Emergencies

Read this before you need it. In an emergency, the useful knowledge is the knowledge you already have. This chapter covers the situations in this book where minutes matter: poisoning, paracetamol overdose, opioid overdose, anaphylaxis, choking, severe hypoglycaemia, carbon monoxide, and severe allergic and drug reactions.

Nothing here replaces emergency services. Call them.

The universal rules

1. Call emergency services (999 in the UK, 911 in the US, 112 across the EU and much of the world). If in doubt, call.
2. Do not wait for symptoms. Several of the most dangerous exposures in this book produce nothing for hours (Chapter 65).
3. Take the packet, bottle, or plant with you, or photograph it.
4. Do not induce vomiting. This advice was reversed decades ago; it causes aspiration and further injury.
5. Stay with the person.
6. Tell them everything, including alcohol, recreational drugs, and supplements. Emergency staff need the truth, not a tidy version, and they are not there to judge.

Poisons information services:

Put your local number in your phone now.

1. Paracetamol overdose

The most important single item in this book.

If more paracetamol has been taken than the maximum dose, get medical help immediately, however well the person feels.

Why it is different from other overdoses:

• No symptoms for 24 hours, or mild nausea at most. People feel completely fine.
• By the time symptoms appear (day 2 to 3), liver damage is underway.
• The antidote, N-acetylcysteine, is nearly 100 percent effective within 8 hours and much less so after 24.

This applies equally to accidental overdose from combination cold and flu remedies, which is the commonest route (Chapter 64).

What to do: call 999 or go to an emergency department. Take the packets. Say when it was taken and how much. Do not wait to see what happens.

2. Opioid overdose

Recognise the triad:

1. Unresponsive or barely rousable
2. Slow, shallow, or absent breathing (often under 8 to 10 breaths a minute)
3. Pinpoint pupils

Plus blue or grey lips and fingertips, gurgling or snoring, limp body.

What to do:

1. Call an ambulance.
2. Give naloxone if available: intranasal spray or intramuscular injection into the thigh.
3. Rescue breaths if trained; otherwise open the airway and put them in the recovery position.
4. Repeat naloxone after 2 to 3 minutes if no response. Multiple doses are often needed with fentanyl and nitazenes.
5. Stay. Naloxone wears off before most opioids do, and they can deteriorate again.

Naloxone is harmless if given to someone who has not taken opioids. There is no downside to giving it on suspicion. It is available without prescription in many countries and free from harm reduction services (Chapter 68).

3. Anaphylaxis

Recognise it: Airway, Breathing, Circulation.

• Airway: swelling of lips, tongue, or throat; hoarse voice; difficulty swallowing; noisy breathing
• Breathing: wheeze, breathlessness, persistent cough
• Circulation: dizziness, collapse, pale and clammy, feeling of impending doom

Plus, usually, hives, flushing, swelling, vomiting. 10 to 20 percent have no skin signs.

What to do:

1. Adrenaline auto-injector into the outer mid-thigh, immediately. Through clothing if necessary. Hold for the time the device specifies.
2. Call 999 and say "anaphylaxis."
3. Lie them flat with legs raised. Sitting up only if breathing is the dominant problem; on their side if vomiting or unconscious.

   Do not let them stand up or walk. Standing during anaphylaxis has caused deaths.

4. Second dose after 5 minutes if no improvement.
5. Hospital regardless of improvement, because of biphasic reactions.

Antihistamines do not treat anaphylaxis. Delay in giving adrenaline is the factor most consistently associated with death (Chapter 98).

4. Choking

Ask: "Are you choking?"

If they can cough, speak, or breathe: encourage coughing. Do not intervene.

If they cannot:

Adults and children over 1:

1. Five sharp back blows between the shoulder blades with the heel of your hand, leaning them forward.
2. Five abdominal thrusts: stand behind, fist above the navel, sharp inward and upward pulls.
3. Alternate until it clears or they become unconscious.
4. If unconscious: call 999 and start CPR.

Infants under 1: no abdominal thrusts. Five back blows face down along your forearm, head lower than body, then five chest thrusts (two fingers on the breastbone), alternating.

After any abdominal thrusts, seek medical assessment for internal injury.

Highest-risk foods for young children: whole grapes and cherry tomatoes (cut lengthways into quarters), whole nuts (none under 5), raw carrot sticks, popcorn, hard sweets, marshmallows, and large chunks of apple or meat.

5. Severe hypoglycaemia

Only insulin and sulfonylureas cause it. Beta blockers mask the early warning signs.

Early (conscious, able to swallow): the 15-15 rule

1. 15 to 20 g fast carbohydrate: 4 to 5 glucose tablets, 150 to 200 mL fruit juice or non-diet cola, or a tube of glucose gel. Not chocolate, whose fat slows absorption.
2. Wait 15 minutes, re-test.
3. Repeat if still below 4.0 mmol/L.
4. Then a longer-acting carbohydrate to prevent recurrence.

Severe (confused, unable to swallow, unconscious, or fitting):

1. Do not put anything in their mouth.
2. Recovery position.
3. Give glucagon (injection or nasal spray) if available and you know how.
4. Call an ambulance.

Alcohol causes delayed hypoglycaemia, often overnight, by suppressing liver glucose production (Chapter 76).

6. Carbon monoxide poisoning

Colourless, odourless, and it kills people in their sleep.

Symptoms mimic flu: headache, nausea, dizziness, confusion, weakness, breathlessness.

The clue that distinguishes it: symptoms that improve when you leave the building and return when you come back, and others in the household or pets affected at the same time.

What to do:

1. Get everyone out into fresh air immediately.
2. Turn off the appliance if you can do so safely, and open windows.
3. Call emergency services, and the gas emergency number.
4. Do not go back in.
5. Get medical assessment, even if you feel better; treatment is high-flow oxygen.

Prevention: a CO alarm in every home with any fuel-burning appliance, tested regularly. Sources: faulty boilers, gas fires, blocked flues, generators, barbecues brought indoors or into a tent (a repeated cause of deaths), and engines running in garages (Chapter 95).

7. Poisoning in children

The commonest scenarios: a visitor's handbag on the floor, medicines on a bedside table, iron tablets or vitamin gummies that look like sweets, and e-liquid.

What to do:

1. Call 999 or your poisons centre immediately.
2. Do not induce vomiting.
3. Do not give anything to drink unless told to.
4. Take the container with you.
5. Do not wait for symptoms.

Button batteries are a separate and immediate emergency. A swallowed button battery can burn through the oesophagus within two hours and cause fatal bleeding. Go straight to an emergency department; do not wait, do not induce vomiting, and do not give food or drink. Tell them it may be a button battery.

Other high-risk household items: liquid laundry capsules (severe eye and airway injury), e-liquid, iron tablets, paracetamol, antifreeze, and essential oils.

8. Severe drug reactions

Seek urgent help for any of these:

9. Food poisoning

Most resolves in 24 to 72 hours with fluids. Oral rehydration solution is the treatment (Chapter 59).

Seek help if there is:

• Blood in stool or vomit
• High fever
• Signs of dehydration: no urine for 8 hours, dizziness on standing, sunken eyes, lethargy
• Symptoms lasting more than 3 days, or severe abdominal pain
• Any of it in a baby, an older person, someone pregnant, or someone immunosuppressed
• Neurological symptoms: double vision, drooping eyelids, difficulty swallowing or speaking, descending weakness. This is botulism until proven otherwise and is a medical emergency
• Recent travel, or a suspected shared source affecting several people

Do not take loperamide with bloody diarrhoea or high fever (Chapter 71).

10. Specific poisonings from this book

11. What to have and know before you need it

In the house:

• Carbon monoxide alarm, tested
• Smoke alarms
• Poisons centre number in your phone
• Paracetamol, ibuprofen, oral rehydration sachets, antihistamine, plasters, thermometer
• Aspirin 300 mg to chew during a suspected heart attack
• Personal emergency medicines where everyone can find them: adrenaline auto-injectors (two), reliever inhaler, GTN spray, glucose gel, naloxone. Check expiry dates.

Know:

• How to use an adrenaline auto-injector, including which device you have
• CPR and choking first aid, including the different technique for infants
• The recovery position
• Your own and your family's allergies and medicines, written down
• Where the gas and water shut-offs are

Do a first aid course. It takes a few hours and it is the highest-return use of that time you will ever make.

12. The bottom line

• Call for help early. Do not wait for symptoms, especially with paracetamol.
• Do not induce vomiting, ever.
• Take the packet with you.
• Paracetamol overdose looks like nothing for a day and the antidote works best within 8 hours.
• Anaphylaxis: adrenaline into the outer thigh immediately, and keep them lying down.
• Opioid overdose: naloxone, ambulance, stay. It is harmless if you were wrong.
• Button batteries and carbon monoxide are immediate emergencies, and CO symptoms that improve when you leave the house are the clue.
• Wild mushroom poisoning that seems to get better after a day is the dangerous pattern.

👉 Last chapter: the myths, gathered.