Practical directions to save lives
Management of poisoning
Author : Professor Ravindra Fernando
As a young intern in the early 1990s, working in a Base Hospital in
faraway Nuwara Eliya, we had to treat many patients who arrived in
hospital after poisoning. They were mostly poor people working in the
estates or who were in vegetable cultivation.
Poisons, especially insecticides and weedicides were house hold items
for many of them. Some died, especially those who came late to hospital,
but many survived. Relatives of those who died gradually accepted the
fate of the deceased; they said it was the wish of the gods.
They thanked us for our heroic efforts, often in the middle of the
night to save their kith and kin. For the families of those who
survived, we were the gods who performed a miracle. It was the humble
gratitude of these poor people who kept us going.
Little would they have known that it was not us but the science that
has saved their lives. The science on the principles of management of
poisoning was put into pen by the renowned academic and the most senior
Professor of Forensic Medicine of the University of Colombo, Prof.
Ravindra Fernando who was also the pioneer who started the National
Poisons Information Centre many years ago.
In Sri Lanka, more than 100,000 patients are admitted to state
hospitals for poisoning annually. In 2008, 1311 patients died of
It is among the first ten leading causes of death in state hospitals.
According to Police statistics, 2241 Sri Lankans committed suicide by
poisoning (almost 56% of all suicides) in 2009.The new edition of the
“Management of Poisoning” is out and is available now.
This updated and revised new edition will certainly help reduce the
morbidity and mortality from poisoning and improve the alarming
statistics Prof. Ravindra Fernando has mentioned in the Foreword of his
It is one of those publications that give practical directions to
doctors, nurses and para-medicals involved in the management of
poisoning. Its reader friendliness, will save many lives as the
preceding editions have done.
The majority of acute poisoning cases seen in clinical practice, as
those I have explained at the outset, are deliberate or accidental
In Sri Lanka, due to its agrarian base, pesticides are the common
culprit. Mild poisoning as a result of absorption through the skin or
through inhalation is a common occupational hazard among people who
As professor explains in his book, acute poisoning is a medical
emergency and especially in the case of chemicals such as
organophosphates, cyanides and certain drugs, appropriate interventions
in the first few minutes of management decides life and death.
The book gives not just information, but attempts to make it a
complete educational experience. Education means not only a change in
knowledge but of knowledge, skills and attitudes.
In additions to the knowledge that most books on poisoning give the
reader, through statements such as the paragraph quoted below, the great
professor attempts to change the attitudes of young doctors as well.He
states that the attitude of a few medical and paramedical staff to treat
these patients with contempt, and to discharge them as soon as possible,
He criticises the fact that a heavy smoker who suffers from a
myocardial infarct or an alcoholic with bleeding oesophageal varices
gets sympathy and better care, than a poor young woman admitted with
For the noble professional circumstances such as these do not matter.
His priorities are clear: save life whenever it is possible and when
death is inevitable make the remaining bit of life as comfortable as
Toxicology is the discipline that integrates relevant scientific
information to help preserve and protect health from the hazards
presented by chemical and physical agents. Prof. Fernando’s book is on
medical toxicology, the science that deals with the management of
patients poisoned with pesticides, drugs, natural toxins like snake
venom and plants, and various other chemicals.Prof Ravindra Fernando,
clearly explains the importance of maintaining adequate breathing and
circulation as the first priority in acute poisoning.
He details simple things such as ensuring a clear air way by removing
secretions from the mouth and throat, removing dentures, if present, and
supporting the lower jaw to be held forward and placing the patient on
He then explains how antidotes can be given for certain poisons and
the importance of supportive therapy.
Techniques such gastric lavage are explained together with the pros
and cons of doing it as well as the induction of emesis and Whole Bowel
Other techniques which any house officer in this emergency setting
should be familiar with including, alkaline diuresis and acid diuresis
as well as those reserved for more experienced doctors such as
peritoneal dialysis and haemoperfusion are also dealt with in the book.
The guidance he gives on the management of anaphylaxis would be
useful to doctors not only in the case of poisoning but in other
instances as well.
Special instructions are given for cases of inhalation, eye
irritation by poisons and for cases of skin contact.
Much of the book deals with clinical features and management of some
commonly encountered or easily accessible poisons.
The book has several chapters and sections. In the first chapter, the
basic principles of management of poisoning are discussed. The chapter
on “Medico-Legal Aspects of Poisoning” considers some of the issues
physicians face in their practice.
The “General Index” helps the reader to check poisons or groups of
poisons discussed in this book. With the assistance of the Registrar of
Pesticides and the members of his office the “Pesticide Generic Name
Index” and a “Pesticide Trade Name Index” have been included which help
to identify pesticides.
Prof. Ravindra Fernando does not stop at just treatment.
He stresses on following up as well.
He says that ‘once the patient is fit to be discharged, doctors
should carefully assess his or her socio-economic and psychological
The reason to consume poison must be determined. Doctors or nurses
should counsel them adequately before discharge’.
I understand that a team of local and foreign experts in toxicology
have also provided advise to Prof. Fernando on some sections of this
useful book, which is I am sure will be referred to many times a day by
doctors, especially in rural hospitals in Sri Lanka, where poisoning is
a major killer.
No review of a book is complete without a few words on the man whose
pen was behind the writing.
Professor Ravindra Fernando my beloved teacher, qualified as a doctor
with M.B.B.S. (Ceylon) from the University of Sri Lanka in 1975. He
passed his Diploma in Medical Jurisprudence (Clinical and Pathology)
London in 1980.
He also has the degrees of FRCP from the Royal Colleges of
Physicians, London, Edinburgh and Glasgow, FRCPath.(UK), MD (Sri Lanka),
FCCP and FCCGP.
He is the recipient of WHO Fellowships on ‘Medical Education’.
He has over 80 academic publications and presentations to his credit
and has written over 15 books, published in Sri Lanka and abroad.
He has held many prestigious positions in including the President of
the Asia Pacific Association of Medical Toxicology, the founder
Secretary General of the Indo-Pacific Association of Law, Medicine and
Science, President of the Sri Lanka Medical Association, President of
the Ceylon College of Physicians, President of the College of Forensic
Pathologists of Sri Lanka and the Chairman of the Board of Studies in
Forensic Medicine, Post Graduate Institute of Medicine, University of
Most of all he is The Father of the National Poisons Information
Centre, which he established in the General Hospital, Colombo using
funds mobilised from his own personal efforts through the International
Development Research Centre (IDRC), Canada and other donors.
WManagement of Poisoning is available at the office of the Sri Lanka
Medical Association (SLMA), Colombo 7, and the Department of Forensic
Medicine and Toxicology, Faculty of Medicine, Colombo 8.