Guidelines for poison control
II. Technical guidance - 8. Model formats for collecting, storing, and reporting data; 9. Library requirements for poison information centres
It is an essential function of poison information centres to collect data on chemical substances, on commercial and other products, and on communications (i.e. on enquiries to the centre, requests for information, and reports on poisoning cases). Both the operation of the centre and regular activity reports will be simplified if these data are recorded in standardized formats.
To provide advice on management of a patient poisoned by a specific substance, centres must have information on the physical, chemical, and toxicological properties of the substance, its effects on various organ systems and body functions, and diagnostic observations, including results of laboratory tests. The IPCS INTOX
Package includes formats for the systematic recording of such information on chemicals, pharmaceuticals, poisonous plants, and poisonous and venomous animals. An example is given in Annex 3.
A very simple format for recording data on commercial chemical and pharmaceutical products may be adequate, but a more comprehensive format, such as that designed for the IPCS INTOX Package and shown in Annex 4, is recommended.
Poison information centres are encouraged to keep systematic records of all their communications, i.e. incoming and outgoing enquiries by telephone, fax, telex, letter, etc., and of personal consultations. Collection of these data is of the utmost importance: they should contain a complete record of any poisoning incident and of any individual poisoned or exposed to poison who has consulted the centre personally or about whom there has been a consultation. The amount of data that should be recorded may vary according to the needs and resources of the centre, as well as the scientific background of the staff in charge of the information service, but records should in any case be as complete as possible. Annex 5 shows the harmonized format developed for use in the IPCS INTOX system. The number of fields used on the record would be decided by the centre concerned, on the basis of its needs and resources, and would depend, among other considerations, on whether data are to be registered on paper or computerized (for which additional items or codes could be included in the form). A harmonized form for case data is valuable in many circumstances but particularly for epidemiological studies and clinical research.
It is not usually possible to complete the clinical case-record fully on a single occasion, and some mechanism should be established for communicating with the responsible treating physician, or even with the patient, in order to collect more data on the evolution and outcome of the case. One such mechanism might be a "follow-up" call or a letter from the centre, asking the physician who treated a poisoned patient to complete the missing information or send a copy of the full record, if this is possible and confidentiality can be guaranteed.
In the case of a regional or global system for the collection of clinical data to permit more extensive epidemiological and clinical research, the model form should be brief and concise. Many of the items that are appropriate to local studies may be irrelevant for global surveys. Further developments in this area are being undertaken by the IPCS.
Centres are encouraged to prepare annual reports of their activities, again using a standardized reporting format. A number of countries have their own annual report formats. In North America, the American Association of Poison Control Centers' Toxic Exposure Surveillance System (TESS) is used. The format prepared by the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) was subsequently adopted by the European Commission,1 and consideration is being given to its revision. The proposed format, developed through the IPCS INTOX Project, is given in Annex 6. Further work is being done on this to establish an internationally harmonized format with controlled vocabulary and defined terms.
9. Library requirements for poison information centres
Books, journals, and other published literature are indispensable for the work of a poison information centre. There are a number of basic documents that are considered essential for establishing a centre; in addition, specialized literature is needed by staff responsible for patient management or for toxicological analysis. Each centre should have at its disposal documentation that is relevant to the national or regional situation and written, whenever possible, in the local language(s). The main literature requirements include the following:
*indexes, guides, and listings relating to medicines and to agricultural and other chemical products on the local market, plus the local pharmacopoeia
*books or other publications on the animal and plant toxins of the region
*standard textbooks of medicine (general and paediatric), chemistry, pharmacology, and analytical toxicology
*journals of medicine and toxicology
*dictionaries relating to the main areas covered by the documentation in the centre.
1 Official journal of the European Communities, No. C329/13, 31 December 1990.
It is most important for toxicological data to be kept up to date and maintained in a rational, readily accessible filing system or in a computerized archive. The Microisis System - software developed by the International Development Research Centre of Canada - has proved to be very valuable in this connection, and is generally available through UNESCO or the libraries of local medical schools.
While the volume and complexity of both bibliographical and non- bibliographical data relating to toxicology have greatly increased, the computer can expedite access to them. Many databases may be accessed on-line by telephone, and a growing number of databases are now available on compact disk (CD-ROM) using disk-players that operate in conjunction with relatively inexpensive desk-top computers. The use of computers is thus of enormous value for a centre's information work.
The remainder of this section is devoted to lists of relevant books and journals (most of which are published in English and other major European languages) and to details of other information sources and educational material; these are recommended on the understanding that any centre will have to make its selection in the light of local resources, types of activity, and the principal poisoning problems that occur in the area.
Medical and general toxicology
Baselt RC, Cravey RH. Disposition of toxic drugs and chemicals in man, 3rd ed. Chicago, Year Book Medical, 1989.
Dreisbach RH, Robertson WO. Handbook of poisoning: prevention, diagnosis and treatment, 12th ed. Los Altos, CA, Appleton & Lange, 1982.
Ellenhorn MJ, Barceloux DG. Medical toxicology: diagnosis and treatment of human poisoning. New York, Elsevier, 1988.
Goldfrank LR et al., eds. Goldfrank's toxicologic emergencies, 5th ed. Norwalk, CT, Appleton & Lange, 1994.
Gossel TA, Bricker JD. Principles of clinical toxicology, 3rd ed. New York, Raven Press, 1984.
Gosselin RE, Smith RP, Hedge HC. Clinical toxicology of commercial products, 5th ed. Baltimore, MD, Williams & Wilkins, 1984.
Haddad LM, Winchester JF, eds. Clinical management of poisoning and drug overdose, 2nd ed. Philadelphia, Saunders, 1990.
Klaassen CD, ed. Casarett and Doull's toxicology: the basic science of poisons, 5th ed. New York, McGraw-Hill, 1996.
Noji EK, Kelen GD, eds. Manual of toxicologic emergencies. Chicago, Year Book Medical, 1989.
Baud F, Barriot P, Riou B. Les antidotes. Paris, Masson, 1992.
Bismuth C et al. Toxicologie clinique, 4th ed. Paris, Flammarion, 1987.
Bozza-Marrubini ML, Laurenzi RG, Uccelli P. Intossicazioni acute: meccanismi, diagnosi e terapia, 2nd ed. Milan, Organizzazione Editoriale Medico Farmaceutica, 1987.
Astolfi E et al. Toxicologia de pregrado, 3rd ed. Buenos Aires, Lopez, 1986.
Dreisbach RH, Robertson WO. Manual de intoxicaciones: prevención, diagnosis y tratamiento, 12th ed. Los Altos, CA, Appleton & Lange, 1987.
Fogel de Korc E. Patología toxicológia. Oficina del Libro, 1992.
Repetto M. Toxicológia fundamental. Madrid, Cientifico Medica, 1987.
Krienke EG et al. Vergiftungen im Kindesalter, 2nd ed. Stuttgart, Enke, 1986.
Lindner E. Toxikologie der Nahrungsmittel. Thieme, Stuttgart, 1991.
Ludewig R, Lohs KH. Akute Vergiftungen, 6th ed. Stuttgart, Fischer, 1981.
Moeschlin S. Klinik und Therapie der Vergiftungen, 7th ed. Stuttgart, Thieme, 1986.
Späth G. Vergiftungen und akute Arzneimittelüberdosierungen, 2nd ed. Berlin, De Gruyter, 1982.
Velvart J. Toxikologie der Haushaltprodukte, 2nd ed. Berne, Huber, 1988.
Wirth W, Gloxhuber C. Toxikologie, 4th ed. Stuttgart, Thieme, 1985.
American Hospital Formulary Service drug information. Bethesda, MD, American Society of Hospital Pharmacists (annual publication).
Briggs GG, Freeman RK, Yaffe JS. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk, 3rd ed. Baltimore, MD, Williams & Wilkins, 1990.
Davies DM, ed. Textbook of adverse drug reactions, 4th ed. Oxford, Oxford University Press, 1991.
Dukes MNG, ed. Meyler's side effects of drugs: an encyclopedia of adverse reactions and interactions. 11th ed. Amsterdam, Elsevier, 1989.
Gilman AG et al., eds. Goodman & Gilman's The pharmacological basis of therapeutics, 9th ed. New York, Pergamon, 1996.
Hansten PD. Drug interactions: clinical significance of drug-drug interactions, 5th ed. Philadelphia, Lea & Febiger, 1985.
Olson KR. Poisoning and drug overdose, 2nd ed. Norwalk, CT, Appleton & Lange, 1994. Physicians' desk reference. Oradell, NJ, Medical Economics (published annually).
Reynolds JEF, ed. Martindale: the extra pharmacopoeia, 31st ed. London, Pharmaceutical Press, 1996.
Stockley IH. Drug interactions, 3rd ed. Oxford, Blackwell Scientific, 1994.
Occupational and industrial toxicology
Ash M, Ash I. Thesaurus of chemical products, Vols 1 & 2, 2nd ed. London, Edward Arnold, 1992.
Budavari S, ed. Merck index: an encyclopedia of chemicals, drugs and biologicals, 12th ed. Rahway, NJ, Merck & Co., 1996.
Clayton GD, Clayton FE, eds. Patty's industrial hygiene and toxicology. Vol. 1, General principles, 3rd ed. New York, Wiley, 1981.
Clayton GD, Clayton FE, eds. Patty's industrial hygiene and toxicology, Vols 2A, 2B, 2C, 2D, 2E, 2F, 4th ed. New York, Wiley, 1993-1994.
Hayes WJ, Laws ER, eds. Handbook of pesticide toxicology. San Diego, Academic Press, 1991 (3 volumes).
Lenga RE, Votoupal KL, eds. The Sigma Aldrich library of chemical safety data. Milwaukee, Aldrich Chemical Co., 1992.
Proctor NH, Hughes JP, Fischman ML, eds. Chemical hazards of the workplace, 3rd ed. Philadelphia, Lippincott, 1991.
Plestina R. Prevention, diagnosis and treatment of insecticide poisoning. Geneva, World Health Organization, 1984 (unpublished WHO document WHO/VBC/84.889, obtainable on request from Programme for the Promotion of Chemical Safety, World Health Organization, 1211 Geneva 27, Switzerland).
Rom WN, ed. Environmental and occupational medicine. Boston, MA, Little, Brown, 1992.
Sax NI, Lewis RJ, eds. Dangerous properties of industrial materials, 8th ed. New York, Van Nostrand Reinhold, 1992.
Sax NI. Hazardous chemicals desk reference, 3rd ed. New York, Van Nostrand Reinhold, 1993.
Sax NI. Rapid guide to hazardous chemicals in the workplace, 3rd ed. New York, Van Nostrand Reinhold, 1993.
Snyder JR, ed. Ethel Browning's toxicity and metabolism of industrial solvents. 2nd ed. Amsterdam, Elsevier, Vol. 1 1987, Vols 2 & 3 1990.
Tomlin C, ed. The pesticide manual - a world compendium, 10th ed. Farnham, British Crop Protection Council, 1994.
Encyclopédie Medico-Chirurgicale. Toxicologie-pathologie professionelle. Paris, Editions Techniques, 1991.
Lauwerys R. Toxicologie industrielle et intoxications professionelles, 3rd ed. Paris, Masson, 1990.
Quer-Brossa S. Toxicológia industrial. Barcelona, Salvat Editores, 1983.
Wirkstoffe in Pflanzenschutz und Schädlingsbekämpfungsmitteln, 2nd ed. Frankfurt, Industrieverband Agrar, 1990.
Baselt RC, Cravey RH. Disposition of toxic drugs and chemicals in man, 4th ed. Foster City, CA, Chemical Toxicology Institute, 1995.
Curry AS, ed. Analytical methods in human toxicology, Part 1. Deerfield Beach, FL, VCH, 1985.
Curry AS, ed. Analytical methods in human toxicology, Part 2. Deerfield Beach, FL, VCH, 1986.
Curry AS. Poison detection in human organs, 4th ed. Springfield, IL, Charles C. Thomas, 1988.
De Zeeuw RA et al., eds. Gas-chromatographic retention indices of toxicologically relevant substances on packed or capillary columns with dimethylsilicone stationary phases, 3rd ed. Deerfield Beach, FL, VCH, 1992.
Eller PM, ed. NIOSH manual of analytical methods, Vol. 1, 3rd ed. Cincinnati, OH, National Institute of Occupational Safety and Health, 1984.
Environmental health criteria. Geneva, World Health Organization (series).
Feigl F. Spot tests in organic analysis, 7th ed. Amsterdam, Elsevier, 1966.
Flanagan RJ et al. Basic analytical toxicology. Geneva, World Health Organization, 1995.
Moffat AC et al., eds. Clarke's isolation and identification of drugs in pharmaceuticals, body fluids, and post-mortem material, 2nd ed. London, Pharmaceutical Press, 1986.
Stewart CP, Stolman A. Toxicology: mechanism and analytical methods, Vol. 1. New York and London, Academic Press, 1960.
Stewart CP, Stolman A. Toxicology: mechanism and analytical methods, Vol. 2. New York and London, Academic Press, 1961.
Sunshine I. Methodology for analytical toxicology. Cleveland, OH, Chemical Rubber Company Press, 1975.
United Nations Division of Narcotic Drugs. Recommended methods for testing: manuals for use by national narcotics laboratories. New York, United Nations, 1984-1989.1
World Health Organization/Food and Agriculture Organization. Data sheets on pesticides (unpublished WHO documents, available on request from Programme for the Promotion of Chemical Safety, World Health Organization, 1211 Geneva 27, Switzerland).
Books on natural poisons should be selected according to the real incidence of risks of poisoning by animals or plants in the geographical area concerned. Illustrated guides, with drawings, photographs, or even specimens, are very useful for the identification of local plants and animals (fungi, snakes, spiders, scorpions, insects, marine animals, etc.). Most of the valuable literature will therefore come from the geographical area itself, but certain books can be recommended, since natural toxins are distributed worldwide.
Bresinsky A, Besl H. A colour atlas of poisonous fungi: a handbook for pharmacists, doctors and biologists. London, Wolfe, 1990.
Frohne D, Pfändner HJ. A colour atlas of poisonous plants: a handbook for pharmacists, doctors, toxicologists, and biologists. London, Wolfe, 1984.
Halstead BW. Poisonous and venomous marine animals of the world, 2nd ed. Princeton, NJ, Darwin Press, 1988.
Lampe KF, McCann MA. American Medical Association handbook of poisonous and injurious plants. Chicago, American Medical Association, 1985.
Lincott G, Mitchel DH. Toxic and hallucinogenic mushroom poisoning. New York, Van Nostrand Reinhold, 1977.
Publications specializing in toxicology of the eye, central nervous system, heart, lung, kidney, liver, and skin, as well as books on toxins and cancer, on effects of drugs in pregnancy and lactation, and on drugs of abuse, may be required whenever information is needed on specific target organs or systems. Examples include the following:
1Separate publications for testing different substances.
Barken RM. Rosen P, eds. Emergency paediatrics: a guide for emergency and urgent care, 4th ed. St Louis, MO, CV Mosby, 1993.
Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk, 4th ed. Baltimore, MD, Williams & Wilkins, 1994.
Descotes J. Immunotoxicology of drugs and chemicals, 2nd ed. Amsterdam, Elsevier, 1988.
Fisher AA. Contact dermatitis, 3rd ed. Philadelphia, Lea & Febiger, 1986.
Grant WM, Schuman JS. Toxicology of the eye, 4th ed. Springfield, IL, Charles C. Thomas, 1993.
Books dealing with veterinary toxicology may be helpful in some cases. Examples include the following:
Bartik M, Piskac A. Veterinary toxicology. New York, Elsevier, 1981.
Booth NH, McDonald LE. Veterinary pharmacology and therapeutics, 6th ed. Ames, IA, Iowa State University Press, 1988.
Garner RJ et al. Veterinary toxicology, 3rd ed. London, Balliere Tindall, 1988.
Howard J. Current veterinary therapy: food animal practice. Philadelphia, Saunders, 1986.
Kirk RW. Current veterinary therapy: small animal practice. Philadelphia, Saunders/Harcourt-Brace Jovanovich, 1989.
Osweiler GD et al. Clinical and diagnostic veterinary toxicology, 3rd ed. Dubuque, IA, Kendall/Hunt, 1985.
Robinson NE. Current therapy in equine medicine, 2nd ed. Phildelphia, Saunders, 1987.
Hapke HJ. Toxikologie für Veterinärmediziner. Stuttgart, Ferdinand Enke, 1988.
Books on eco-toxicology and environmental toxicology are also important, as poison information centres are frequently involved in, or consulted about, the management and assessment of environmental problems and their effects on health.
Bearing in mind that the information requested from a centre can sometimes involve highly specialized branches of medicine, it is recommended that the centre - or other readily accessible libraries - have well known, up-to-data textbooks on paediatrics, nephrology, hepatology, lung diseases, gastroenterology, cardiology, ophthalmology, gynaecology and obstetrics, dermatology, psychiatry, etc.
A list of some of the numerous periodicals that deal essentially with toxicology or closely related areas is given below. It should be noted that, in many countries, there are local journals on toxicology, usually published by national scientific associations. It is recommended that any poison information centres should also have access to journals devoted to more general clinical, industrial, chemical, and ecological topics.
Adverse drug reactions and toxicological reviews. Published by Oxford University Press, Oxford, England.
American journal of industrial medicine. Published by Wiley, New York, NY, USA.
Annals of occupational hygiene. Published by Pergamon, Elmsford, NY, USA.
Archives of environmental contamination and toxicology. Published by Springer Verlag, New York, USA.
Archives of environmental health. Published by Heldref (Helen Dwight Reid Educational Foundation), Washington, DC, USA.
Archives of toxicology. Published by Springer Verlag, Berlin, USA.
Biochemical pharmacology. Published by Pergamon, Elmsford, NY, USA.
British journal of industrial medicine. Published by British Medical Association, London, England.
Drug safety (formerly Medical toxicology). Published by ADIS Press, Auckland, New Zealand.
EHP (Environmental health perspectives). Published by US Department of Health and Human Services, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA.
Human and experimental toxicology. Published by Macmillan, Basingstoke, England.
Journal of the American Industrial Hygiene Association. Published by American Industrial Hygiene Association, Akron, OH, USA.
Journal of toxicology - clinical toxicology. Published by Marcel Dekker Inc., New York, NY, USA.
Neurotoxicology. Published by Raven Press, New York, USA.
Pharmacology and toxicology. Published by Munksgaard, Copenhagen, Denmark.
Scandinavian journal of work, environment and health. Published by Finnish Institute of Occupational Health, Helsinki, Finland.
Toxicology. Published by Elsevier, Limerick, Ireland.
Toxicology and applied pharmacology. Published by Academic Press, San Diego, CA, USA.
Toxicology letters. Published by Elsevier, Amsterdam, Netherlands.
Toxicon. Published by Pergamon, Elmsford, NY, USA.
Veterinary and human toxicology. Published by Comparative Toxicology Laboratories, Manhattan, KS, USA.
Archives belges de médecine sociale et d'hygiène (formerly Archives belges de médecine sociale, hygiène, médecine du travail et médecine légale). Published by Archives belges de médecine sociale et d'hygiène, Brussels, Belgium.
Archives des maladies professionnelles de médecine du travail et de sécurité sociale. Published by Masson, Paris, France.
Thérapie. Published by Doin, Paris, France.
Medicina del lavoro. Published by Istituti Clinici di Perfezionamento, Milan, Italy.
Toxicología. Published by Sociedad Uruguaya de Toxicología y Ecotoxicología del Uruguay, Montevideo, Uruguay.
Access to other medical journals that may contain reports of relevance to the work of the centre is recommended, notably those dealing with emergency medicine, epidemiology, intensive care, occupational medicine, pharmacology and adverse drug reactions, clinical medicine, paediatrics, public health, and psychiatry. Journals and newsletters published by agencies dealing with accident prevention or associations that undertake research in this area may also be useful.
Current awareness publications, abstracts, and bibliographical indexes are useful for updating information. Although they are expensive, they are usually available at teaching hospitals and in university libraries. They include:
* Current contents
* Toxicology abstracts
* Excerpta medica
* Index medicus
Publications of international organizations
The Environmental Health Criteria series published by WHO provides valuable data on priority chemicals (see Annex 7).
Poison information centres may also derive useful information from certain publications produced by the Food and Agriculture Organization of the United Nations, the International Labour Organisation, the International Register of Potentially Toxic Chemicals, and the United Nations Environment Programme. Centres should ask the local representatives or national correspondents of these agencies for lists of their publications.
Monographs from the International Agency for Research on Cancer on the evaluation of the carcinogenic risk of chemicals to humans provide reliable, up-to-date information on a large number of chemicals (contact IARC, 158 Cours Albert-Thomas, 69372 Lyon Cedex 08, France).
Computerized databases provide easy, on-line access to a wide range of useful information, but may be expensive to maintain. Some databases (e.g. Dialog, CIS, Medline, Toxline) have already been adopted by the more experienced poison information centres, but the more specific ones should be carefully chosen according to local needs and resources. A comprehensive list of databases can be provided on request from IPCS, World Health Organization, 1211 Geneva 27, Switzerland.
Educational material is sometimes produced by government agencies, nongovernmental organizations, manufacturers' associations, scientific societies, accident prevention agencies, and other institutions interested in the prevention and correct management of poisoning. Such material can also be produced by the staff of poison information centres for the training of professional health care workers and others or for the information of the community.
For example, the library at a poison information centre may have, for distribution, a government-produced poster on the safe use of pesticides; it may design and print a leaflet on the safe storage of medicines at home; it may distribute a booklet on the recognition of poisonous fungi; or it may develop, for distribution to clinicians, highly specialized protocols for the treatment of the most common types of poisoning.
Posters, booklets, leaflets, bulletins, video cassettes, or audiovisual displays relevant to the local situation should also be available at the centre's library.