Poisoning and toxicity

• Poisoning and toxicity occurs when individuals drink, eat, breathe, inject, or touch enough of a chemical (also called a poison or toxin) to cause illness or death. A poison is any substance that is harmful to the body when eaten, breathed, injected, or absorbed through the skin. Any substance can be poisonous if enough is taken.
• Poisoning is the most common cause of nonfatal accidents in the home. More than two million people suffer some type of poisoning each year in the United States. Drugs, including prescription, over-the-counter (OTC), and illegal drugs, are the most common source of serious poisonings and poisoning-related deaths. Most poisonings involve everyday household items such as cleaning supplies, drugs, cosmetics, and personal care items. Other common poisons include gases, agricultural products, plants, industrial chemicals, vitamins, and foods (such as raw or undercooked meats). However, almost any substance ingested in sufficiently large quantities can be toxic. Infants and young children are especially vulnerable due to their weight and size.
• The dangers of poisoning range from short-term illness to brain damage, coma, and death. Some poisons in very small amounts can cause illness or injury. Some poisons cause immediate injury, such as battery acid or household cleaners. Other poisons may take years of exposure to create a health problem, such as heavy metals (lead, arsenic, mercury). The Centers for Disease Control and Prevention (CDC) defines a poisoning that occurs by accident as "unintentional poisoning" and a poisoning that results from a conscious, willful decision (such as suicide or homicide) as "intentional poisoning." Unintentional poisoning includes the use of drugs or chemicals for recreational purposes in excessive amounts, such as an overdose. Unintentional poisoning also includes the excessive use of drugs or chemicals for non-recreational purposes, such as by an infant or child. Intentional poisonings include suicide, such as medication overdosage.
• Poisoning is a significant global public health problem. According to the CDC, 32,691 deaths were reported in 2005 as a result of poisoning. Of these, 23,618 (72%) were reported as unintentional, 5,833 (18%) were reported as intentional, and 3,240 (10%) were of undetermined intent. In 2004, 95% of unintentional and undetermined poisoning deaths were caused by drugs, most commonly opioid pain medications, cocaine, and heroin. In the same year, 75% of intentional poisoning suicides were caused by illegal and legal drugs. The CDC also reports that men were 2.1 times more likely to die from unintentional poisoning and 1.3 times more likely to die from intentional poisoning than women.
• Young children are particularly vulnerable to accidental poisoning in the home, as are elderly people, often from confusion. Hospitalized people and industrial workers are also vulnerable to accidental poisoning by drugs errors and from exposure to toxic chemicals, respectively.
• The damage caused by poisoning depends on the poison, the amount taken, and the age and underlying health of the person who takes it. Some poisons are not very potent and cause problems only with prolonged exposure or repeated ingestion of large amounts. Other poisons are so potent that just a drop on the skin can cause severe damage.
• On average, poison centers nationally handle one poison exposure every 14 seconds.
• Most poisonings involve everyday household items such as cleaning supplies, drugs (prescription, over-the-counter, and illegal), cosmetics, and personal care items.

• Heavy metal poisoning
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• Aluminum poisoning: Many of the symptoms of aluminum toxicity mimic those of Alzheimer's disease and osteoporosis ("thinning" of the bones). Colic (excessive crying in infants), digestive problems, interference with the metabolism of calcium, extreme nervousness, anemia, headaches, decreased liver and kidney function, memory loss, speech problems, and aching muscles can all be caused by aluminum toxicity.
• Aluminum is excreted by the kidneys, therefore toxic amounts can impair kidney function. Aluminum can also accumulate in the brain causing seizures and reduced mental alertness.
• Arsenic poisoning:
  The first sensations of arsenic poisoning include a metallic taste in the mouth, excessive saliva production, and problems swallowing. The next stage is to suffer vomiting and diarrhea coupled with garlic-like breath, stomach cramps, and excessive sweating. As the poison's effects progress, the patient will suffer seizures and go into shock, dying within a few hours. If death does not occur at this stage, it will happen after a few days when the kidney fails.
• Lead poisoning: There are many different health effects associated with elevated blood lead levels. Young children under the age of six
  are especially vulnerable to lead's harmful health effects, because their brains and central nervous system are still being formed. For them, even very low levels of exposure can result in reduced IQ, learning disabilities, attention deficit disorders, behavioral problems, stunted growth, impaired hearing, and kidney damage. At high levels of exposure, a child may become mentally retarded, fall into a coma, and even die from lead poisoning.
• Mercury poisoning: Mercury poisoning is the negative effects on human's nervous system and other bodily systems due to the over-exposure of mercury. Today, people are more aware of the dangers of mercury and many of its uses have been discontinued. However, mercury exposure is still an occupational hazard for people in many industries and mercury is present in the environment around us. There is also the risk of exposure due to a thermometer breaking or mercury leaking out of a thermostat or any number of mercury-containing devices. If mercury vapor is inhaled, as much as 80% may enter the bloodstream.
• Carbon monoxide poisoning
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• Early symptoms of carbon monoxide poisoning such as headaches, nausea, and fatigue, are often mistaken for the flu because the deadly gas goes undetected in a home. Prolonged exposure can lead to brain damage and even death.
• Radon poisoning
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• No immediate symptoms of radon poisoning are present. Radon exposure contributes to 7,000-30,000 lung cancer deaths each year. Smokers are at higher risk of developing radon-induced lung cancer.
• Other chemical poisoning
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• Chronic exposure is chemical poisoning that occurs slowly and insidiously over a prolonged period of time. Many chronic, degenerative diseases have been linked to environmental pollution or poisoning. The list may include cancer, memory loss, allergies, multiple chemical sensitivity, chronic fatigue syndrome, infertility in adults, learning and behavioral disorders, developmental abnormalities, and birth defects in children.
• Drug poisoning
  :
• The effects vary depending on the type of drug and how it is taken. When the individual calls the emergency services, give as much information as possible. While waiting for help to arrive, look for containers that might help the individual to identify the drug.
• Drugs that can cause poisoning and toxicity include: painkillers such as aspirin, acetaminophen (Tylenol®), or opiates (such as morphine); nervous system depressants and tranquillizers including barbiturates and benzodiazepines; stimulants and hallucinogens (such as lysergic acid diethylamide or LSD); amphetamines; and chemotherapeutic medications such as anthracycline chemotherapy drugs, including doxorubicin (Adriamycin®). Doxorubicin use may lead to heart toxicity. Bleomycin (Blenoxane®) use may lead to lung damage. Nerve toxicity may occur as a result of chemotherapy use. Lithium may cause thyroid and kidney toxicity. Methotrexate (Rheumatrex®) and lometrexol toxicity both may cause folic acid to be depleted from the body. Cyclosporine (Sandimmune®) may cause kidney toxicity in organ transplant patients.

• Acute Poisoning
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• In many cases, the identity of the poison is known to the patient or the parents of the affected child. If a poisoning is suspected, the individual or a caretaker should immediately call a local Poison Control Center (1-800-222-1222) for advice. If instructed by the Poison Control Center to get medical help, the individual or their caretaker should bring a sample of the poison to the doctor's office or emergency room. Emergency 911 should be called if the individual or child is in immediate danger.
• Chronic Poisoning
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• Chronic environmental poisoning is more difficult to diagnose. To find out if environmental pollution is causing a person to be sick, a doctor will conduct a thorough physical exam of the patient. The doctor also obtains a thorough medical history with detailed information concerning the food and water sources, as well as the nature of the person's work or the place where they live. Lab tests may include blood and urine tests and hair sample analysis. In addition, liver and kidney function tests are also conducted to see if these organs are affected. The doctor also inquires about other diseases the patient may have developed recently.

• For acute poisoning, 911 or a local poison control center (1-800-222-1222) should be called immediately. The toll-free number is a national hotline launched nationwide in 2002 by the American Association of Poison Control Centers (AAPCC) to provide 24-hour poison treatment and prevention services. If a child is suspected of eating or drinking hazardous chemicals, parents should look for the container and call for instructions. Patients or parents of the poisoned child should wait for instructions before administering anything by mouth. Treatment of a particular poison depends on the identity of the poison and how the poison was absorbed into the body.
• Inhaled poisons: Treatment of inhaled poison includes bringing the individual out and away from the area contaminated with poisonous gas. The individual should be given oxygen and other respiratory support as necessary.
• Skin and eye contamination: If an individual's skin comes into contact with toxic chemicals, the contaminated clothing should be removed, the chemical carefully brushed off the skin, and the body flushed with running water to dilute the poison. The wounds, if any, should be covered with sterile gauze or cloth. If serious, the person will usually be transferred to the hospital for the treatment of a chemical burn. If toxic or caustic chemicals get in the eyes, the affected person should remove glasses or any contact lenses from the eyes immediately, rinse the eyes well with clean water or normal saline solution, and go to the emergency room for further treatment or observation.
• Ingested poisons: Depending on the specific type of ingested poisons, syrup of ipecac, activated charcoal, and/or pumping the contents of the stomach out can be used.
• Formerly, it was recommended to keep a bottle of syrup of ipecac on hand in order to induce vomiting in case of poisoning. Recent research, however, shows no benefit from this practice. In addition, the research shows that the medicine is not always administered properly.
• Activated charcoal is also an effective treatment for many chemical poisons. It can absorb poisons quickly and in large amounts. In addition, it is nontoxic, may be stored for a long time, and can be conveniently given at home. Charcoal works by binding to irritating or toxic substances in the stomach and intestines. This prevents the toxic drug or chemical from spreading throughout the body. The toxic drug or chemical and the activated charcoal will be excreted in the stools without harming the body.
• Charcoal should not be used to treat poisoning caused by corrosive products, such as lye or other strong acids, or petroleum products, such as gasoline, kerosene, or cleaning fluids. Charcoal may make the condition worse and delay the diagnosis and treatment. In addition, charcoal is also not effective if the poison is lithium, cyanide, iron, ethanol, or methanol.
• Gastric lavage may also be used to treat chemical poisoning under certain circumstances. This procedure is done by healthcare professionals in emergency rooms only. Lavage fluids (saline water or water) are given through a large tube down the patient's throat and the stomach contents are pumped out. This procedure is repeated many times until the physician is confident that most of the toxic substance is removed. Then a specific antidote for the chemical or activated charcoal can be given to absorb the rest. Sometimes, antidotes are available to neutralize poison and render it harmless. The following are some of the common antidotes: naloxone (Narcan®) - used for opiate (including morphine, methadone or heroin) overdose; atropine - used for organophosphate (insecticide) poisoning; acetylcysteine used for acetaminophen (Tylenol®) toxicity; and Digoxin Immune Fab (Digibind®) used for digoxin toxicity.
• Chronic chemical poisoning:
  Treatment of chronic chemical poisoning involves identifying the poison, eliminating the source of poison from the patient's environment, and symptomatic treatment of the condition. Chelation therapy can be used to remove heavy metals, such as lead, iron, mercury, copper, nickel, zinc, cadmium, beryllium, and arsenic. This treatment uses chelating agents, such as ethylenediamine tetraacetic acid (EDTA) and dimethylsuccinate (DMSA), to bind and precipitate metals and remove them from the body.

Note
: Poisoning is considered a medical emergency. Individuals who have been poisoned should contact a poison control center immediately and consult with their healthcare provider.

A

Strong scientific evidence

• Calcium
  : Calcium is the most abundant mineral in the human body and has several important functions. More than 99% of total body calcium is stored in the bones and teeth where it supports the structure. The remaining 1% is found throughout the body in blood, muscle, and the intracellular fluid. Calcium is needed for muscle contraction, blood vessel constriction and relaxation, the secretion of hormones and enzymes, and nervous system signaling. A constant level of calcium is maintained in body fluid and tissues so that these vital body processes function efficiently. Hyperphosphatemia (high phosphate level in the blood) is associated with increased cardiovascular mortality in adult dialysis patients. Calcium carbonate or acetate can be used effectively as phosphate binders. Use may increase calcium-phosphate products in blood. Treatment of high blood phosphorous levels should only be done under the supervision of a qualified healthcare professional.
• Calcium gluconate is used in the treatment of hypermagnesemia (high magnesium level in the blood). Case studies suggest intravenous calcium can aid in the improvement of symptoms. Treatment of magnesium toxicity should only be done under the supervision of a qualified healthcare professional.
• Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with high levels of calcium in the blood, high levels of calcium in urine, high levels of parathyroid hormone, bone tumors, digitalis toxicity, ventricular fibrillation, kidney stones, kidney disease, or sarcoidosis (inflammation of lymph nodes and various other tissues). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria (absence of hydrochloric acid in gastric juices) or irregular heartbeat. Calcium appears to be safe during pregnant or breastfeeding women; talk to a healthcare provider to determine appropriate dosing during pregnancy and breastfeeding.

B

Good scientific evidence

• Calcium
  : Calcium gluconate may aid in antagonizing the cardiac toxicity and arrhythmia (abnormal heart rhythm) associated with hyperkalemia (high potassium level in the blood), provided the patient is not receiving digitalis drug therapy. Treatment of hyperkalemia should only be done under the supervision of a qualified healthcare professional.
• Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with high levels of calcium in the blood, high levels of calcium in urine, high levels of parathyroid hormone, bone tumors, digitalis toxicity, ventricular fibrillation, kidney stones, kidney disease, or sarcoidosis (inflammation of lymph nodes and various other tissues). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria (absence of hydrochloric acid in gastric juices) or irregular heartbeat. Calcium appears to be safe during pregnant or breastfeeding women; talk to a healthcare provider to determine appropriate dosing during pregnancy and breastfeeding.
• Chelation
  : EDTA chelation became well known during the 1950s, when it was proposed as a method to cleanse the blood and blood vessel walls of toxins and minerals. For many years, chelation therapy has been used with calcium disodium EDTA to treat heavy metal toxicity. It is still an accepted medical therapy for lead toxicity, and several studies report lower levels of lead in the blood and slower progression of kidney failure. Chelation therapy may also be used to treat iron, arsenic, mercury, or cobalt poisoning. However, some research results are mixed. More studies are needed to clarify.
• Avoid in patients taking anticoagulants or antiplatelets. Avoid during root canal therapy. Avoid if pregnant or breastfeeding.

C

Unclear or conflicting scientific evidence

• Calcium
  : A chelating treatment of calcium has been suggested to reduce blood levels of lead in cases of lead toxicity. Reduced symptoms have been observed in most, but not all, patient case reports and case histories. Adequate calcium intake appears to be protective against lead toxicity. Treatment of lead toxicity should only be done under supervision of a qualified healthcare professional.
• Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with high levels of calcium in the blood, high levels of calcium in urine, high levels of parathyroid hormone, bone tumors, digitalis toxicity, ventricular fibrillation, kidney stones, kidney disease, or sarcoidosis (inflammation of lymph nodes and various other tissues). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria (absence of hydrochloric acid in gastric juices) or irregular heartbeat. Calcium appears to be safe during pregnant or breastfeeding women; talk to a healthcare provider to determine appropriate dosing during pregnancy and breastfeeding.
• Chlorophyll
  : Chlorophyll is a chemoprotein commonly known for its contribution to the green pigmentation in plants, and is related to protoheme, the red pigment of blood. It can be obtained from green leafy vegetables (broccoli, Brussels sprouts, cabbage, lettuce, and spinach), algae (Chlorella and Spirulina), wheat grass, and numerous herbs (alfalfa, damiana, nettle, and parsley). Yusho poisoning is caused by ingestion of rice oil contaminated with polychlorinated biphenyls, specifically polychlorinated dibenzofurans (PCDFs) and polychlorinated biphenyls (PCBs). A chlorophyll-rich diet may increase PCDF and PCB elimination, but further high quality research is needed.
• Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously with photosensitivity, compromised liver function, diabetes, or gastrointestinal conditions or obstructions. Use cautiously if taking immunosuppressants or antidiabetes agents. Avoid if pregnant or breastfeeding.
• Clay
  : Clay lozenges have been used historically in the treatment of mercuric chloride poisoning and were officially mentioned in several European pharmacopoeias, including the Royal College, until the middle 19th Century. However, there is not enough scientific evidence to recommend the use of clay by mouth for mercuric chloride poisoning at this time, as there is a risk of clay itself containing contaminants.
• There is a lack of reports of allergy to clay in the available scientific literature. However, in theory, allergy/hypersensitivity to clay, clay products, or constituents of clay may occur. Avoid if pregnant or breastfeeding.
• Folate (folic acid)
  : Folate and folic acid are forms of a water-soluble B vitamin. Folate occurs naturally in food, and folic acid is the synthetic form of this vitamin. Folate may lower blood arsenic concentrations and thereby contribute to the prevention of arsenic poisoning. Additional research is needed in this area.
• Avoid if allergic or hypersensitive to folate or any folate product ingredients. Use cautiously if receiving coronary stents or with anemia or seizure disorders. It is recommended that pregnant women consume 400 micrograms of folate daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.
• Iron
  : Iron deficiency may increase the risk of lead poisoning in children. However, the use of iron supplementation in lead poisoning should be reserved for those individuals who are truly iron deficient or for those individuals with continuing lead exposure, such as continued residence in lead-exposed housing.
• Iron is a trace mineral, and hypersensitivity is unlikely. Avoid with known allergy/hypersensitivity to products containing iron. Avoid excessive intake. Avoid iron supplements with blood disorders that require frequent blood transfusions. Use iron supplements cautiously with a history of kidney disease, intestinal disease, peptic ulcer disease, enteritis, colitis, pancreatitis, hepatitis, alcoholism, or with a history of heart disease. Use cautiously in those who plan to become pregnant, or in those older than age 55. Pregnant or breastfeeding women should consult their healthcare professionals before beginning iron supplementation.
• Reishi
  : Reishi mushroom (Ganoderma lucidum), also known as ling zhi in China, grows wild on decaying logs and tree stumps. Reishi occurs in six different colors, but the red variety is most commonly used and commercially cultivated in East Asia and North America. Ganoderma lucidum has shown a beneficial effect in treating Russula subnigricans (RSP) poisoning in limited study. Further well-designed clinical trials are needed to confirm these results.
• Avoid if allergic or hypersensitive to any constituents of Ganoderma lucidum or any member of its family. Use cautiously with diabetes, blood disorders (including hemophilia), low blood pressure, or ulcers. Reishi is likely safe when consumed in amounts generally found in foods in non-allergic pregnant or breastfeeding women.
• Safflower
  : Based on preliminary study, safflower (Carthamus tinctorius) oil may effectively remit the symptoms of neurotoxicity from lithium. However, more studies are needed to better understand safflower's effect on lithium toxicity.
• Avoid if allergic/hypersensitive to safflower, safflower oil, daisies, ragweed, chrysanthemums, marigolds, or any related constituents. Use parenteral safflower oil emulsions cautiously in newborns. Use cautiously if taking anticoagulants (blood thinners) or anti-platelet drugs, immunodepressants or pentobarbital. Use cautiously with diabetes, low blood pressure, liver problems, bleeding disorders, or skin pigmentation conditions. Use cautiously if pregnant or breastfeeding.
• Spirulina
  : The term spirulina refers to a large number of cyanobacteria or blue-green algae. Spirulina extract plus zinc may be useful for the treatment of arsenic poisoning. Additional research is needed to confirm early study findings.
• Avoid if allergic or hypersensitive to spirulina or blue-green algae. Use cautiously with phenylketonuria, autoimmune diseases, bleeding disorders, diabetes, osteoporosis or if taking products containing the blue-green algae species Anabaena spp., Aphanizomenon spp., and Microcystis spp. Use cautiously in underweight patients or in those taking antiobesity agents or appetite suppressants. Use cautiously if consuming a high-protein diet. Avoid in children and pregnant or breastfeeding women.
• zinc
  : Limited available study has shown that a combination of spirulina extract plus zinc may be useful for the treatment of chronic arsenic poisoning with melanosis and keratosis. More research is needed to confirm the effects of zinc alone.
• Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride because evidence of safety and effectiveness are currently lacking. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.

• Avoid eating contaminated fish, especially fish that comes from known contaminated areas or a lot of big fish, such as shark, swordfish, or tuna, which tend to contain higher amounts of mercury than smaller fish. According to healthcare professionals, pregnant women should not consume more than seven ounces of tuna per week. Mercury can cause brain damage in the developing fetus. It is best to avoid eating shark, swordfish, king mackerel, or tilefish because they contain high levels of toxins.
• Paint may contain lead and cadmium that can harm a developing fetus and cause learning disabilities in small children. It is important not to paint or remodel a home while pregnant or when the children are still small. If the individual lives in a home built before 1960, it is very likely that it contains some lead paint. Homes built between 1960 and 1978 may also contain lead paint, but are very unlikely to do so. In 1978, the Consumer Product Safety Commission finally issued its ban against lead-based paint. If an individual lives in a home built before 1978 that also has been allowed to deteriorate for a few years, lead-contaminated dust may be a problem. To find out if a home contains lead paint or a lead-based paint hazard, hire a professional.
• Limiting use of chemicals inside the house as much as possible and instead using natural alternatives, such as baking soda (as cleaner, deodorizer), distilled white vinegar (as cleaner), essential oils (as fragrances), lemon juice (as cleaner), and liquid soaps (as detergents) is important.
• Ventilation inside the home may be increased with the use of fans if toxic fumes are present.
• Radon and carbon monoxide testing kits are commercially available for the home or office. They may be purchased at a local home store.
• Consider installing tile or wood floors in new homes instead of new carpet. Have the house tested for radon.
• Avoiding toxic chemical exposure as much as possible if pregnant is important.
• Healthcare professionals recommend keeping all medications, petroleum products, and cleaning products locked and away from small children as well as installing child-proof locks or gates to prevent children from finding poisons.
• Avoiding mixing up household cleaning products is important. Nontoxic chemicals when mixed together can release toxic gases or cause explosion (such as Clorox® and ammonia).
• Keeping all chemicals in original containers, properly identified and stored away from foods is important, as is disposing all hazardous chemicals properly according to the manufacturer's instructions.
• It is best to use stainless steel, glass, or iron cookware to avoid aluminum poisoning. Stainless steel is the best choice.