Symptoms and Treatment of Specific Poisons 

ACE inhibitors

Angioedema, hypotension

Acephate

—

See table

NAcetaminophen Poisoning: Treatment

Acetanilide

Aniline dyes and oil

Chloroaniline

Phenacetin (acetophenetidin, phenylacetamide)

Cyanosis due to formation of methemoglobin and sulfhemoglobin, dyspnea, weakness, vertigo, angina, rashes and urticaria, vomiting, delirium, depression, respiratory and circulatory failure

Ingestion:

Skin contact: Clothing removed and area washed with copious soap and water; then as for inhalation

Inhalation: Oxygen, respiratory support, blood transfusion

Low concentration: Mild mucosal irritation

High concentration: See Caustic Ingestion

Supportive care with irrigation and dilution

Acetone

Ketones

• Numerous glues and adhesives

• Nail polish remover

Ingestion: As for inhalation, except for direct pulmonary effect

Inhalation: Bronchial irritation, pneumonia (pulmonary congestion and edema, decreased respiration, dyspnea), drunkenness, stupor, ketosis, cardiac arrhythmias

Removal from source

Respiratory support, oxygen and fluids, correction of metabolic acidosis

Acetonitrile

Cosmetic nail adhesive

Converted to cyanide, with usual symptoms and signs

See Cyanides

Acetophenetidin

Acetanilide

—

Acetylsalicylic acid

See

—

Acids and alkalis

See specific acids and alkalis (eg, , Fluorides) and Caustic Ingestion

Eye contact: See Overview of Eye Trauma

Skin contact: See Burns

—

Treatment of Caustic Ingestion and Treatment of Burns

Adhesives (eg, airplane glues or cements (model-building)

See Acetone, Benzene (toluene), and Petroleum distillates

—

• Beer

• Whiskey and other liquors

• Wine

Emotional lability, impaired coordination, flushing, nausea, vomiting, stupor to coma, respiratory depression

Supportive care, IV glucose for hypoglycemia

Alcohol, isopropyl

• Rubbing alcohol

Dizziness, incoordination, stupor to coma, gastroenteritis, hemorrhagic gastritis, hypotension

Ketosis without acidosis

No retinal injury or acidosis

Supportive care, IV glucose, correction of dehydration and electrolyte abnormalities

For gastritis, IV H2 blockers or proton pump inhibitors

Alcohol, methyl (methanol, wood alcohol)

• Paint solvent

• Solid canned fuel

• Varnish

• Windshield washer fluid

Severe toxicity with 60–250 mL (2–8 ounces) in adults or 8–10 mL (2 teaspoons) in children

Latency period 12–18 hours

Headache, weakness, leg cramps, vertigo, seizures, retinal injury, dimmed vision, metabolic acidosis, decreased respiration

Hemodialysis (which is definitive treatment)

Aldrin

See Chlorinated and other halogenated hydrocarbons

—

Alkalis

See Acids and alkalis

—

Aminophylline

Wakefulness, restlessness, anorexia, vomiting, dehydration, seizures, tachycardia

In adults, greater toxicity after acute overdose added to chronic intake

> 50–100 mg/L (>278–555 micromol/L), acidosis, seizures, or coma, possibly dialysis

Ammonia gas (anhydrous ammonia [NH3])

Irritation of eyes and respiratory tract, cough, choking, abdominal pain

Flushing of eyes for 15 minutes with tap water or saline

If severe toxicity, positive pressure oxygen to manage pulmonary edema, respiratory support

Ammonia water (ammonium hydroxide [NH4OH])

See Caustic Ingestion

—

Ammoniated mercury (NH2HgCl)

See Caustic Ingestion

—

Ammonium carbonate ([NH4]2CO3)

See Caustic Ingestion

—

Ammonium fluoride (NH4F)

See Fluorides

—

Amphetamines

• Methedrone (4-MeO)

• Phenmetrazine

  Synthetic cathinones (bath salts)

Increased activity, exhilaration, talkativeness, insomnia, irritability, exaggerated reflexes, anorexia, diaphoresis, tachyarrhythmia, anginal chest pain, psychotic-like states, inability to concentrate or sit still, paranoia

For patients without asthma, beta-blockers possibly helpful but rarely necessary

Aniline

See Acetanilide

—

• Desirudin

Supportive care (eg, whole blood transfusion, consideration of prothrombin complex concentrates or hemodialysis)

Andexanet alfa competitively binds to the Xa inhibitor:

Low-dose andexanet alpha: Initial IV bolus of 400 mg at 30 mg/min followed by 4 mg/min for up to 120 minutes

High-dose andexanet alpha: Initial IV bolus of 800 mg at a rate of 30 mg/min followed by 8 mg/min for up to 120 minutes

Supportive care (eg, whole blood transfusion)

Anticoagulants, warfarins

Single ingestion—typically not serious

With multiple ingestions, coagulopathy with increased PT/INR

Higher risk of coagulopathy with single dose of superwarfarins

For single ingestion, observation

Vitamin K Toxicity) until INR is normal, transfusion with fresh frozen plasma if necessary

Antidepressants

See , , SSRIs, , Tricyclic antidepressants,

—

Antifreeze

See Ethylene glycol

—

Antihistamines

Anticholinergic symptoms (eg, tachycardia, hyperthermia, mydriasis, warm and dry skin, urinary retention, ileus, delirium)

For diagnostic or therapeutic trial or for treatment of severe symptoms refractory to sedation (CAUTION:

Antihyperglycemic drugs, oral

See Hypoglycemic drugs, oral

—

Antimony

• Stibophen

• Tartar emetic

Throat constriction, dysphagia, burning GI pain, vomiting, diarrhea, GI hemorrhage, dehydration, pulmonary edema, renal failure, lactic acidosis, liver failure, shock

Antipsychotic drugs (1st-generation)

A wide range of effects (eg, sedation, seizures, excitement, coma, dystonia, hypotension, tachycardia, ventricular arrhythmias or torsades de pointes, anticholinergic effects, hyperthermia, agranulocytosis, or hypothermia)

For ventricular arrhythmias, consideration of alkalinization

Antipsychotic drugs (2nd-generation)

For ventricular arrhythmias, consideration of alkalinization

Ant poison

Depends on ingredients, see Arsenic (sodium arsenate) and

—

Arsenic

• Donovan solution

• Fowler solution

• Herbicides (some)

• Paris green

• Pesticides (some)

• Sodium arsenate

Throat constriction, dysphagia, burning GI pain, vomiting, diarrhea, GI hemorrhage, dehydration, pulmonary edema, renal failure, lactic acidosis, liver failure, shock

Arsine gas

Acute hemolytic anemia

Transfusions, diuresis

Asphalt

See Petroleum distillates

—

See

—

• Hyoscyamus

• Stramonium

Anticholinergic symptoms (eg, tachycardia, hyperthermia, mydriasis, warm and dry skin, urinary retention, ileus, delirium)

For diagnostic or therapeutic trial or for treatment of severe symptoms refractory to sedation, which is rarely needed (CAUTION:

Automobile exhaust

See Carbon monoxide

—

Barbiturates

Bradycardia, hypothermia, confusion, delirium, loss of corneal reflex, respiratory failure, drowsiness, ataxia, coma

For severe cases, hemodialysis

Barium compounds (soluble)

• Depilatories

• Explosives

• Fireworks

• Rat poisons

Vomiting, abdominal pain, diarrhea, tremors, seizures, colic, hypertension, cardiac arrest, dyspnea and cyanosis, ventricular fibrillation, severe hypokalemia, skeletal muscle weakness

For dyspnea and cyanosis, oxygen

Bath salts

See Amphetamines

—

Belladonna

See

—

Benzene

• Benzol

• Hydrocarbons

• Model airplane glue

• Toluene

• Toluol

• Xylene

Dizziness, weakness, headache, euphoria, nausea, vomiting, ventricular arrhythmia, paralysis, seizures

With chronic poisoning, aplastic anemia, hypokalemia, leukemia, CNS depression

Irritability, CNS excitation, muscle spasms, atonia, tonic-clonic seizures, respiratory failure, pulmonary edema, nausea, vomiting, obtundation, coma

Decontamination with water, avoidance of vomiting and aspiration, oxygen, respiratory support, ECG monitoring (ventricular fibrillation can occur early)

For severe anemia, blood transfusions

Replacement of potassium as necessary

Gamma-benzene hexachloride

Hexachlorocyclohexane

Irritability, CNS excitation, muscle spasms, atonia, tonic-clonic seizures, respiratory failure, pulmonary edema, nausea, vomiting, obtundation, coma

Benzine (benzin)

See Petroleum distillates

—

Benzodiazepines

Sedation to coma, particularly if drugs are accompanied by alcohol

Hypotension

Airway control

For hypotension, IV fluids and vasopressors

)

Benzol

See Benzene

—

Beta-blockers

Hypotension, bradycardia, seizures, cardiac arrhythmias, hypoglycemia, altered mental status

Close monitoring and attention to airway maintenance

Bichloride of mercury

See Mercury

—

Bichromates

See Chromic acid

—

Bidrin (dicrotophos)

See Organophosphates

—

Bifenthrin

See Pyrethroids

—

Bismuth compounds

Acute: Abdominal pain, oliguria, acute renal failure

Chronic: Poor absorption, ulcerative stomatitis, anorexia, progressive encephalopathy

Guidelines for Chelation Therapy)

Bitter almond oil

See Cyanides

—

Bleach, chlorine

See Hypochlorites

—

Nausea, vomiting, diarrhea, hemorrhagic gastroenteritis, weakness, lethargy, CNS depression, seizures, “boiled lobster” rash, shock

Removal from skin, prevention or treatment of electrolyte abnormalities and shock, control of seizures

For severe poisoning (rare), dialysis

Bromates

Vomiting, diarrhea, epigastric pain, acidosis, deafness

Supportive care, thiosulfate to reduce bromate to less toxic bromide

For renal failure, hemodialysis

Bromides

Nausea, vomiting, rash (may be acneiform), slurred speech, ataxia, confusion, psychotic behavior, coma, paralysis, negative anion gap

For severe poisoning, hemodialysis

Bromine

Highly corrosive

With exposure to liquid or vapor, skin and mucous membrane burns

Aggressive decontamination, supportive care

Respiratory depression, ataxia, seizures

Butyl nitrate

See Nitrites

—

Cadmium

• Cadmium oxide fumes (eg, from welding)

Ingestion: Severe gastric cramps, vomiting, diarrhea, dry throat, cough, dyspnea, headache, shock, coma, brown urine, renal failure

Inhalation: Pneumonitis with dyspnea and bilateral pulmonary infiltrates, hypoxia, death

For inhalation, oxygen, sometimes bronchodilators and corticosteroids

See Aminophylline

—

Calcium channel blockers

Nausea, vomiting, confusion, bradycardia, hypotension, total cardiovascular collapse

Toxicity sometimes occurring after hyperglycemia

For sustained-release preparations, consideration of whole-bowel irrigation

Consideration of IV lipid emulsion

Calomel

See Mercury

—

Camphor

• Camphorated oils

Camphor odor on breath, headache, confusion, delirium, hallucinations, seizures, coma

Cannabinoids, synthetic (synthetic marijuana)

Hypertension, tachycardia, MI, nausea, vomiting, agitation, hallucinations, psychoses, seizures, convulsions, stroke

See also Cannabinoids, synthetic

Beta-blockers may help relieve cardiac symptoms, but are rarely necessary

See also Cannabinoids, synthetic

Canned fuel, solid

See Alcohol, methyl

—

Cantharides

• Spanish fly

Irritated skin and mucous membranes, skin vesicles, nausea, vomiting, bloody diarrhea, burning pain in back and urethra, respiratory depression, seizures, coma, abortion, menorrhagia

Respiratory support, treatment of seizures, maintenance of fluid balance, avoidance of all oils derived from cantharides

No specific antidote

Carbamates

• Aldicarb

• Bendiocarb

• Benomyl

• Carbaryl

• Carbofuran

• Fenothiocarb

• Methiocarb

• Methomyl

• Oxamyl

• Propoxur

Slightly to highly toxic effects; similar to those of organophosphates except cholinesterase inhibition is not permanent

See Organophosphates

See Organophosphates

Progressive CNS depression, seizures (occasional), cardiac arrhythmia (rare)

Supportive care after decontamination, heart rate monitoring

Carbolic acid

See Phenols

—

Carbonates (ammonium, potassium, sodium)

See Caustic Ingestion

—

Carbon bisulfide or disulfide

Carbon dioxide

Dyspnea, weakness, tinnitus, palpitations, asphyxia

Respiratory support, oxygen

Carbon monoxide

Variable toxicity depending on length of exposure, concentration inhaled, and respiratory and circulatory rates

Various symptoms depending on % carboxyhemoglobin in blood

Headache, vertigo, vomiting, dyspnea, confusion, dilated pupils, seizures, coma

100% Oxygen by mask, respiratory support if needed, immediate measurement of carboxyhemoglobin level; if carboxyhemoglobin is more than about 25%, consideration of hyperbaric oxygen in consultation with poison control center (see Carbon Monoxide Poisoning)

Carbon tetrachloride (sometimes used in chemical manufacturing and some cleaning fluids)

Nausea, vomiting, abdominal pain, headache, confusion, visual disturbances, CNS depression, ventricular fibrillation, kidney injury, liver injury, cirrhosis

Washing of skin, oxygen, respiratory support, monitoring of kidney and liver function and appropriate treatment

Carbonyl iron

See Iron

—

Cathinones (substituted)

See Amphetamines

—

Caustic soda (sodium hydroxide)

See Caustic Ingestion

—

Chloral hydrate

Chloral amide

Drowsiness, confusion, shock, coma, respiratory depression, kidney injury, liver injury

For ventricular arrhythmias, respiratory support, assessment of concomitant ingestions, beta-blockers

Chlorates and nitrates

• Herbicides

• Manufacture of explosives and matches

Vomiting, nausea, diarrhea, cyanosis (methemoglobin), toxic nephritis, shock, seizures, CNS depression, coma, jaundice

For complex cases, possibly dialysis

Chlordane

See Chlorinated and other halogenated hydrocarbons

—

Chlorethoxyfos

See Organophosphates

—

Chlorinated and other halogenated hydrocarbons (in many insecticides)

• Aldrin

• Benzene hexachloride

• Chlordane

• Chlorothalonil

• DDD (2-dichlorethane)

• DDT (chlorophenothane)

• Dicofol

• Dieldrin

• Dienochlor

• Dilan

• Endosulfan

• Endrin

• Heptachlor

• Methoxychlor

• Perchlordecone

• Prolan

• Toxaphene

• Other chlorinated organic insecticides and industrial compounds

Slightly toxic effects (eg, with methoxychlor) to highly toxic effects (eg, with dieldrin)

Vomiting (early or delayed), paresthesias, malaise, coarse tremors, seizures, pulmonary edema, ventricular fibrillation, respiratory failure

For renal and liver failure, monitoring, and supportive care

Chlorine (see also Hypochlorites)

• Chlorinated lime

• Chlorine water

• Tear gas

Ingestion: Irritation, corrosion of mouth and GI tract, possible ulceration or perforation, abdominal pain, tachycardia, prostration, circulatory collapse

Inhalation: Severe respiratory and ocular irritation, glottal spasm, cough, choking, vomiting, pulmonary edema, cyanosis

Ingestion: Dilution with water or milk, treatment of shock

Inhalation:

Chloroaniline

See Acetanilide

—

Chloroform

Asphyxiation

Drowsiness, coma

Possible acute liver injury

Ingestion: Observation for kidney and liver damage; respiratory, cardiac, and circulatory support

Inhalation: Respiratory, cardiac, and circulatory support

Chlorothalonil

See Chlorinated and other halogenated hydrocarbons

—

Chlorothion

See Organophosphates

—

Chlorpyrifos

See Organophosphates

—

Chromic acid and chromates

• Bichromates

• Chromates

Corrosive effects due to oxidation, ulcerated and perforated nasal septum, severe gastroenteritis, shock, vertigo, coma, nephritis

Dilution with milk or water, cautious use of fluids and electrolytes to support kidney function, consideration of N

Irritation of skin and mucous membranes

See Chromic acid

—

Bradycardia, sedation, periodic apnea, hypotension, hypothermia

Coal gas

See Carbon monoxide

—

Cobalt

Tachycardia, tachypnea and hypoxia after inhalation, skin and mucous membrane irritation, glomerulonephritis, hypothyroidism (rare)

Supportive care, decontamination with water and soap

Cobaltous chloride

See Nitrogen oxides

—

Stimulation then depression, nausea, vomiting, loss of self-control, anxiety, hallucinations, sweating, hyperthermia, seizures, MI (rare)

Observation for myocardial or pulmonary disorder (usually before emergency department arrival)

For hyperthermia, external cooling

Nausea, hemorrhagic gastritis, multiorgan failure, pancytopenia, sepsis

• Cupric sulfate, acetate, or subacetate

• Cuprous chloride or oxide

Vomiting, burning sensation, metallic taste, diarrhea, pain, shock, jaundice, anuria, seizures

Guidelines for Chelation Therapy), electrolyte and fluid balance, respiratory support, monitoring of GI tract, treatment of shock, control of seizures, monitoring for liver and renal failure

Corrosive sublimate (mercuric chloride)

See Mercury

—

Coumaphos

See Organophosphates

—

Creosote, cresols

See Phenols

—

Cyanides

• Bitter almond oil (artificial and natural)

• Hydrocyanic acid

• Potassium cyanide

• Prussic acid

• Sodium cyanide

• Wild cherry syrup

Tachycardia, headache, drowsiness, hypotension, coma, rapid severe acidosis, seizures, death, possibly bitter almond odor on breath, bright red venous blood

Very rapidly lethal (in 1–15 minutes)

Speed essential

Inhalation: Removal from source

Inhalation or ingestion: 100% Oxygen, respiratory support

Cyfluthrin

See Pyrethroids

—

Cypermethrin

See Pyrethroids

—

DDD (2-dichlorethane)

See Chlorinated and other halogenated hydrocarbons

—

DDT (chlorophenothane)

See Chlorinated and other halogenated hydrocarbons

—

Demeton

See Organophosphates

—

Deodorizers, household

See Naphthaleneand Paradichlorobenzene

—

Depilatories

See Barium compounds

—

Detergent powders

See Caustic Ingestion

—

Diazinon

See Organophosphates

—

Dichlorvos

See Organophosphates

—

Dicofol

See Chlorinated and other halogenated hydrocarbons

—

Dieldrin

See Chlorinated and other halogenated hydrocarbons

—

Dienochlor

See Chlorinated and other halogenated hydrocarbons

—

Diethylene glycol

See Ethylene glycol

—

Digitalis

Digitoxin

See

—

Dilan

See Chlorinated and other halogenated hydrocarbons

—

Dimethoate

See Organophosphates

—

Dinitrobenzene

See Nitrobenzene

—

Dinitro-o-cresol

• Herbicides

• Pesticides

Fatigue, thirst, flushing, nausea, vomiting, abdominal pain, hyperpyrexia, tachycardia, loss of consciousness, dyspnea, respiratory arrest, skin absorption

Fluid therapy, oxygen, anticipation of kidney and liver toxicity, no specific antidote, detergents to rinse skin

Lethargy, nystagmus, pinpoint pupils, tachycardia, coma, respiratory depression (NOTE: Toxicity may be delayed up to 12 hours.)

Diquat

See Paraquat

—

Dishwasher detergents

See Caustic Ingestion

—

Disulfoton

See Organophosphates

—

Donovan solution

See Arsenic

—

Drain cleaners

See Caustic Ingestion

—

Endosulfan

See Chlorinated and other halogenated hydrocarbons

—

Endrin

See Chlorinated and other halogenated hydrocarbons

—

Ergot derivatives

Thirst, diarrhea, vomiting, light-headedness, burning feet, increased heart rate and BP, cardiovascular collapse, seizures, hypotension, coma, abortion, gangrene of feet, cataracts

Benzodiazepine or a short-acting barbiturate for seizures

Eserine

See 

—

Esfenvalerate

See Pyrethroids

—

See Alcohol, ethyl

—

Ether

See Chloroform

—

Ethion

See Organophosphates

—

Ethylene glycol, diethylene glycol

• Most automotive antifreeze

Ingestion: Inebriation but no alcohol odor on breath, nausea, vomiting

Later, carpopedal spasm, lumbar pain, oxalate crystalluria, oliguria progressing to anuria and acute renal failure, respiratory distress, seizures, coma

Eye contact: Iridocyclitis

Ingestion:

Hemodialysis, which is definitive treatment

Eye contact: Flushing of eyes

Explosives

See Barium compounds (fireworks) and Nitrogen oxides

—

Famphur

See Organophosphates

—

Fava bean (favism)

Symptoms of hemolysis

Treatment of hemolysis

Fenthion

See Organophosphates

—

Ferric salts

See Iron

—

Ferrous salts (eg, gluconate, sulfate)

See Iron

—

Fireworks

See Barium compounds

—

Fluorides

• Ammonium fluoride

• Fluorine

• Hydrofluoric acid

• Rat poisons

• Roach poisons

• Soluble fluorides generally

Ingestion of small or moderate doses: Salty or soapy taste

Ingestion of large doses: Tremors, seizures, CNS depression, shock, renal failure

Skin and mucosal contact: Painful superficial or deep burns

Inhalation: Intense eye and nasal irritation, headache, dyspnea, sense of suffocation, glottal edema, pulmonary edema, bronchitis, pneumonia, mediastinal and subcutaneous emphysema due to bleb rupture

Ingestion:

Skin and mucosal contact:

Inhalation:

Fluvalinate

See Pyrethroids

—

Formaldehyde

• Formalin (may contain methyl alcohol)

Ingestion: Oral and gastric pain, nausea, vomiting, hematemesis, shock, hematuria, anuria, coma, respiratory failure

Skin contact: Irritation, coagulation necrosis (with high concentrations), dermatitis, hypersensitivity

Inhalation: Eye, nose, and respiratory tract irritation; laryngeal spasm and edema; dysphagia; bronchitis; pneumonia

Ingestion:

Skin contact: Washing with copious soap and water

Inhalation: Flushing of eyes with saline, oxygen, respiratory support

Fowler solution

See Arsenic

—

Fuel, canned

See Alcohol, methyl

—

Fuel oil

See Petroleum distillates

—

Gas

See specific gas, eg, Ammonia gas, Carbon monoxide , Chlorine (tear gas), Hydrogen sulfide (sewer gas, volatile hydrides), and Organophosphates (nerve gas)

—

Gasoline

See Petroleum distillates

—

Glues, model airplane

See Acetone,Benzene (toluene), and Petroleum distillates

—

Gold salts

Gold chloride: Liver and kidney toxicity

Cyanide gold salts: Cyanide toxicity

See Cyanide Treatment (above)

See Table Guidelines for Chelation Therapy

Minor GI problems, possibly altered levels of other drugs

Nonspecific supportive measures

Heptachlor

See Chlorinated and other halogenated hydrocarbons

—

Herbicides

See specific ingredient (eg, Arsenic, Dinitro-o-cresol, Chlorates and nitrates)

—

Hexachlorocyclohexane

See Gamma-benzene hexachloride

Hexaethyltetraphosphate

See Organophosphates

—

Histamine-2 blockers

See H2 blockers

—

Hydrides, volatile

See Hydrogen sulfide

—

Hydrocarbons

See petroleum distillates andHydrocarbon Poisoning

— and Hydrocarbon Poisoning

Hydrocarbons, chlorinated

See Chlorinated and other halogenated hydrocarbons

—

Hydrocarbons, halogenated

See Chlorinated and other halogenated hydrocarbons

—

Hydrochloric acid

See Caustic Ingestion

—

Hydrocyanic acid

See Cyanides

—

Hydrofluoric acid

See Fluorides

—

Hydrogen chloride or fluoride

See Caustic Ingestion

—

Hydrogen sulfide

• Alkali sulfides

• Phosphine

• Sewer or manure gas

• Volatile hydrides

lacrimation and burning eyes, cough, dyspnea, pulmonary edema, caustic skin burns, erythema, pain, profuse salivation, nausea, vomiting, diarrhea, confusion, vertigo, sudden collapse, unconsciousness

Oxygen, respiratory support

Hyoscyamus

See Belladonna

—

Hypochlorites

• Bleach, chlorine

• Javelle water

Usually mild pain and inflammation of oral and GI mucosa

Cough, dyspnea, vomiting, skin vesicles

If usual 6% household preparations have been ingested, dilution with milk (little else required)

If concentrated forms have been ingested, esophagoscopy, treatment of shock

Hypoglycemic drugs, oral

Sulfonylureas

• Chlorpropamide

Hypoglycemia, diaphoresis, lethargy, confusion

For lactic acidosis, supportive care and hemodialysis

Inhalational anesthetics

• Chloroform

• Ether

• Nitrous oxide

• Trichloromethane

Asphyxiation

Drowsiness, coma

With nitrous oxide, delirium

With chloroform, possible acute liver injury

Ingestion: Observation for kidney and liver damage; respiratory, cardiac, and circulatory support

Inhalation: Respiratory, cardiac, and circulatory support

Insecticides

See specific agentChlorinated and other halogenated hydrocarbons, Organophosphates, Paradichlorobenzene, and Pyrethroids

—

Iodine

Burning pain in mouth and esophagus, brown-stained mucous membranes, laryngeal edema, vomiting, abdominal pain, diarrhea, shock, nephritis, circulatory collapse

Milk, starch, or flour po; early airway support; fluid and electrolytes; treatment of shock; early, aggressive airway management

Iodoform (triiodomethane)

Dermatitis, vomiting, cerebral depression, excitation, coma, respiratory difficulty

Ingestion: Dilution with milk or water, respiratory support

Skin contact:

Iron

 (NOTE: Children’s chewables with iron are remarkably safe.)

Vomiting, upper abdominal pain, pallor, cyanosis, diarrhea, drowsiness, shock; possible toxicity if > 20 mg/kg of elemental iron is ingested

For serum iron >400–500 mcg/dL (>Iron Poisoning, Treatment

Isofenphos

See Organophosphates

—

CNS stimulation, seizures, obtundation, coma, hepatotoxicity

Javelle water

See Hypochlorites

—

Kerosene

See Petroleum distillates

—

Ketones

See Acetone

—

Lambda-cyhalothrin

See Pyrethroids

—

Lead

• Lead salts

• Solder

• Some paints and painted surfaces

Acute ingestion: Thirst, burning abdominal pain, vomiting, diarrhea; CNS symptoms (eg, irritability, inattentiveness, decreased level of consciousness, seizures)

Acute inhalation: Insomnia, headache, ataxia, mania, seizures

Chronic exposure: Anemia, peripheral neuropathy, confusion, lead encephalopathy, acceleration of atherosclerosis

See Lead Poisoning

Lead, tetraethyl

Vapor inhalation, skin absorption, or ingestion: CNS symptoms (eg, insomnia, restlessness, ataxia, delusions, mania, seizures)

Lime, chlorinated

See Chlorine

—

See Gamma-benzene hexachloride and Chlorinated and other halogenated hydrocarbons

—

Nausea, vomiting, diarrhea, tremors,fasciculations, drowsiness, diabetes insipidus, ataxia, seizures, hypothyroidism

Acute:> 4 mEq/L (4 mmol/L)

Chronic: If symptoms are severe, dialysis

Lye (sodium hydroxide [NaOH])

Ingestion: see Caustic Ingestion

Skin exposure, see Symptoms and Signs of Burns

Ingestion: see Caustic Ingestion

Skin exposure, see Treatment of Burns

Lysergic acid diethylamide (LSD)

Confusion, hallucinations, hyperexcitability, coma, flashbacks

Supportive care, benzodiazepines

See Organophosphates

—

See Potassium permanganate

—

Mercury, compounds of

• Ammoniated mercury

• Bichloride of mercury

• Calomel

• Corrosive sublimate

• Diuretics, mercurial

• Mercuric chloride (corrosive sublimate)

• Merthiolate

Acute: Severe gastroenteritis, burning mouth pain, salivation, abdominal pain, vomiting, colitis, nephrosis, anuria, uremia

With alkyl and phenyl mercurials, skin burns

Chronic: Gingivitis, mental disturbance, neurologic deficits

Guidelines for Chelation Therapy)

Maintenance of fluid and electrolyte balance, hemodialysis for renal failure, observation for GI perforation

Skin contact: Soap and water for scrubbing

Mercury, elemental

• Liquid (skin contact, ingestion)

• Vapor

Liquid: If ingested, no symptoms

If injected IV, pulmonary emboli

Mercury vapor: Severe pneumonitis

Liquid: If ingested, no treatment needed

If injected IV, supportive care

Mercury vapor: Supportive care

Merthiolate (thimerosal)

See Mercury—usually nontoxic

—

Metaldehyde

• Slug bait

Nausea, vomiting, retching, abdominal pain, muscular rigidity, hyperventilation, seizures, coma

Metals

See entries for specific metals

See table Guidelines for Chelation Therapy

Lactic acidosis

For lactic acidosis, supportive care and hemodialysis

Methanol, methyl alcohol

See Alcohol, methyl

—

Methidathion

See Organophosphates

—

Methoxychlor

See Chlorinated and other halogenated hydrocarbons

—

Methyl parathion

See Organophosphates

—

See

—

Methylene chloride

See Carbon monoxide

See Carbon monoxide

Mineral spirits

See Petroleum distillates

—

Usually benign

Most commonly, sedation, confusion, tachycardia

Observation for ≥ 8 hours

Model airplane glues, solvents

See Acetone, Benzene, Petroleum distillates, and Toluene

—

Monoamine oxidase (MAO) inhibitors

Nonspecific and highly variable symptoms, which are often delayed 6–24 hours

Sympathomimetic toxidromes, headache, nausea, dystonia, hallucinations, nystagmus, fasciculations, diarrhea, seizures, agitation, muscle rigidity

Hypotension and bradycardia (which may be ominous)

Consideration of gastric emptying, supportive care

Monosodium glutamate

Burning sensations throughout the body, facial pressure, anxiety, chest pain (Chinese restaurant syndrome)

Supportive care

Moth balls, crystals, or repellent cakes

See Naphthalene, Camphor, and Paradichlorobenzene

—

Mushrooms, poisonous

See Mushroom Poisoning

Nail polish remover

See Acetone

—

Naled

See Organophosphates

—

Naphtha

See Petroleum distillates

—

Naphthalene

• Deodorizer cakes

• Moth balls, crystals, or repellent cakes (see also Paradichlorobenzene)

Ingestion: Abdominal cramps, nausea, vomiting, headache, confusion, dysuria, intravascular hemolysis, seizures, hemolytic anemia in people with G6PD deficiency

Skin contact: Dermatitis, corneal ulceration

Inhalation: Headache, confusion, vomiting, dyspnea

Ingestion: Blood transfusion for severe hemolysis, urine alkalinization for hemoglobinuria, benzodiazepines to control seizures

Skin contact: Clothing removed if formerly stored with naphthalene moth balls, flushing of skin and eyes

Naphthols

See Phenols

—

Nerve gas agents

See Organophosphates

—

Nickel

Hypersensitivity dermatitis

Chronic inhalation: Pulmonary inflammation

Removal from the source, irrigation with water

Nickel carbonyl

Pneumonitis, cyanosis, delirium, seizures (see also Nickel)

See Tobacco

—

Nitrates

See Chlorates and nitrates

—

Nitric acid

See Caustic Ingestion

—

Nitrites

• Amyl nitrite

• Butyl nitrite

• Potassium nitrite

• Sodium nitrite

Methemoglobinemia, cyanosis, anoxia, GI disturbance, vomiting, headache, dizziness, hypotension, respiratory failure, coma

Oxygen

Nitrobenzene

• Artificial bitter almond oil

• Dinitrobenzene

Bitter almond odor (suggests cyanides), drowsiness, headache, vomiting, ataxia, nystagmus, brown urine, convulsive movements, delirium, cyanosis, coma, respiratory arrest

See Acetanilide

Nitrogen oxides (see also Chlorine, Fluorides, Hydrogen sulfide, Sulfur dioxide; and Environmental Pulmonary Disease)

• Air contaminants that form atmospheric oxidants and that have been liberated from missile fuels, explosives, or agricultural wastes

• Cobaltous chloride

• Hydrogen chloride

• Hydrogen fluoride

Delayed onset of symptoms with nitrogen oxides unless heavy concentration

Fatigue, cough, dyspnea, pulmonary edema

Later, bronchitis, pneumonia

Bed rest, oxygen as soon as symptoms develop

² BSA in children to possibly prevent pulmonary fibrosis

See Cyanides

—

Nitrous oxide

See Chloroform

—

Nausea, vomiting, CNS toxicity (eg, seizures with massive overdoses)

Clinical observation, supportive care

Octamethyl pyrophosphoramide

See Organophosphates

—

Oil of wintergreen

See

—

Oils

See Acetanilide (aniline oil) and Petroleum distillates (fuel oil, lubricating oils)

—

Opioids

Pinpoint pupils, drowsiness, shallow respirations, spasticity, respiratory failure

Organophosphates

• Acephate

• Bidrin

• Chlorethoxyfos

• Chlorothion

• Chlorpyrifos

• Coumaphos

• Demeton

• Diazinon

• Dichlorvos

• Dimethoate

• Disulfoton

• Ethion

• Famphur

• Fenthion

• Hexaethyltetraphosphate

• Isofenphos

• Leptophos

• Merphos

• Methidathion

• Methyl parathion

• Mipafox

• Naled

• Nerve gas agents

• Octamethyl pyrophosphoramide

• Oxydemeton-methyl

• Parathion

• Phorate

• Phosdrin

• Phosmet

• Pirimiphos-methyl

• Temefos

• Terbufos

• Tetrachlorvinphos

• Trichlorfon

• Triorthocresyl phosphate

Absorption via skin, inhalation, or ingestion: Nausea, vomiting, abdominal cramping, excessive salivation, increased pulmonary secretion, headache, rhinorrhea, blurred vision, miosis, slurred speech, mental confusion, difficulty breathing, frothing at the mouth, coma

Removal of clothing, flushing and washing of skin

For attendants, avoidance of self-contamination

Oxalic acid

Oxalates

Burning pain in throat, vomiting, intense pain, hypotension, tetany, shock, glottal and kidney damage, oxaluria

Oxydemeton-methyl

See Organophosphates

—

Paints

For lead-containing paints, see Lead

—

Paint thinners

See Alcohol, methyl; Petroleum distillates (mineral spirits); and Turpentine

—

Paradichlorobenzene

• Insecticides

• Moth repellents

• Pesticides

• Toilet bowl deodorizers

Abdominal pain, nausea, vomiting, diarrhea, seizures, tetany (rare)

Paraldehyde

Oxygen, respiratory support

Paraquat (a strong corrosive)

Diquat

Immediate: GI pain and vomiting

Within 24 hours: Respiratory failure (but no pulmonary problems with diquat)

Parathion

See Organophosphates

—

Paris green

See Arsenic

—

Perchlordecone

See Chlorinated and other halogenated hydrocarbons

—

See Pyrethroids

—

Pesticides

See specific compounds

—

Petroleum distillates (see Hydrocarbon Poisoning)

• Asphalt

• Benzine (benzin)

• Fuel oil

• Gasoline

• Kerosene

• Lubricating oils

• Mineral spirits

• Model airplane glue

• Naphtha

• Petroleum ether

• Tar

Ingestion: Burning throat and stomach, vomiting, diarrhea, pneumonia only if aspiration has occurred

Vapor inhalation: Euphoria, burning in chest, headache, nausea, weakness, CNS depression, confusion, dyspnea, tachypnea, rales, possibly myocardial sensitization to catecholamines (which can result in cardiac arrhythmias)

Aspiration: Early acute pulmonary changes

Because major problems result from aspiration and not GI absorption, gastric evacuation usually not warranted

Supportive care for pulmonary edema, oxygen, respiratory support

Phenacetin

See Acetanilide

—

Phencyclidine (PCP)

Inattentiveness with eyes open, agitation, violent behavior, unconsciousness, tachycardia, hypertension

Quiet environment

Benzodiazepines if needed to provide sedation

Phenols

• Carbolic acid

• Creosote

• Cresols

• Guaiacol

• Naphthols

Corrosive effects, mucous membrane burns, pallor, weakness, shock, seizures in children, pulmonary edema, smoky urine, esophageal stricture (rare)

Respiratory, cardiac, and circulatory failure

Phenothiazines

Extrapyramidal symptoms (eg, ataxia, muscular and carpopedal spasms, torticollis), usually idiosyncratic

With overdose, dry mouth, drowsiness, seizures, coma, respiratory depression

Phenylpropanolamine

Nervousness, irritability, bradycardia, hypertension plus other sympathomimetic effects

Phorate

See Organophosphates

—

Phosdrin

See Organophosphates

—

Phosmet

See Organophosphates

—

Phosphine

See Hydrogen sulfide

—

Phosphodiesterase (PDE) 5 inhibitors

Hypotension, tachycardia, chest pain, arrhythmias, vision loss, priapism

Supportive care, IV fluids and vasopressors, urologic consultation to treat priapism, avoidance of nitrates

Phosphoric acid

See Caustic Ingestion

—

Phosphorus (yellow or white)

• Rat poisons

• Roach powders (Note: Red phosphorus is unabsorbable and nontoxic.)

Stage 1:

Stage 2: Symptom-free 8 hours to several days

Stage 3: Nausea, vomiting, diarrhea, liver enlargement, jaundice, hemorrhages, kidney damage, seizures, coma

Toxicity enhanced by alcohol, fats, or digestible oils

Protection of patient and attendant from vomitus and feces

For phosphorus embedded in skin:

• Submersion of the patient’s body in water

• Irrigation with dilute K permanganate or cupric sulfate (250 mg in 250 mL of water), recommended by some experts

• Prevention of shock

• Meticulous surgical debridement

• Eserine

• Pilocarpus genus

Dizziness, weakness, vomiting, cramping pain, bradycardia, possibly seizures, agitation

Benzodiazepine as needed to provide sedation

Pilocarpus genus

See 

—

Pirimiphos-methyl

See Organophosphates

—

Potash (potassium hydroxide or potassium carbonate)

See Acids and alkalis

—

Potassium cyanide

See Cyanides

—

Potassium nitrite

See Nitrites

—

Potassium permanganate

Brown discoloration and burns of oral mucosa, glottal edema, hypotension, kidney involvement

Dilution with water or milk, consideration of early endoscopy, maintenance of fluid balance

Agitation, sinus tachycardia, seizures, coma

Withdrawal syndrome similar to withdrawal symptoms after stopping gamma-hydroxybutyrate (GHB)

Supportive care, benzodiazepines for seizures and agitation

Prolan

See Chlorinated and other halogenated hydrocarbons

—

Propoxyphene

See Opioids

—

Prussic acid

See Cyanides

—

Pyrethrin, and pyrethroids

• Bifenthrin

• Cyfluthrin

• Cypermethrin

• Esfenvalerate

• Fluvalinate

• Lambda-cyhalothrin

• Pyrethrin

• Resmethrin

• Sumithrin

• Tefluthrin

• Tetramethrin

Allergic response (including anaphylactic reactions and skin sensitivity) in sensitive people; otherwise, low toxicity unless vehicle is a petroleum distillate

Thorough washing of skin, symptomatic and supportive care

Rat poisons

See specific components (eg, Barium compounds, Fluorides, Phosphorus [yellow or white], Thallium salts, Anticoagulants, warfarins)

—

Resmethrin

See Pyrethroids

—

Resorcinol (resorcin)

Vomiting, dizziness, tinnitus, chills, tremor, delirium, seizures, respiratory depression, coma, methemoglobinemia

Roach poisons

See Fluorides, Phosphorus, and Thallium salts

—

Rubbing alcohol

See Alcohol, isopropyl

—

Salicylates

See

—

See

—

See Belladonna

—

See Arsenic and Thallium salts

—

Sewer gas

See Hydrogen sulfide

—

Silver salts

Stained lips (white, brown, then black), argyria (slate gray or blue skin discoloration), gastroenteritis, shock, vertigo, seizures

Smog

See Sulfur dioxide

—

Soda, caustic (Na hydroxide)

For ingestions, see Caustic Ingestion, for skin contact see Burns

Sodium carbonate

See Acids and alkalis

—

Sodium cyanide

See Cyanides

—

See Fluorides

—

Sodium hydroxide

See Caustic Ingestion for skin contact see Burns

See Caustic Ingestion for skin contact see Burns

Solder

See Cadmium and Lead

—

SSRIs

Commonly, sedation, vomiting, tremor, tachycardia

Possibly, seizures, hallucinations, hypotension, serotonin syndrome

Rarely, death

Airway protection; consideration of alkalinization for QRS widening; admission of patients who have symptoms > 6 hours after ingestion

For severe symptoms, consideration of IV lipid emulsion

Stibophen

See Arsenic

—

Stramonium

See Belladonna

—

Strychnine

Restlessness; hyperacuity of hearing, vision, and tactile sensation

Violent myoclonus that simulates generalized seizures but with intact mental status, caused by minor stimuli; complete muscle relaxation between apparent seizures; perspiration; respiratory arrest

For severe seizures, neuromuscular blockade and mechanical ventilatory support

Sulfur dioxide

• Smog

Respiratory tract irritation, sneezing, cough, dyspnea, pulmonary edema

Removal from contaminated area, oxygen, positive pressure breathing, respiratory support

Sulfuric acid

For ingestion, see Caustic Ingestion for skin contact see Burns

—

Sumithrin

See Pyrethroids

—

Syrup of wild cherry

See Cyanides

—

Tar

See Petroleum distillates

—

Tartar emetic

See Arsenic

—

Tear gas

See Chlorine (see also Hypochlorites)

—

Tefluthrin

See Pyrethroids

—

Temefos

See Organophosphates

—

Terbufos

See Organophosphates

—

Tetrachlorvinphos

See Organophosphates

—

Tetraethyl lead

See Lead, tetraethyl

—

Tetramethrin

See Pyrethroids

—

Thallium salts (formerly used in ant, rat, and roach poisons)

Abdominal pain (colic), vomiting (may be bloody), diarrhea (may be bloody), stomatitis, excessive salivation, tremors, leg pains, paresthesias, polyneuritis, ocular and facial palsy, delirium, seizures, respiratory failure, loss of hair about 3 weeks after poisoning

Consultation with poison control center for latest information advisable

See Aminophylline

—

Thyroxine

Usually asymptomatic

Rarely, increasing irritability progressing to thyroid storm in 5–7 days

Tobacco

Excitement, confusion, muscular twitching, weakness, abdominal cramps, generalized myoclonus, CNS depression, rapid respirations, palpitations, cardiovascular collapse, coma, respiratory failure

Toilet bowl cleaners, deodorizers

See Symptoms of Caustic Ingestion and Paradicholorobenzene

See Treatment of Caustic Ingestion and —

Toluene, toluol

See Benzene

—

Toxaphene

See Chlorinated and other halogenated hydrocarbons

—

Trichlorfon

See Organophosphates

—

Trichloromethane

See Chloroform

—

Tricyclic antidepressants

Anticholinergic effects (eg, blurred vision, urinary hesitation), CNS effects (eg, drowsiness, stupor, coma, ataxia, restlessness, agitation, hyperactive reflexes, muscle rigidity, seizures), cardiovascular effects (eg, tachycardia, other arrhythmias, bundle branch block, QRS widening, impaired conduction, heart failure), respiratory depression, hypotension, shock, vomiting, hyperpyrexia, mydriasis, diaphoresis

> 7.45 (constant infusion may be needed)

For severe poisoning, consideration of IV lipid emulsion

Triiodomethane

See Iodoform (triiodomethane)

—

Tungsten

Exposure may cause diffuse interstitial pulmonary fibrosis. See Overview of Interstitial Lung Disease

Overview of Interstitial Lung Disease

Turpentine

• Some paint solvents

• Some varnishes

Turpentine odor, burning oral and abdominal pain, coughing, choking, respiratory failure, nephritis

Respiratory support, oxygen, control of pain, monitoring of kidney function

Valproate

Progressive CNS and respiratory depression

Hyperammonemia with or without hepatic toxicity

Respiratory and cardiovascular supportive measures, monitoring of liver function

Symptomatic hyperammonemia: L-Carnitine 100 mg/kg (6 g maximum) IV over 30 minutes with maintenance dose of 15 mg/kg every 4 hours

Asymptomatic hyperammonemia: L-Carnitine 100 mg/kg orally every 6 hours (3 g/day maximum)

Varnish

See Alcohol, methyl and Turpentine

—

Possibly sedation, seizures, QRS prolongation, sympathomimetic symptoms (eg, tremor, mydriasis, tachycardia, hypertension, diaphoresis), hypotension

Rarely death

Observation for ≥ 6 hours

For QRS prolongation, consideration of alkalinization

Vitamins with iron

See Iron

—

See Anticoagulants, warfarins

—

Wild cherry syrup (natural, not artificially flavored)

See Cyanides

—

Wintergreen oil

Symptoms and Signs

—

Wood alcohol

See Alcohol, methyl

—

Xylene

See Benzene

—

Zinc

See Zinc Toxicity

See table Guidelines for Chelation Therapy

See

—