Poisoning

Definition

Poisoning occurs when any substance interferes with normal body functions after it is swallowed, inhaled, injected, or absorbed. The branch of medicine that deals with the detection and treatment of poisons is known as toxicology.

Description

Poisonings are a common occurrence. About 10 million cases of poisoning occur in the United States each year. In 80% of the cases, the victim is a child under the age of five. About 50 children die each year from poisonings. Curiosity, inability to read warning labels, a desire to imitate adults, and inadequate supervision lead to childhood poisonings.

The elderly are the second most likely group to be poisoned. Mental confusion, poor eyesight, and the use of multiple drugs are the leading reasons why this group has a high rate of accidental poisoning. A substantial number of poisonings also occur as suicide attempts or drug overdoses.

Poisons are common in the home and workplace, yet there are basically two major types. One group consists of products that were never meant to be ingested or inhaled, such as shampoo, paint thinner, pesticides, houseplant leaves, and carbon monoxide. The other group contains products that can be ingested in small quantities, but which are harmful if taken in large amounts, such as pharmaceuticals, medicinal herbs, or alcohol. Other types of poisons include the bacterial toxins that cause food poisoning, such as Escherichia coli ; heavy metals, such as the lead found in the paint on older houses; and the venom found in the bites and stings of some animals and insects. The staff at a poison control center and emergency room doctors have the most experience diagnosing and treating poisoning cases.

Causes and symptoms

The effects of poisons are as varied as the poisons themselves; however, the exact mechanisms of only a few are understood. Some poisons interfere with the metabolism. Others destroy the liver or kidneys, such as heavy metals and some pain relief medications, including acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (Advil, Ibuprofen). A poison may severely depress the central nervous system, leading to coma and eventual respiratory and circulatory failure. Potential poisons in this category include anesthetics (e.g. ether and chloroform), opiates (e.g., morphine and codeine), and barbiturates. Some poisons directly affect the respiratory and circulatory system. Carbon monoxide causes death by binding with hemoglobin that would normally transport oxygen throughout the body. Certain corrosive vapors trigger the body to flood the lungs with fluids, effectively drowning the person. Cyanide interferes with respiration at the cellular level. Another group of poisons interferes with the electrochemical impulses that travel between neurons in the nervous system. Yet another group, including cocaine, ergot, strychnine, and some snake venoms, causes potentially fatal seizures.

Severity of symptoms can range from headache and nausea to convulsions and death. The type of poison, the amount and time of exposure, and the age, size, and health of the victim are all factors which determine the severity of symptoms and the chances for recovery.

Plant poisoning

There are more than 700 species of poisonous plants in the United States. Plants are second only to medicines in causing serious poisoning in children under age five. There is no way to tell by looking at a plant if it is poisonous. Some plants, such as the yew shrub, are almost entirely toxic: needles, bark, seeds, and berries. In other plants, only certain parts are poisonous. The bulb of the hyacinth and daffodil are toxic, but the flowers are not; while the flowers of the jasmine plant are the poisonous part. Moreover, some plants are confusing because portions of them are eaten as food while other parts are poisonous. For example, the fleshy stem (tuber) of the potato plant is nutritious; however, its roots, sprouts, and vines are poisonous. The leaves of tomatoes are poisonous, while the fruit is not. Rhubarb stalks are good to eat, but the leaves are poisonous. Apricots, cherries, peaches, and apples all produce healthful fruit, but their seeds contain a form of cyanide that can kill a child if chewed in sufficient quantities. One hundred milligrams (mg) of moist, crushed apricot seeds can produce 217 mg of cyanide.

Common houseplants that contain some poisonous parts include:

• Aloe
• Amaryllis
• Cyclamen
• Dumb cane (also called Dieffenbachia)
• Philodendron

Common outdoor plants that contain some poisonous part include:

• Bird of paradise flower
• Buttercup
• Castor bean
• Chinaberry tree
• Daffodil
• English ivy
• Eucalyptus
• Foxglove
• Holly
• Horse chestnut
• Iris
• Jack-in-the-pulpit
• Jimsonweed (also called thornapple)
• Larkspur
• Lily-of-the-valley
• Morning glory
• Nightshade (several varieties)
• Oleander
• Potato
• Rhododendron
• Rhubarb
• Sweet pea
• Tomato
• Wisteria
• Yew

Symptoms of plant poisoning range from irritation of the skin or mucous membranes of the mouth and throat to nausea, vomiting, convulsions, irregular heartbeat, and even death. It is often difficult to tell if a person has eaten a poisonous plant because there are no tell-tale empty containers and no unusual lesions or odors around the mouth.

Many cases of plant poisoning involve plants that contain hallucinogens, such as peyote cactus buttons, certain types of mushrooms, and marijuana. A recent case of plant poisoning in France concerned Datura, or moonflower, a plant that has become popular with young people trying to imitate Native American puberty rites.

Other cases of plant poisoning result from the use of herbal dietary supplements that have been contaminated by toxic substances. The Food and Drug Administration (FDA) has the authority to monitor herbal products on the market and issue warnings about accidental poisoning or other adverse affects associated with these products. For example, in 2002 a manufacturer of nettle capsules found to contain lead recalled the product following a warning from the FDA. Other dietary supplements have been found to contain small quantities of prescription medications or even toxic plants.

Household chemicals

Many products used daily in the home are poisonous if swallowed. These products often contain strong acids or strong bases (alkalis). Toxic household cleaning products include:

• ammonia
• bleach
• dishwashing liquids
• drain openers
• floor waxes and furniture polishes
• laundry detergents, spot cleaners, and fabric softeners
• mildew removers
• oven cleaners
• toilet bowl cleaners

Personal care products found in the home can also be poisonous. These include:

• deodorant
• hairspray
• hair straighteners
• nail polish and polish remover
• perfume
• shampoo

Signs that a person has swallowed one of these substances include evidence of an empty container nearby, nausea or vomiting, and burns on the lips and skin around the mouth if the substance was a strong acid or alkali. The chemicals in some of these products may leave a distinctive odor on the breath.

Pharmaceuticals

Both over-the-counter and prescription medicines can help the body heal if taken as directed. However, when taken in large quantities, or with other drugs where there may be an adverse interaction, they can act as poisons. Drug overdoses, both accidental and intentional, are the leading cause of poisoning in adults. Medicinal herbs should be treated like pharmaceuticals and taken only in designated quantities under the supervision of a knowledgeable person. Herbs that have healing qualities when taken in small doses can be toxic in larger doses, or may interact with prescription medications in unpredictable ways.

Drug overdoses cause a range of symptoms, including excitability, sleepiness, confusion, unconsciousness, rapid heartbeat, convulsions, nausea, and changes in blood pressure. The best initial evidence of a drug overdose is the presence of an empty container near the victim.

Other causes of poisonings

People can be poisoned by fumes they inhale. Carbon monoxide is the most common form of inhaled poison. Other toxic substances that can be inhaled include:

• farm and garden insecticides and herbicides
• gasoline fumes
• insect repellent
• paint thinner fumes

Diagnosis

Initially, poisoning is suspected if the victim shows changes in behavior and signs or symptoms previously described. Hallucinations or other psychiatric symptoms may indicate poisoning by a hallucinogenic plant. Evidence of an empty container or information from the victim are helpful in determining exactly what substance has caused the poisoning. Some acids and alkalis leave burns on the mouth. Petroleum products, such as lighter fluid or kerosene, leave a distinctive odor on the breath. The vomit may be tested to determine the exact composition of the poison. Once hospitalized, the patient may be given blood and urine tests to determine his or her metabolic condition.

Treatment

Treatment for poisoning depends on the poison swallowed or inhaled. Contacting the poison control center or hospital emergency room is the first step in getting proper treatment. The poison control center's telephone number is often listed with emergency numbers on the inside cover of the telephone book, or it can be reached by dialing the operator. The poison control center will ask for specific information about the victim and the poison, then give appropriate first aid instructions. If the patient is to be taken to a hospital, a sample of vomit and the poison container should be taken along, if they are available.

Most cases of plant poisoning are treated by inducing vomiting, if the patient is fully conscious. Vomiting can be induced by taking syrup of ipecac, an over-the-counter emetic available at any pharmacy.

For acid, alkali, or petroleum product poisonings, the patient should not vomit. Acids and alkalis can burn the esophagus if they are vomited, and petroleum products can be inhaled into the lungs during vomiting, resulting in pneumonia.

Once under medical care, doctors have the option of treating the patient with a specific remedy to counteract the poison (antidote) or with activated charcoal to absorb the substance inside the patient's digestive system. In some instances, pumping the stomach may be required. This technique, which is known as gastric lavage, involves introducing 20-30 mL of tap water or 9% saline solution into the patient's digestive tract and removing the stomach contents with a siphon or syringe. The process is repeated until the washings are free of poison. Medical personnel will also provide supportive care as needed, such as intravenous fluids or mechanical ventilation.

If the doctor suspects that the poisoning was not accidental, he or she is required to notify law enforcement authorities. Most cases of malicious poisoning concern family members or acquaintances of the victim, but the number of intentional random poisonings of the general public has increased in recent years. A case reported in 2003 involved the use of nicotine to poison 1700 pounds of ground beef in a Michigan supermarket. Over a hundred persons fell ill after eating the poisoned beef.

Prognosis

The outcome of poisoning varies from complete recovery to death, and depends on the type and amount of the poison, the health of the victim, and the speed with which medical care is obtained.

Prevention

Most accidental poisonings are preventable. The number of deaths of children from poisoning has declined from about 450 per year in the 1960s to about 50 each year in the 1990s. This decline has occurred mainly because of better packaging of toxic materials and better public education.

Actions to prevent poisonings include:

• removing plants that are poisonous
• keeping medicines and household chemicals locked and in a place inaccessible to children
• keeping medications in child-resistant containers
• never referring to medicine as "candy"
• keeping cleaners and other poisons in their original containers
• disposing of outdated prescription medicines
• not purchasing over-the-counter medications with damaged protective seals or packaging
• avoiding the use of herbal preparations not made by a reputable manufacturer

KEY TERMS

Antidote— A medication or remedy for counteracting the effects of a poison.

Emetic— A medication or substance given to induce vomiting.

Gastric lavage— A technique for washing poison out of the stomach by instilling water or saline solution through a tube, removing the stomach contents by suction, and repeating the process until the washings are free of poison. It is also called stomach pumping.

Toxicology— The branch of medicine that deals with the effects, detection, and treatment of poisons.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Poisoning." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Arouko, H., M. D. Matray, C. Braganca, et al. "Voluntary Poisoning by Ingestion of Datura stramonium. Another Cause of Hospitalization in Youth Seeking Strong Sensations." [in French] Annales de médecine interne 154, Spec no. 1 (June 2003): S46-S50.

Centers for Disease Control and Prevention. "Nicotine Poisoning After Ingestion of Contaminated Ground Beef—Michigan, 2003." Morbidity and Mortality Weekly Report 52 (May 9, 2003): 413-416.

Hirshon, Jon Mark, MD, MPH. "Plant Poisoning, Herbs." eMedicine January 18, 2002. 〈http://www.emedicine.com/EMERG/topic449.htm〉.

Salomone, Joseph A., III, MD. "Toxicity, Hallucinogen." eMedicine November 27, 2001. 〈http://www.emedicine.com/emerg/topic223.htm〉.

ORGANIZATIONS

American Association of Poison Control Centers (AAPCC). 3201 New Mexico Avenue, Suite 330, Washington, DC 20016. (202) 362-7217. POISONING EMERGENCIES: (800) 222-1222. 〈http://www.aapcc.org〉.

National Toxicology Program (NTP) of the National Institute of Environmental Health Sciences (NIEHS). P. O. Box 12233, Research Triangle Park, NC 27709. (919) 541-3419. 〈http://www.ntpserver.niehs.nih.gov〉.

U. S. Food and Drug Administration (FDA). 5600 Fishers Lane, Rockville, MD 20857. (888) 463-6332. 〈http://www.fda.gov〉.

OTHER

Arizona Poison and Drug Information Center Page. 〈http://www.pharmacy.arizona.edu/centers/poisoncenter〉.

"Homeowner Chemical Safety." Centers for DiseaseControl. 〈http://www.cdc.gov/niosh/nasd/docs2/pdfs/as23900.pdf〉.

"Poisonous Plant Databases." University of Maryland. 〈http://www.inform.umd.edu〉.

Poisoning

Definition

Poisoning occurs when any substance interferes with normal body functions after it is swallowed, inhaled, injected, or absorbed. The branch of medicine that deals with the detection and treatment of poisons is known as toxicology.

Description

Children are the most common victims of poisoning in the United States. Curiosity, inability to read warning labels, a desire to imitate adults, and inadequate supervision lead to most childhood poisonings.

The elderly are the second most likely group to be poisoned. Mental confusion, poor eyesight, and the use of multiple drugs are the leading reasons this group has a high rate of accidental poisoning. A substantial number of poisonings also occur as suicide attempts or drug overdoses.

Poisons are common in the home and workplace, yet there are basically two major types. One group consists of products that were never meant to be ingested or inhaled, such as shampoo, paint thinner, pesticides, houseplant leaves, and carbon monoxide. The other group contains products that can be ingested in small quantities, but which are harmful if taken in large amounts, such as pharmaceuticals, medicinal herbs, or alcohol. Other types of poisons include the bacterial toxins that cause food poisoning , such as Escherichia coli ; heavy metals, such as the lead found in the paint on older houses; and the venom found in the bites and stings of some animals and insects. The staff at a poison control center and emergency room doctors have the most experience diagnosing and treating poisoning cases.

Demographics

Poisonings are a common occurrence. About 10 million cases of poisoning occur in the United States each year. In 80 percent of the cases, the victim is a child under the age of five. About 50 children die each year from poisonings.

Causes and symptoms

The effects of poisons are as varied as the poisons themselves; however, the exact mechanisms of only a few are understood. Some poisons interfere with the metabolism. Others destroy the liver or kidneys, such as heavy metals and some pain relief medications, including acetaminophen and nonsteroidal anti-inflammatory drugs (ibuprofen). A poison may severely depress the central nervous system, leading to coma and eventual respiratory and circulatory failure. Potential poisons in this category include anesthetics (e.g. ether and chloroform), opiates (e.g., morphine and codeine), and barbiturates. Some poisons directly affect the respiratory and circulatory system. Carbon monoxide causes death by binding with hemoglobin that would normally transport oxygen throughout the body. Certain corrosive vapors trigger the body to flood the lungs with fluids, effectively drowning the person. Cyanide interferes with respiration at the cellular level. Another group of poisons interferes with the electrochemical impulses that travel between neurons in the nervous system. Yet another group, including cocaine, ergot, strychnine, and some snake venoms, causes potentially fatal seizures.

Severity of symptoms can range from headache and nausea to convulsions and death. The type of poison, the amount and time of exposure, and the age, size, and health of the victim are all factors which taken together determine the severity of symptoms and the chances for recovery.

Plant poisoning

There are more than 700 species of poisonous plants in the United States. Plants are second only to medicines in causing serious poisoning in children under age five. There is no way to tell by looking at a plant if it is poisonous. Some plants, such as the yew shrub, are almost entirely toxic: needles, bark, seeds, and berries. In other plants, only certain parts are poisonous. The bulb of the hyacinth and daffodil are toxic, but the flowers are not; while the flowers of the jasmine plant are the poisonous part. Moreover, some plants are confusing because portions of them are eaten as food while other parts are poisonous. For example, the fleshy stem (tuber) of the potato plant is nutritious; however, its roots, sprouts, and vines are poisonous. The leaves of tomatoes are poisonous, while the fruit is not. Rhubarb stalks are good to eat, but the leaves are poisonous. Apricots, cherries, peaches, and apples all produce healthful fruit, but their seeds contain a form of cyanide that can kill a child if chewed in sufficient quantities. One hundred milligrams (mg) of moist, crushed apricot seeds can produce 217 mg of cyanide.

Common houseplants that contain some poisonous parts include the following:

• aloe
• amaryllis
• cyclamen
• dumb cane (also called Dieffenbachia)
• philodendron

Common outdoor plants that contain some poisonous part include the following:

• bird of paradise flower
• buttercup
• castor bean
• chinaberry tree
• daffodil
• English ivy
• eucalyptus
• foxglove
• holly
• horse chestnut
• iris
• jack-in-the-pulpit
• jimsonweed (also called thornapple)
• larkspur
• lily-of-the-valley
• morning glory
• nightshade (several varieties)
• oleander
• potato
• rhododendron
• rhubarb
• sweet pea
• tomato
• wisteria
• yew

Symptoms of plant poisoning range from irritation of the skin or mucous membranes of the mouth and throat to nausea, vomiting , convulsions, irregular heartbeat, and even death. It is often difficult to tell if a person has eaten a poisonous plant because there are no tell-tale empty containers and no unusual lesions or odors around the mouth.

Many cases of plant poisoning involve plants that contain hallucinogens, such as peyote cactus buttons, certain types of mushrooms, and marijuana. Poisoning has occurred with Datura, or moonflower, a plant that has become popular with young people trying to imitate Native American puberty rites.

Other cases of plant poisoning result from the use of herbal dietary supplements that have been contaminated by toxic substances. The Food and Drug Administration (FDA) has the authority to monitor herbal products on the market and issue warnings about accidental poisoning or other adverse affects associated with these products. For example, in 2002 a manufacturer of nettle capsules found to contain lead recalled the product following a warning from the FDA. Other dietary supplements have been found to contain small quantities of prescription medications or even toxic plants.

Household chemicals

Many products used daily in the home are poisonous if swallowed. These products often contain strong acids or strong bases (alkalis). Toxic household cleaning products include the following:

• ammonia
• bleach
• dishwashing liquids
• drain openers
• floor waxes and furniture polishes
• laundry detergents, spot cleaners, and fabric softeners
• mildew removers
• oven cleaners
• toilet bowl cleaners

Personal care products found in the home can also be poisonous. These include:

• deodorant
• hairspray
• hair straighteners
• nail polish and polish remover
• perfume
• shampoo

Signs that a person has swallowed one of these substances include evidence of an empty container nearby, nausea or vomiting, and burns on the lips and skin around the mouth if the substance is a strong acid or alkali. The chemicals in some of these products may leave a distinctive odor on the breath.

Pharmaceuticals

Both over-the-counter and prescription medicines can help the body heal if taken as directed. However, when taken in large quantities, or with other drugs with which there may be an adverse interaction, they can act as poisons. Drug overdoses, both accidental and intentional, are the leading cause of poisoning in adults. Medicinal herbs should be treated like pharmaceuticals and taken only in designated quantities under the supervision of a knowledgeable person. Herbs that have healing qualities when taken in small doses can be toxic in larger doses or may interact with prescription medications in unpredictable ways.

Drug overdoses cause a range of symptoms, including excitability, sleepiness, confusion, unconsciousness, rapid heartbeat, convulsions, nausea, and changes in blood pressure. The best initial evidence of a drug over-dose is the presence of an empty container near the victim.

Other causes of poisonings

People can be poisoned by fumes they inhale. Carbon monoxide is the most common form of inhaled poison. Other toxic substances that can be inhaled include:

• farm and garden insecticides and herbicides
• gasoline fumes
• insect repellent
• paint thinner fumes

When to call the doctor

A doctor or poison control center should be called if any form of poisoning is suspected or if children or other persons behave in an odd manner.

Diagnosis

Initially, poisoning is suspected if the victim shows changes in behavior and signs or symptoms previously described. Hallucinations or other psychiatric symptoms may indicate poisoning by a hallucinogenic plant. Evidence of an empty container or information from the victim is helpful in determining exactly what substance has caused the poisoning. Some acids and alkalis leave burns on the mouth. Petroleum products, such as lighter fluid or kerosene, leave a distinctive odor on the breath. The vomit may be tested to determine the exact composition of the poison. Once hospitalized, the person may be given blood and urine tests to determine his or her metabolic condition.

Treatment

Treatment for poisoning depends on the poison swallowed or inhaled. Contacting the poison control center or hospital emergency room is the first step in getting proper treatment. The poison control center's telephone number is often listed with emergency numbers on the inside cover of the telephone book, or it can be reached by dialing the operator. The poison control center will ask for specific information about the victim and the poison then give appropriate first aid instructions. If the person is to be taken to a hospital, a sample of vomit and the poison container should be taken along, if they are available.

For acid, alkali, or petroleum product poisonings, the person should not vomit. Acids and alkalis can burn the esophagus if they are vomited, and petroleum products can be inhaled into the lungs during vomiting, resulting in pneumonia .

Once the victim is under medical care, doctors have the option of treating the person with a specific remedy to counteract the poison (antidote) or with activated charcoal to absorb the substance inside the individual's digestive system. In some instances, pumping the stomach may be required. This technique, which is known as gastric lavage, involves introducing 20 to 30 mL of tap water or 9 percent saline solution into the person's digestive tract and removing the stomach contents with a siphon or syringe. The process is repeated until the washings are free of poison. Medical personnel will also provide supportive care as needed, such as intravenous fluids or mechanical ventilation.

If the doctor suspects that the poisoning was not accidental, he or she is required to notify law enforcement authorities. Most cases of malicious poisoning concern family members or acquaintances of the victim, but the number of intentional random poisonings of the general public has increased in the late 1990s and early 2000s. A case reported in 2003 involved the use of nicotine to poison 1,700 pounds of ground beef in a Michigan supermarket. Over 100 persons fell ill after eating the poisoned beef.

Prognosis

The outcome of poisoning varies from complete recovery to death and depends on the type and amount of the poison, the health of the victim, and the speed with which medical care is obtained.

Prevention

Most accidental poisonings are preventable. The number of deaths of children from poisoning has declined from about 450 per year in the 1960s to about 50 each year in the 1990s. This decline has occurred mainly because of better packaging of toxic materials and better public education.

Actions to prevent poisonings include:

• removing plants that are poisonous
• keeping medicines and household chemicals locked and in a place inaccessible to children
• keeping medications in child-resistant containers
• never referring to medicine as candy
• keeping cleaners and other poisons in their original containers
• disposing of outdated prescription medicines
• not purchasing over-the-counter medications with damaged protective seals or packaging
• avoiding the use of herbal preparations not made by a reputable manufacturer

Parental concerns

Parents should monitor the activities and substances to which their children are exposed. The number of the nearest Poison Control Center should be posted next to every telephone in the house. The number can be found on the first page of any telephone book.

KEY TERMS

Antidote —A remedy to counteract a poison or injury. Also refers to a substance which cancels the effect of homeopathic remedies

Emetic —A medication intended to cause vomiting. Emetics are sometimes used in aversion therapy in place of electric shock. Their most common use in mainstream medicine is in treating accidental poisoning.

Gastric lavage —Also called a stomach pump. For this procedure, a flexible tube is inserted through the nose, down the throat, and into the stomach and the contents of the stomach are suctioned out. The inside of the stomach is rinsed with a saline (salt water) solution.

Toxicology —The branch of medical pharmacology dealing with the detection, effects, and antidotes of poisons.

Resources

BOOKS

Hu, Howard. "Heavy Metal Poisoning." In Harrison's Principles of Internal Medicine, 15th ed. Edited by Eugene Braunwald et al. New York: McGraw-Hill, 2001, pp. 2590–4.

Klaasen, Curtis D. Casarett and Doull's Toxicology: The Basic Science of Poisons, 6th ed. New York: McGraw-Hill, 2001.

Linden, Christopher H., and Michael J. Burns. "Poisoning and Drug Overdosage." In Harrison's Principles of Internal Medicine, 15th ed. Edited by Eugene Braunwald et al. New York: McGraw-Hill, 2001, pp. 2595–615.

Robertson, William O. "Chronic Poisoning: Trace Metals and Others." In Cecil Textbook of Medicine, 22nd ed. Edited by Lee Goldman et al. Philadelphia: Saunders, 2003, 91–9.

Rodgers, George C., and Nancy J. Matyunas. "Poisonings: Drugs, Chemicals and Plants." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2003, pp. 2362–74.

Salerno, Denise A., and Stephen C. Aronoff. "Non-bacterial Food Poisoning." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2003, pp. 2375–7.

PERIODICALS

Dahlgren, J. G., et al. "Health effects of diazinon on a family." Journal of Toxicology. Clinical Toxicology 42, no. 5 (2004): 579–91.

Munidasa, U. A., et al. "Survival pattern in patients with acute organophosphate poisoning receiving intensive care." Journal of Toxicology. Clinical Toxicology 42, no. 4 (2004): 343–7.

Richardson, W. H., et al. "A case of type F botulism in southern California." Journal of Toxicology. Clinical Toxicology 42, no. 4 (2004): 383–7.

Vanarsdale, J. L., et al. "Lead Poisoning from a Toy Necklace." Pediatrics 114, no. 4 (2004): 1096–9.

ORGANIZATIONS

American Academy of Clinical Toxicology. 777 East Park Dr., PO Box 8820, Harrisburg, PA 17105–8820. Web site: <www.clintox.org/index.html>.

American Academy of Emergency Medicine. 611 East Wells St., Milwaukee, WI 53202. Web site: <www.aaem.org/>.

American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: <www.aafp.org/>.

American Academy of Pediatrics. 141 Northwest Point Blvd., Elk Grove Village, IL 60007–1098. Web site: <www.aap.org/default.htm>.

American Association of Poison Control Centers. 3201 New Mexico Ave., NW, Washington, DC 20016. Web site: <www.aapcc.org/>.

American College of Emergency Physicians. PO Box 619911, Dallas, TX 75261–9911. Web site: <www.acep.org/>.

American College of Occupational and Environmental Medicine. 55 West Seegers Rd., Arlington Heights, IL 60005. Web site: <www.acoem.org/>.

American College of Osteopathic Emergency Physicians. 142 E. Ontario St., Suite 550, Chicago, IL 60611. Web site: <www.acoep.org/>.

WEB SITES

"About Food Poisoning." Virginia Department of Agriculture & Consumer Services. Available online at <www.vdacs.virginia.gov/foodsafety/poisoning.html> (accessed December 22, 2004).

"Childhood Lead Poisoning Prevention Program." Centers for Disease Control and Prevention. Available online at <www.cdc.gov/nceh/lead/lead.htm>(accessed December 22, 2004).

"Diseases and Disorders: Links Pertaining to Poisoning." Karolinska Institute. Available online at <www.mic.ki.se/Diseases/C21.613.html> (accessed December 22, 2004).

"Mushroom Poisoning in Children." American Academy of Family Practice. Available online at <http://familydoctor.org/129.xml> (accessed December 22, 2004).

"Poisoning." MedlinePlus. Available online at <www.nlm.nih.gov/medlineplus/poisoning.html> (accessed December 22, 2004).

"Poisoning." The Merck Manual. Available online at <www.merck.com/mrkshared/mmanual/section23/chapter307/307a.jsp> (accessed December 22, 2004).

"Signs and Symptoms of Pesticide Poisoning." University of Nebraska Cooperative Extension. Available online at <http://ianrpubs.unl.edu/Pesticides/ec2505.htm> (accessed December 22, 2004).

L. Fleming Fallon, Jr., MD, DrPH

Poisoning

Definition

Poisoning is the state produced by the introduction of toxic substances, that is, any substance that produces an injurious or fatal effect, into the body.

Description

Poisoning commonly involves the introduction of poisonous elements from outside the body. The term also can apply to noxious material produced within the body that, because of a disease condition such as kidney or liver failure, cannot be removed; or toxins produced by bacteria, as in the case of food poisoning. Poisons can enter the body from multiple external sources. They can be swallowed; inhaled, as in the case of carbon monoxide or aerosol compounds; or they can enter via the skin, as in snake or insect bites and even radiation from the sun that we call sun poisoning. Some question exists regarding whether electromagnetic fields (EMFs) also produce damaging effects within the body.

Poisoning is a common occurrence. An estimated 10 million cases of poisoning occur in the United States each year. In 2000, 2 million exposures to poisonous substances were reported to United States Poison Control. In 50% of the cases, the victim is a child under the age of five. The most common toxic substances taken in are cosmetics and personal care products, followed by home cleaning products, medications, and plants. Most poisonings, nearly 89%, occur in the home, and are accidental.

About 50 children die each year in the United States from poisoning. Curiosity, inability to read warning labels, a desire to imitate adults, and inadequate supervision lead to childhood poisonings. The elderly are the second most likely group to be poisoned. Mental confusion, poor eyesight, and the use of multiple drugs are the leading reasons why this group has a high rate of accidental poisoning. A substantial number—approximately 11% of all poisonings—also occur as suicide attempts.

Poisons taken internally are common in the home and workplace. There are basically two major types. One group consists of products that were never meant to be safely ingested or inhaled, such as shampoo, paint thinner, pesticides, houseplant leaves, and carbon monoxide. The other group contains products that can be ingested in small quantities, but which are harmful if taken in large amounts. These include pharmaceuticals, medicinal herbs, or alcohol. Other types of poisons include the bacterial toxins that cause food poisoning, such as Escherichia coli; heavy metals, such as the lead found in the paint on older houses; and the venom found in the bites and stings of some animals and insects. The staff at a poison control center and emergency room doctors have the most experience diagnosing and treating poisoning cases.

Causes and symptoms

The effects of poisons are as varied as the poisons themselves. The exact mechanisms of only a few are understood. Some poisons interfere with the metabolism. Others destroy the liver or kidneys, such as heavy metals and some pain relief medications, including acetaminophen (Tylenol) and nonsteroidal antiinflammatory drugs (Advil, Ibuprofen). A poison may severely depress the central nervous system, leading to coma and eventual respiratory and circulatory failure. Potential poisons in this category include anesthetics (e.g. ether and chloroform); opiates (e.g. morphine and codeine); and barbiturates. Some poisons directly affect the respiratory and circulatory systems. Carbon monoxide causes death by binding with hemoglobin that would normally transport oxygen throughout the body. Certain corrosive vapors trigger the body to flood the lungs with fluids, effectively drowning the person. Cyanide interferes with respiration at the cellular level. Another group of poisons interferes with the electrochemical impulses that travel between neurons in the nervous system. Another group, including cocaine, ergot, strychnine, and some snake venoms, causes potentially fatal seizures.

Severity of poisoning symptoms can range from headache and nausea to convulsions and death. The type of poison; the amount and time of exposure; and the age, size, and health of the victim are all factors that determine the severity of symptoms and the chances for recovery.

Plant poisoning

There are more than 700 species of poisonous plants in the United States. Plants are second only to medicines in causing serious poisoning in children under age five. The appearance of a plant offers no determination of its poison. Some plants, such as the yew shrub, are almost entirely toxic: needles, bark, seeds, and berries. In other plants, only certain parts are poisonous. The bulb of the hyacinth and daffodil are toxic, but the flowers are not. It is the flowers of the jasmine plant that are poisonous. Some plants are confusing because portions of them are eaten as food while other parts are poisonous. For example, the fleshy stem (tuber) of the potato plant is nutritious; however, its roots, sprouts, and vines are poisonous. The leaves of tomatoes are poisonous, while the fruit is not. Rhubarb stalks are good to eat, but the leaves are poisonous. Apricots, cherries, peaches, and apples all produce healthful fruit, but their seeds contain a form of cyanide that can kill a child if chewed in sufficient quantities. One hundred milligrams (mg) of moist, crushed apricot seeds can produce 217 milligrams of cyanide.

Common houseplants that contain some poisonous parts include:

• aloe
• amaryllis
• Boston ivy
• caladium
• cyclamen
• dumbcane (also called Dieffenbachia)
• philodendron

Common outdoor plants that contain some poisonous part include:

• azalea
• bird-of-paradise flower
• black cherry
• buttercup
• calla lilly
• castor bean
• chinaberry tree
• caffodil
• delphinium
• English ivy
• eucalyptus
• foxglove
• holly
• horse chestnut
• hydrangea
• iris
• jack-in-the-pulpit
• jimsonweed (also called thornapple)
• larkspur
• lily-of-the-valley
• morning glory
• nightshade (several varieties)
• oleander
• potato
• rhododendron
• rhubarb
• sweet pea
• tomato
• wisteria
• yew

Symptoms of plant poisoning range from irritation of the skin or mucous membranes of the mouth and throat to nausea, vomiting, convulsions, irregular heartbeat, and even death. It is often difficult to tell if a person has eaten a poisonous plant because there are no telltale empty containers and no unusual lesions or odors around the mouth.

Household chemicals

Many products used daily in the home are poisonous if swallowed. These products often contain strong acids or strong bases (alkalis). Toxic household cleaning products include:

• ammonia
• bleach
• dishwashing liquids
• drain openers
• floor waxes and furniture polishes
• laundry detergents, spot cleaners, and fabric softeners
• mildew removers
• oven cleaners
• toilet bowl cleaners

Personal care products found in the home can also be poisonous. These include:

• deodorant
• hair spray
• hair straighteners
• nail polish and polish remover
• perfume
• shampoo

Signs that a person has swallowed one of these substances include evidence of an empty container nearby, nausea or vomiting, and burns on the lips and skin around the mouth if the substance is a strong acid or alkali. The chemicals in some of these products may leave a distinctive odor on the breath.

Pharmaceuticals

Both over-the-counter and prescription medicines can help the body heal if taken as directed. When taken in large quantities, or with other drugs where there may be an adverse interaction, they can subsequently act as poisons. Drug overdoses, both accidental and intentional, are the leading cause of poisoning in adults. Medicinal herbs should be treated like pharmaceuticals and taken only in designated quantities under the supervision of a knowledgeable person. Herbs that have healing qualities when taken in small doses can be toxic in larger doses.

Diagnosis

Initially, poisoning is suspected if the victim shows changes in behavior and the signs or symptoms previously described. Evidence of an empty container or information from the victim are helpful in determining exactly what substance has caused the poisoning. Some acids and alkalis leave burns on the mouth. Petroleum products, such as lighter fluid or kerosene, leave a distinctive odor on the breath. Vomitus may be tested to determine the exact composition of the poison. Once hospitalized, blood and urine tests may be done on the patient to determine his metabolic condition.

Treatment

Treatment for poisoning depends on the poison swallowed or inhaled. Contacting a poison control center or hospital emergency room is the first step in getting proper treatment. The poison control center's telephone number is often listed with emergency numbers on the inside cover of the telephone book, or can be reached by dialing 911 or the operator. The poison control center will ask for specific information about the victim and the poison, then give appropriate first aid instructions. If the patient is to be taken to a hospital, a sample of vomitus and the poison container should be taken along, if they are available.

Most cases of plant poisoning are treated by inducing vomiting, if the person is fully conscious. Vomiting can be induced by taking syrup of ipecac, an over-the-counter product available at any pharmacy.

For acid, alkali, or petroleum product poisonings, the patient should not be made to vomit. Acids and alkalis can burn the esophagus if they are vomited, and petroleum products can be inhaled into the lungs during vomiting, resulting in aspiration pneumonia.

Once under medical care, doctors have the option of treating the patient with a specific remedy to counteract the poison (antidote) or with activated charcoal to absorb the substance inside the patient's digestive system. In some instances, pumping the stomach may be required. Medical personnel will also provide supportive care as needed, such as intravenous fluids or mechanical ventilation.

Prognosis

The outcome of poisoning varies from complete recovery to death, and depends on the type and amount of the poison, the health of the victim, and the speed with which medical care is obtained.

Health care team roles

In most cases, a poisoning victim will initially be discovered by a family member or friend. Once the health care staff has been engaged at the request of those involved, it can include:

• Staff at local poison control centers. These are people specially trained regarding the properties and treatment of poisons. Staff may include physicians and nurses who are especially skilled at obtaining necessary information regarding the poison and providing the needed facts in regard to treatment.
• Emergency medical technicians (EMTs), specially trained in providing emergency care to people outside of hospitals. Often under the supervision of an emergency room physician, EMTs are frequently the first to provide medical intervention. They work from ambulances, providing the initial care often in the home, or place where the poisoning took place.
• If the poisoning victim is transported to a hospital emergency room, a licensed physician trained in emergency medicine will either begin or take further measures to negate the effect of the poison.
• Both registered nurses (RNs), and licensed practical nurses (LPNs) work in hospital emergency rooms, and are often located in poison control centers. In emergency rooms, both RNs and LPNs will be responsible for monitoring vital signs, obtaining specimens of vomitus, administering medications such as activated charcoal or ipecac, or providing assistance in carrying out procedures such as gastric lavage (pumping the stomach). Providing reassurance to frightened patients and families, and offering information regarding poisons, especially to the families of children that have been poisoned, are both critical elements of care.
• Clinical laboratory scientists have specialized training and must pass a state examination. They draw blood samples or test urine to do toxic screens for various drugs, or other tests that determine what toxic substance has been ingested.

• Radiologic technologists have specialized training and must pass a state examination. They may be called upon to take a chest x ray to ensure that the person has not aspirated (had foreign material such as vomit enter the lungs), causing aspiration pneumonia.

Prevention

Most accidental poisonings are preventable. The number of deaths of children from poisoning in the United States has declined from about 450 per year in the 1960s to about 50 each year in the 1990s. This decline has occurred primarily due to better packaging of toxic materials, and to better public education.

Actions to prevent poisonings include:

• removing plants that are poisonous
• keeping medicines and household chemicals locked and in a place inaccessible to children
• keeping medications in child-resistant containers
• never referring to medicine as "candy"
• keeping cleaners and other poisons in their original containers
• disposing of outdated prescription medicines

KEY TERMS

Acid— A chemical substance that contains the element hydrogen and has a pH above seven, which is considered neutral. Acids are generally described as sour or biting in character.

Alkali— A chemical substance that has the ability to neutralize acid. It has a pH below seven, which is considered neutral, and is generally described as caustic in nature.

Aspiration pneumonia— Fluid entering the lungs through choking or vomiting, and leading to infection of the lung.

Gastric lavage— Insertion of a tube into the stomach for the purpose of washing out and removing toxic material.

Ipecac— A medication made from the dried root of a plant native to Brazil, often used to induce vomiting.

Resources

BOOKS

Kozier, Barbara, RN, MN, Erb, Glenora, RN, BSN, Blais, Kathleen, RN, EdD, Wilkinson, Judith M., RNC, MA, MS. Fundamentals of Nursing, Concepts, Process and Practice, 5th ed. Redwood City, CA: Addison-Wesley, 1995.

Venes, Donald, and Clayton L. Thomas and Clarence Wilber Taber, eds. Taber's Cyclopedic Medical Dictionary, 19th ed. Philadelphia,: F. A. Davis Co., 2001.

OTHER

Chemical and Pharmaceutical Press. One World Trade Center, Suite 5151, New York, NY 10048. 〈http://www.cppress.com/html〉.

Karolinska Institutet. "Poisoning." Web page with world-wide links to poison networks, and other related information on poisoning topics. 〈http://www.mic.ki.se/Diseases/c21.613.html〉.

Massachusetts Poison Control Center, Poisoning Basics. 300 Longwood Ave., Boston, MA 02115 〈http://www.mapoison.org/commonpoisons/basics.htm〉.

National Library of Medicine, National Insitutes of Health. TOXNET. Toxicology Data Network. 〈http://toxnet.nlm.nih.gov〉.

ParentsPlace.com. Health. Focus on First Aid Kit. "Poison Control Centers of the U.S." Nationwide listing of state poison control departments. 〈http://www.parentsplace.com/health/firsstaid/gen/0,3375,886,00.html〉.

Poisoning

Definition

Poisoning is the state produced by the introduction of toxic substances; that is, any substance that produces an injurious or fatal effect, into the body.

Description

Poisoning commonly involves the introduction of poisonous elements from outside the body. The term also can apply to noxious material produced within the body that, because of a disease condition such as kidney or liver failure, cannot be removed; or toxins produced by bacteria , as in the case of food poisoning . Poisons can enter the body from multiple external sources. They can be swallowed; inhaled, as in the case of carbon monoxide or aerosol compounds; or they can enter via the skin, as in snake or insect bites; and even via radiation from the sun that we call sun poisoning. Some question exists regarding whether electro-magnetic fields (EMFs) also produce damaging effects within the body.

Poisoning is a common occurrence. An estimated 10 million cases of poisoning occur in the United States each year. 2.24 million exposures to poisonous substances were reported to United States Poison Control Centers in 1998. In 50% of the cases, the victim is a child under the age of five. The most common toxic substances taken in are cosmetics and personal care products, followed by home cleaning products, medications and plants. Most poisonings, nearly 89%, occur in the home, and are accidental.

About 50 children die each year in the United States from poisoning. Curiosity, inability to read warning labels, a desire to imitate adults, and inadequate supervision lead to childhood poisonings. The elderly are the second most likely group to be poisoned. Mental confusion, poor eyesight, and the use of multiple drugs are the leading reasons why this group has a high rate of accidental poisoning. A substantial number—approximately eleven percent of all poisonings—also occur as suicide attempts.

Poisons taken internally are common in the home and workplace. There are basically two major types. One group consists of products that were never meant to be ingested or inhaled, such as shampoo, paint thinner, pesticides, houseplant leaves, and carbon monoxide. The other group contains products that can be safely ingested in small quantities, but which are harmful if taken in large amounts. These include pharmaceuticals, medicinal herbs, or alcohol. Other types of poisons include the bacterial toxins that cause food poisoning, such as Escherichia coli; heavy metals, such as the lead found in the paint on older houses; and the venom found in the bites and stings of some animals and insects. The staff at a poison control center and emergency room doctors have the most experience diagnosing and treating poisoning cases.

Causes and symptoms

The effects of poisons are as varied as the poisons themselves. The exact mechanisms of only a few are understood. Some poisons interfere with the metabolism . Others destroy the liver or kidneys , such as heavy metals and some pain relief medications, including acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (Advil, Ibuprofen). A poison may severely depress the central nervous system , leading to coma and eventual respiratory and circulatory failure. Potential poisons in this category include anesthetics (e.g. ether and chloroform); opiates (e.g. morphine and codeine); and barbiturates. Some poisons directly affect the respiratory and circulatory systems. Carbon monoxide causes death by binding with hemoglobin that would normally transport oxygen throughout the body. Certain corrosive vapors trigger the body to flood the lungs with fluids, effectively drowning the person. Cyanide interferes with respiration at the cellular level. Another group of poisons interferes with the electrochemical impulses that travel between neurons in the nervous system. Another group, including cocaine, ergot, strychnine, and some snake venoms, causes potentially fatal seizures.

Severity of poisoning symptoms can range from headache and nausea to convulsions and death. The type of poison; the amount and time of exposure; and the age, size, and health of the victim are all factors that determine the severity of symptoms and the chances for recovery.

Plant poisoning

There are more than 700 species of poisonous plants in the United States. Plants are second only to medicines in causing serious poisoning in children under age five. The appearance of a plant offers no determination of its poison. Some plants, such as the yew shrub, are almost entirely toxic: needles, bark, seeds, and berries. In other plants, only certain parts are poisonous. The bulb of the hyacinth and daffodil are toxic, but the flowers are not. It is the flowers of the jasmine plant that are the poisonous part. Some plants are confusing because portions of them are eaten as food while other parts are poisonous. For example, the fleshy stem (tuber) of the potato plant is nutritious; however, its roots, sprouts, and vines are poisonous. The leaves of tomatoes are poisonous, while the fruit is not. Rhubarb stalks are good to eat, but the leaves are poisonous. Apricots, cherries, peaches, and apples all produce healthful fruit, but their seeds contain a form of cyanide that can kill a child if chewed in sufficient quantities. One hundred milligrams (mg) of moist, crushed apricot seeds can produce 217 milligrams of cyanide.

Common houseplants that contain some poisonous parts include:

• aloe
• amaryllis
• Boston ivy
• caladium
• cyclamen
• dumb cane (also called Dieffenbachia)
• philodendron

Common outdoor plants that contain some poisonous part include:

• azalea
• bird-of-paradise flower
• black cherry
• buttercup
• calla lilly
• castor bean
• chinaberry tree
• caffodil
• delphinium
• English ivy
• eucalyptus
• foxglove
• holly
• horse chestnut
• hydrangea
• iris
• jack-in-the-pulpit
• jimson weed (also called thornapple)
• larkspur
• lily-of-the-valley
• morning glory
• nightshade (several varieties)
• oleander
• potato
• rhododendron
• rhubarb
• sweet pea
• tomato
• wisteria
• yew

Symptoms of plant poisoning range from irritation of the skin or mucous membranes of the mouth and throat to nausea, vomiting, convulsions, irregular heartbeat, and even death. It is often difficult to tell if a person has eaten a poisonous plant because there are no telltale empty containers and no unusual lesions or odors around the mouth.

Household chemicals

Many products used daily in the home are poisonous if swallowed. These products often contain strong acids or strong bases (alkalis). Toxic household cleaning products include:

• ammonia
• bleach
• dishwashing liquids
• drain openers
• floor waxes and furniture polishes
• laundry detergents, spot cleaners, and fabric softeners
• mildew removers
• oven cleaners
• toilet bowl cleaners

Personal care products found in the home can also be poisonous. These include:

• deodorant
• hair spray
• hair straighteners
• nail polish and polish remover
• perfume
• shampoo

Signs that a person has swallowed one of these substances include evidence of an empty container nearby, nausea or vomiting, and burns on the lips and skin around the mouth if the substance is a strong acid or alkali. The chemicals in some of these products may leave a distinctive odor on the breath.

Pharmaceuticals

Both over-the-counter and prescription medicines can help the body heal if taken as directed. When taken in large quantities, or with other drugs where there may be an adverse interaction, they can subsequently act as poisons. Drug overdoses, both accidental and intentional, are the leading cause of poisoning in adults. Medicinal herbs should be treated like pharmaceuticals and taken only in designated quantities under the supervision of a knowledgeable person. Herbs that have healing qualities when taken in small doses can be toxic in larger doses.

Diagnosis

Initially, poisoning is suspected if the victim shows changes in behavior and the signs or symptoms previously described. Evidence of an empty container or information from the victim are helpful in determining exactly what substance has caused the poisoning. Some acids and alkalis leave burns on the mouth. Petroleum products, such as lighter fluid or kerosene, leave a distinctive odor on the breath. Vomitus may be tested to determine the exact composition of the poison. Once hospitalized, blood and urine tests may be done on the patient to determine his metabolic condition.

Treatment

Treatment for poisoning depends on the poison swallowed or inhaled. Contacting a poison control center or hospital emergency room is the first step in getting proper treatment. The poison control center's telephone number is often listed with emergency numbers on the inside cover of the telephone book, or can be reached by dialing 911 or the operator. The poison control center will ask for specific information about the victim and the poison, then give appropriate first aid instructions. If the patient is to be taken to a hospital, a sample of vomitus and the poison container should be taken along, if they are available.

Most cases of plant poisoning are treated by inducing vomiting, if the person is fully conscious. Vomiting can be induced by taking syrup of ipecac , an over-thecounter product available at any pharmacy.

For acid, alkali, or petroleum product poisonings, the patient should not be made to vomit. Acids and alkalis can burn the esophagus if they are vomited, and petroleum products can be inhaled into the lungs during vomiting, resulting in aspiration pneumonia .

Once under medical care, doctors have the option of treating the patient with a specific remedy to counteract the poison (antidote) or with activated charcoal to absorb the substance inside the patient's digestive system . In some instances, pumping the stomach may be required. Medical personnel will also provide supportive care as needed, such as intravenous fluids or mechanical ventilation.

Prognosis

The outcome of poisoning varies from complete recovery to death, and depends on the type and amount of the poison, the health of the victim, and the speed with which medical care is obtained.

KEY TERMS

Acid —A chemical substance that contains the element hydrogen and has a pH above seven, which is considered neutral. Acids are generally described as sour or biting in character.

Alkali —A chemical substance that has the ability to neutralize acid. It has a pH below seven, which is considered neutral, and is generally described as caustic in nature.

Aspiration pneumonia —Fluid entering the lungs through choking or vomiting, and leading to infection of the lung.

Gastric lavage —Insertion of a tube into the stomach for the purpose of washing out and removing toxic material.

Ipecac —A medication made from the dried root of a plant native to Brazil, often used to induce vomiting.

Health care team roles

In most cases, a poisoning victim will initially be discovered by a family member or friend. Once the health care staff has been engaged at the request of those involved, it can include:

• Staff at local poison control centers. These are people specially trained regarding the properties and treatment of poisons. Staff may include physicians and nurses who are especially skilled at obtaining necessary information regarding the poison and providing the needed facts in regard to treatment.
• Emergency medical technicians (EMTs), are specially trained in providing emergency care to people outside of hospitals. Often under the supervision of an emergency room physician, EMTs are frequently the first to provide medical intervention. They work from ambulances, providing the initial care often in the home, or place where the poisoning took place.
• If the poisoning victim is transported to a hospital emergency room, a licensed physician trained in emergency medicine will either begin or take further measures to negate the effect of the poison.
• Both registered nurses (RNs), and licensed practical nurses (LPNs) work in hospital emergency rooms, and are often located in poison control centers. In emergency rooms, both RNs and LPNs will be responsible for monitoring vital signs , obtaining specimens of vomitus, administering such medications as activated charcoal or ipecac, or providing assistance in carrying out such procedures as gastric lavage (pumping the stomach). Providing reassurance to frightened patients and families, and offering information regarding poisons, especially to the families of children that have been poisoned, are both critical elements of care.
• Clinical laboratory scientists have specialized training and must pass a state examination. They draw blood samples or test urine to do toxic screens for various drugs, or other tests that determine what toxic substance has been ingested.
• Radiologic technologists have specialized training and must pass a state examination. They may be called upon to take a chest x ray to ensure that the person has not aspirated (had foreign material such as vomit enter the lungs), causing aspiration pneumonia.

Prevention

Most accidental poisonings are preventable. The number of deaths of children from poisoning in the United States has declined from about 450 per year in the 1960s to about 50 each year in the 1990s. This decline has occurred primarily due to better packaging of toxic materials, and to better public education.

Actions to prevent poisonings include:

• removing plants that are poisonous
• keeping medicines and household chemicals locked and in a place inaccessible to children
• keeping medications in child-resistant containers
• never referring to medicine as "candy"
• keeping cleaners and other poisons in their original containers
• disposing of outdated prescription medicines

Resources

BOOKS

Kozier, Barbara, RN, MN, Erb, Glenora, RN, BSN, Blais, Kathleen, RN, EdD, Wilkinson, Judith M., RNC, MA, MS. Fundamentals of Nursing, Concepts, Process and Practice, 5^th ed. Redwood City, CA: Addison-Wesley, 1995.

Venes, Donald, and Clayton L. Thomas and Clarence Wilber Taber, eds. Taber's Cyclopedic Medical Dictionary, 19^th ed. Philadelphia,: F. A. Davis Co., 2001.

OTHER

Chemical and Pharmaceutical Press. One World Trade Center, Suite 5151, New York, NY 10048. <http://www.cppress.com/html>.

Karolinska Institutet. "Poisoning." Web page with worldwide links to poison networks, and other related information on poisoning topics. <http://www.mic.ki.se/Diseases/c21.613.html>.

Massachusetts Poison Control Center, Poisoning Basics. 300 Longwood Ave., Boston, MA 02115 <http://www.mapoison.org/commonpoisons/basics.htm>.

National Library of Medicine, National Insitutes of Health. TOXNET. Toxicology Data Network. <http://toxnet.nlm.nih.gov>.

ParentsPlace.com. Health. Focus on First Aid Kit. "Poison Control Centers of the U.S." Nationwide listing of state poison control departments. <http://www.parentsplace.com/health/firsstaid/gen/0,3375,886,00.html>.

Joan M. Schonbeck

POISONING

POISONING. Throughout history and across cultures food and drink have been used to deliver lethal poison. Since a person's demise from a slow-acting poison mimics so many natural diseases, and there is typically a time lapse between administration and expiration, this method made it almost impossible in early times to prove homicide. With the advent of chemical analyses for poisons (rudimentary arsenic tests were introduced in the 1840s) and autopsy, poisoning in the early twenty-first century, if suspected, is readily detected.

Poisoning in History

Since at least Greek and Roman times, there is historical documentation of poisonings. During the reign of Artaxerxes II of Persia (405–359 B.C.E.), it was said that his queen, Parsysatis, poisoned her daughter-in-law, Satira, by serving slices of fowl carved with a knife that had been coated on one side with venom. This allowed the queen to dine with Satira—Parsysatis reserving for herself the uncontaminated slices.

When selecting food or wine to serve as vehicles for poison, poisoners prefer a substance that will mask the bitter taste of the poison. Consequently, sweet foods were often selected. Wine had the advantage of preventing the victim from being on guard. Tea, coffee, hot chocolate, tarts (sweet and savory), jams, puddings, fruit pies, pastries, steak and kidney pie, chocolates, corned beef, porridge, and rice have all been used in poisonings.

According to medieval literature, many prelates, sovereigns, and pretenders or heirs to the throne were victims of poisoning plots. The murderers were most often from the victim's inner circle. In 1152, for example, Hugues d'Amboise was poisoned by a coterie of his knights at a banquet given by his brother. The historical heyday for poisonings was Renaissance Italy (1400–1700). So many deaths occurred that Romans hardly believed that any man of prominence or wealth had died a natural death. The legendary Borgia family, specifically Lucretia, gained a wide reputation for poisonings, especially of cardinals. Cantarella, a slow-acting poison, was said to have been dropped into food or drink, even sacramental wine. These murders were supposedly undertaken on behalf of Lucretia's father, Pope Alexander VI, who as head of the Roman Catholic Church was heir to the cardinals' estates. As these allegations were repeated, they became part of the historical record. More recently, they been revealed to be outright myth.

There are other instances in which an assumed poisoning has profound historical implications. When the exiled Napoleon Bonaparte died in 1821, his demise was at first attributed to stomach cancer, but examination of his hair has found the presence of arsenic. In the 1960s, the U.S. Central Intelligence Agency (CIA) devised a number of food-and drink-based poisons for assassination, including a lethal milkshake intended for Cuban leader Fidel Castro. Ultimately, the spy agency abandoned this, as the delivery system was too unreliable; it was thought to be much easier to get a target to inhale poisonous gas. In his 1962 autobiography, the late King Hussein I of Jordan relates his uncovering of a Syrian Intelligence plot to bribe his cook to poison his food. The tip-off: The untimely deaths of the palace cats, victims of the assassin's experiments.

Poisoning in Fiction

Poisonings have become the stuff of myth and legend, and a staple of mystery writers. The premeditation of the crime—acquisition of poison, calculation of lethal dosage, decision about which food or drink to use, preparation of the concoction, and making the victim consume it—adds to the insidiousness of the murder. In the fairy tale Snow White, a story that has survived for centuries in all European countries and languages, the wicked queen offers Snow White a poisoned apple that will induce a deathlike coma. The duel scene in Shakespeare's Hamlet features a poisoned cup of wine intended for the prince but mistakenly and fatally drunk by his mother, Queen Gertrude. In the 1941 American play "Arsenic and Old Lace," two seemingly innocent sisters in their sixties poison twelve men (a thirteenth as the curtain falls) with their homemade, arsenic-laced elderberry wine. In the 1996 literary mystery bestseller The Debt to Pleasure by John Lancaster, gourmet murderer Tarquin Winot suffers a brief setback when his intended victim turns down one of Winot's famous mushroom (Death Cap) omelets, saying he is allergic to eggs. After arguing that migraine is a small price to pay for gustatory pleasure, Winot recoups and whips up mushrooms on toast. In this poisoning, the food is not simply a disguise for poison, but the poison itself.

Gender and Poisoning

Although poisonings are committed by both men and women, they have been stereotyped as a female crime. In 1584, English writer Reginald Scot claimed women had invented poisoning and were "addicted" to the method. Nineteenth-century European writers, including criminologists, always profiled the poisoner as female. As recently as 1961, criminologist Otto Pollak claimed in The Criminality of Women that poison was the murder method of choice of most female offenders. Women's social roles as wives, meal-preparers, and caretakers, he argued, afford them unique opportunities to commit poisonings.

Throughout the literature, there are numerous examples of poisonings associated not only with women but also with their adultery, magic, and witchcraft. The near hysteria that swept nineteenth-century Victorian England, generated by tabloid reports of trials of forty women for putting arsenic in their husbands' food, was misplaced paranoia. When death records were examined, it was found that spousal murder of all kinds had risen dramatically between 1830 and 1900, with about one thousand people being found guilty. More than 90 percent of these murders were committed by men, the result of beatings and stabbings; only twenty cases were poisonings of wives by husbands.

In the twentieth century, concerns about poisoning of both food and water came to focus on bioterrorism. In a celebrated case in 1984 in The Dalles, Oregon, members of a religious cult inserted salmonella bacteria in salad-bar foods, provoking 751 cases of infection. The purpose (this was only a trial run) was to keep voters away from the polls in an election several weeks hence where a land-use issue involving the cult's property could have an unfavorable outcome. Intentional criminal poisoning was not suspected at first; it was proved a year later. A paper written on the case was not published until 1997 out of fear of stimulating "copy-cat" incidents. Two other cases in Asia in 1996 include a mass poisoning with cyanide inserted into a curry stew at a festival in Japan, killing four people and, in India, the contamination of rice at a canteen with datura, a poisonous weed of the nightshade family, causing fifty-two fatalities. In the wake of the terrorist attacks in New York and Washington in 2001, the possibility of intentional poisoning of the food and/or water supply is being taken very seriously, particularly where botulinum toxin, the most deadly chemical known, is concerned. Where heads of state and other dignitaries are concerned, this has translated into extensive background checks on food preparers, servers, and suppliers as well as x-raying of liquor and produce received by restaurants and close surveillance in the kitchen.

BIBLIOGRAPHY

Chelminski, Rudolph. "Did Napoleon Die at the Hands of a Secret Assassin?" Smithsonian 13, no. 1 (1982): 76–82, 84–85.

Durant, Will. The Renaissance: A History of Civilization in Italy from 1304–1576 A . D . New York: Simon and Schuster, 1953.

Farrell, Michael. Poisons and Poisoners: An Encyclopedia of Homicidal Poisonings. London: Hale, 1992.

Hussein I, King. Uneasy Lies the Head: The Autobiography of His Majesty King Hussein I of the Hashemite Kingdom of Jordan. New York: Geis, 1962.

Lancaster, John. The Debt to Pleasure: A Novel. New York: Holt, 1996.

Marks, John D. The Search for the "Manchurian Candidate": The CIA and Mind Control. New York: Times Books, 1978.

Pollak, Otto. The Criminality of Women. New York: A. S. Barnes, 1961.

Robb, G. "Circe in Crinoline: Domestic Poisonings in Victorian England." Journal of Family History 22, no. 2 (1997): 176–190.

Serventi, Silvano. "The Taste Test." Slow (1999): 10–17.

Linda Murray Berzok

Royal Tasters

During the Middle Ages and Renaissance, fear of poisoning was so great that royalty required that their food and drink to be tasted in their presence before they would eat. The tasting—a complex ceremony—usually fell to the food-preparers and servers. For Charles the Bold, Duke of Burgundy from 1467 to 1477, for example, the kitchen steward first tasted all food under the watchful eyes of the house steward. Then, as each dish was uncovered before the duke, a sample was given to official plate-bearer for tasting. The butler was the last servant to taste the dishes.

Wine required its own ritual. The royal cupbearer poured the libation into not only the duke's glass but into a tumbler as well. The glass was immediately covered, and water was added to the tumbler, which was drunk by the cupbearer's assistant. Only then would the wineglass be placed in front of the duke.

Tasting practices were largely abandoned in the mid-sixteenth century, although the ceremony was retained until the seventeenth century. Tasting is still practiced in the early twenty-first century in some Middle Eastern countries and Thailand.

In some form, tasting rituals have been with us since hunter-gatherer days when it was by trial and error that our ancestors learned to distinguish toxic from nontoxic plants. In the 1990s, research on taste has identified a subset of people known as supertasters, most often female, who have the genetic ability to sense tastes more intensely. They are so supersensitive to bitter tastes (a characteristic of poison) that the flavor actually causes them pain.