POISONINGS SPAN A LIFETIME Originally written 1/2002, Revised 5/2012 Donna Lotzer, RPh. Poison Education Coordinator UW Hospital and Clinics Poison Prevention and Education Center, Madison (608) 265-8160 ppec@uwhealth.org www.uwhealth.org/poison Donna Lotzer Senior Clinical Pharmacist Poison Education Coordinator UW Hospital and Clinics Poison Prevention and Education Center

POISONS CAN BE FOUND EVERYWHERE ! sspprittzzzz Potential poisons can be found inside the home, outdoors, at work or shopping malls, and can fall into a wide variety of categories. We will get into details on these items as we go along. Think about what might be included on the list! Outdoors include poisonous plants like nettles, poison ivy or wild parsnip, along with bug and weed killers and insects/spiders/snakes. Indoors one might find plants, cleaners, medicines and carbon monoxide. Routes of poisoning include swallowing, skin and eye contact and inhalation, along with bites and stings. (Ask audience for ideas) Glass Cleaner

LEARN ABOUT “OOPS MOMENTS” AND HOW TO BE SAFE AROUND THE HOME  Learn how to make your home safe and poison-free for yourselves and the grandkids  Find out how to be safe with medicines  Wonder why accidents can happen to the best of us? As we get older things do not get easier (!). For those who are lucky enough to be in their own home accidental poisonings can happen in the blink of an eye. For those who live with others, or in an assisted living setting some concerns (faulty furnace) are less likely, but mistakes can still happen to a senior adult, visiting family members, or pets.

WHATS AN OLDER PERSON TO DO ? Be Aware (room by room survey) Take Care (point out possible hazards) Be Prepared (have pharmacy & poison center phone numbers posted) Many medication errors occur in the home. Recent data show that 11% of people suffered some level of harm and we will look at the details in a little while. Take a walk around your home, then consider how the rooms would look at knee-high levels!!! This is the “eye-height” for a small child, and the world looks much different from this angle. Also remember that an enterprising child might decide to move a chair to a countertop, then climb to reach a window ledge storage area, medicine cabinet, or the top of the refrigerator (which is a favorite place for adults to store medicines). If meds are kept on windowsills or the kitchen table it may be convenient for adults but also dangerously accessible to children/grandchildren. Kids are also quick to realize that bottles may not have “safety caps” and this increases the chances of accidental ingestion which could lead to problems. If drugs are kept in “med minders” they are usually not child-safe, so again they are accessible to youngsters. When traveling remember that purses and suitcases are fun places for kids to explore, and they usually try to sample anything they may see. These containers can also open accidentally, spilling the contents and mixing up pills that may look a lot alike – ask your pharmacist for help in identifying them ASAP, or if it is after hours call the poison center because they can do an ID from the imprint on the pill.

WISCONSIN POISON CENTER  One number for help 1-800-222-1222 anytime, anywhere in WI and the country  Center located at Children's Hospital of Wisconsin, Milwaukee  Education/outreach from Madison and Milwaukee This is the single most important informational point to get across to the audience…Anytime, anywhere in Wisconsin the poison center can be reached for questions concerning potentially harmful situations. The toll-free number should be found inside the front cover of local phone books along with other emergency numbers for ambulance, police and fire. This service is provided at NO charge to the caller The national 800 number was activated in the fall of 2001. Callers are generally automatically routed to the poison center covering the area they are calling from. This means that callers in WI will get the Milwaukee poison center but when traveling the same number will allow callers to speak with a local poison center and get the emergency help they need in a timely manner. With cell phones it is possible that a person may get a different poison center, depending on their carrier and coverage of certain parts of the country but there will always be a poison center to answer the call, regardless of the caller’s location.

SOME POISONS ARE NOT OBVIOUS  Faulty furnaces and heaters produce deadly carbon monoxide  Mixing chemicals can cause noxious fumes  “Seeing” without glasses leads to mistakes  Spoiled food looks like edible food It is especially important to remember that poisons can come in a variety of forms, some of which are not the most obvious. We tend to think of poisons as medicines, plants & mushrooms, industrial chemicals, or items labeled as harmful or poisonous. In fact, poisons like carbon monoxide (CO) cause illness and kill adults and children alike every year. CO can be produced from faulty heating sources like wood stoves and LP gas or kerosene heaters, or when a chimney becomes blocked or cracked. Any appliance that uses LP or natural gas is a potential source of CO. Automobile and boat exhaust also are high in CO content and people can die from poisoning when their exhaust system is damaged and fumes accumulate inside the vehicle. Generators which run on gasoline engines also can produce toxic or fatal amounts of CO. Mixing chemicals is a very common mistake, and is made more of a problem because warning labels are printed in very small type on the back bottom of labels, and few people take the time to read the information. If acid cleaners are mixed with ones containing chlorine bleach noxious fumes of chlorine gas can be produced. If ammonia based cleaners are mixed with bleach, fumes of chloramine result. Both mixtures cause choking and coughing and shortness of breath as well as eye, nose and throat irritation. More serious reactions include chemical pneumonia or fluid buildup in the lungs. Many mistakes are made by persons who grab the wrong product because they attempt to navigate in the dark, or without their glasses on and they cannot distinguish one item from another. Common mistakes include mixing up toothpaste and items like diaper rash ointment, Ben Gay®, hydrocortisone cream, etc. Eye ointment has been confused with Super Glue® (!). It is always possible to accidentally become ill from bad food…many people associate food poisoning with picnics and mayonnaise, but raw meats, stuffed turkey, or improperly canned foods like green beans or mushrooms can also cause serious illness. Being aware of proper storage conditions and how long food is kept in the refrigerator can lessen the chances of food going bad. Consult a home economist or the poison center for advice on proper food storage.

LOOK-ALIKE PRODUCTS “Mistaken identity” leads to problems Cleaners mixed up with sport drinks Comet cleanser or Parmesan cheese Candy looks like kid’s vitamins Plants and mushrooms – edible or poison Taking the wrong medicine or dose Call the poison center for advice! 1-800-222-1222 nationally Bottle shape and size are two of the most likely reasons why people drink the wrong item – they do not or cannot read the labels and take a gulp without realizing what they have swallowed until it is too late. Comet cleanser and Parmesan cheese come in shiny green containers with shaker tops so could again be confused, at least till the product is tasted. Gummy candy and gummy vitamins are identical for all quick look situations and so a child could eat a handful of vitamins by mistake. This happens to adults too!! Taking the wrong medicine or dose can happen because the pills all look the same, or because an older adult cannot read the label. Ask a pharmacist for larger type print on the label to help out, or consider color-coding bottles if that will help.

SHOE BOXES AND MYSTERY MEDS Proper storage for meds is important Check to see if they have expired Sort through that shoe box! Caution for duplicate ingredients in Rx and OTC products Make sure you know what goes in the refrigerator (insulin, Xalatan, Augmentin) and when it is OK to have it at room temp (when actual container is in use for Xalatan and most insulin). It is NOT a good idea to automatically put meds in the refrigerator as it could decrease their potency and effectiveness. Some liquids could turn to sludge if they get cold! For products bought over the counter (OTC) it is a good idea to check the expiration date a couple of times a year, and safely dispose of anything that has gone past that date. If the print is too small to read, or hard to find (crimp on a tube of cream) ask your pharmacist for help. Sorting through a collection of prescription and OTC meds is always interesting – I do this for seniors a couple of times a year, and sometimes find expired drugs, half-used prescriptions, samples that they are not sure how to take (or if they should take them at all!) and at times even drugs given to them by others! It is important to know what is in any drugs you are taking, whether they are prescription or OTC’s. It is easy to use two products with the same or a closely related pain reliever (acetaminophen, ibuprofen), or two products that can each cause one to feel sleepy or dizzy. When in doubt consult with your pharmacist or doctor, or even the poison center.

HAVING A SENIOR MOMENT ??  A little confused?  Things happen fast?  Unexpected visitors?  Change of routine?  How did that happen?  Should I bother to check it out? It is easy for an older person to become somewhat confused and forget what would normally be a simple task. This could include use of cleaners, medicine-related accidents etc. Visitors to the home can have newly “hazardous” substances like cigarettes or items in purses/packs. When a household routine is changed errors can occur as well. Older persons may feel foolish and not want to admit that they have made a mistake, or worry that this admission could lead to others seeing them as dependent, so they will not call for help. Remember that one can remain anonymous when calling the poison center, although the caller’s phone number is requested on all calls.

BEING A GRANDPARENT MEANS…  Youngsters get into things “in a flash”  Potential for poisoning is higher than in adults  Poison center staff are always ready to help out – just call 1-800-222-1222 Now it is good to change from thinking about what we as older adults could do to accidentally poison ourselves, and look at what happens when our families, friends, and neighbors have small children around. Kids are always much quicker than adults, and if they are in a new location they think that they must explore completely. Nationally about 50% of the total number of poisoning exposures annually are to children aged five years and younger. Adults in the home need to be aware of whether a child can open safety latches and gates, closures on prescription bottles and cleaners, or reach under counters and steps to find potential poisons.

I DON’T NEED A POISON CENTER…OR DO I?  I can’t read that tiny print on cleaner labels – OOPS – it says don’t mix them!  I’ll store items where I can reach them – OOPS – that’s mouse poison in the pantry!  My medicines have snap caps to make opening easy – OOPS – my grandchild just ate some!! Warnings are usually in the very smallest print – take a Sharpie marker and write on the bottle what it is used for and if it should not be mixed with other cleaners: “DO NOT MIX WITH BLEACH” might be an example for a toilet bowl cleaner that contains an acid chemical. Never put food items with things that cannot be eaten, or would be harmful if eaten Never trust the closures on medicines – kids are often better than adults in getting them open!

TIPS TO PREVENT POISONING  Read/follow labels  Lock poisons out of sight and reach  Look for & use child-resistant packages  Don’t take medicine in front of children  Separate storage for cleaners and food Focus on children 5 years old and under because nationally 50% of all accidental poisonings happen in this age group. Adults must read and follow label information for the proper dose and interval to give medicines. Be sure not to mix cleaners because this could produce noxious fumes. Don’t give adult products to a child. Be sure to have child locks on cupboards and do not put cleaners in with food items. Remember that a child can climb to a higher level with chairs and countertops so high does not imply safe. Packages of cleaners and medicines and other items have closures that are “child-resistant”. This does NOT mean a child can’t open the product if given enough time and some ingenuity. The intent is to slow them down long enough for an adult to prevent an exposure. Take medicine out of the immediate sight of children, who will try to imitate what they see an adult doing. Do NOT call their medicine “candy” to get them to take it…they will not see a difference and assume taking more on their own is OK. Peak call times are from 4PM-10PM and the busiest hour for the poison center is 7-8PM.

GRANDPARENT/CAREGIVER’S ROLE IN POISON PREVENTION  Poison prevention saves everyone time, money, and worry  Grandparents/caregivers need to know:  When to call the poison center  Access is through a toll-free number: 1-800-222-1222 A phone call to the poison center can save a family member the panic of an unneeded trip to the clinic or emergency room, or a call for an ambulance when it is not needed. If the situation requires these measures, the poison center staff will assist, including calling the ambulance or health care facility to notify them that the patient needs help and is coming in, as well as what needs to be done to treat the person. If poison prevention suggestions were practiced to the fullest possible extent it may mean that the poison center would actually get fewer calls on children and adults getting into something potentially harmful, but then again calls might actually increase if people chose to call ahead of time for informational purposes. People need to know they can call anytime, toll-free, without obligation or fear of being reported to any outside agency. Promotional materials are available for the asking, free of charge by calling the same toll-free phone number. The Poison Prevention and Education Center in Madison can be reached at 608-265-8160.

“MY GRANDCHILD JUST GOT INTO…”  Separate youngster and item immediately  Fluids generally OK if ingestion  Skin & eye exposure will need flushing  Call the poison center at once - do not wait for the child to become ill Many times the adult is so intent on calling for help that the child is left with the substance that caused the problem to start with! Take containers away from the youngster. Sweep the mouth for ingested solids like pills, cigarettes, mushrooms or plant pieces. If something has been swallowed the child can have a bit of fluids to dilute but do not force fluids to avoid the risk of choking or vomiting. If something is on the skin it needs to be washed off immediately to avoid the potential for irritation or even burns. At times soap and water may not be the most effective substance but it is always OK for initial use. (For example, gasoline or motor oil on the skin does not come off easily with usual hand washing but use baby or vegetable oil and work it in, wash off with soap and water and repeat if needed, and the material will come off quite easily!). For eye exposures use warm tap water and gently flush under the lids…(the poison center can give helpful suggestions on how to do this in a screaming small child!) Do not delay in calling - maybe get another person to call while you clean up the child?

POISON CENTER WILL NEED TO KNOW...  What was taken/spilled/splashed/inhaled?  How much was involved & when did this happen?  Age and weight of person?  How is the toddler/child/adult right now? Poison center staff need to understand the situation so they will ask questions about the exposure and the child or adult who is the patient. A very important piece of information is the phone number of the caller, so that if the connection is lost or a follow-up call needs to be made that information is there. It also helps the poison center to know where their calls come from in the state. Of course with cell phones phone numbers can be anywhere in the country, so further information may be needed on caller location. Have the container of what the child got into or a plant sample or anything that can help to describe the substance. Ingredients off a label are important. How long ago did the exposure happen?? How much was taken/spilled? How old is the child/person? If they took medicine the poison center will ask for weight to calculate how much is too much to be safely taken. Is the child/person having any medical problems at the time of the call? This goes along with the time since the exposure, as most drugs will not show problems right away while cleaners show immediate effects and some mouse baits may have no indication of a problem for a day or two. Bites and stings can cause immediate redness and swelling and then increasing complications over time.

THE TAKE-HOME MESSAGE IS…  To prevent poisonings, watch kids carefully !! SUMMARY: There will always be kids and kids will always be looking to get into something they should not, so knowing what to do and where to call in a potential poisoning emergency is the key to easy management of these exposures. Remembering that kids under 6 years old are the primary target age group, that over 90% of all exposures are in the home, that virtually all will turn out to be harmless or minor exposures are all good things to know, but always remember that “When in doubt, check it out” anytime, anywhere.  When in doubt, check it out with the poison center at 1-800-222-1222

Poison Trivia Which is the most dangerous product for a child to swallow? Calamine lotion Laundry bleach (5% chlorine) Arthritis pain relief ointment (with oil of wintergreen) Answer? We’re going to complete a little trivia test to see if you can guess which products are the most toxic. You can work on these answers with others in this class (assign one question to a small group or work on the questions in pairs). Hopefully, you’re sitting next to someone smart. Actually, your response will likely be a guess, because unless you are a toxicologist, we wouldn’t expect you to know the answer. The answer is arthritis pain relief ointment. Oil of wintergreen is also known as methyl salicylate, a form of aspirin. One swallow of 99% methyl salicylate is the equivalent of 22 adult aspirin! Many people consider bleach to be really dangerous, but while laundry bleach may cause a couple of episodes of vomiting and leaves a bad taste in the mouth it can be treated at home. Calamine lotion is completely non-toxic.

Poison Trivia cont’d… Which is the most dangerous for a child to swallow? 1 prescription pill for diabetes pencil lead 1 cigarette butt Answer? The answer is a prescription pill for diabetes. The categories of medication known as sulfonylureas, Diabenes, Glyburide, Glucotrol, and others, are toxic even in one dose. A child would require hospitalization because the effect on their blood sugar might be seen for up to 24 hours. While the nicotine in cigarettes is toxic, most Poison Centers don’t refer children into the hospital until they’ve eaten more than three butts or one whole cigarette. These higher doses can cause vomiting and seizures. What’s in pencil lead? Graphite. It’s not lead. It is totally harmless as well.