Poison Prevention and Management

By Aaron LePoire, Pharm.D., PGY1 resident, Meijer/Ferris State University/Pfizer Community-Based Pharmacy
Residency Program, Hudsonville

Pharmacist Learning Objectives:

1. Identify available resources for poison control education and information.
2. Recognize common poisons and primary prevention practices.
3. Review appropriate management of selected toxicities.

Pharmacy Technician Learning Objectives:

1. Identify common potential household toxins.
2. Recognize strategies for primary prevention of poisoning.
3. Describe available resources for poison management.

Introduction
Since 2011, unintentional poisoning has surpassed motor vehicle accidents as the leading
cause of injury-related deaths, with unintentional poisoning accounting for 21% of all injury deaths
in 2014.1 Each year, for the last five years, more than one million poison exposures have been
reported to the American Association of Poison Control Centers (AAPCC) among children less
than six years of age.2 One of the Healthy People 2020 goals is to prevent an increase in nonfatal
poisonings; however, the rate of nonfatal poisonings has been steadily increasing from 304.8 per
100,000 population in 2008 to 414.6 per 100,000 population in 2015.3 The AAPCC annual report
from 2015 documented that the 55 poison control centers in the United States received nearly three
million calls and averaged a call regarding a human exposure every 14.5 seconds.4 The Children’s
Hospital of Michigan Regional Poison Control Center in Detroit provides services for the entire
state of Michigan, and each poison control center handles calls from a different region in the
country.5
Most human exposures to toxic products are unintended, with 78.4 percent of exposures
classified as unintentional in 2015.4 In injury prevention literature, “unintentional” is the preferred
term over “accidental,” since an accident implies a random happening by chance, while poisonings
are a preventable, predictable event, unlike other types of injuries.2 Unintentional exposures can be
attributed to general causes, therapeutic errors and misuse, among others.4 Exposure to dangerous
or potentially dangerous substances primarily occurs in children, with 47 percent of poison control
calls for human exposures occurring in children less than six years of age, and 70 percent of calls
taking place from a residential location.4 With the increasing number of deaths due to unintentional
poisoning, pharmacists are in a unique and accessible position to identify the toxicological resources
available, recognize potential adverse events due to poisoning and provide counseling on actions to
take in case of an emergency.

Table 1. List of common potential household toxins.2,4

Household cleaning supplies
Cosmetics
Vitamins/Dietary supplements
Art supplies
Essential oils
Antifreeze
Batteries
Laundry detergent

Figure 1. Injury death rates in the United States6

Motor vehicle traffic, poisoning, and drug poisoning death rates
United States: 2000-2015
18
Death Rate Per 100,000 Population

16
14
12
10
8
6
4
2
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year

Poisonings Drug Poisonings Motor Vehicle

Primary Prevention
Primary prevention should be the main focus for reducing the number of unintentional
poisoning deaths and includes education, legislation and product engineering.2 Some examples of
product engineering measures to prevent poisoning include bittering agents, poison warning labels
and flow restrictors for liquid medications.2 Flow restrictors such as those found on infant
acetaminophen bottles can increase the time it takes to empty a bottle as well as reduce the amount
of liquid removed, allowing more time for a child to be discovered with the substance before
ingestion.2 In 2015, the American Academy of Pediatrics issued a statement regarding the dosing of
liquid medications, recommending the exclusive use of metric dosing for liquid medications rather
than teaspoons or tablespoons, along with providing a milliliter based dosing device for the patient.7
Legislation and regulation can have a significant impact on reducing unintentional poisoning, and
after the 1966 regulation on package sizes of baby aspirin, aspirin poisoning deaths decreased from
144 deaths in 1960 to 12 deaths in 1980.2

Table 2. Significant Legislation and Regulation for Poison Prevention2

Year Legislation/Regulation Impact

1906 Pure Food and Drug Act Created Food, Drug, and Insecticide Administration
which became the Food and Drug Administration (FDA)
in 1930.
1927 Caustic Poison Act Required warning labels for lye and other caustic
substances.

1951 Durham-Humphrey Created OTC and prescription medication categories.

Amendment

1961 Public Law 87-319 Designated National Poison Prevention Week as the third
week in March.

1966 Baby aspirin packaging Restricted baby aspirin to 36 tablets per container.
regulation

1970 Poison Prevention Required child-resistant packaging for certain drugs and
Packaging Act household products.

1997 FDA regulation on iron Required unit-dose packaging for iron products with 30
packaging mg or more per dose. Regulation withdrawn in 2003.

2000 Public Law 106-174 Established the nationwide toll-free poison control
telephone number.

2008 FDA OTC cough and FDA recommends to not use in children less than two,
cold recommendation and the Consumer Healthcare Products Association issued
warnings for children less than four.

2011 FDA guidance on dosage Improved consistency between dosing instructions and
delivery devices devices for liquid OTC medications.

2016 Child Nicotine Poisoning Required child-resistant packaging for liquid nicotine used
Prevention Act with electronic cigarettes.

Resources
While most pharmacists may not be in a position to enact legislation or engineer safer
products, pharmacists can participate in education, which plays a massive role in preventing
unintentional poisonings. There are many resources available for pharmacists and the general public
to access and use to educate people of any age or background on poison prevention. The American
Association of Poison Control Centers (AAPCC) has educational resources including videos,
brochures, and presentations available on their website at www.AAPCC.org/prevention.8 The
Health Resources & Services Administration (HSRA) provides educational materials on their
website, www.PoisonHelp.hrsa.gov, including poison prevention tips and articles, brochures and
videos pertaining to poison control.9 HSRA also sponsors a program called “Taking Your Medicines
Safely” which provides training to individuals interested in delivering an educational program to
older adults in settings such as senior centers, libraries or churches.9 This educational program
covers a variety of areas including ways to keep track of medications, the potential problems with
over-the-counter medications and questions to ask about medications they are taking.9 The Central
Ohio Poison Center sponsors the “Be Poison Safe” and “Be Poison Wise” programs which offer
poison prevention educational materials intended for providers, children, parents, and the general
public at little or no charge.10 National Poison Prevention Week, which was established in 1961,
occurs every year during the third full week in March.8 Poison centers and other organizations
throughout the country organize events and activities during this week to promote awareness of
poison prevention measures. These resources, along with many other programs and organizations,
are helpful places to start when promoting awareness and safer practices in the community.
There are multiple resources available to inform both healthcare providers and the general
population about the dangers of a variety of poisonous substances. The most readily available
resources are provided by AAPCC, who through the use of the National Poison Center phone
number, also known as the Poison Help line (1-800-222-1222), can connect an individual to a trained
medical expert at the closest poison control center. The staff at the poison centers are comprised of
registered nurses, pharmacists, physicians, physician assistants and medical and clinical toxicologists
who have received specialized toxicology training.4 Not only do poison control centers assist with
acute exposure, they also answer questions regarding drug identification, compounding, drug-food
and drug-drug interactions, safe handling and disposal of chemicals, withdrawal, foreign
medications, drug use during pregnancy and breastfeeding, environmental exposure, and
toxicological information for specific substances.4,11 During 2015, poison control centers also made
almost 2.7 million follow-up calls in 46.8 percent of human exposure cases in order to monitor
management and outcomes of cases.4 Monitoring these cases helps to inform guidelines and
prevention education. Poison control centers can also help reduce healthcare costs by decreasing the
amount of emergency department visits. A study conducted at the Utah Poison Control Center
found that among patients who called the center from 2009-2014, the poison center potentially
saved an annual cost of $16.6-$24.4 million dollars in unneeded medical charges, with the annual
expenses for a poison control center averaging only $2.5 million dollars.12 Poison control centers are
an invaluable resource for the public and healthcare professionals, and should be considered a first
line option when encountering questions on toxicology.

Table 3. Strategies to prevent exposure to potential toxins in children.2

Do not refer to medications as candy, refer to it by the correct name.
Safely dispose of unneeded medications and store other medications appropriately.
Keep products in their original containers. Do not transfer substances to alternate containers.
Post poison control center number near a telephone or program it into your cell phone.
Keep potential poisons out of sight and reach of children.
Use safety latches on drawers and cabinets where potential household toxins are kept.
Do not eat or drink while using art products and wash skin after using.
Do not take medication in view of children who may copy the behavior.
Replace safety caps immediately after medication use.

Another resource available through AAPCC is their website (www.poisonhelp.org) which

launched in March of 2017 and allows an individual to input a substance, answer questions about the
exposure and receive advice on how to proceed.13 For more in-depth information on specific
medications and chemicals, the National Library of Medicine Toxicology and Environmental Health
Information Program (TEHIP) provides resources for healthcare professionals and the general
public on poison control through the TOXNET database.14 Some of the resources available through
the TEHIP website include the Hazardous Substances Data Bank, Toxicology Literature Online
(TOXLINE) and the Household Products Database.14 The TEHIP website also has information
available to consumers, with interactive learning for both children and adults. Pharmacists may
utilize these resources to answer questions patients may have about specific products or to review
literature regarding a product or chemical.
While prevention is an important aspect of poison control, acute exposure to dangerous or
potentially dangerous substances may warrant a more emergent response. As a pharmacist, it is vital
to know how to respond to an emergency situation involving an intentional or unintentional
poisoning. If an individual has collapsed, had a seizure, has trouble breathing or cannot be
awakened, call 911 immediately.13 If a patient or caregiver needs urgent assistance, but the exposure
does not necessarily warrant a 911 call, the Poison Help line can be called for further instructions.
For the poisoned patient, the cornerstone to treatment is supportive care, and many patients can be
treated with supportive care and decontamination alone. In the following sections, more specific
management principles will be discussed for a few of the more common exposures.

Gastrointestinal Decontamination
The American Academy of Pediatrics no longer recommends the use of ipecac syrup in the
event of acute ingestion of a potential toxin.15 Inducing vomiting can increase the difficulty of
administering needed poison treatment in a healthcare setting, and could lead to other adverse
events, including lethargy and diarrhea.15 Activated charcoal has also been historically used for
gastric decontamination and works by adsorbing chemicals and preventing gastrointestinal
absorption of the toxic substance. The use of activated charcoal has also been declining, with use in
3.7 percent of pediatric poisoning cases in 1993 compared to 0.684 percent in 2015.4 While there is
evidence to use activated charcoal in select situations, the use of activated charcoal at home is not
recommended without the specific guidance of a healthcare professional.15 The efficacy of activated
charcoal is greatest if used within one hour of acute ingestion, although benefits can still be seen if
given later than one hour.16 Activated charcoal can be administered orally as a single dose or as
multiple doses, although evidence is limited with the use of multiple doses.17 A serious risk of
activated charcoal administration is pulmonary aspiration due to improper administration, which can
lead to aspiration pneumonitis or death.15 Because of this, activated charcoal is commonly
administered via nasogastric tubes in emergency departments.15 Other adverse events include bowel
obstruction and emesis.16 The tolerability of activated charcoal can also pose a problem, with one
randomized trial reporting adults consumed on average only 83 percent of their first dose of oral
activated charcoal suspension and 27 percent of patients vomited after administration.16
Whole bowel irrigation (WBI) is another form of gastrointestinal decontamination where an
osmotically balanced polyethylene glycol electrolyte solution is administered in order to induce liquid
stool and flush the ingested substance from the bowel.17 WBI may be useful when sustained-release
formulations of medications or toxins not adsorbed by activated charcoal are ingested.17 Gastric
lavage may also be used for gastric decontamination, and has been commonly referred to as
“stomach pumping.”17 A large bore orogastric tube is used and small amounts of fluid are instilled
and then aspirated repeatedly in order to extract toxins from the stomach.17 Gastric lavage has
largely fallen out of favor due to risk of complications and unclear benefit, with the American
Academy of Clinical Toxicology issuing a statement in 2004 recommending that gastric lavage not
be routinely used in the management of poisoned patients.18 Other gastrointestinal decontamination
methods include endoscopy or surgery which may be indicated if less invasive methods are
inadequate to remove a life-threatening toxin.17

Table 4. Top 5 substance classes involved in human exposures in 2015.4

Analgesics
Household products
Cosmetic/Personal care products
Sedatives/Hypnotics/Antipsychotics
Antidepressants

Iron
Iron toxicity is common among children, although incidence has been decreasing since the
implementation of various public health initiatives, including the 1997 FDA regulation requiring
products with 30 mg or more of elemental iron to be in unit-dose packaging.2 However, this
regulation was withdrawn in 2003 due to a court decision that ruled the FDA did not have the
authority to regulate the packaging of dietary supplements for poison prevention.2 Iron is available
in many different forms, with some of the more toxic forms being ferrous fumarate, sulfate and
gluconate.19 Iron is also commonly found in prenatal vitamins. Iron can become toxic following
ingestion of 20 mg/kg elemental iron, with symptoms including nausea, vomiting, diarrhea,
abdominal pain and hematemesis.19 Iron tablets may have some radiopacity depending on the
formulation and the amount of elemental iron, and a plain radiograph of the abdomen may show the
presence of iron, although radiographs showing little or no iron do not necessarily rule out a
significant ingestion.20 Management of iron toxicity can include whole bowel irrigation, but should
not include activated charcoal due to reduced binding to iron.19 Deferoxamine is another therapeutic
option which binds to ferric iron and the complex is then excreted through the kidneys, causing the
urine to become orange or reddish brown.20 Patients should be treated with a continuous IV
infusion of deferoxamine when exhibiting signs of systemic toxicity, anion gap metabolic acidosis,
significant number of tablets on abdominal radiograph or with an iron level >500 mcg/dL.19,20 Initial
administration can cause hypotension, and fluid replacement is preferred for reversal of hypotension
over slowing the rate of administration.20 Duration of deferoxamine treatment can vary based on
resolution of toxicity or the patient’s clinical status, but a typical duration of treatment is 24 hours.20
Duration longer than 24 hours should be avoided due to the toxicities associated with prolonged
deferoxamine use including acute respiratory distress syndrome.19,20
 Active Learning

RM, a 32-year-old female, comes into the pharmacy to pick up her prenatal vitamins from the
pharmacy with her two-year-old daughter. What counseling points could you give RM to
decrease the chances of an unintentional poisoning?

Feedback
RM could be counseled about the importance of keeping the vitamins out of reach of her
daughter, not taking them in front of her daughter and keeping the poison control number
programmed in her cell phone. She should also be educated that prenatal vitamins contain iron,
which can be harmful if too much is ingested, especially in children.

Acetaminophen
Acetaminophen toxicity can occur in a variety of settings, in part due to acetaminophen
being an ingredient in a variety of combination products and having numerous brand names. A
survey on patient knowledge of acetaminophen found only 11 percent of patients could correctly
identify acetaminophen and APAP as alternative names for the brand name.21 Some of the
symptoms that may occur in acetaminophen toxicity include nausea, vomiting, malaise, pallor and
diaphoresis; although, many patients are asymptomatic.22 Treatment is determined by use of the
Rumack-Matthew nomogram evaluating the acetaminophen concentration and time since
ingestion.23 Other indications besides using the nomogram could include evidence of liver injury, an
unknown amount of time since ingestion with an acetaminophen concentration >10 mcg/mL or
ingestion of >150 mg/kg or 7.5 grams of acetaminophen where concentration will not be known
until more than eight hours after ingestion.23 Treatment for early presentation can include activated
charcoal or gastric emptying, although gastric lavage is not routinely recommended.22,23 N-
Acetylcysteine (NAC) should be administered either IV or orally and the FDA-approved treatment
protocols include a 20-hour IV and 72-hour oral protocols.23 Oral NAC is not tolerated well, with
approximately 33 percent of patients experiencing nausea and vomiting.23 If vomiting occurs within
60 minutes of an orally administered dose, the dose should be repeated.23 The most likely
mechanism of action of NAC in acetaminophen toxicity is the restoration of hepatic glutathione
stores, which helps prevent the conversion of acetaminophen to the toxic metabolite N-acetyl-p-
benzoquinoneimine (NAPQI) and helps to detoxify the already formed NAPQI.23 Additional
options for acetaminophen removal include hemodialysis, plasma exchange or liver dialysis.22

Beta-Blockers
Beta-adrenergic antagonist toxicity may result in bradycardia, hypotension, bronchospasm,
hypoglycemia, delirium, coma and seizures.24,25 Symptoms usually present within six hours of
ingestion; however, sotalol and sustained-release products may have delayed toxicity in overdose.25
Agents with more lipophilic properties such as propranolol may have an increased risk of delirium,
coma and seizures even without the presence of hypotension.24,25 Propranolol poisoning may also
have an increase in bradycardia, hypotension, impaired atrioventricular conduction and widened
QRS interval due to propranolol having the most membrane-stabilizing activity among the beta-
adrenergic antagonists.24,25 Sotalol in particular can cause electrocardiogram changes with a
prolonged QT interval.25 For patients presenting with beta-adrenergic antagonist poisoning, initial
treatment should consist of atropine and intravenous fluids to resolve bradycardia and
hypotension.24,25 For patients who do not respond to initial treatment, glucagon may be trialed as a
positive inotrope.25 Glucagon can be initiated with an initial slow bolus, which may be repeated if no
response is seen.24 When a response is seen through increased pulse or blood pressure, a continuous
infusion may be started.24 A common adverse event with glucagon administration is emesis, which
may require the administration of an antiemetic.25 IV calcium salts may also be useful to reverse
hypotension, with both calcium gluconate and calcium chloride being used.25 Calcium must be
monitored if using one of the IV calcium salts. Vasopressors may also be used if a combination of
the above treatments are ineffective. An epinephrine infusion may be useful by exerting a positive
inotropic and chronotropic effect.25 Insulin and glucose present another possible option for those
who are refractory to other treatment options. A high-dose insulin infusion is combined with a
continuous IV infusion of dextrose in order to maintain euglycemia.24 Response to high-dose insulin
therapy may be delayed for up to 60 minutes, and it is important to maintain other treatments during
this window.24,25 Other possible therapies in patients who are refractory to the previous treatments
include lipid emulsion therapy, sodium bicarbonate or magnesium with arrhythmias and
hemodialysis.25

Salicylates
Salicylate toxicity can cause a variety of symptoms, including increased respiratory rate,
tinnitus, hyperpyrexia, vertigo, altered mental status, anion gap metabolic acidosis and acute
respiratory distress syndrome.26,27 Aspirin can be fatal with as few as ten 325 milligram tablets in
children.27 Another common salicylate toxicity occurring in children is ingestion of oil of
wintergreen. The active ingredient in oil of wintergreen is methyl salicylate, and pure oil of
wintergreen contains at least 98 percent methyl salicylate, with five milliliters equivalent to seven
grams of aspirin.28 As essential oils become more popular, patients must be aware that children
younger than six years can experience systemic toxicity with as little as a taste of oil of wintergreen.26
During management of salicylate toxicity, activated charcoal binds to aspirin and can be used for
decontamination, with earlier administration preferred.26,27 Supportive care is an essential aspect of
salicylate overdose; however, patients should not be intubated unless absolutely necessary.
Intubation and sedation increase the possibility of respiratory acidosis which may allow more
salicylate diffusion across the blood-brain barrier and increase toxicity.27 The mainstay treatment in
salicylate toxicity is supportive care along with serum and urine alkalinization.26,27 Alkalinization
helps shift salicylate out of the central nervous system into the serum, where it can be eliminated by
the kidneys.26,27 Salicylate is also more easily excreted by the kidneys when the urine is alkalinized.26,27
A sodium bicarbonate bolus followed by infusion is used for alkalinization, maintaining a urine pH
between 7.5 and 8.0.27 Hypokalemia and hypovolemia must also be corrected, since hypokalemia
may prevent alkalinization of the urine due to potassium and hydrogen exchange in the renal
tubules.26,27 Salicylate poisoning may also interfere with glucose metabolism, and dextrose
administration may be required to correct hypoglycemia, especially in patients with altered mental
status.27 Hemodialysis may also be indicated in select patient populations.26,27
 Active Learning

One of your patients has questions about using eucalyptus oil for sinus problems in her four-
year-old child. What resources could you use to find information on the toxicity profile of
eucalyptus oil?

Feedback: Some of the resources available to find toxicology information on substances

include contacting the Poison Help Line at 1-800-222-1222, the Poison Help website
(www.poisonhelp.org) and the TOXNET databases online through the U.S. National Library
of Medicine.

Conclusion
Pharmacists are in a unique position to be involved with poison prevention and control.
Pharmacists are one of the most easily accessible healthcare providers, and patients may be unaware
of the resources available to them or the significance of preventing unintentional poisoning in both
children and adults. There are many ways pharmacists can make a difference to help decrease the
rate of unintentional poisonings, including working in poison control centers and promoting
primary prevention at their practice sites. With the rate of nonfatal and fatal poisonings increasing in
the United States, pharmacists play a vital role in helping to reverse the trend. Primary prevention
should be the main focus for reducing the amount of poisonings, and education is one of the easiest
ways pharmacists can get involved. Pharmacists can educate patients they encounter in the pharmacy
or take their efforts into the community and present materials to a variety of different audiences.
People of all ages are at risk for unintentional poisoning, and educating the public on how to
prevent poisoning is crucial to decreasing preventable injuries and death. Pharmacists should also be
prepared to respond to an acute poisoning situation, and know what resources are available to be
more confident when encountering situations where someone may have come into contact with a
dangerous or potentially dangerous substance.

References

1. Kochanek KD, Murphy SL, Xu J, Tejada-vera B. Deaths: final data for 2014. Natl Vital Stat
Rep. 2016;65(4):1-122.
2. Kelly, NR. Prevention of poisoning in children. In: Post TW, ed, UpToDate, Waltham,
MA;2013. Up To Date website. Updated June 15, 2017. Accessed on July 12, 2017.
3. U.S. Department of Health and Human Services. Injury and violence prevention. Healthy
People 2020 website. https://www.healthypeople.gov/2020/topics-objectives/topic/injury-
and-violence-prevention. Updated July 13, 2017. Accessed July 14, 2017.
4. Mowry JB, Spyker DA, Brooks DE, Zimmerman A, Schauben JL. 2015 annual report of the
American Association of Poison Control Centers' National Poison Data System (NPDS):
33rd annual report. Clin Toxicol (Phila). 2016;54(10):924-1109.
5. Michigan Regional Poison Control Center. Meet the team. Children’s Hospital of Michigan –
DMC website. https://www.childrensdmc.org/for-parents/health-advocacy/poison-
control-center/meet-the-team. Accessed July 14, 2017.
6. Center for Disease Control and Prevention. Fatal injury reports, national, regional, and state,
1981-2015. WISQARS™ website. https://webappa.cdc.gov/sasweb/ncipc/mortrate.html.
Updated February 19, 2017. Accessed July 12, 2017.
7. Metric units and the preferred dosing of orally administered liquid medications. Committee
on Drugs. Pediatrics. 2015;135(4):784-787; DOI: 10.1542/peds.2015-0072.
8. American Association of Poison Control Centers (AAPCC). Prevention. AAPCC website.
http://www.aapcc.org/prevention/. Accessed July 14, 2015.
9. Health Resources & Services Administration. Resources. Poison Help website.
https://www.poisonhelp.hrsa.gov/resources/index.html. Accessed July 14, 2017.
10. Central Ohio Poison Center. Poison prevention resources. Nationwide Children’s Hospital
website. http://www.nationwidechildrens.org/poison-prevention-resources. Accessed July
14, 2017.
11. Armahizer MJ, Johnson D, Deusenberry CM, Foley JJ, Krenzelok EP, Pummer TL.
Evaluation of pharmacist utilization of a poison center as a resource for patient care. J Pharm
Pract. 2013;26(3):220-7.
12. Tak CR, Malheiro MC, Bennett HK, Crouch BI. The value of a poison control center in
preventing unnecessary emergency department visits and hospital charges: A multi-year
analysis. Am J Emerg Med. 2016.
13. American Association of Poison Control Centers (AAPCC). I need help. Poison Help
website. https://www.poisonhelp.org. Published March 2017. Accessed July 14, 2017.
14. National Library of Medicine. NLM resources on poison control. Toxicology and
Environmental Health Information Program website.
https://sis.nlm.nih.gov/enviro/poisoninginformation.html. Published April 22, 2014.
Updated June 1, 2016. Accessed July 14, 2017.
15. Poison treatment in the home. American Academy of Pediatrics Committee on Injury,
Violence, and Poison Prevention. Pediatrics. 2003;112(5):1182-5.
16. Juurlink D. Activated charcoal for acute overdose: a reappraisal. British Journal of Clinical
Pharmacology [serial online]. March 2016;81(3):482-487.
17. Hendrickson RG, Kusin S. Gastrointestinal decontamination of the poisoned patient. In:
Post TW, ed, UpToDate, Waltham, MA;2013. Up To Date website. Updated January 24,
2017. Accessed on July 13, 2017.
18. Vale JA, Kulig K. Position paper: gastric lavage. J Toxicol Clin Toxicol. 2004;42(7):933-43.
19. Perrone J. Iron. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds.
Goldfrank's Toxicologic Emergencies, 10e. New York, NY: McGraw-Hill; 2015. Accessed July 10,
2017.
20. Liebelt EL. Acute iron poisoning. In: Post TW, ed, UpToDate, Waltham, MA;2013. Up To
Date website. Updated May 30, 2017. Accessed on July 11, 2017.
21. Hornsby LB, Whitley HP, Hester EK, Thompson M, Donaldson A. Survey of patient
knowledge related to acetaminophen recognition, dosing, and toxicity. J Am Pharm Assoc.
2010;50(4):485-9.
22. Hendrickson RG. Acetaminophen. In: Hoffman RS, Howland M, Lewin NA, Nelson LS,
Goldfrank LR. eds. Goldfrank's Toxicologic Emergencies, 10e. New York, NY: McGraw-Hill;
2015. Accessed July 10, 2017.
23. Heard K, Dart R. Acetaminophen (paracetamol) poisoning in adults: treatment. In: Post
TW, ed, UpToDate, Waltham, MA;2013. Up To Date website. Updated May 18, 2017.
Accessed on July 11, 2017.
24. Brubacher JR. β-Adrenergic Antagonists. In: Hoffman RS, Howland M, Lewin NA, Nelson
LS, Goldfrank LR. eds. Goldfrank's Toxicologic Emergencies, 10e. New York, NY: McGraw-Hill;
2015.
25. Barrueto F. Beta blocker poisoning. In: Post TW, ed, UpToDate, Waltham, MA;2013. Up To
Date website. Updated April 11, 2017. Accessed on July 11, 2017.
26. Lugassy DM. Salicylates. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank
LR. eds. Goldfrank's Toxicologic Emergencies, 10e. New York, NY: McGraw-Hill; 2015. Accessed
July 11, 2017.
27. Boyer EW, Weibrecht, KW. Salicylate (aspirin) poisoning in adults. In: Post TW, ed,
UpToDate, Waltham, MA;2013. Up To Date website. Updated January 9, 2017. Accessed on
July 12, 2017.
28. Shawn L. Essential Oils. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank
LR. eds. Goldfrank's Toxicologic Emergencies, 10e. New York, NY: McGraw-Hill; 2015. Accessed
July 12, 2017.