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suggest that 20 g is sufficient. As an alternative charcoal tablets have been suggested, but since the adsorptive powers of charcoal depend entirely on its surface area, compression into tablet form destroys the whole object of its use. The other property required of an all-purpose antidote, which charcoal lacks, is the ability to neutralize acids or alkalis. There have in the past been attempts to prepare a universal antidote. Indeed, Martindale's Extra Pharmacopoeia lists a preparation under that very name containing charcoal, magnesium oxide and tannic acid, the last two constituents being intended to neutralize acids and alkalis respectively. However, Picchioni (1974) and Hayden & Comstock (1975) report that universal antidote is inferior to charcoal alone as an antidote, and advise that as a remedy it should be discouraged. The present situation is that there is no generally acceptable all-purpose oral antidote against ingested poisons that does not have serious theoretical or practical limitations on its use. The nearest approach is activated charcoal BP, which has the approval of many authorities. But practical considerations make it difficult to recommend as a regular pre-packaged component of first-aid kits. My conviction is that further work is needed to devise a remedy that would avoid the practical disadvantages of charcoal but retain its virtues. Perhaps activated aluminium oxide could form the basis for such an antidote. It combines both high adsorptive qualities with amphoteric properties that could be useful in neutralizing either acid or alkali. The addition of liquid paraffin to the preparation would also provide a medium which might dissolve some organic chemicals and in theory could reduce both gastric motility and gastric absorption. Such a brew would have more consumer appeal than charcoal, would combine adsorption and neutralization and, if prepackaged for addition to first-aid kits, would be less likely to end up in the afternoon cup of tea than evaporated milk. The need for developing such an antidote is reinforced by the requirements of the Health and Safety at Work Act, which requires the supplier to provide information on the potential health hazards of a market product with advice on appropriate first-aid treatment to protect against it. Although the induction of vomiting by first aiders is an unreliable and sometimes hazardous procedure, there are a few chemicals which are so toxic and rapidly acting that death will follow if they are not evacuated from the stomach immediately. Two examples are sodium cyanide, which is a common industrial processing reagent, and some of the more active organophosphorus compounds, such as Phosdrin. For sodium cyanide the oral antidote is a mixture of the familiar solutions A and B which act by rapid intragastric

conversion of the cyanide ion to a harmless inactive form. It is a great pity that the Health and Safety Executive no longer advise its use in their revised cyanide poisoning wall poster SHW 385, since it is harmless and needs no skilled medical expertise or judgment to administer. For Phosdrin, on the other hand, there is no known oral antidote, and emesis is the only effective immediate treatment. The problem is to decide when or when not to advise the induction of vomiting in the safety literature accompanying a company's products. The following rule of thumb may help in making this decision. It is based on the assumption that, unless a suicide attempt has been made, no more than 20 ml of any chemical is likely to have been ingested. Thus, if the rat oral LD50 dose of the active ingredient calculated for a 70 kg man, divided by a safety factor of 5, is contained in 20 cc or less of the product, the advice to induce vomiting as a firstaid measure may be included in all safety literature. These figures should be regarded as flexible; each author of a saftey data sheet may introduce his own safety factor. The intention is to suggest a formula which can help to quantify and so rationalize a decision on whether to instruct a first aider to induce vomiting or to avoid it. In extreme emergencies the hazards and recriminations of doing nothing can be greater than the lesser ones inherent in the traditional methods of inducing emesis. In the final analysis, however, the clinical judgement of the author must always take precedence over any simple rule of thumb and in no way should it be allowed to pre-empt a decision on whether gastric lavage should be prescribed once the casualty has reached hospital or a medical centre. REFERENCES Hayden J W & Comstock E G (1975) Clinical Toxicology 8, 515-533 Picchioni A L (1974) In: Toxicology Annual. Ed. C L Winek. Dekker, New York; p 27 St John Ambulance Association and Brigade, St Andrew Ambulance Association and the British Red Cross Society (1976) First Aid Manual. 3rd edn

Professor D J Gee (Department of Forensic Medicine, University of Leeds, 30 Hyde Terrace, Leeds, LS2 9LN) Forensic Aspects of Swallowed Poisons It is difficult to see what the forensic aspects of the emergency treatment of swallowed poisons could be, but there may be two areas in which such aspects exist. One is in the pathology of poisoning. There are few deaths from poisoning in hospital in

Symposium Report

Table 1 Fatal poisonings not admitted to hospital, Leeds, 1975: 28 cases involving a single drug

Quinalbarbitone sodium (Tuinal) Pentobarbitone sodium (Nembutal) Amylobarbitone (Amytal) Quinalbarbitone sodium (Seconal) Pentobarbitone sodium (Carbrital) Amitriptyline Imipramine Trimipramine Aspirin Pentazocine Flurazepam (Dalmane) Sodium chlorate

No. of cases 10 4 3 2 1 2 1 1

1 1 1

Leeds and those that do occur usually show pathological change grossly modified by time and treatment. So the early stages of poisoning, when emergency treatment would be appropriate, are probably only seen in a forensic pathology practice, in the examination of people dying untreated outside hospital. Secondly, there are medicolegal aspects of swallowed poisons which are relevant to emergency treatment, such as the hazards of legal actions for negligence; or the complications which may arise from poisoning due to drug addiction, asssisted suicide, or attempted homicide.

Pathology of Untreated Swallowed Poisons The Leeds University Department of Forensic Medicine carries out autopsies on most people dying outside hospital and referred to the Coroner in the Leeds Metropolitan District, which has a population of over half a million. The cases of poisoning examined in 1975 have been reviewed and are compared with non-pediatric cases of poisoning admitted to the Leeds General Infirmary in that year. There were 756 hospital admissions for poisoning (297 males, 459 females), and 5 of these patients died: 2 from paracetamol; one each from chloral hydrate, flurazepam (Dalmane), indomethacin. By Table 2 Fatal poisonings not admitted to hospital, Leeds, 1975: 10 cases involving more than one substance

Aspirin, chlorpromazine, alcohol Phenobarbitone, nortriptyline Quinalbarbitone sodium (Tuinal), diazepam (Valium) Butobarbitone (Soneryl), dihydrocodeine tartrate (DF 118) Aspirin, dothiepin hydrochloride (Prothiaden), alcohol Meprobamate, nortriptyline Paracetamol, dextropropoxyphene, alcohol Butobarbitone (Soneryl), diazepam (Valium), alcohol

No. of cases I I 2

1 I I 2

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comparison the Forensic Department made 38 autopsies on deaths from poisoning, out of a total of 1137 autopsies carried out by the department during 1975. Of these 38, poisoning was by a single drug in 28 (Table 1). Barbiturates took pride of place as the commonest lethal drug, and quinalbarbitone sodium (Tuinal) headed the list, as it did in a previous survey for the years 1963-69 (Gee et al. 1974). Each of the remaining 10 cases took a mixture of drugs (Table 2). The commonest types of poisons taken by people admitted to hospital were different, tranquillizers being taken much more frequently than barbiturates (Table 3). In view of the important role of gastric lavage or emesis in emergency treatment, I thought it important to look at the quantity of drug remaining in the stomach at the time of death in our fatal cases of poisoning. I had hoped to compare this with the quantity of drugs recovered by gastric lavage from persons admitted to hospital, but I found that this was impossible as the washings, although kept for a time on the wards, were never analysed quantitatively. So, being compelled to confine attention to the results of our autopsies, I chose an arbitrary level of 1 gram of drug, as indicating a substantial gastric residue. By this definition, 13 (30 %) of our cases had such residues (Table 4), which were not confined to any particular type of drug. We found, as might have been expected, that bigger residues occurred in people who had taken larger amounts of drugs but there was no preponderance of large gastric residues of drugs in any particular age group of the victims. Where large amounts of Table 3 Principal drugs involved in cases of poisoning admitted to hospital, Leeds, 1975 No. of cases

Tranquillizers Unspecified drugs Salicylates Barbiturates Aniline derivatives Alcohol

229 126 81 61 39 38

Table 4 Cases where stomach contents at autopsy included 1 gram of drug No. of cases Quinalbarbitone sodium 5

(Tuinal) Pentobarbitone sodium (Carbrital) Aspirin &c. Amylobarbitone (Amytal) Meprobamate &c. Butobarbitone (Soneryl) &c.

Phenobarbitone &c.

1 2 2 I I

1

I

13

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Table 5 Tissue distribution of drugs at autopsy: barbiturate and asprin

Barbiturate

Ref. No.

Drug

19770

Quinalbarbitone sodium (Tuinal) Quinalbarbitone sodium (Tuinal) Aspirin Chlorpromazine Alcohol Aspirin

20267

Aspirin

19659

20538

No. of tablets or capsules

Stomach

Blood

(mg)

(mg/100 ml)(mg/J00 g) (mg/J00 g) ingested

200

2.2

Liver

Brain

7.9

4.6

10

3600

1.3

18

4.6

24

6400 1600

7.8 0.2 356 89

11 1

3.8 0.2

40 64

-

240

drugs are present in the stomach contents their presence is usually advertised by discoloration of the stomach wall, or the presence of a coloured gelatin plug in the aesophagus (Gee et al. 1974). The amount of drug present in the stomach did not bear any constant relationship to the levels in the various tissues of the body, as found by analysis. Thus, as Table 5 indicates, each victim died when the level of barbiturate in the brain reached the same point, although the quantities elsewhere were different and the ratio of barbiturate in the blood to that in the liver suggests that death took longer to occur in the first case. One difficulty in forensic cases is the impossibility of knowing when the poison was taken, and when the victim died. Usually at least the night hours have elapsed between the person having been last seen alive and well, and having been found dead. Another difficulty is in assessing the relative importance of each drug when more than one has been taken. Thus, in Table 5, the principal cause of death in the first case of aspirin poisoning was presumably the coincident high alcohol level. This appears to have caused very rapid death, with a large gastric residue, compared to the second case. Yet would gastric lavage have been of much value in either of them? Both these cases died with the same main morbid anatomical feature, gross pulmonary cedema. This does not appear to be a factor which looms large in the clinical view of such cases, but it always impresses me as one of the principle post-mortem findings. Thus, in our 38 cases, pulmonary cedema was present in 31 and was gross iii 11 of them. Although it could be postulated that trivial amounts of cedema could be a post-mortem artefact, I do not think this can be true of the more pronounced examples. The incidence of gross pulmonary cedema in our cases was largely independent of the type of drug: it was found in 2/2 cases with quinalbarbitone sodium (Seconal) ingestion; in 3/10 with quinalbarbitone sodium (Tuinal); in 1/3 with amylobarbitone (Amytal); and in 5/10 where more than one drug was ingested. Pulmonary cedema is of course well known as a particularly prominent feature at

-

-

54

30

179

autopsy in deaths from certain drugs, such as methaqualone. The mechanism for the formation of pulmonary cedema in most cases of poisoning is not obvious, but a possible cause might be regurgitation, and inhalation of stomach contents. This hazard appears to be important in clinical situations, and is a principal reason for placing the patient in the lateral or 'coma' position during treatment. Therefore, I looked to see what the incidence of regurgitation into the airway was in these fatalities, and found it to be much less than I had expected. It occurred in only 6 (16 %) of our 38 cases. A few of the others had some mucus in the trachea, but most had completely clear airways. The type of poison taken made little difference to the occurrence of regurgitation: the drugs involved (1 case each) were: aspirin; quinalbarbitone sodium; butobarbitone and dihydrocodeine tartrate; amylobarbitone; paracetamol and dextropropoxyphene hydrochloride; trimipramine. Nor did it matter whether the stomach residue was large (2 cases) or small (4 cases). Moreover, the fact of regurgitation was not related to the severity of pulmonary cedema. Inhalation of vomit thus appears to be a minor factor in causing pulmonary cedema or death in these cases. The pulmonary cedema may be due to central nervous system involvement, or peripheral circulatory failure, but I think another factor which merits consideration is the general health of the patient. Table 6 shows the ages of the persons admitted to the Leeds General Infirmary for

Table 6 Hospital admissions for poisoning, Leeds, 1975: by age and sex Age-group 1 1-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90

No. of cases Male Female

53 95 57 42 40 9 1

107 144 86 64 21 23 14

-

-

5 deaths: aged 23, 35, 40, 57 and 84 years

Symposium Report

poisoning in 1975. The majority are young people, between the ages of 10 and 40 years, who would be expected to be otherwise healthy. In contrast, Table 7 shows that the 38 fatal poisonings examined were mainly among older people aged from 40 to 80 years. These, as might be expected, often had preexisting coronary artery disease, frequently severe. This may be a more important factor in causing death than is generally recognized. There must of course be other factors involved in causing these older people to die before reaching hospital. More of them may be determined suicides than is the case in the younger group of hospital admissions, and also more of the older people may live on their own, and so not be found in time for them to be treated. It is rare for us to see cases of poisoning by the old-style corrosive substances. This is fortunate, because the pathology is of such devastating damage that one feels it would be better not treated. There is, of course, no problem for the pathologist, of dosage or cause of death in such cases. But they may bring other problems, questions about why the poisoning was allowed to

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hospital one Saturday afternoon following an overdose of aspirin. No investigations or treatment were carried out, and she was left in bed for the afternoon. A few hours later she suddenly had a fit and died. The autopsy revealed a large amount of salicylate in the stomach, which could have been washed out. I believe no litigation followed this, but it is obviously the kind of situation in which it could. , It seems that first aiders and ambulance men are not at present at danger from litigation, but the casualty officers and junior doctors on the wards are. Whether this situation will change, especially if the doctrine of compensation without proof of fault comes into being here, as it is doing elsewhere, remains to be seen. I suspect that it may. I also wonder whether sooner or later, it will be thought negligent to provide the means of poisoning, by allowing drugs to accumulate in a patient's possession, due to overprescribing and frequent changes of prescriptions. There is always the problem of criminal acts in relation to swallowed poisons. In such cases what is done to the patient may be the subject of further legal enquiries. Such problems may occur in drug occur. addicts. At one autopsy performed recently on a Medicolegal Problems Associated young man who died at a 'drugs party', it seemed with Swallowed Poisons at first that he had died from the combined effects in of the local branches the medical Colleagues of alcohol and some sedative. the story defence organizations confirm that allegations of as it unfolded suggested thatHowever, he had probably negligence are not uncommon, but almost all are drowned, due to unskilled attempts by other drugconfined to treatment, or lack of it, when the users at the party to administer a saline emetic, and patient arrives at hospital. The normal practice in the possibility of manslaughter arose. Finally, it my area, whereby the general practitioner when was discovered that his massive, frothy, pulnotified of a case of poisoning summons an ambu- monary cdema was due to a totally unsuspected lance, but does not attend the patient himself, does overdose of injected morphine. not appear to cause any legal problems. These only The rare charge of abetting a suicide, under the start when the patient arrives at hospital. It seems Suicide Act of 1961, has been invoked more than that the principal areas of trouble are in mis- once recently. In these circumstances statements diagnosing poisoning, or in failing to take all and possibly verbal evidence in court will be proper steps when the diagnosis has been made. required from those treating the victim. Special Examples of the first are poisoning by aspirin care will be necessary to ensure careful records and iron preparations in children, who may appear of the events are kept, and that to safeguard any misleadingly well for a period of time; thus the samples obtained, though preserving the condiagnosis may be missed and they may be unwisely fidence of the patient while he lives. sent home. For example, a woman was admitted to Cases of poisoning, should be notified when appropriate to the proper authorities as an Table 7 emergency measure. Dr R Goulding and his colCases of fatal poisoning autopsied by Forensic Department, Leeds, 1975: by age and sex leagues (Rogers et al. 1976) have drawn attention to poisoning as an aspect of the 'battered baby' No. of cases Age-group Male Female syndrome. Recently an autopsy was done on a one11-20 1 0 year-old child, who had been poisoned by her 21-30 1 0 mother. The mother had in the previous few days 2 31-40 1 attempted to poison her 6-week-old baby, who had 4 41-50 4 51-60 3 3 been admitted and diagnosed in hospital as suffer61-70 2 5 ing from barbiturate poisoning. The baby lived. 3 71-80 8 81-90 0 1 But no one warned the authorities in time to prevent the second child being successfully 16 22 poisoned.

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Acknowledgments: I am indebted to H M Coroners, for whom these autopsies were performed; to Mr R A Dalley and the staff of the West Yorkshire Public Analyst's Department, who made the analyses; to Mr A Firth and the Records Department of the Leeds General Infirmary; and to the staff of the Department of Forensic Medicine, Leeds University. REFERENCES Gee D J, Dailey R A, Green M A & Perkin L A (1974) In: Post-mortem Diagnosis of Barbiturate Poisoning in Forensic Toxicology. Ed. B Ballantyne. Wright, Bristol; pp 37-51 Rogers D, Tripp J, Bentouim A, Robinson A, Berry D & Goulding R (1976) British Medical Journal i, 793

DISCUSSION

Major General R J Gray (British Red Cross Society) said that ever since first aid training had been placed on a formal basis in the latter part of the 19th century it had been considered desirable to include instruction on simple remedies for use in the emergency treatment of swallowed poisons. He quoted as a typical example the handbook 'Accidental Injuries, their Relief and Immediate Treatment', by Sir James Cantlie of the Charing Cross Hospital, published in 1884. It had a subtitle, commended to some presentday authors: 'How to prevent accidents becoming more serious'. The remedies recommended were not so different from those still favoured today. It was of interest to note that Cantlie did not consider table salt to be an effective emetic, but preferred ipecac wine. General Gray suspected that there had been little advance in our knowledge of simple effective treatments since those days but emphasized that the modern first aider expected to be taught to provide some form of treatment. Dr P J Roylance (Pharmaceutical Industry) noted that Dr Goulding and Dr Volans had rejected the use of table salt as an emetic and that eight deaths due to saline emetics had been described. He wondered whether the deaths reported could not be put into the context of the number of saline treatments administered. According to his rough calculations the incidences of death seemed to be of the order of 0.04 %, a figure of which his medical colleagues might be reasonably proud. Dr G N Volans replied that his statement was based on the efficacy of salt as an emetic. He rated it as one-quarter that of ipecachuana and he thought that there was overwhelming evidence against its use - a poor emetic but a very good poison.

Dr A Ward Gardner (Society of Occupational

Medicine) asked the speakers if they could make a clear recommendation for first aiders. Professor D J Gee replied that his inclination was to recommend that no treatment should be attempted until the victim reached hospital. Dr R Goulding agreed, adding that, in his opinion, the administration of ipecacuanha as an emetic to children was best entrusted to responsible hands. Dr J M L Gilks said he thought that there was a duty to give first aiders some positive advice, i.e. to do nothing, or to do something, even if unlikely to be successful, to cause emesis by the traditional use of the fingers, or to administer a harmless but effective antidote by mouth. As regards the last, some type of formula was required on the lines of those used by the authors of product information sheets. Dr Volans thought that there should be more emphasis on the diagnosis and general recognition of symptoms, so that first aiders could determine which victims were most at risk. Activated charcoal had not been ignored in the Poisons Unit but it was difficult to obtain, difficult to administer and there was difficulty in obtaining evidence of its effectiveness, despite attempted trials. The need was for a product that was easy to prepare and administer, such as a sachet added to water.

Major General Gray agreed with Dr Volans that diagnosis and recognition of symptoms were of prime importance but a procedure, other than by injection or ipecacuanha, needed to be taught. Dr R H Jackson (British Pediatric Association) said that the results of experiments on laboratory

animals (dogs) provoked quite different reactions in comparison with human beings. He considered saline emetic to be dangerous especially in children; ipecacuanha syrup could not be regarded as a universal antidote, and it was not likely to be available in every household. Further, it must be remembered that the emotional state of the mother of a poisoned child could cause her to forget to check the dose of antidote. The alleged objection to activated charcoal was the refusal of the child to take it but, in a trial held in 1970, 860% of the children involved accepted it readily. The success of the trial lay in the deftness of the staff. Aversion to its use appeared to rest primarily with hospital staffs and not with patients. Dr V Dallos (Casualty Surgeons Assoc.) queried the stability of the activated charcoal-phenobarbitone complex. She was aware of favourable American reports of the use of activated charcoal in

Symposium Report

paracetamol, phenothiazine and tricyclic antidepressant poisoning in children, but had no information of its use in barbiturate poisoning. Dr Volans replied that this combination had been tried but proved difficult to administer because of the large dose of charcoal needed. Dr Dallos asked for guidance on the correct legal procedure relating to gastric lavage and the retention of specimens for analysis.

Professor Gee replied that the amount of fluid used in the lavage should be noted and about 100 ml retained for analysis. It was useful to keep a sample for a time in case it was needed, especially in nonroutine cases. Dr B Lucas (Medical Commission on Accident Prevention) asked whether Dr Jackson thought too much was expected of first aiders. If there was a distance problem in the victim reaching a treatment centre, should not a doctor be sent to the victim? Dr Jackson thought there was no single answer. Distance could well preclude the availability of a doctor. Dr Lucas thought there was great danger in administering emetics for poisoning prior to loss of consciousness. The aim of the first aider should be to maintain a clear airway and not administer emergency treatment for the poisoning itself.

Dr P A B Raffle (Chief Medical Officer, St John Ambulance Association) disagreed that first aiders were or should be told to do nothing. Rather should they be instructed to take constructive action by maintaining a clear airway and affording supportive treatment. Dr J Keir Howard (Imperial Chemical Industries Ltd) considered that there should be a global approach to the problem. In the Far East poisoning was mainly caused by toxic pesticides and the victim's relatives might be the only people available to help. He considered that the onus must lie with the suppliers of pesticides to provide advice or treatment for pesticide poisoning. He thought that the induction of vomiting in conscious patients must be advised. Dr J C Graham (Surgeon-in-Chief, St John Ambulance Brigade) expressed agreement with Dr Howard. Suppliers of toxic substances to industry needed to provide information on treatment in case of ingestion by workers. In regard to the point raised by Dr Lucas, he considered that the main

777

hazard in cases of poisoning was loss of consciousness and the first priority in life saving was the maintenance of a clear airway. First aiders would rarely have to deal with cases of poisoning (possibly once in a lifetime of first-aid practice) and lacked both the experience and knowledge for the safe use of more sophisticated procedures. Dr Lucas said that all ambulance men were taught basic first aid and some the more advanced procedures, intubation, infusions &c. In dealing with poisoning they were taught to carry out the basic procedures, i.e. maintenance of a clear airway and

ventilation. Dr M H Hall (Casualty Surgeons Association) said that there was no evidence that the training of ambulance men in advanced techniques increased the saving of life. Such training schemes were now discouraged and it was considered that the best results would be obtained by ensuring that everyone dealing with these situations was proficient in basic first aid. Dr Goulding agreed with positive advice on supportive treatment, though the position might be different in other countries, for instance Australia. He thought that sachets of charcoal should be available as an absorbent. He was dubious about recommending the routine use of emesis in this country. Dr Gilks said that some lethal compounds (pesticides) could kill in minutes and immediate action to cause emesis must be taken. This was included in safety data sheets. As to activated charcoal, it was not available because there was no demand. Laboratory charcoal was readily available but could not lawfully be used for medicinal purposes. He considered that work was needed on an allpurpose antidote, and wondered whether aluminium oxide would be acceptable.

Miss R E Bailey (Chief Nursing Officer, St John Ambulance Brigade) expressed concern over the medicolegal aspect regarding volunteer first aiders as opposed to ambulance men and first aiders in industry. Dr D Douglas (Health and Safety Executive) made three points: (1) Instructions to workers should emphasize prevention rather than treatment. (2) Contamination must be avoided by separating catering places from work places where there were toxic materials. (3) Adequate warning signs and labels must be displayed. He added that proper provisions for the storage and transport of toxic substances needed to be observed, and recommended that the teaching of basic first-aid procedures should be encouraged.

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Dr J B Wilson (Chief Medical Officer, St Andrew's Ambulance Association) said he always stressed the basic procedures in first-aid training and recommended the traditional methods such as causing emesis. He considered that the saving of even one life justified such methods. Miss M S Christian (Chairman) said that the symposium had reached no clear decision as to what first aiders should be taught: should only supportive treatment be taught, or was there a case for emesis in the conscious patient? No one had followed up Dr Hall's point on the use of tincture of ipecacuanha. Was it necessary to produce emesis in all overdose patients? Dr Gilks listed his priorities in the following order: prevention; learning to recognize poisoning when it occurred, and its developing symptoms, note the type of poison; use of supportive treatment by the amateur and more sophisticated treatment by those more intensively trained. He thought more research was indicated, both in the laboratory and on the administration of such treatments as ipecac to children and adult victims of swallowed poisons. Dr Volans supported the need for prevention through greater awareness by workers of the chemicals with which they were dealing. He agreed on the need to induce vomiting when pesticides were involved; otherwise the need was for early transfer to a treatment centre. An all-purpose antidote such as charcoal or aluminium oxide was required.

Major General Gray agreed with the previous two speakers. So far as the volunteer first aider was concerned, there seemed no alternative, in the present state of knowledge, but to place the emphasis on supportive treatment and rapid transfer. Dr Goulding considered that the majority view was in fact a conservative one. He was not in favour of ineffective emesis and, whilst he agreed on the importance of saving life, nevertheless the fact had to be faced that a significant percentage of poison victims would die even after reaching hospital. In his opinion the first aider's task was to assess the severity of the condition and act accordingly, i.e. rapid transfer or basic treatment. Out of the 100 000 cases of poisoning admitted to hospital each year in England and Wales 80 90 % did not need medical treatment. Of the 4000 who did about 3000 were found dead, of the remaining 1000 about one-half were moribund on arrival at hospital.

Miss Christian (Chairman) thanked Dr Raffle and his colleagues for organizing the Symposium, and all those who had contributed to it. Although she did not think that any specific answers to the main questions had been given, there was food for thought by all those concerned with the problem of poisoning.

Acknowledgment: The symposium was supported financially by the Jubilee Fund of the Institute of Petroleum and the Chemical Industry Safety and Health Council.

Forensic aspects of swallowed poisons.

772 Proc. roy. Soc. Med. Volume 70 November 1977 suggest that 20 g is sufficient. As an alternative charcoal tablets have been suggested, but since...
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