Poisoning and poison control centres in Canada Chandrakant P. Shah, md, mrcp(glas), frcp[c], ms; Harry W. Bain, md, Michael G. Martin, ba sc, md
Summary: Poisoning is a major and Increasing health problem in the Western world. In 1972 the 310 poison control centres in Canada reported 53 531 enquiries about poisoning, 40% in adults. In 1964 the numbers of
hospital admissions and deaths due to poisoning in this country were 2446 and 38, respectively, but in 1972 the figures were 6263 and 319, respectively. Most of the hospitalizations and deaths
among adults. Of 100 Canadian poison control centres two thirds were staffed by "any nurse in the emergency room", most of whom had received no training to answer the phone enquiries. However, two thirds agreed a training program is needed. Only 6.7% of 223 parents surveyed stated they would call a poison control centre if their child had accidentally swallowed a large amount of a poisonous substance. Regionalization of centres, a training program for personnel answering telephone enquiries, the need for crisis intervention as part of poison control programs, and public education about poisoning and poison control centres are the new challenges facing those providing health services. were
malades
hospitalises
pour intoxication
et le nombre des deces etaient, dans notre pays, de 2446 et de 38,
respectivement, alors qu'en 1972 ces chiffres etaient passe a 6263 et 319, respectivement. La plupart des hospitalisations et des deces concernaient des adultes. Sur 100 centres antipoisons deux tiers n'avaient comme equipe que I'infirmiere de service a I'urgence, la majorite d'entre elles n'ayant du reste aucune formation speciale pour repondre efficacement aux appels telephoniques. Parmi les personnes questionnees, deux tiers admettaient la necessite d'un programme de formation. questionnes 6.7% qu'ils centre antipoison
Des 223 parents
seulement ont affirme
appelleraient
un
si leur enfant avait accidentellement
avale
une
toxique.
forte quantite d'une substance
nouveaux defis que doivent ces centres on peut citer les
Parmi les
affronter
points suivants: la regionalisation des centres, un programme de formation destine au personnel appele a repondre aux appels telephoniques, le besoin d'intervenir en periode de crise, considere comme faisant partie des programmes therapeutiques des centres
l'enseignement a dispenser au public concernant les intoxications les centres antipoisons.
et
Resume: Les intoxications et les centres
antipoisons
au
Canada
Dans le monde occidental I'intoxication est devenu un probleme sanitaire considerable dont I'ampleur ne cesse de croitre. En 1972 les 310 centres antipoisons du Canada avaient signale 53 531 demandes de renseignements, dont 40% concernaient des adultes. En 1964 le nombre de From the departments of pediatrics and preventive medicine, University of Toronto, and The Hospital for Sick Children, Toronto Reprint requests to: Dr. C.P. Shah, The Hospital for Sick Children, 555 University Ave.. Toronto,
Ont. M5G 1X8
et
elsewhere in the Western a major health problem:1"3 an estimated 50 000 Cana¬ dians are poisoned each year.1 Despite the increasing number of poison con¬ trol centres in Canada little has been written about the Canadian situation.4 How individual centres are staffed5"7 and the need for pharmacists and clin¬ ical toxicologists in poison control cen¬ tres89 have been studied, but the need for training programs for persons an¬ swering the calls in a poison control centre has been neglected. In Canada,
as
world, poisoning is
frcp[c];
This study examined the magnitude of the problem of poisoning in Can¬ ada, the staffing pattern of poison con¬ trol centres across the country and parental knowledge of poison control centres.
Methods Data on poisoning were obtained from the medical social statistics bureau of Health and Welfare Canada.1 To study the staffing patterns of poison control centres and the need for formal training an English or French questionnaire was sent in the summer of 1973 to all centres east of Saskat¬ chewan, to all centres in Saskatoon, Regina, Calgary, Edmonton, Vancou¬ ver and Victoria, and to a 5% random sample of the remaining small centres. The questionnaire requested a report on the number of calls answered, the location of the centre in the hospital, the number and type of persons an¬ swering the calls and their interest in a training program. To study parental knowledge of poi¬ son control centres a questionnaire was given to 223 parents attending the gen¬ eral medical clinic at The Hospital for Sick Children over a 1-week period in the summer of 1973. They were asked how many children they had, what lan¬ guage was spoken at home, what they would do if their child ingested a poi¬ sonous substance, whether their child had ever taken such substances and, if so, what they had done about it.
Definition In this paper the term "poisoning" refers to enquiries about potential poi¬ soning and actual poisoning. Results Magnitude of the problem The total number of enquiries re¬ garding poisoning and the subsequent number of hospital admissions more than doubled from 1964 to 1972 but
CMA JOURNAL/SEPTEMBER 20, 1975/VOL. 113 523
the number of deaths increased 840%, from 38 to 319 (Table I) or from 1.6 to 6.0/1000 cases. Death from poison¬ ing occurred mainly in the age group
1 to
25, 21 reported 26
to 100, 10 re¬ 100 to 500 and 7 reported more than 500 calls. In all provinces except Alberta and British Columbia over 75% of telephone calls were made to only one or two centres. The Hospital for Sick Children in Toronto and Sainte-Justine Hospital in Montreal handled 29% of all calls in Canada.
ported
propriate persons for training. Of those who believed a course is required 75% stated it should be of 1 week's dura¬ tion or less. Typical comments from
25 years and over and was the result of drug overdose with suicidal intent. The number of cases followed up also increased appreciably in this period. Of poisoning cases in which age was specified 61% were in children under Poisoning was reported by telephone 5 years of age, 8% in children 5 to in 48% of cases and through the emer¬ 14, 15% in persons 15 to 24 and 16% gency room in the rest. A parent called in those 25 or older. Cleaning and pol- in 44.8% of cases and a physician in ishing agents were the leading cause 5.2%. In all provinces except Ontario of poisoning among children up to 4 about 50% of calls were made by years of age, accounting for 15% of someone other than the victim's parent cases. Acetylsalicylic acid ranked sec¬ or physician. ond for this age group, accounting for 13% of cases. Among persons aged 15 to 24 years 63.4% of poisonings were Staffing patterns with central nervous system drugs, the two commonest groups being tranquil¬ Of 120 poison control centres sur¬ lizers (18.8%) and lysergic acid die- veyed to examine staffing patterns 100 thylamide and other hallucinogens responded. Eighty of the centres were (18.5%). Among persons aged 25 years combined with an emergency room and or more 51% were poisoned by ingestapproximately 60 were staffed fulling tranquillizers, barbiturates and time by "any nurse in the emergency other sedatives, tranquillizers being the room" (Table III). About two thirds of most frequent agent (in 25% of all the centres permitted six or more peo¬ cases); most individuals had attempted ple to answer the poisoning calls in a suicide by taking an overdose of a given month (Table IV). Only 8 of the medication. centres claimed to have any staff with In only 39% of all cases was in¬ extensive training in poison control; in formation on outcome, including after 26 centres the staff had had some train¬ effects, provided. Morbidity and mor¬ ing, in 43 they had received training on tality were highest in patients aged 25 the job, in 14 none had any training and 9 did not answer. years or more (Table II). There were 310 poison control cen¬ Sixty-six percent of respondents tres in Canada in 1972 (compared with stated that a formal training program 223 in 1964), Alberta and British Co¬ for personnel of a poison control tele¬ lumbia having the largest number phone service is needed and 60% also 112 and 70, respectively. In 1972, 154 stated that if such a course were estab¬ centres reported no calls, 118 reported lished they would consider sending ap¬
Greek and the remainder other lan¬ guages. All 223 parents answered the ques¬ tion of what they would do if they found their child had accidentally swal¬ lowed a large amount of a poisonous substance, but only 30 had actually dealt with such a situation. While 71.8% of the 223 stated they would go to or call the hospital only 56.5% of the 30 had done so; 6.7% of the 223
Table I.Number of poisoning cases, subsequent hospital admissions and and deaths reported by poison control centres in Canada, 1946-721
control centres
.
1964
NA
=
1965
1966
1967
1968
1969
1970
those who did not believe a course is necessary were: the present system of on-the-job training is adequate; the staff is too large to train; the cost and location of the training program are prime considerations and the funds would.be better spent in educating the public and improving the accessibility of the larger centres. Comments on poison control in gen¬ eral were as follows: poisoning is a minor problem in our centre or patients can readily be referred to a larger cen¬ tre (17 respondents); a better filing sys¬ tem is needed (3); centres should be regionalized (9); centres should be run by a few specific persons (4); more in¬ formation on toxic plants is needed at centres
(2).
Parental knowledge of the poison control centre at The Hospital for Sick Children A total of 223 questionnaires were completed. Except for eight families all had telephones at home; 59.2% spoke English at home, 20.2% Italian, 5.8%
follow-ups Table lll.Staffing pattern of poison
1971
1972
follow-up data not available.
Table II.Number of poisoning Canada1
cases
reported, by
outcome and age group in
Outcome
Age group (yr) 0-4 5-9 10-14 15-24 25 +
Unspecified Total
14028 6263 319 ?Symptoms serious enough to necessitate hospitalization. 524 CMA JOURNAL/SEPTEMBER 20, 1975/VOL. 113
Unspecified 17 725 1405 1085 5 055 4922 2 729
Total 30691 2072 1622 7 623 8230 3293
32921
53531
Table IV.Number of poison control staff answering enquiries in average month No. of staff 1 2-5 6-10 21 11 20 16 21-40 9 40+ 4 No answer 19
Average no. per centre per month
No. of centres 11 20
11.2
stated they would phone a poison con¬ trol centre and 13.3% of the 30 had done so. Discussion Statistics Canada reported a total of 2185 deaths among Canadians in 1972 due to adverse effects of medicinal agents and toxic effects of nonmedicinal substances, effects of the former agents including death (suicide) and allergic reactions.1 The number of ac¬ cidental deaths by poisoning for the same year reported by Statistics Can¬ ada was 783, whereas the number re¬ ported by the poison control program of Health and Welfare Canada was 319. This discrepancy arose because reporting to the poison control program was voluntary and the staffing pattern of most centres was erratic. Our findings suggest there has been a shift of incidence of poisoning from children to adults, and poisoning in adults is much more serious. The role of poison control centres must change with the changing needs of our com¬
munity.
Role of the physician Much of the responsibility for pre¬ venting future poisonings, intentional and unintentional, rests with physicians, for more than 60% of all reported poisonings are in children and are preventable. The physician can contribute by ensuring that all medicines are dispensed in "childproof" containers and are properly labelled. Of the cases re¬ ported in which there was information as to containers (11% of the total), in only 12.5% was the container child¬ proof and in 38.9% it had no warning label.1 A program in Essex County, On¬ tario in which drugs were dispensed only in childproof containers resulted in a 73% reduction in the incidence of poisoning in children.10 The physician can also educate the parents. There is no coordinated pro¬ gram to alert parents to the danger of household products, the commonest source of poisoning in children. Much of the formal counselling is done by public health nurses after a poisoning. In 90% of poisoning cases one or both parents were supervising the child when he was poisoned; almost 50% of poi¬ sonings occurred in the kitchen, bathroom or bedroom.1 Prompt treatment of poisoning is es¬ sential, for 28% of patients treated within 2 hours die or have serious res¬ idual symptoms, compared with 67% of those treated later. The incidence of poisoning in adults is increasing at an alarming rate and is now estimated at 1.4/1000 Canadian adults .yr.11 In the last 5 years the num¬ ber of cases has tripled and the rela¬
proportion has doubled.1 One keep themselves informed of the constudy2 indicates that 85% of such cases stantly changing patterns of drug use. represent an impulsive gesture, often in Information could be relayed to prac¬ response to a domestic or financial tising physicians, thus providing an accrisis. celerated system of feedback on the One study11 found that in 70% of abuse of various drugs. Most telephone cases the agent used was prescribed for callers require only reassurance and the person by a physician. The drugs perhaps advice on simple first-aid.1*15 most commonly used by persons over However, many of the smaller centres 15 years of age were tranquillizers reported that in most instances it is (22.2%), barbiturates (10%) and sali- suggested the victim be taken to an cylates and non-narcotic analgesics emergency department even though less (9.9%). In approximately 10% of than one third of victims require medi¬ cases a combination of drugs (exclud¬ cal treatment. ing alcohol) was ingested, and in 36% Regionalization of poison control of men and 11% of women alcohol centres would require toll-free tele¬ was also ingested. These authors also phone service to each centre and multifound that physicians write an average lingual personnel for some centres. In of three prescriptions for an adult each the City of Toronto, for example, 37% year and that one third of the prescrip¬ of the population cannot converse in tions are for mood-modifying drugs. English or French.16 Since morbidity There is also evidence that the fre¬ and mortality increase rapidly with the quency of a particular agent being used time taken to begin treatment an in¬ in a suicide attempt depends on the terpreter must be available. The fact availability of that agent and is in¬ that 50% of all telephone enquiries dependent of the frequency of use of are made by someone other than the any other agent.12'13 This means that victim's parent or physician may mean reducing the amount of drugs available that in some cases time has been spent should cause an overall decrease in the searching for an interpreter. number of intentional poisonings. The physician's role in preventing suicide, Training of poison control personnel then, is to identify and treat patients at Poison control personnel need train¬ risk and to review his or her prescrib¬ in toxicology and in the following ing ing practices. According to some au¬ aspects of poisoning: thors14 suicide is becoming a socially 1. use of existing information Proper acceptable means of relieving stress, storage-retrieval systems. and approximately 20% of persons at2. Clinical assessment of poisoning tempting suicide have done so at least cases to judge, from the telephone call, tive
other time. Crisis intervention some of which answer more than 60 calls a day, are serving a population with a suicide risk that is above average (J.Z. Garson, personal communication, 1973). Such services, however, are currently available to only a limited number of Canadians. Per¬ haps poison control centres, in cooper¬ ation with physicians, could provide crisis intervention services on a regional basis. Regionalization of poison control one
centres,
centres
whether the victim should be taken to
hospital. 3. Management
of persons in dis¬
tress. Personnel must be able to reas-
sure the caller, be sympathetic and ob¬ tain all necessary information without causing undue delay in treatment. 4. Accurate recording of case in¬ formation and compilation of up-todate statistics. 5. Education of the public and the medical profession in methods of poi¬ son control. 6. Use of available public health and social services to follow up cases when necessary.
Before preventive measures can be successfully implemented poison con¬ trol centres must be administered more efficiently. Regionalization of centres Public education would allow each to serve a larger A program of public education di¬ population and trained individuals rected at all age and economic groups could be hired for specific jobs. For is needed not only to acquaint people example, each centre has a file of about with poison control facilities but also 12 000 product-information cards and to alert them to the sources of poison¬ has access to another 8000 cards in ing. All new parents should be warned Ottawa, yet an estimated 250 000 po¬ of the hazards in their homes before tentially toxic products are available to their children point them out; present the Canadian consumer.4 Also, each of education programs on household sa¬ the larger centres now answers 10 to fety are inadequate. The public should 20 calls daily. Maintaining so extensive also be informed of current trends and a filing system, dealing with callers and dangers in the use of "street drugs". A reporting cases should be the responsi¬ decade ago, when large numbers of bility of one or two trained people who American youths began experimenting CMA
JOURNAL/SEPTEMBER 20, 1975/VOL.
113 527
.zI.©w sinemeE (levodopa and carbidopa combination) INDICATIONS Treatment of Parkinson's syndrome with exception of drug induced parkinsonism. DOSAGE SUMMARY Therapy must be Individualized and drug administration continuously matched to the needs and tolerance of the patient. Because of the enhancement of levodopa effects provided by SINEMET*, titration and adjustment of dosage sheuld be made in small steps, without exceeding recommended dosage ranges. Therapy in Patients not receiving Levodopa: Initially 1A tablet once or twice a day, increase by 1/2 tablet every three days if desirable. An optimum dose of 3 to 5 tablets a day divided into 4 to 6 doses. Therapy in Patients receiving Levodopa: Discontinue levodopa for at least 12 hours, then give approximately 20% of the previous levodopa dose in 4 to 6 divided doses. Please consult monograph for complete information including initial dosage, transfer from levodopa or other agents, adjustment and maintenance. CONTRAINDICATIONS When a sympathomimetic amine is contraindicated; with monoamine oxidase inhibitors, which should be discontinued two weeks prior to starting SINEMET*; in uncompensated cardiovascular, endocrine, hematologic, hepatic, pulmonary or renal disease; in narrowangle glaucoma; in patients with suspicious, undiagnosed skin lesions or a history or melanoma. WARNINGS When given to patients receiving levodopa alone, discontinue levodopa at least 12 hours before initiating SINEMET* at a dosage that provides approximately 20% of previous levodopa. Not recommended in drug-induced extrapyramidal reactions; contraindicated in management of intention tremor and Huntington's chorea. Levodopa related central effects such as involuntary movements may occur at lower dosages and sooner, and the 'on and off' phenomenon may appear earlier with combination therapy. Monitor carefully all patients for the development of mental changes, depression with suicidal tendencies, or other serious antisocial behaviour. Cardiac function should be monitored continuously during period of initial dosage adjustment in patients with arrhythmias. Safety of SINEMET* in patients under 18 years of age not established. Pregnancy and lactation: In women of childbearing potential, weigh benefits against risks. Should not be given to nursing mothers. Effects on human pregnancy and lactation unknown. PRECAUTIONS General: Periodic evaluations of hepatic, hematopoietic, cardiovascular and renal function recommended in extended therapy. Treat patients with history of convulsions cautiously. Physical Activity: Advise patients improved on SINEMET* to increase physical activities gradually, with caution consistent with other medical considerations. In Glaucoma: May be given cautiously to patients with wide angle glaucoma, provided intraocular pressure is well controlled and can be carefully monitored during therapy. With Antihypertensive Therapy:Assymptomatic postural hypotension has been reported occasionally, give cautiously to patients on antihypertensive drugs, checking carefully for changes in pulse rate and blood pressure. Dosage adjustment of antihypertensive drug may be required. With Psychoactive Drugs: If concomitant administration is necessary, administer psychoactive drugs with great caution and obeerve patients for unusual adverse reactions. With Anes-
thetics: Discontinue SINEMET* the night before general anesthesia and reinstitute as soon as patient can take medication orally. ADVERSE REACTIONS Most Common: Abnormal Involuntary Movements-usually diminished by dosage reduction-choreiform, dystonic and other involuntary movements. Muscle twitching and blepharospasm may be early signs of excessive dosage. Other SerIous Reactions: Oscillations in performance: diurnal variations, independent oscillations in akinesia with stereotyped dyskinesias, sudden akinetic crises related to dyskinesias, akinesia paradoxica (hypotonic freezing) and 'on and off' phenomenon. Psychiatric:, paranoid ideation, psychotic episodes, depression with or without development of suicidal tendencies and dementia. Rarely convulsions (causal relationship not established). Cardiac irregularities and/or palpitations, orthostatic hypotensive episodes, anorexia, nausea, vomiting and dizziness. Other adverse reactions that may occur: Psychiatric: increased libido with serious antisocial behavior, euphoria, lethargy, sedation, stimulation, fatigue and malaise, confusion, insomnia, nightmares, hallucinations and delusions, agitation and anxiety. Neurologic: ataxia, faintness, impairment of gait, headache, increased hand tremor, akinetic episodes, akinesia paradoxica', increase in the frequency and duration of the oscillations in performance, torticollis, trismus, tightness of the mouth, lips or tongue, oculogyric crisis, weakness, numbness, bruxism, priapism. Gastrointestinal: constipation, diarrhea, epigastric and abdominal distress and pain, flatulence; eructation, hiccups, sialorrhea; difficulty in swallowing, bitter taste, dry mouth; duodenal ulcer; gastrointestinal bleeding; burning sensation of the tongue. Cardiovascular: arrhythmias, hypotension, nonspecific ECG changes, flushing, phlebitis. Hematologic: hemolytic anemia, leukopenia, agranulocytosis. Dermatologic: sweating, edema, hair loss, pallor, rash, bad odor, dark sweat. Musculoskeletal: low back pain, muscle spasm and twitching, musculoskeletal pain. Respiratory: feeling of pressure in the chest, cough, hoarseness, bizarre breathing pattern, postnasal drip. Urogenital: urinary frequency, retention, incontinence, hematuria, dark urine, nocturia, and one report of interstitial nephritis. SpecialSenses: blurred vision, diplopia, dilated pupils, activation of latent Homers syndrome. Miscellaneous: hot flashes, weight gain or loss. Abnormalities in laboratory tests reported with levodopa alone, which may occur with SINEMET*: Elevations of blood urea nitrogen, SGOT, SGPT, LDH, bilirubin, alkaline phosphatase or protein bound iodine. Occasional reduction in WBC, hemoglobin and hematocrit. Elevations of uric acid with colorimetric method. Positive Coombs tests reported both with SINEMET* and with levodopa alone, but hemolytic anemia extremely rare. FOR COMPLETE PRESCRIBING INFORMATION PLEASE REFER TO PRODUCT MONOGRAPH WHICH IS AVAILABLE ON REQUEST HOW SUPPLIED Ca88O4.TabletsSlNEMET* 250, dapple-blue, oval, biconvex, scored, compressed tablets coded M5D654, each containing 25 mg of carbidopa and 250 mg of levodopa. Available in bottles of 100.
C MERCK I SHARP I
DOHME CANADA LIMITED
with drugs, the major source of information was the public press. Only when drug abuse became a problem in Canadian cities did health officials begin to try to. guide the public. There should be some control of the amount and nature of advertising of patent medicines, and their packaging and distribution, for at present these drugs account for 25% of all poisonings.3 Conclusion In summary, the new steps a poison control program should be taking are: promoting childproof packaging of medication and warning labels for hazardous products, educating parents about the hazards of household prodducts, regionalizing centres, hiring multilingual staff for certain centres, establishing crisis intervention as part of the program, initiating training programs for centre personnel, and educating physicians to manage cases promptly and to review their prescribing practices. We thank Dr. E. Napke, chief of the poison control and drug adverse reaction program of Health and Welfare Canada, for his valuable assistance in this study. References 1. Poison Control Program Statistics, 1964 to 1972. Ottawa, Health and Welfare Canada 2. PATEL AR, ROY M, WILSON GM: Self poisoning and alcohol. Lancet 2: 1099, 1972
3. SMITH AJ: Self-poisoning with drugs: a worsening situation. Br Med / 4: 157, 1972 4. WILDEMAN RA: Poison Control - Continued Chaos or Future Co-ordination. Final report of the Poison Control Center Evaluation Project, London, Ont. Dec 1971 (mimeo) 5. CIMINO JA: New York City's poison control center. Public Healih Rep 83: 396, 1968 6. WRIGHT WH: How one poison control center
works. Am I Nurs 66: 1988, 1966 7. How the poison control center operates at Memorial Osteopathic. Osteopath Hosp 16: 13, 1972
8. KERNAGHAN SG: Poison prevention: pharmacists wanted. Hospitals 47: 155, 1973
9. ROSENBLUM M: Manpower needs for toxicology. Arch Environ Health 16: 438, 1968 10. BYCAULT HJ: Five years with 5 million child resistant containers (abstr), in Proceedings oj
the 15th annual meeting of American Association of Poison Control Centers, New York, Oct 16, 1972
11. S.ss M, PURDY M, DEvENYI P: Drug overdoses in a Canadian city. Am I Public Health 63: 215, 1973
12. HEWITT D, MILNER J: Drug-related deaths in the United States - first decade of an epidemic. Health Serv Rep 89: 211, 1974 13. HASSALL C, TRETHOWAN WH: Suicide in Birmingham. Br Med 1 1: 717, 1972 14. SMITH JS, DAVIDSON K: Changes in the pattern of admissions for attempted suicide in Newcastle upon Tyne during the 1960s' Br
Med 1 4: 412, 1971
15. Ross GL, ELWOOD HS, HAGGERTY RJ: Evalu-
ation of a poison control center, in Program Evaluation in the Health Fields, edited by SCHULBERG HC, SHELDON A, BAKER F, New York, Behavioral Pubns, 1970, pp 369-82
.Trademark(MC-973)
530 CMA JOURNAL/SEPTEMBER 20, 1975/VOL. 113
16. Statistics Canada Bulletin. 92 773 (spec pub #3), Ottawa, Dec 1972, p 2-61
Summary: Poisoning is a major and Increasing health problem in the Western world. In 1972 the 310 poison control centres in Canada reported 53 531 enquiries about poisoning, 40% in adults. In 1964 the numbers of
hospital admissions and deaths due to poisoning in this country were 2446 and 38, respectively, but in 1972 the figures were 6263 and 319, respectively. Most of the hospitalizations and deaths
among adults. Of 100 Canadian poison control centres two thirds were staffed by "any nurse in the emergency room", most of whom had received no training to answer the phone enquiries. However, two thirds agreed a training program is needed. Only 6.7% of 223 parents surveyed stated they would call a poison control centre if their child had accidentally swallowed a large amount of a poisonous substance. Regionalization of centres, a training program for personnel answering telephone enquiries, the need for crisis intervention as part of poison control programs, and public education about poisoning and poison control centres are the new challenges facing those providing health services. were
malades
hospitalises
pour intoxication
et le nombre des deces etaient, dans notre pays, de 2446 et de 38,
respectivement, alors qu'en 1972 ces chiffres etaient passe a 6263 et 319, respectivement. La plupart des hospitalisations et des deces concernaient des adultes. Sur 100 centres antipoisons deux tiers n'avaient comme equipe que I'infirmiere de service a I'urgence, la majorite d'entre elles n'ayant du reste aucune formation speciale pour repondre efficacement aux appels telephoniques. Parmi les personnes questionnees, deux tiers admettaient la necessite d'un programme de formation. questionnes 6.7% qu'ils centre antipoison
Des 223 parents
seulement ont affirme
appelleraient
un
si leur enfant avait accidentellement
avale
une
toxique.
forte quantite d'une substance
nouveaux defis que doivent ces centres on peut citer les
Parmi les
affronter
points suivants: la regionalisation des centres, un programme de formation destine au personnel appele a repondre aux appels telephoniques, le besoin d'intervenir en periode de crise, considere comme faisant partie des programmes therapeutiques des centres
l'enseignement a dispenser au public concernant les intoxications les centres antipoisons.
et
Resume: Les intoxications et les centres
antipoisons
au
Canada
Dans le monde occidental I'intoxication est devenu un probleme sanitaire considerable dont I'ampleur ne cesse de croitre. En 1972 les 310 centres antipoisons du Canada avaient signale 53 531 demandes de renseignements, dont 40% concernaient des adultes. En 1964 le nombre de From the departments of pediatrics and preventive medicine, University of Toronto, and The Hospital for Sick Children, Toronto Reprint requests to: Dr. C.P. Shah, The Hospital for Sick Children, 555 University Ave.. Toronto,
Ont. M5G 1X8
et
elsewhere in the Western a major health problem:1"3 an estimated 50 000 Cana¬ dians are poisoned each year.1 Despite the increasing number of poison con¬ trol centres in Canada little has been written about the Canadian situation.4 How individual centres are staffed5"7 and the need for pharmacists and clin¬ ical toxicologists in poison control cen¬ tres89 have been studied, but the need for training programs for persons an¬ swering the calls in a poison control centre has been neglected. In Canada,
as
world, poisoning is
frcp[c];
This study examined the magnitude of the problem of poisoning in Can¬ ada, the staffing pattern of poison con¬ trol centres across the country and parental knowledge of poison control centres.
Methods Data on poisoning were obtained from the medical social statistics bureau of Health and Welfare Canada.1 To study the staffing patterns of poison control centres and the need for formal training an English or French questionnaire was sent in the summer of 1973 to all centres east of Saskat¬ chewan, to all centres in Saskatoon, Regina, Calgary, Edmonton, Vancou¬ ver and Victoria, and to a 5% random sample of the remaining small centres. The questionnaire requested a report on the number of calls answered, the location of the centre in the hospital, the number and type of persons an¬ swering the calls and their interest in a training program. To study parental knowledge of poi¬ son control centres a questionnaire was given to 223 parents attending the gen¬ eral medical clinic at The Hospital for Sick Children over a 1-week period in the summer of 1973. They were asked how many children they had, what lan¬ guage was spoken at home, what they would do if their child ingested a poi¬ sonous substance, whether their child had ever taken such substances and, if so, what they had done about it.
Definition In this paper the term "poisoning" refers to enquiries about potential poi¬ soning and actual poisoning. Results Magnitude of the problem The total number of enquiries re¬ garding poisoning and the subsequent number of hospital admissions more than doubled from 1964 to 1972 but
CMA JOURNAL/SEPTEMBER 20, 1975/VOL. 113 523
the number of deaths increased 840%, from 38 to 319 (Table I) or from 1.6 to 6.0/1000 cases. Death from poison¬ ing occurred mainly in the age group
1 to
25, 21 reported 26
to 100, 10 re¬ 100 to 500 and 7 reported more than 500 calls. In all provinces except Alberta and British Columbia over 75% of telephone calls were made to only one or two centres. The Hospital for Sick Children in Toronto and Sainte-Justine Hospital in Montreal handled 29% of all calls in Canada.
ported
propriate persons for training. Of those who believed a course is required 75% stated it should be of 1 week's dura¬ tion or less. Typical comments from
25 years and over and was the result of drug overdose with suicidal intent. The number of cases followed up also increased appreciably in this period. Of poisoning cases in which age was specified 61% were in children under Poisoning was reported by telephone 5 years of age, 8% in children 5 to in 48% of cases and through the emer¬ 14, 15% in persons 15 to 24 and 16% gency room in the rest. A parent called in those 25 or older. Cleaning and pol- in 44.8% of cases and a physician in ishing agents were the leading cause 5.2%. In all provinces except Ontario of poisoning among children up to 4 about 50% of calls were made by years of age, accounting for 15% of someone other than the victim's parent cases. Acetylsalicylic acid ranked sec¬ or physician. ond for this age group, accounting for 13% of cases. Among persons aged 15 to 24 years 63.4% of poisonings were Staffing patterns with central nervous system drugs, the two commonest groups being tranquil¬ Of 120 poison control centres sur¬ lizers (18.8%) and lysergic acid die- veyed to examine staffing patterns 100 thylamide and other hallucinogens responded. Eighty of the centres were (18.5%). Among persons aged 25 years combined with an emergency room and or more 51% were poisoned by ingestapproximately 60 were staffed fulling tranquillizers, barbiturates and time by "any nurse in the emergency other sedatives, tranquillizers being the room" (Table III). About two thirds of most frequent agent (in 25% of all the centres permitted six or more peo¬ cases); most individuals had attempted ple to answer the poisoning calls in a suicide by taking an overdose of a given month (Table IV). Only 8 of the medication. centres claimed to have any staff with In only 39% of all cases was in¬ extensive training in poison control; in formation on outcome, including after 26 centres the staff had had some train¬ effects, provided. Morbidity and mor¬ ing, in 43 they had received training on tality were highest in patients aged 25 the job, in 14 none had any training and 9 did not answer. years or more (Table II). There were 310 poison control cen¬ Sixty-six percent of respondents tres in Canada in 1972 (compared with stated that a formal training program 223 in 1964), Alberta and British Co¬ for personnel of a poison control tele¬ lumbia having the largest number phone service is needed and 60% also 112 and 70, respectively. In 1972, 154 stated that if such a course were estab¬ centres reported no calls, 118 reported lished they would consider sending ap¬
Greek and the remainder other lan¬ guages. All 223 parents answered the ques¬ tion of what they would do if they found their child had accidentally swal¬ lowed a large amount of a poisonous substance, but only 30 had actually dealt with such a situation. While 71.8% of the 223 stated they would go to or call the hospital only 56.5% of the 30 had done so; 6.7% of the 223
Table I.Number of poisoning cases, subsequent hospital admissions and and deaths reported by poison control centres in Canada, 1946-721
control centres
.
1964
NA
=
1965
1966
1967
1968
1969
1970
those who did not believe a course is necessary were: the present system of on-the-job training is adequate; the staff is too large to train; the cost and location of the training program are prime considerations and the funds would.be better spent in educating the public and improving the accessibility of the larger centres. Comments on poison control in gen¬ eral were as follows: poisoning is a minor problem in our centre or patients can readily be referred to a larger cen¬ tre (17 respondents); a better filing sys¬ tem is needed (3); centres should be regionalized (9); centres should be run by a few specific persons (4); more in¬ formation on toxic plants is needed at centres
(2).
Parental knowledge of the poison control centre at The Hospital for Sick Children A total of 223 questionnaires were completed. Except for eight families all had telephones at home; 59.2% spoke English at home, 20.2% Italian, 5.8%
follow-ups Table lll.Staffing pattern of poison
1971
1972
follow-up data not available.
Table II.Number of poisoning Canada1
cases
reported, by
outcome and age group in
Outcome
Age group (yr) 0-4 5-9 10-14 15-24 25 +
Unspecified Total
14028 6263 319 ?Symptoms serious enough to necessitate hospitalization. 524 CMA JOURNAL/SEPTEMBER 20, 1975/VOL. 113
Unspecified 17 725 1405 1085 5 055 4922 2 729
Total 30691 2072 1622 7 623 8230 3293
32921
53531
Table IV.Number of poison control staff answering enquiries in average month No. of staff 1 2-5 6-10 21 11 20 16 21-40 9 40+ 4 No answer 19
Average no. per centre per month
No. of centres 11 20
11.2
stated they would phone a poison con¬ trol centre and 13.3% of the 30 had done so. Discussion Statistics Canada reported a total of 2185 deaths among Canadians in 1972 due to adverse effects of medicinal agents and toxic effects of nonmedicinal substances, effects of the former agents including death (suicide) and allergic reactions.1 The number of ac¬ cidental deaths by poisoning for the same year reported by Statistics Can¬ ada was 783, whereas the number re¬ ported by the poison control program of Health and Welfare Canada was 319. This discrepancy arose because reporting to the poison control program was voluntary and the staffing pattern of most centres was erratic. Our findings suggest there has been a shift of incidence of poisoning from children to adults, and poisoning in adults is much more serious. The role of poison control centres must change with the changing needs of our com¬
munity.
Role of the physician Much of the responsibility for pre¬ venting future poisonings, intentional and unintentional, rests with physicians, for more than 60% of all reported poisonings are in children and are preventable. The physician can contribute by ensuring that all medicines are dispensed in "childproof" containers and are properly labelled. Of the cases re¬ ported in which there was information as to containers (11% of the total), in only 12.5% was the container child¬ proof and in 38.9% it had no warning label.1 A program in Essex County, On¬ tario in which drugs were dispensed only in childproof containers resulted in a 73% reduction in the incidence of poisoning in children.10 The physician can also educate the parents. There is no coordinated pro¬ gram to alert parents to the danger of household products, the commonest source of poisoning in children. Much of the formal counselling is done by public health nurses after a poisoning. In 90% of poisoning cases one or both parents were supervising the child when he was poisoned; almost 50% of poi¬ sonings occurred in the kitchen, bathroom or bedroom.1 Prompt treatment of poisoning is es¬ sential, for 28% of patients treated within 2 hours die or have serious res¬ idual symptoms, compared with 67% of those treated later. The incidence of poisoning in adults is increasing at an alarming rate and is now estimated at 1.4/1000 Canadian adults .yr.11 In the last 5 years the num¬ ber of cases has tripled and the rela¬
proportion has doubled.1 One keep themselves informed of the constudy2 indicates that 85% of such cases stantly changing patterns of drug use. represent an impulsive gesture, often in Information could be relayed to prac¬ response to a domestic or financial tising physicians, thus providing an accrisis. celerated system of feedback on the One study11 found that in 70% of abuse of various drugs. Most telephone cases the agent used was prescribed for callers require only reassurance and the person by a physician. The drugs perhaps advice on simple first-aid.1*15 most commonly used by persons over However, many of the smaller centres 15 years of age were tranquillizers reported that in most instances it is (22.2%), barbiturates (10%) and sali- suggested the victim be taken to an cylates and non-narcotic analgesics emergency department even though less (9.9%). In approximately 10% of than one third of victims require medi¬ cases a combination of drugs (exclud¬ cal treatment. ing alcohol) was ingested, and in 36% Regionalization of poison control of men and 11% of women alcohol centres would require toll-free tele¬ was also ingested. These authors also phone service to each centre and multifound that physicians write an average lingual personnel for some centres. In of three prescriptions for an adult each the City of Toronto, for example, 37% year and that one third of the prescrip¬ of the population cannot converse in tions are for mood-modifying drugs. English or French.16 Since morbidity There is also evidence that the fre¬ and mortality increase rapidly with the quency of a particular agent being used time taken to begin treatment an in¬ in a suicide attempt depends on the terpreter must be available. The fact availability of that agent and is in¬ that 50% of all telephone enquiries dependent of the frequency of use of are made by someone other than the any other agent.12'13 This means that victim's parent or physician may mean reducing the amount of drugs available that in some cases time has been spent should cause an overall decrease in the searching for an interpreter. number of intentional poisonings. The physician's role in preventing suicide, Training of poison control personnel then, is to identify and treat patients at Poison control personnel need train¬ risk and to review his or her prescrib¬ in toxicology and in the following ing ing practices. According to some au¬ aspects of poisoning: thors14 suicide is becoming a socially 1. use of existing information Proper acceptable means of relieving stress, storage-retrieval systems. and approximately 20% of persons at2. Clinical assessment of poisoning tempting suicide have done so at least cases to judge, from the telephone call, tive
other time. Crisis intervention some of which answer more than 60 calls a day, are serving a population with a suicide risk that is above average (J.Z. Garson, personal communication, 1973). Such services, however, are currently available to only a limited number of Canadians. Per¬ haps poison control centres, in cooper¬ ation with physicians, could provide crisis intervention services on a regional basis. Regionalization of poison control one
centres,
centres
whether the victim should be taken to
hospital. 3. Management
of persons in dis¬
tress. Personnel must be able to reas-
sure the caller, be sympathetic and ob¬ tain all necessary information without causing undue delay in treatment. 4. Accurate recording of case in¬ formation and compilation of up-todate statistics. 5. Education of the public and the medical profession in methods of poi¬ son control. 6. Use of available public health and social services to follow up cases when necessary.
Before preventive measures can be successfully implemented poison con¬ trol centres must be administered more efficiently. Regionalization of centres Public education would allow each to serve a larger A program of public education di¬ population and trained individuals rected at all age and economic groups could be hired for specific jobs. For is needed not only to acquaint people example, each centre has a file of about with poison control facilities but also 12 000 product-information cards and to alert them to the sources of poison¬ has access to another 8000 cards in ing. All new parents should be warned Ottawa, yet an estimated 250 000 po¬ of the hazards in their homes before tentially toxic products are available to their children point them out; present the Canadian consumer.4 Also, each of education programs on household sa¬ the larger centres now answers 10 to fety are inadequate. The public should 20 calls daily. Maintaining so extensive also be informed of current trends and a filing system, dealing with callers and dangers in the use of "street drugs". A reporting cases should be the responsi¬ decade ago, when large numbers of bility of one or two trained people who American youths began experimenting CMA
JOURNAL/SEPTEMBER 20, 1975/VOL.
113 527
.zI.©w sinemeE (levodopa and carbidopa combination) INDICATIONS Treatment of Parkinson's syndrome with exception of drug induced parkinsonism. DOSAGE SUMMARY Therapy must be Individualized and drug administration continuously matched to the needs and tolerance of the patient. Because of the enhancement of levodopa effects provided by SINEMET*, titration and adjustment of dosage sheuld be made in small steps, without exceeding recommended dosage ranges. Therapy in Patients not receiving Levodopa: Initially 1A tablet once or twice a day, increase by 1/2 tablet every three days if desirable. An optimum dose of 3 to 5 tablets a day divided into 4 to 6 doses. Therapy in Patients receiving Levodopa: Discontinue levodopa for at least 12 hours, then give approximately 20% of the previous levodopa dose in 4 to 6 divided doses. Please consult monograph for complete information including initial dosage, transfer from levodopa or other agents, adjustment and maintenance. CONTRAINDICATIONS When a sympathomimetic amine is contraindicated; with monoamine oxidase inhibitors, which should be discontinued two weeks prior to starting SINEMET*; in uncompensated cardiovascular, endocrine, hematologic, hepatic, pulmonary or renal disease; in narrowangle glaucoma; in patients with suspicious, undiagnosed skin lesions or a history or melanoma. WARNINGS When given to patients receiving levodopa alone, discontinue levodopa at least 12 hours before initiating SINEMET* at a dosage that provides approximately 20% of previous levodopa. Not recommended in drug-induced extrapyramidal reactions; contraindicated in management of intention tremor and Huntington's chorea. Levodopa related central effects such as involuntary movements may occur at lower dosages and sooner, and the 'on and off' phenomenon may appear earlier with combination therapy. Monitor carefully all patients for the development of mental changes, depression with suicidal tendencies, or other serious antisocial behaviour. Cardiac function should be monitored continuously during period of initial dosage adjustment in patients with arrhythmias. Safety of SINEMET* in patients under 18 years of age not established. Pregnancy and lactation: In women of childbearing potential, weigh benefits against risks. Should not be given to nursing mothers. Effects on human pregnancy and lactation unknown. PRECAUTIONS General: Periodic evaluations of hepatic, hematopoietic, cardiovascular and renal function recommended in extended therapy. Treat patients with history of convulsions cautiously. Physical Activity: Advise patients improved on SINEMET* to increase physical activities gradually, with caution consistent with other medical considerations. In Glaucoma: May be given cautiously to patients with wide angle glaucoma, provided intraocular pressure is well controlled and can be carefully monitored during therapy. With Antihypertensive Therapy:Assymptomatic postural hypotension has been reported occasionally, give cautiously to patients on antihypertensive drugs, checking carefully for changes in pulse rate and blood pressure. Dosage adjustment of antihypertensive drug may be required. With Psychoactive Drugs: If concomitant administration is necessary, administer psychoactive drugs with great caution and obeerve patients for unusual adverse reactions. With Anes-
thetics: Discontinue SINEMET* the night before general anesthesia and reinstitute as soon as patient can take medication orally. ADVERSE REACTIONS Most Common: Abnormal Involuntary Movements-usually diminished by dosage reduction-choreiform, dystonic and other involuntary movements. Muscle twitching and blepharospasm may be early signs of excessive dosage. Other SerIous Reactions: Oscillations in performance: diurnal variations, independent oscillations in akinesia with stereotyped dyskinesias, sudden akinetic crises related to dyskinesias, akinesia paradoxica (hypotonic freezing) and 'on and off' phenomenon. Psychiatric:, paranoid ideation, psychotic episodes, depression with or without development of suicidal tendencies and dementia. Rarely convulsions (causal relationship not established). Cardiac irregularities and/or palpitations, orthostatic hypotensive episodes, anorexia, nausea, vomiting and dizziness. Other adverse reactions that may occur: Psychiatric: increased libido with serious antisocial behavior, euphoria, lethargy, sedation, stimulation, fatigue and malaise, confusion, insomnia, nightmares, hallucinations and delusions, agitation and anxiety. Neurologic: ataxia, faintness, impairment of gait, headache, increased hand tremor, akinetic episodes, akinesia paradoxica', increase in the frequency and duration of the oscillations in performance, torticollis, trismus, tightness of the mouth, lips or tongue, oculogyric crisis, weakness, numbness, bruxism, priapism. Gastrointestinal: constipation, diarrhea, epigastric and abdominal distress and pain, flatulence; eructation, hiccups, sialorrhea; difficulty in swallowing, bitter taste, dry mouth; duodenal ulcer; gastrointestinal bleeding; burning sensation of the tongue. Cardiovascular: arrhythmias, hypotension, nonspecific ECG changes, flushing, phlebitis. Hematologic: hemolytic anemia, leukopenia, agranulocytosis. Dermatologic: sweating, edema, hair loss, pallor, rash, bad odor, dark sweat. Musculoskeletal: low back pain, muscle spasm and twitching, musculoskeletal pain. Respiratory: feeling of pressure in the chest, cough, hoarseness, bizarre breathing pattern, postnasal drip. Urogenital: urinary frequency, retention, incontinence, hematuria, dark urine, nocturia, and one report of interstitial nephritis. SpecialSenses: blurred vision, diplopia, dilated pupils, activation of latent Homers syndrome. Miscellaneous: hot flashes, weight gain or loss. Abnormalities in laboratory tests reported with levodopa alone, which may occur with SINEMET*: Elevations of blood urea nitrogen, SGOT, SGPT, LDH, bilirubin, alkaline phosphatase or protein bound iodine. Occasional reduction in WBC, hemoglobin and hematocrit. Elevations of uric acid with colorimetric method. Positive Coombs tests reported both with SINEMET* and with levodopa alone, but hemolytic anemia extremely rare. FOR COMPLETE PRESCRIBING INFORMATION PLEASE REFER TO PRODUCT MONOGRAPH WHICH IS AVAILABLE ON REQUEST HOW SUPPLIED Ca88O4.TabletsSlNEMET* 250, dapple-blue, oval, biconvex, scored, compressed tablets coded M5D654, each containing 25 mg of carbidopa and 250 mg of levodopa. Available in bottles of 100.
C MERCK I SHARP I
DOHME CANADA LIMITED
with drugs, the major source of information was the public press. Only when drug abuse became a problem in Canadian cities did health officials begin to try to. guide the public. There should be some control of the amount and nature of advertising of patent medicines, and their packaging and distribution, for at present these drugs account for 25% of all poisonings.3 Conclusion In summary, the new steps a poison control program should be taking are: promoting childproof packaging of medication and warning labels for hazardous products, educating parents about the hazards of household prodducts, regionalizing centres, hiring multilingual staff for certain centres, establishing crisis intervention as part of the program, initiating training programs for centre personnel, and educating physicians to manage cases promptly and to review their prescribing practices. We thank Dr. E. Napke, chief of the poison control and drug adverse reaction program of Health and Welfare Canada, for his valuable assistance in this study. References 1. Poison Control Program Statistics, 1964 to 1972. Ottawa, Health and Welfare Canada 2. PATEL AR, ROY M, WILSON GM: Self poisoning and alcohol. Lancet 2: 1099, 1972
3. SMITH AJ: Self-poisoning with drugs: a worsening situation. Br Med / 4: 157, 1972 4. WILDEMAN RA: Poison Control - Continued Chaos or Future Co-ordination. Final report of the Poison Control Center Evaluation Project, London, Ont. Dec 1971 (mimeo) 5. CIMINO JA: New York City's poison control center. Public Healih Rep 83: 396, 1968 6. WRIGHT WH: How one poison control center
works. Am I Nurs 66: 1988, 1966 7. How the poison control center operates at Memorial Osteopathic. Osteopath Hosp 16: 13, 1972
8. KERNAGHAN SG: Poison prevention: pharmacists wanted. Hospitals 47: 155, 1973
9. ROSENBLUM M: Manpower needs for toxicology. Arch Environ Health 16: 438, 1968 10. BYCAULT HJ: Five years with 5 million child resistant containers (abstr), in Proceedings oj
the 15th annual meeting of American Association of Poison Control Centers, New York, Oct 16, 1972
11. S.ss M, PURDY M, DEvENYI P: Drug overdoses in a Canadian city. Am I Public Health 63: 215, 1973
12. HEWITT D, MILNER J: Drug-related deaths in the United States - first decade of an epidemic. Health Serv Rep 89: 211, 1974 13. HASSALL C, TRETHOWAN WH: Suicide in Birmingham. Br Med 1 1: 717, 1972 14. SMITH JS, DAVIDSON K: Changes in the pattern of admissions for attempted suicide in Newcastle upon Tyne during the 1960s' Br
Med 1 4: 412, 1971
15. Ross GL, ELWOOD HS, HAGGERTY RJ: Evalu-
ation of a poison control center, in Program Evaluation in the Health Fields, edited by SCHULBERG HC, SHELDON A, BAKER F, New York, Behavioral Pubns, 1970, pp 369-82
.Trademark(MC-973)
530 CMA JOURNAL/SEPTEMBER 20, 1975/VOL. 113
16. Statistics Canada Bulletin. 92 773 (spec pub #3), Ottawa, Dec 1972, p 2-61
