Poisoning First Aid: Ingestions, Inhalations, Bites, and Antidotes

Introduction

Poisoning occurs when exposure to a substance causes harmful effects on the body. It is a leading cause of unintentional injury death in the United States, driven primarily by opioid overdoses. Poisonings can occur through ingestion, inhalation, injection, absorption through skin or eyes, or envenomation. Immediate management varies by route, substance, and severity.

Poison Control Center

Contact	Number	Available 24/7
Poison Control Hotline	1-800-222-1222	Yes (24 hours, 365 days)
WebPOISONCONTROL	poison.org	Online triage tool
Text	Some regions support text	Varies by region
Language services	Interpreters available in 150+ languages	Yes

When to Call Poison Control

Situation	Action
Unintentional ingestion (child)	Call immediately for guidance
Medication error	Call to determine toxicity
Occupational exposure	Call for management recommendations
Chemical splash to eye or skin	Call while flushing
Known or suspected overdose	Call for specific management
Unknown substance ingestion	Call for identification guidance
Bites and stings (venomous)	Call for management
ANY poisoning concern	Call before presenting to ED if stable

General Approach to Poisoned Patient

Initial Assessment and Management

Step	Action	Rationale
1	Scene safety	Ensure no ongoing exposure risk to rescuer
2	Remove from exposure	Move patient away from toxic environment
3	Assess ABCs	Airway, breathing, circulation
4	Call 911 for unstable patient	Emergency medical services
5	Call Poison Control (1-800-222-1222)	Specific management guidance
6	Gather information	Substance, amount, time, symptoms
7	Decontaminate	Remove contaminated clothing, flush skin/eyes
8	Antidote if available	Specific reversal agents
9	Transport to hospital	For monitoring and further care

Information to Gather for Poison Control

Question	Examples
Substance involved	Name of medication/chemical, strength/concentration
Amount taken	Number of pills, volume of liquid
Time of exposure	Exact time or estimate
Age and weight of patient	Especially important for children
Current symptoms	Any complaints, changes in behavior
Pre-existing conditions	Medical history, medications
Intentional vs accidental	Suicide attempt vs unintentional
Treatment already given	First aid, ipecac, activated charcoal

Ingested Poisons

Activated Charcoal

Aspect	Details
Mechanism	Adsorbs toxins in GI tract preventing systemic absorption
Dose	1 g/kg (max 50 g) single dose
Timing	Most effective within 1 hour of ingestion
Contraindications	Impaired airway (no gag reflex), caustic ingestions, hydrocarbons, ileus
Administration	Oral or via NG tube (mixed with water, tastes like grit)
Multiple doses	For sustained-release drugs (theophylline, phenobarbital, dapsone, carbamazepine)
Adverse effects	Vomiting, aspiration (rare if given correctly)
Do NOT give with	Sorbitol (cathartic) - no longer recommended
Drug interactions	Reduces absorption of oral antidotes (NAC, fomepizole)

Ipecac Syrup

Aspect	Current Status
Recommendation	No longer recommended by poison control centers
Reason	Unreliable, risk of aspiration, contraindicated in many ingestions
Former use	Gastric emptying for pediatric ingestions
Current status	Removed from most home medicine cabinets

Gastric Lavage

Aspect	Details
Indications	Life-threatening ingestion presenting within 1 hour
Contraindications	Caustics, hydrocarbons, impaired airway
Method	Large-bore orogastric tube, warm saline aliquots
Benefit	Limited, rarely indicated
Location	Hospital setting only

Whole Bowel Irrigation

Aspect	Details
Agent	Polyethylene glycol (GoLYTELY, MiraLAX)
Rate	Adults: 1-2 L/hour; Children: 25-40 mL/kg/hour
Indications	Sustained-release drugs, iron, lead, cocaine, lithium, body packers
Contraindications	Ileus, obstruction, hemodynamic instability, GI bleeding
Route	Oral or NG tube
Goal	Clear rectal effluent

Inhaled Poisons

Carbon Monoxide (CO) Poisoning

Aspect	Details
Sources	Fires, furnaces, generators, car exhaust, kerosene heaters
Mechanism	Binds hemoglobin with 200x affinity of oxygen (carboxyhemoglobin)
Symptoms	Headache, nausea, dizziness, confusion, loss of consciousness
Cherry-red skin	Late finding, NOT common
Diagnosis	CO-oximetry (pulse oximetry reads falsely normal)
Mild toxicity	COHb <10-15%: headache, dyspnea
Moderate	COHb 15-30%: confusion, weakness, chest pain
Severe	COHb >30%: loss of consciousness, seizure, death

Treatment	Details
Immediate	100% O2 via non-rebreather mask
Duration	100% O2 until COHb <5% (half-life reduced from 4-6h to 1-2h)
Hyperbaric oxygen (HBO)	2.5-3 ATA; half-life reduced to 20 minutes
HBO indications	COHb >25%, loss of consciousness, neurologic symptoms, seizure, cardiac ischemia, pregnancy with COHb >15%
Delayed neuropsychiatric sequelae	Memory loss, cognitive decline, Parkinsonism (days to weeks after)

Cyanide Poisoning

Aspect	Details
Sources	Smoke inhalation (fires), industrial exposure, nitroprusside, amygdalin (apricot pits, laetrile)
Mechanism	Binds cytochrome c oxidase, inhibits cellular respiration (histotoxic hypoxia)
Symptoms	Severe metabolic acidosis, seizures, coma, respiratory arrest
Odor	Bitter almonds (genetic ability to smell varies)
Treatment	Sodium nitrite + sodium thiosulfate (cyanide antidote kit) or hydroxocobalamin (Cyanokit)

Smoke Inhalation

Components	Effects
CO	Cellular hypoxia
Cyanide	Histotoxic hypoxia
Heat	Upper airway thermal injury
Irritants (aldehydes, ammonia, HCl)	Chemical tracheobronchitis
Particulates	Bronchospasm, ventilation impairment

Absorbed Poisons

Skin Decontamination

Step	Action
1	Remove ALL contaminated clothing (cut off if necessary)
2	Brush off dry powders (DO NOT wet organophosphates)
3	Irrigate skin with copious water or saline for 15-20 minutes
4	Wash with mild soap and water
5	Attention to skin folds, nails, hair
6	Protect rescuer (gloves, gown, mask)

Eye Decontamination

Step	Action
1	Remove contact lenses
2	Irrigation with water or saline for 15-30 minutes
3	Morgan lens for prolonged irrigation
4	Continue until pH normal if chemical
5	Refer to ophthalmologist
6	Alkali burns require prolonged irrigation (hours)

Organophosphate Poisoning

Aspect	Details
Sources	Pesticides, insecticides (malathion, parathion, chlorpyrifos)
Mechanism	Irreversible acetylcholinesterase inhibition
Symptoms	SLUDGE + DUMBBELS
SLUDGE	Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis
DUMBBELS	Diarrhea, Urination, Miosis, Bronchospasm/Bradycardia, Emesis, Lacrimation, Salivation/Sweating
CNS	Seizures, coma, respiratory depression
Treatment	Atropine (large doses, titrated to drying secretions, HR >100 not target) + Pralidoxime (2-PAM, reactivates enzyme) + Diazepam (seizures)

Opioid Overdose

Recognition

Sign	Description
Respiratory depression	Slow, shallow, or absent breathing
CNS depression	Unconscious, unresponsive
Pinpoint pupils	Miosis (bilateral, 1-2 mm)
Cyanosis	Blue lips, nail beds, skin
Hypotension	Decreased blood pressure
Bradycardia	Slow heart rate
Hypothermia	Low body temperature

Naloxone (Narcan) Administration

Aspect	Intranasal (IN)	Intramuscular (IM)	Intravenous (IV)
Dose (adult)	4 mg (1 spray)	0.4-2 mg	0.04-0.4 mg
Dose (child)	4 mg (1 spray)	0.1 mg/kg	0.1 mg/kg
Onset	2-5 minutes	2-5 minutes	1-2 minutes
Duration	30-90 minutes	30-90 minutes	20-90 minutes
Repeat	Every 2-3 minutes	Every 2-3 minutes	Every 2-3 minutes
Advantage	No needle, easy	Reliable absorption	Fastest onset
Disadvantage	Absorption variable	Needle required	IV access needed

Naloxone Administration Steps

Step	Instruction
1	Check scene safety (needles, environment)
2	Attempt to wake victim: shout, shake
3	Call 911
4	Open airway, check breathing
5	Administer naloxone (IN or IM)
6	Begin rescue breathing (10-12 breaths/min)
7	If no chest rise: re-position, check airway
8	Repeat naloxone in 2-3 minutes if no response
9	Prepare to start CPR if no pulse
10	Stay with patient until EMS arrives

Post-Naloxone Care

Consideration	Management
Awake patient	Explain what happened, monitor for re-sedation
Withdrawal symptoms	Agitation, nausea, vomiting, diarrhea, sweating (not dangerous)
Violence/agitation	May occur; ensure safety, calm approach
Re-sedation	Naloxone may wear off before opioid; repeat as needed
Transport	All patients should go to ED (heroin, prescription opioids >36h observation)
Co-ingestants	Suspect polysubstance (alcohol, benzodiazepines)
Withdrawal management	Supportive care; clonidine for autonomic symptoms

Acetaminophen (Paracetamol) Poisoning

Toxicity

Aspect	Details
Toxic dose (acute)	Adults: >7.5-10 g (150 mg/kg); Children: >200 mg/kg
Mechanism	NAPQI metabolite depletes glutathione, causes hepatic necrosis
At-risk populations	Malnutrition, alcoholism, CYP2E1 induction, GSH depletion
Antidote	N-acetylcysteine (NAC)

Rumack-Matthew Nomogram (Acute Ingestion)

Time Post-Ingestion	Probable Hepatotoxicity (line)	Treatment Line
4 hours	150 mcg/mL	150 mcg/mL
6 hours	100 mcg/mL	75 mcg/mL
8 hours	50 mcg/mL	37.5 mcg/mL
12 hours	25 mcg/mL	18.75 mcg/mL
16 hours	12.5 mcg/mL	9.4 mcg/mL

NAC Dosing

Protocol	Dose	Route
IV (standard 21-hour)	150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours	IV
IV (FDA)	150 mg/kg loading, then 50 mg/kg at 4h, then 100 mg/kg at 16h	IV
Oral	140 mg/kg loading, then 70 mg/kg q4h x 17 doses	PO (NG preferred)

Venomous Bites and Stings

Snake Bites

Species	Venom Type	Geographic Location	Symptoms
Pit vipers (rattlesnake, copperhead, cottonmouth)	Hemotoxic	Americas, Asia	Swelling, hemorrhage, coagulopathy, compartment syndrome
Elapidae (coral snake, cobra, mamba)	Neurotoxic	Americas (coral), Africa, Asia	Paralysis, respiratory failure
Sea snakes	Myotoxic	Indo-Pacific oceans	Myoglobinuria, paralysis

Management	Details
First aid	Immobilize affected limb, keep calm, do NOT cut or suck venom
Tourniquet	NOT recommended for most snakebites (may worsen local injury)
Pressure immobilization	For neurotoxic snakes (elapids): wrap entire limb, limit spread
Antivenom	Specific to species; more effective when given early
Do NOT	Use ice, electric shock, alcohol, tourniquets
Hospital	Observe for minimum 8-12 hours

Spider Bites

Spider	Venom	Presentation	Treatment
Black widow (Latrodectus)	Neurotoxic (alpha-latrotoxin)	Sharp pain, muscle cramps, rigidity, abdominal pain	Antivenom, opioids, benzodiazepines, calcium gluconate (controversial)
Brown recluse (Loxosceles)	Hemotoxic (sphingomyelinase D)	Necrotic ulcer, hemolysis, DIC	Supportive care, wound care, dapsone (controversial), surgical debridement rarely

Scorpion Stings

Aspect	Details
Dangerous species	Centruroides (Arizona bark scorpion) in US
Symptoms	Local pain, numbness, hypersalivation, roving eye movements, respiratory distress
Treatment	Supportive; antivenom (Anascorp) for severe cases

Hymenoptera (Bees, Wasps, Hornets, Ants)

Insect	Venom	Reaction
Honey bee	Apamin, phospholipase A2, histamine	Local pain/swelling; anaphylaxis in allergic
Yellow jacket/paper wasp	Similar to bee	Local pain; anaphylaxis in allergic
Fire ant	Piperidine alkaloids	Sterile pustules at sting site; allergic reactions

Stinger management	Remove by scraping (Do NOT squeeze)
Local reaction	Ice, elevation, antihistamines, NSAIDs
Severe allergic	Epinephrine IM, call 911

Medication-Specific Overdose Management

Drug	Toxic Effects	Specific Treatment
Benzodiazepines	Sedation, respiratory depression, coma	Flumazenil (rarely used; risk of seizure in tolerant patients)
Beta-blockers	Bradycardia, hypotension, hypoglycemia	Glucagon, high-dose insulin euglycemia therapy
Calcium channel blockers	Bradycardia, hypotension, hyperglycemia	IV calcium, high-dose insulin euglycemia therapy, vasopressors
Digoxin	Arrhythmias (bradycardia, AV block), nausea, visual changes	Digoxin-specific Fab (Digibind)
Iron	GI bleeding, metabolic acidosis, organ failure	Deferoxamine (chelation)
Lithium	Neurologic: tremor, confusion, seizure, coma	Normal saline, hemodialysis (for severe)
Methanol/ethylene glycol	Metabolic acidosis, visual changes, renal failure	Fomepizole (preferred) or ethanol; hemodialysis
Methemoglobin inducers	Cyanosis, hypoxia (normal pO2), chocolate-brown blood	Methylene blue (1-2 mg/kg IV)
Salicylates (aspirin)	Tinnitus, hyperventilation, metabolic acidosis, respiratory alkalosis	Bicarbonate, hemodialysis

Poisoning in Children

Aspect	Consideration
Common ingestions	Medications (grandparents’), cleaning products, cosmetics, plants
Exploratory	Toddlers (1-3 years) most at risk
Weight-based dosing	Toxicity threshold lower due to small size
Developmental	Small children may eat multiple substances
Prevention	Childproof caps, lock cabinets, keep out of reach

Prevention

Home Poison Prevention

Strategy	Implementation
Safe storage	Medications in locked cabinet, original containers
Childproof caps	Always re-secure after use
Out of reach and sight	Store substances out of children’s view
Proper labeling	Never transfer to food containers
Dispose properly	Expired medications, used patches
Plant identification	Know toxic house and garden plants
Carbon monoxide detectors	Install on every level of home
Be prepared	Keep poison control number visible (1-800-222-1222)