DRUG THERAPY OF DRUG THERAPY OF ACUTE POISONINGACUTE POISONING

Two of the most dreaded and insidous Two of the most dreaded and insidous mushrooms found in Swedish forests: the mushrooms found in Swedish forests: the

hepatoxic Amanita virosa and the nephrotoxic hepatoxic Amanita virosa and the nephrotoxic Cortinarius speciocissimusCortinarius speciocissimus

Acute Poisoning in the Emergency Acute Poisoning in the Emergency DepartmentDepartment

Common - 3-5% of ED attendancesCommon - 3-5% of ED attendances2000 Deaths per year2000 Deaths per yearSome of the highest rates of deliberate Some of the highest rates of deliberate

poisoning in Europepoisoning in EuropeOften multiple drugsOften multiple drugsDON’T FORGET ALCOHOL !!DON’T FORGET ALCOHOL !!

PoisoningPoisoning PoisoningPoisoning can be defined as a chemical injury to body can be defined as a chemical injury to body

organs or a chemically induced disturbance of the organs or a chemically induced disturbance of the functions in biological systems. Such toxic effects may functions in biological systems. Such toxic effects may follow the exposure to exogenous (environmental) follow the exposure to exogenous (environmental) substances. By tradition an agent has been considered substances. By tradition an agent has been considered as a poison if it may damage the organism in a very as a poison if it may damage the organism in a very small dose. The toxic properties of a certain poison are small dose. The toxic properties of a certain poison are often specific, and hence the clinical symptoms after often specific, and hence the clinical symptoms after exposure to a poison may be quite characteristic. exposure to a poison may be quite characteristic. Substances that normally are considered as harmless Substances that normally are considered as harmless may also, if the dose is big enough, cause deleterious may also, if the dose is big enough, cause deleterious effects and thereby act as poisons. Examples of this are effects and thereby act as poisons. Examples of this are sodium chloride, oxygen and water. sodium chloride, oxygen and water.

The science devoted to the study of the structures, The science devoted to the study of the structures, effects and fate of poisonous substances is called effects and fate of poisonous substances is called toxicology.toxicology. This is nowadays a wide, heterogeneous and This is nowadays a wide, heterogeneous and rapidly expanding discipline. Clinical toxicology is a rapidly expanding discipline. Clinical toxicology is a subentity that deals with problems related to poisonings subentity that deals with problems related to poisonings in humans and their treatment. in humans and their treatment.

Biological poisoningBiological poisoning Acute poisoning is exposure to a poison on one occasion Acute poisoning is exposure to a poison on one occasion

or during a short period of timeor during a short period of time. Symptoms develop in . Symptoms develop in close relation to the exposure. Absorption of a poison is close relation to the exposure. Absorption of a poison is necessary for systemic poisoning. In contrast, necessary for systemic poisoning. In contrast, substances that destroy tissue but do not absorb, such substances that destroy tissue but do not absorb, such as as lyelye, are classified as , are classified as corrosivescorrosives rather than poisons.rather than poisons.

Chronic poisoning is long-term repeated or continuous Chronic poisoning is long-term repeated or continuous exposure to a poison where symptoms do not occur exposure to a poison where symptoms do not occur immediately or after each exposure.immediately or after each exposure. The patient The patient gradually becomes ill, or becomes ill after a long latent gradually becomes ill, or becomes ill after a long latent period. Chronic poisoning most commonly occurs period. Chronic poisoning most commonly occurs following exposure to poisons that following exposure to poisons that bioaccumulatebioaccumulate such such as as mercurymercury and and leadlead..

Types of poisoningTypes of poisoning Deliberate:Deliberate:

Overdose as self-harm or suicide attemptOverdose as self-harm or suicide attempt Child abuse ± Child abuse ± Munchausen'sMunchausen's syndromesyndrome byby proxyproxy Third party (attempted homicide, terrorist, warfare)Third party (attempted homicide, terrorist, warfare)

Accidental:Accidental: Most episodes of paediatric poisoning.Most episodes of paediatric poisoning. Dosage error:Dosage error:

IatrogenicIatrogenic Patient errorPatient error

Recreational useRecreational use Environmental:Environmental:

PlantsPlants FoodFood Venomous stings/bitesVenomous stings/bites

Industrial exposuresIndustrial exposures

General ManagementGeneral Management

A (Airway)A (Airway)B (Breathing)B (Breathing)C (Circulation)C (Circulation)D (Disability-AVPU/ Glasgow Coma Scale)D (Disability-AVPU/ Glasgow Coma Scale)DEFG ( Don’t ever forget the Glucose)DEFG ( Don’t ever forget the Glucose)GET A SET OF BASIC OBSERVATIONSGET A SET OF BASIC OBSERVATIONS

For effective management of an acutely poisonedFor effective management of an acutely poisoned

victim, five complementary steps are requiredvictim, five complementary steps are required::

1. Resuscitation and initial stabilization1. Resuscitation and initial stabilization

2. Diagnosis of type of poision2. Diagnosis of type of poision

3. Nonspecific therapy3. Nonspecific therapy

4. Specific therapy4. Specific therapy

5. Supportive care5. Supportive care

ResuscitationResuscitationAirway:Airway:

Open, suction, maintain and intubate as Open, suction, maintain and intubate as necessary.necessary.

Breathing:Breathing:Assess work and effectiveness of ventilation.Assess work and effectiveness of ventilation.Give oxygen ±Give oxygen ±assistedassisted ventilationventilation (avoid (avoid

mouth-to-mouth).mouth-to-mouth).Respiratory depression - consider opiates, Respiratory depression - consider opiates,

benzodiazepinesbenzodiazepines, early , early salicylatesalicylate poisoningpoisoning..Tachypnoea - consider metabolic acidosis Tachypnoea - consider metabolic acidosis

e.g. salicylates, methanol.e.g. salicylates, methanol.

ResuscitationResuscitation (cont’d) (cont’d)Circulation:Circulation:

Attach a cardiac monitor, assess pulse, blood Attach a cardiac monitor, assess pulse, blood pressure and perfusion. Establish intravenous pressure and perfusion. Establish intravenous access.access.

Tachycardia/irregular pulse - consider Tachycardia/irregular pulse - consider overdose of salbutamol, overdose of salbutamol, antimuscarinicsantimuscarinics, , tricyclicstricyclics, , quininequinine, , phenothiazinephenothiazine, , chloralchloral hydratehydrate, , cardiaccardiac glycosidesglycosides, amfetamines, , amfetamines, and and theophyllinetheophylline poisoning. poisoning.

If hypotensive consider giving fluid bolus If hypotensive consider giving fluid bolus (colloid) or, if necessary, inotropes.(colloid) or, if necessary, inotropes.

ResuscitationResuscitation (cont’d) (cont’d) Disability:Disability:

Assess consciousness level (Assess consciousness level (GlasgowGlasgow ComaComa ScaleScale).). Coma may suggest benzodiazepines, alcohol, opiates, tricyclics, Coma may suggest benzodiazepines, alcohol, opiates, tricyclics,

or barbiturates.or barbiturates. Check pupils and eye movements:Check pupils and eye movements:

Large - consider anticholinergics, Large - consider anticholinergics, sympathomimeticssympathomimetics, tricyclics., tricyclics. Small - consider opiates or cholinergics.Small - consider opiates or cholinergics. If opiates suspected give 0.8-2 mg naloxone iv/im every 2-3mins up If opiates suspected give 0.8-2 mg naloxone iv/im every 2-3mins up

to 10 mg until response (children: 10 mcg/kg iv/im repeated up to to 10 mg until response (children: 10 mcg/kg iv/im repeated up to 0.2 mg/kg), repeated doses may be required thereafter as it has a 0.2 mg/kg), repeated doses may be required thereafter as it has a shorter half-life than most opiates.shorter half-life than most opiates.

Unreactive - causes include barbiturates, Unreactive - causes include barbiturates, carboncarbon monoxidemonoxide, , hydrogen sulphide, cyanide/cyanogens, head injury/hydrogen sulphide, cyanide/cyanogens, head injury/hypoxiahypoxia..

Unequal - slight variation can be normal - but consider head injury.Unequal - slight variation can be normal - but consider head injury. Strabismus - can be seen with carbamazepine overdose.Strabismus - can be seen with carbamazepine overdose. PapilloedemaPapilloedema - associated with methanol, carbon monoxide and - associated with methanol, carbon monoxide and

glutethimide.glutethimide. NystagmusNystagmus - seen with CNS acting agents e.g. phenytoin. - seen with CNS acting agents e.g. phenytoin.

ResuscitationResuscitation (cont’d) (cont’d) Disability:Disability:

Check blood glucose - if hypoglycaemic give 50 Check blood glucose - if hypoglycaemic give 50 ml 50% dextrose iv (children: 5 ml/kg of 10% ml 50% dextrose iv (children: 5 ml/kg of 10% dextrose iv).dextrose iv).

Hyperglycaemia - organophosphates, theophyllines, Hyperglycaemia - organophosphates, theophyllines, MAOIs or salicylate.MAOIs or salicylate.

HypoglycaemiaHypoglycaemia - insulin, oral hypoglycaemics, alcohol or - insulin, oral hypoglycaemics, alcohol or salicylate.salicylate.

Seizures - if prolonged/recurrent initially give Seizures - if prolonged/recurrent initially give diazepam 5-10 mg iv (Child: 0.25-0.4 mg/kg iv or diazepam 5-10 mg iv (Child: 0.25-0.4 mg/kg iv or pr) or midazolam (0.15 mg/kg) IM/IV. Many drugs pr) or midazolam (0.15 mg/kg) IM/IV. Many drugs can induce seizures including tricyclics, can induce seizures including tricyclics, theophylline, opiates, cocaine and amfetamines.theophylline, opiates, cocaine and amfetamines.

HistoryHistory

What was taken, how much, when, and by what What was taken, how much, when, and by what route?route?

Was alcohol consumed too?Was alcohol consumed too? Any vomiting since ingestion?Any vomiting since ingestion? Past medical history, current medications and Past medical history, current medications and

allergies.allergies. Was a suicide note left?Was a suicide note left? Is the patient pregnant?Is the patient pregnant? Histories from others including: family, friends, Histories from others including: family, friends,

paramedics, police and observers.paramedics, police and observers.

General examinationGeneral examination Directed cardiovascular, respiratory, abdominal and Directed cardiovascular, respiratory, abdominal and

neurological examination.neurological examination. Vital signs, pupils etc. mentioned in Resuscitation section Vital signs, pupils etc. mentioned in Resuscitation section

above.above. Temperature - Temperature - hypothermiahypothermia (phenothiazines, barbiturates, (phenothiazines, barbiturates,

or tricyclics) or hyperthermia (amfetamines, ecstasy, or tricyclics) or hyperthermia (amfetamines, ecstasy, MAOIs, cocaine, antimuscarinics, theophylline, MAOIs, cocaine, antimuscarinics, theophylline, serotoninserotonin syndromesyndrome).).

Muscle rigidity (ecstasy, amfetamines).Muscle rigidity (ecstasy, amfetamines). Skin - cyanosis (Skin - cyanosis (methaemoglobinaemiamethaemoglobinaemia), very pink ), very pink

(carboxyhaemoglobinaemia, cyanide, hydrogen sulphide), (carboxyhaemoglobinaemia, cyanide, hydrogen sulphide), blisters (barbiturates, TCAs, benzodiazepines), needle blisters (barbiturates, TCAs, benzodiazepines), needle tracks, hot/flushed (anticholinergics).tracks, hot/flushed (anticholinergics).

Breath - ketones (diabetic/alcoholic ketoacidosis), "bitter Breath - ketones (diabetic/alcoholic ketoacidosis), "bitter almonds" (cyanide), "garlic-like" (organophosphates, almonds" (cyanide), "garlic-like" (organophosphates, arsenic), "rotten eggs" (hydrogen sulphide), organic arsenic), "rotten eggs" (hydrogen sulphide), organic solvents.solvents.

Mouth - perioral acneiform lesions (solvent abuse), dry Mouth - perioral acneiform lesions (solvent abuse), dry mouth (anticholinergics), hypersalivation mouth (anticholinergics), hypersalivation (parasympathomimetics).(parasympathomimetics).

InvestigationsInvestigations 12 lead electrocardiogram.12 lead electrocardiogram. U+E, lab glucose, anion gap ± lactate & osmolal gap.U+E, lab glucose, anion gap ± lactate & osmolal gap. LFT & clottingLFT & clotting ArterialArterial bloodblood gasesgases.. Drug levels (at appropriate interval: paracetamol, Drug levels (at appropriate interval: paracetamol,

salicylates; others: theophylline, digoxin, lithium, anti-salicylates; others: theophylline, digoxin, lithium, anti-epileptics if it was likely that they had been taken).epileptics if it was likely that they had been taken).

Comprehensive toxicology screens not normally Comprehensive toxicology screens not normally indicated in the emergency treatment.indicated in the emergency treatment.

Carboxyhaemoglobin levels if carbon monoxide Carboxyhaemoglobin levels if carbon monoxide poisoning suspected.poisoning suspected.

Urinalysis - rhabdomyolysis, save sample for possible Urinalysis - rhabdomyolysis, save sample for possible toxicological analysis.toxicological analysis.

CXR if pulmonary oedema/aspiration suspected.CXR if pulmonary oedema/aspiration suspected. CT brain may be needed to exclude other causes of CT brain may be needed to exclude other causes of

alterations in conscious level.alterations in conscious level.

Laboratory Investigations : Laboratory Investigations : A few simpleA few simple bedside tests are helpful in diagnosing thebedside tests are helpful in diagnosing the

chemical ingested. A pinkish colour of urine occurschemical ingested. A pinkish colour of urine occurs in in phenothiazine intoxication, as well as inphenothiazine intoxication, as well as in myoglobinuria myoglobinuria and haemoglobinuria. Chocolatecolouredand haemoglobinuria. Chocolatecoloured blood is blood is indicative of methaemoglobinaemia.indicative of methaemoglobinaemia.

Presence of oxalate crystals in urine isPresence of oxalate crystals in urine is typical of ethylene typical of ethylene glycol ingestion. Ketonuriaglycol ingestion. Ketonuria without any metabolic change without any metabolic change occurs in isopropyloccurs in isopropyl alcohol and acetone intoxication alcohol and acetone intoxication while ketonuriawhile ketonuria

with metabolic acidosis is suggestive of salicylatewith metabolic acidosis is suggestive of salicylate poisoning.poisoning.Abdominal X-ray may be useful in diagnosing certainAbdominal X-ray may be useful in diagnosing certain radiopaque toxins which include chloral hydrate,radiopaque toxins which include chloral hydrate, heavy heavy metals, iron, iodides, phenothiazines,metals, iron, iodides, phenothiazines, sustained-release sustained-release preparations and solventspreparations and solvents (chloroform, carbon (chloroform, carbon tetrachloride). However, onetetrachloride). However, one must not exclude a must not exclude a poisoning on the basis of absencepoisoning on the basis of absence of radiopaque density of radiopaque density on X-ray.on X-ray.

TreatmentTreatment Initial managementInitial management Initial management for all poisonings includes ensuring Initial management for all poisonings includes ensuring

adequate adequate cardiopulmonarycardiopulmonary functionfunction and providing and providing treatment for any symptoms such as treatment for any symptoms such as seizuresseizures, , shockshock, , and and painpain..

Poisons that have been injected (e.g. from the sting of Poisons that have been injected (e.g. from the sting of poisonous animals) can be treated by binding the poisonous animals) can be treated by binding the affected body part with a affected body part with a pressurepressure bandagebandage and by and by placing the affected body part in hot water (with a placing the affected body part in hot water (with a temperature of 50°C). The pressure bandage makes temperature of 50°C). The pressure bandage makes sure the poison is not pumped troughout the body and sure the poison is not pumped troughout the body and the hot water breaks down the poison. This treatment the hot water breaks down the poison. This treatment however only works with poisons that are composed of however only works with poisons that are composed of protein-molecules.protein-molecules.[5][5]

TreatmentTreatment Decontamination if appropriate:Decontamination if appropriate:

Avoid contaminating yourself and wear protective Avoid contaminating yourself and wear protective clothing.clothing.

Ensure area is well-ventilated.Ensure area is well-ventilated. The patient should remove soiled clothing and wash The patient should remove soiled clothing and wash

him/herself if possible.him/herself if possible. Put soiled clothing in a sealed container.Put soiled clothing in a sealed container. Wash all contaminated skin/hair with liberal amounts Wash all contaminated skin/hair with liberal amounts

of warm water ±soap.of warm water ±soap. Decontamination may be achieved using Decontamination may be achieved using activatedactivated

charcoalcharcoal, , gastricgastric lavagelavage, , wholewhole bowelbowel irrigationirrigation, or , or nasogastricnasogastric aspirationaspiration. Routine use of emetics (. Routine use of emetics (syrupsyrup ofof IpecacIpecac), ), catharticscathartics or laxatives are no longer or laxatives are no longer recommended. recommended.

TreatmentTreatment (cont’d) (cont’d) Decrease absorption:Decrease absorption:

Gastric emptyingGastric emptying - this is contraindicated if the airway - this is contraindicated if the airway is unprotected or overdose of corrosives or is unprotected or overdose of corrosives or hydrocarbons taken. Complications include hydrocarbons taken. Complications include pulmonarypulmonary aspirationaspiration and and oesophagealoesophageal perforationperforation. Only 30% of . Only 30% of gastric contents are returned and it is proven to be gastric contents are returned and it is proven to be effective if within 1 hour of ingestion (so this is only effective if within 1 hour of ingestion (so this is only generally done if patients present early having taken a generally done if patients present early having taken a potentially fatal dose of drug). Controversially this is potentially fatal dose of drug). Controversially this is sometimes extended if delayed gastric emptying (e.g. sometimes extended if delayed gastric emptying (e.g. presence of coma or overdose of tricyclics or presence of coma or overdose of tricyclics or salicylates) is thought likely.salicylates) is thought likely.

Emesis - no longer recommended.Emesis - no longer recommended.Gastric lavageGastric lavage - Place patient in left lateral head down (20°) - Place patient in left lateral head down (20°)

position, insert large (36-40F) bore tube (children: 16 to 28F) position, insert large (36-40F) bore tube (children: 16 to 28F) into stomach. Remove contents with sequential administration into stomach. Remove contents with sequential administration and aspiration of small (200-300 ml) quantities of warm water and aspiration of small (200-300 ml) quantities of warm water or saline (children: 10-20 ml/kg preferably saline). Alternatively or saline (children: 10-20 ml/kg preferably saline). Alternatively the stomach contents can just be aspirated.the stomach contents can just be aspirated.

TreatmentTreatment (cont’d) (cont’d)ActivatedActivated charcoalcharcoal is the treatment of is the treatment of

choice to prevent absorption of the poison. choice to prevent absorption of the poison. It is usually administered when the patient It is usually administered when the patient is in the emergency room or by a trained is in the emergency room or by a trained emergency healthcare provider such as a emergency healthcare provider such as a Paramedic or EMT. However, charcoal is Paramedic or EMT. However, charcoal is ineffective against ineffective against metalsmetals such as such as sodiumsodium, , potassiumpotassium, and , and lithiumlithium, and , and alcoholsalcohols and and glycolsglycols; it is also not recommended for ; it is also not recommended for ingestion of corrosive chemicals such as ingestion of corrosive chemicals such as acidsacids and and alkalisalkalis..

TreatmentTreatment (cont’d) (cont’d) WholeWhole bowelbowel irrigationirrigation cleanses the bowel, this cleanses the bowel, this

is achieved by giving the patient large amounts is achieved by giving the patient large amounts of a of a polyethylenepolyethylene glycolglycol solution. The osmotically solution. The osmotically balanced polyethylene glycol solution is not balanced polyethylene glycol solution is not absorbed into the body, having the effect of absorbed into the body, having the effect of flushing out the entire flushing out the entire gastrointestinalgastrointestinal tracttract. Its . Its major uses are following ingestion of sustained major uses are following ingestion of sustained release drugs, toxins that are not absorbed by release drugs, toxins that are not absorbed by activated charcoal (i.e. activated charcoal (i.e. lithiumlithium, , ironiron), and for the ), and for the removal of ingested packets of drugs (removal of ingested packets of drugs (bodybody packingpacking/smuggling)/smuggling)

TreatmentTreatment (cont’d) (cont’d)o NasogastricNasogastric aspirationaspiration involves the placement of a involves the placement of a

tube via the nose down into the stomach, the stomach tube via the nose down into the stomach, the stomach contents are then removed via suction. This contents are then removed via suction. This procedure is mainly used for liquid ingestions where procedure is mainly used for liquid ingestions where activated charcoal is ineffective, e.g. activated charcoal is ineffective, e.g. ethyleneethylene glycolglycol poisoningpoisoning..

o CatharticsCathartics were postulated to decrease absorption by were postulated to decrease absorption by increasing the expulsion of the poison from the increasing the expulsion of the poison from the gastrointestinalgastrointestinal tracttract. There are two types of . There are two types of cathartics used in poisoned patients; saline cathartics cathartics used in poisoned patients; saline cathartics ((sodiumsodium sulfatesulfate, , magnesiummagnesium citratecitrate, , magnesiummagnesium sulfatesulfate) and saccharide cathartics () and saccharide cathartics (sorbitolsorbitol). They do ). They do not appear to improve patient outcome and are no not appear to improve patient outcome and are no longer recommendedlonger recommended

Enhanced excretionEnhanced excretion

In some situations elimination of the In some situations elimination of the poison can be enhanced using poison can be enhanced using diuresisdiuresis, , hemodialysishemodialysis, , hemoperfusionhemoperfusion, , hyperbarichyperbaric medicinemedicine, , peritonealperitoneal dialysisdialysis, , exchangeexchange transfusiontransfusion or or chelationchelation. However, this . However, this may actually worsen the poisoning in may actually worsen the poisoning in some cases, so it should always be some cases, so it should always be verified based on what substances are verified based on what substances are involved.involved.

Increase elimination:Increase elimination: Forced diuresisForced diuresis - no longer recommended. - no longer recommended. HaemoperfusionHaemoperfusion and and acid/alkaline diuresisacid/alkaline diuresis - rarely - rarely

used now.used now. HaemodialysisHaemodialysis - severe salicylate, ethylene glycol, - severe salicylate, ethylene glycol,

methanol, lithium, phenobarbital and chlorate methanol, lithium, phenobarbital and chlorate poisonings.poisonings.

Multiple doses of Multiple doses of activated charcoalactivated charcoal - interrupts - interrupts enterohepatic or enteroenteric recirculation. Use 50g enterohepatic or enteroenteric recirculation. Use 50g 4-hourly (children 1g/kg) or 12.5g hourly (children 4-hourly (children 1g/kg) or 12.5g hourly (children 0.25g/kg) to reduce vomiting, but beware severe 0.25g/kg) to reduce vomiting, but beware severe constipation, fluid depletion and avoid repeating constipation, fluid depletion and avoid repeating cathartic agent doses within 24hrs. Used with cathartic agent doses within 24hrs. Used with carbamazepine, dapsone, phenobarbital, quinine, carbamazepine, dapsone, phenobarbital, quinine, salicylate, colchicine, dextropropoxyphene, digoxin, salicylate, colchicine, dextropropoxyphene, digoxin, verapamil and theophylline overdoses.verapamil and theophylline overdoses.

Specific Therapy Specific Therapy If the toxin can be identified, specific therapy If the toxin can be identified, specific therapy

usingusing antidotes should be administeredantidotes should be administered::

PParacetamolaracetamol (acetaminophen)(acetaminophen)

N-N-acetylcysteineacetylcysteine

vitaminvitamin K K anticoagulantsanticoagulants, , e.ge.g. . warfarinwarfarin

vitaminvitamin K K

opioidsopioids naloxonenaloxone

iron (and other heavy iron (and other heavy metals)metals)

desferrioxamine, Deferasirox desferrioxamine, Deferasirox or Deferiproneor Deferiprone

benzodiazepinesbenzodiazepines flumazenilflumazenil

OrganophosphatesOrganophosphates Atropine and Atropine and PralidoximePralidoxime

SUPPORTIVE THERAPY SUPPORTIVE THERAPY Since the antidotes are available only for a fewSince the antidotes are available only for a few toxins, toxins,

treatment of most cases of poisoning istreatment of most cases of poisoning is largely largely supportive supportive

The aim is to preserve the vital organ functions till poison is eliminated from the body and the patient resumes normal physiological functions. Therefore, functions of central nervous system, cardiopulmonary system and renal system should be supported with proper care for coma, seizures, hypotension, arrhythmias, hypoxia, andacute renal failure. The fluid, electrolyte and acidbase status should be closely monitored in all patients.

PreventionPrevention Adult education.Adult education. Double-check dosage before administration.Double-check dosage before administration. Vigilance by health professionals to recognise Vigilance by health professionals to recognise

the early signs of abuse and potential suicide.the early signs of abuse and potential suicide. Put all medicines and household chemicals in a Put all medicines and household chemicals in a

locked child-proof cupboard >1.5 metres off the locked child-proof cupboard >1.5 metres off the ground.ground.

Safely dispose of medicines, chemicals which Safely dispose of medicines, chemicals which are not needed or out of date.are not needed or out of date.

Keep all medicines and chemicals in their Keep all medicines and chemicals in their original containers with clear labeloriginal containers with clear label