, Nolting A, Golor G, Rost KL, Kovar A: Safety of hydroxocobalamin in healthy volunteers in a randomized, placebo-controlled study. Clin.Toxicol.(Phila) 2006; 44 Suppl 1: 17-28
Forsyth JC, Mueller PD, Becker CE, Osterloh J, Benowitz NL, Rumack BH et al.: Hydroxocobalamin as a cyanide antidote: safety, efficacy and pharmacokinetics in heavily smoking normal volunteers. J.Toxicol.Clin.Toxicol. 1993; 31: 277-94
Borron SW, Baud FJ, Barriot P, Imbert M, Bismuth C: Prospective study of hydroxocobalamin for acute cyanide poisoning in smoke inhalation. Ann.Emerg.Med. 2007; 49: 794-801, 801
Houeto P, Hoffman JR, Imbert M, Levillain P, Baud FJ: Relation of blood cyanide to plasma cyanocobalamin concentration after a fixed dose of hydroxocobalamin in cyanide poisoning. Lancet 1995; 346: 605-8
Espinoza OB, Perez M, Ramirez MS: Bitter cassava poisoning in eight children: a case report. Vet.Hum.Toxicol. 1992; 34: 65
Fortin JL, Desmettre T, Manzon C, Judic-Peureux V, Peugeot-Mortier C, Giocanti JP et al.: Cyanide poisoning and cardiac disorders: 161 cases. J.Emerg.Med. 2010; 38: 467-76
Fortin JL, Giocanti JP, Ruttimann M, Kowalski JJ: Prehospital administration of hydroxocobalamin for smoke inhalation-associated cyanide poisoning: 8 years of experience in the Paris Fire Brigade. Clin.Toxicol.(Phila) 2006; 44 Suppl 1: 37-44
Borron SW, Baud FJ, Megarbane B, Bismuth C: Hydroxocobalamin for severe acute cyanide poisoning by ingestion or inhalation. Am J.Emerg.Med. 2007; 25: 551-8
Pontal PG, Bismuth C, Garnier R: Therapeutic attitude in cyanide poisoning: retrospective study of 24 non-lethal cases. Veterinary and Human Toxicology 1982; 24: 286-7
Reade MC, Davies SR, Morley PT, Dennett J, Jacobs IC. Review article: management of cyanide poisoning. Emergency Medicine Australasia 2012; 225-238.
Robert S. Hoffman, M.D., Michele M. Burns, M.D., M.P.H., and Sophie Gosselin, M.D., Ingestion of Caustic Substances. 2020. N Engl J Med 382;18
Perkins GD, Travers AH, Berg RA, et al. Part 3: adult basic life support and automated external defibrillation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation. 2015 Oct 1;95:e43-69.

About this Guideline

Search date/s	2010 - 2018
Question/PICO:	Original literature review undertaken on management of cyanide poisoning, not included in this guideline
Method:	Scoping review for new publications since 2010 on all except cyanide, no significant new publications found
Primary reviewers:	Michael Reade, Kevin Nation
Other consultation	Finlay Macneil, Geoffrey Newman-Martin
Approved:	April 2021
Guidelines superseded:	ANZCOR Guideline 9.5.1 - July 2011

ANZCOR Guidelines

First Aid for Bites, Stings and Poisoning

Search