These guidelines have been withdrawn MOH clinical practice guidelines are considered withdrawn five years after publication unless otherwise specified in individual guidelines. Users should keep in mind that evidence-based guidelines are only as current as the evidence that supports them and new evidence can supersede recommendations made in the guidelines. CLINICAL PRACTICE GUIDELINES Management of Drug Overdose and Poisoning Ministry National Pharmaceutical May 2000 of Health Administration MOH Clinical Practice Guidelines 2/2000 Published by Ministry of Health, Singapore 2000 This publication is meant as a general guide to the management of drug overdose and poisoning and not as an authoritative reference on the subject. Because of the dynamic nature of information on poisoning, readers are advised that decisions regarding drug therapy must be based on the independent judgement of the clinician, changing information about a drug/ chemical and changing medical practices.
While care has been taken to ensure the accuracy of the information presented at the time of publishing, the Ministry of Health, the authors, and the publishing editors will not be liable for any errors or omissions, or any untoward effect arising from the use or misuse of this book. Management of Drug Overdose & Poisoning I Message Clinical toxicology has advanced considerably in the last 10 years since the publication of the first handbook on the management of poisoning by the Ministry of Health. The pattern of poisoning has also changed as people are now exposed to other new drugs and chemicals. New antidotes and therapies have been developed for the management of such poisoning, and are now available to health professionals.
The publication of this new edition on the management of drug overdose and poisoning is most timely. The workgroup has put in great efforts to produce this comprehensive handbook, which will serve as a quick and easy reference for health professionals in the management of poisoning. I would like to congratulate the workgroup members and all contributors for their achievement. I trust that the handbook will meet the information requirements of our healthcare workers.
Dr Chen Ai Ju Director of Medical Services Ministry of Health II Preface The first handbook on management of poisoning was published by the Ministry of Health ten years ago. The objective then was to provide a quick and reliable reference for the complex management of drug overdoses/ poisoning. Since then, great strides have been made in scientific technology, medicine, agriculture and pest control which have led to the development of many new products with associated toxic effects. Therefore, it has become necessary to revise and update the information pertaining to toxicology.
This new edition of the handbook provides comprehensive advice for the management of drug overdose and poisoning. It is organised into 4 main sections, each identified by coloured tags in the right margins. Section A gives an overview of principles in the management of poisoning including the medico-legal and socio-psychiatric aspects. Section B provides information on diagnosis and treatment of overdoses of 11 classes of therapeutic agents.
Section C focuses on household, industrial and metallic poisoning; and Section D is on agricultural poisoning. To make the handbook a practical and useful guide, a comprehensive index with extensive cross referencing is provided. The revision and publishing of the handbook has been a challenging and rewarding task. We hope it will be well utilised by the health professionals.
We would like to record our grateful thanks to the workgroup members for their time and contribution to the various chapters. Mrs Tan Shook Fong Chief Pharmacist/Director National Pharmaceutical Administration Ministry of Health May 2000 III Workgroup Members Chairmen Mrs Tan Shook Fong Dr V Anantharaman Chief Pharmacist/Director Head (Emergency Medicine) National Pharmaceutical Administration Singapore General Hosptial Secretary Ms Chan Cheng Leng Head (Information & Research) National Pharmaceutical Administration Members A/Prof Lee How Sung Mr Toh Kaik Bing Department of Pharmacology Head (New Drug Unit) National University of Singapore National Pharmaceutical Administra- tion Dr Tan Colin Clinical Professor Chao Tzee Cheng Medical Graduate Special Forensic Advisor National Pharmaceutical Administration Institute of Science & Forensic Medicine Dr Bloodworth Chen Bosco Dr Lo Danny Head (Food Laboratory) Head (Toxicology) Institute of Science & Forensic Medicine Institute of Science & Forensic Medicine Mr Tan Kelvin Ms Chua Sheau Bin Pharmacist Pharmacist National Pharmaceutical Administration National Pharmaceutical Administra- tion Ms N Shymala Senior Pharmacist Singapore General Hospital Acknowledgements The Committee would like to express its appreciation to the Kwan Im Thong Hood Cho Temple and the National Medical Research Council (NMRC) for the generous contribution to the printing of this publication. Special thanks to Dr R Ponampalam of the Singapore General Hospital for his invaluable feedback and comments. IV V Contents Message.
II Workgroup Members. III SECTION A - OVERVIEW OF MANAGEMENT 1 Poison Management Systems. 3 2 Principles of Management of Acute Poisoning. 13 3 Decontamination After Poisoning.
41 4 Enhancing the Elimination of Toxic Substances from the Body. 55 5 Medico-Legal Aspects of Poisoning. 69 6 Socio-Psychiatric Aspects of Poisons Management. 71 7 The Toxicology Laboratory.
75 8 Antidotes & Therapeutic Drugs. 89 SECTION B - MEDICINAL POISONING 1 Antihistamines. 143 2 Anti-Infective Agents 2.4 Skeletal Muscle Relaxants .5 Smooth Muscle Relaxants. 188 VI 4 Cardiovascular Drugs 4.6 Nitrites and Nitrates.
212 5 Central Nervous System Drugs 5.1 Analgesics, Antipyretics and Anti-Inflammatory Agents .1 Antacids and Antiflatulents .5 Proton Pump Inhibitors. 272 8 Hormones and Steroids 8.1 Androgens and Anabolic Steroids .6 Thyroid and Antithyroid Drugs. 309 10 Skin and Mucous Membrane Agents 10. 313 VII 11 Vitamins and Iron Preparations 11.
322 SECTION C - HOUSEHOLD, INDUSTRIAL AND METALLIC POISONING 1 Household Chemicals 1.2 Boric Acid and Borates .8 Oxalic Acid and its Salts .10 Phenol and Related Compounds .13 Paraquat and Diquat .1 Acids and Acid-Related Corrosives .2 Alcohols and Glycols .3 Alkalis and Other Alkali-Related Corrosives .5 Corrosive Gases and Oxidising Agents .6 Aldehydes, Ethers and Ketones .9 Hydrogen Cyanide and Derivaties .1 Antimony and Stibine .2 Arsenic and Arsine. 408 SECTION D - PESTICIDE POISONING 1 Carbamates. 415 3 Organo-Chlorine Insecticides. NOTES/UPDATES INDEX 1 S E C T I O N A OVERVIEW OF MANAGEMENT 2 3 CHAPTER 1 Poison Management Systems Introduction Poison management systems refer to the whole series of processes that begin from the time a drug or chemical is produced, to its ingestion as a poison, and all the steps required for a complete patient management.
Such a system may have various components, some of which are: - 1. Formulation and manufacture. Distribution and control of access. Measures to ensure prophylaxis against wrongful ingestion in the home, workplace or general environment.
Community measures for handling one or more episodes of poisoning. Emergency patient management and after-care. Education of patient and relatives. Formulation and Manufacture Drugs and chemicals cause toxicological effects when they gain access to the body in large concentration and when countermeasures are delayed.
Examples of such adverse consequences are numerous. Sometimes modifications in formulation can decrease the tendency to toxicity, for example: 1. Banning or reducing the manufacture or sale of toxic agents such as those used in chemical warfare e. sarin, tabun mustard gas, phosgene and pesticides, e.
dichloro diphenyltrichloroethane (DDT) and aldrin. Modifying the formulation of a product to make it less injurious e. adding methionine to acetaminophen to ensure ready availability of sulphydryl groups during toxic ingestion so as to minimise the likelihood of hepatic damage. Substituting products with less toxic agents but which are at least equally effective, e.
removing alcohol from children’s cough and cold preparations decreases the likelihood of toxicity. The manufacture of chemicals is also a potential source of poisoning on a large scale. Industrial chemical disasters such as what happened in Bhopal, India in the early hours of Dec 3, 1984, when about 45 tons of methyl isocyanate escaped from an insecticide plant is an example of how shortfalls in the manufacturing process affect lives adversely. The catastrophe resulted in 2500 deaths and 50,000 injured persons.
Safety standards in chemical plants have to be a primary concern of states that allow such plants to operate within their boundaries. Distribution and Control of Access Safety aspects and limiting access of chemicals and drugs can be incorporated into the design of the packaging. Some methods may include: - 1. Introducing packaging that allows easy recognition of drugs and that avoids confusion, viz.
avoiding the use of similar labelling and design for different drugs and ensuring that drugs look different in size, shape, texture and colour. Use of child-resistant containers, blister packs and tamper-resistant containers. The increased time and effort required to gain access to the drug decreases the risk of toxic ingestion. Restricting the sale of commonly abused over-the-counter medications e.
analgesics and sedatives, or of toxic agricultural products without licensing of purchaser e. Chemicals in bulk are often transported across roads and highways. Accidents involving the transport vehicles can result in the release of large amounts of these chemicals into the environment. In 1995, the release of a nerve gas (Sarin) in the subway network of Tokyo, Japan, with the resulting large number of casualties, again demonstrated the tremendous potential for terrorist groups to use dangerous agents of chemical warfare to further their political aims.
POISON MANAGEMENT SYSTEMS 5 Prophylaxis Against Wrongful Ingestion People will be able to recognise poisonous/toxic substances and be warned of the possible toxic potential if :- 1. Warning stickers are affixed to household and medicinal products. Such stickers may depict a skull and cross-bones, a serpent or a scowling face. Dark coloured containers are used for storage of poisons not meant for oral ingestion.
Labels are affixed to the back of vehicles transporting hazardous substances in bulk. Below is a list of common sense measures to be taken in the home environment: - a) All medicines and chemicals should be clearly labelled so that both children and adults will be fully aware of the contents. b) Medicines and household chemicals should be kept in safe areas in the home out of reach of children. c) All chemical items should be kept in their original containers.
Never store toxic substances in soda bottles or cups, or any unmarked or unauthorized containers. d) Use child-resistant containers. Keep the caps securely shut between uses. e) Discard household cleaning aids or other products that are no longer used.
f) Store toxic household and garden products in cabinets fitted with safety latches and/or locks. When in use, make sure that an adult is present. Put away the product immediately after use. g) Never equate medicines with candy when administering drugs to children.
Do not make light of or joke to a child about taking medication. h) Never take medication in the dark or if you are not fully awake. If you normally wear glasses, put them on before taking the medicine(s). 6 CHAPTER 1 i) Work with household chemicals in well-ventilated areas.
Do not mix chemicals (e. bleach and toilet-bowl cleaner) unless specifically directed to do so. j) Periodically check and discard medicines no longer in use. Flush them down the toilet.
k) Keep poisonous plants away from children or others likely to ingest them. l) Educate children about the dangers of poisons in the home. Community Measures for Handling Episodes of Poisoning In certain countries such as the United States of America, Israel and Canada, access to Poison Control Centres has made it possible for the community to obtain advice on immediate measures required to minimise adverse effects of ingested or administered chemicals. States with poison control centres have been able to demonstrate improvements in telephone triage patterns, avoidance of excessive visits to emergency departments, and improved outcomes because of the better quality and quantity of information provided to callers.
Communities which have strong and active first-aid programs or that advocate use of activated charcoal as part of home first-aid kits also have the potential to demonstrate better outcomes.