toxicology

Common opioids and opiated

- butorphanol (Stadol) - Codeine -Fentanyl (Sublimaze) - Heroin - Hydrocodone (Vicodin) - Hydromorphone (Dilaudid) - Methadone -Oxycodone hydrochloride (OxyContin) -Oxymorphone (Opana)

The signs and symptoms of poisoning vary according to the specific agent.

- different poisons have different symptoms/signs - burns/blistering, dilated/constricted pupils, faster/slower pulse, 1. The presence of injuries at the patient's mouth strongly suggests the ingestion (swallowing) of a poison. 2. If possible, while obtaining the SAMPLE history, ask the patient: a. What substance did you take? b. When did you take it (or become exposed to it)? c. How much did you ingest? d. Did you have anything to eat or drink before or after you took it? e. Has anyone given you an antidote or any substance orally since you ingested it? f. How much do you weigh? - always be careful while dealing with a child, poisonings of children rarely lead to death, but parents may be really distraught - professional calm manner will ease the situation - however, a single swallow of a single pill has the potential to kill a child - never judge a poisoned patient especially if it was self-harm, treat patient with compassion and respect

Marijuana

- flowering hemp plant is called Cannabis Sativa 1. Marijuana is abused throughout the world. a. Nearly half of Americans have tried marijuana. b. Tetrahydrocannabinol, or THC, is the chemical in the marijuana plant that produces its high. c. Inhaling marijuana smoke produces euphoria, relaxation, and drowsiness. d. It impairs short-term memory and the capacity to do complex thinking and work. e. The euphoria could progress to depression and confusion. - altered perception of time is common, anxiety and panic may occur 2. With very high doses, patients may experience hallucinations or become very anxious or paranoid. a. Reassure the patient and transport with a minimum amount of excitement. 3. Marijuana is often used as a vehicle to get other drugs into the body. - it can be laced with crack or PCP 4. Several states have legalized the recreational use of marijuana, and others allow for the medical use of marijuana and products that contain THC. - ppl have become more aware with the health risks involved a. "Edibles" or baked goods, candies, and other food additives that have been infused with marijuana b. Ingestion can lead to cannabinoid hyperemesis syndrome, characterized by chronic marijuana use and extreme nausea and vomiting that is relieved only by a hot shower or bath - bathing can become compulsive in these patients - definitive treatment is to stop smoking, but PTs may believe smoking will help 5. Synthetic marijuana or "Spice" refers to a variety of herbal incense or smoking blends that resemble THC and produce a similar high. - labeled as a safe alternative, however they have no medical benefit and a high potential to be abused - brand names - K2 'skunk" a. Powerful and unpredictable effects may result, ranging from simple euphoria to complete loss of consciousness.

Sedative-hypnotic drugs

- have been a part of legitimate medicine for a long time - Pts may solicit physicians for various prescriptions 1. Barbiturates and benzodiazepines are easy to obtain and relatively cheap. a. These drugs are CNS depressants and alter the level of consciousness, with effects similar to those of alcohol. i. The patient may appear drowsy, peaceful, or intoxicated. 2. In general, these agents are taken by mouth. - by themselves they don't relieve pain or produce a specific high a. Users often take alcohol or an opioid at the same time to boost their effects. b. Occasionally, the capsules are suspended or dissolved in water and injected to produce a sudden state of ease and contentment c. IV sedative-hypnotic drugs quickly induce tolerance, so the person requires increasingly larger doses. - ur less likely to be called to treat an acute overdose from someone who chronically abuses these drugs - patients attempt suicide with these drugs - they will have marked respiratory depression and may be in a coma 3. These drugs (Chloral hydrate) may be given to people as a "knock-out" drink, or "Mickey Finn," to incapacitate them without their knowledge. - date rape/club drugs such as flunitrazepam (rohyphnol/roofies) and ketamine (Ketalar or "special K") are often colorless, odorless and tasteless - cause an unwary person to become sedated (maybe even unconscious) which may facilitate sexual assault or rape - person wakes up confused with unable to remember what happened 4. Generally, your treatment is to ensure airway is patent, assist ventilations, and provide prompt transport. - watch mental status, u may attempt to stimulate the patient by speaking loudly or gently shaking them, watch for vomiting - as multiple drug use increases u may find it increasingly difficult to determine what ur patient took - best approach is too treat any obvious injuries/illness - drug use make complicate things and make full life support necessary - focus on ABS and airway obstruction (tongue, vomiting, respiratory depression, cardiac arrest)

Abused inhalants

- produce many of the same CNS effects as do other sedative hypnotics 1. These agents are inhaled instead of ingested or injected. - method of abuse is known as huffing a. Some of the more common agents include acetone, toluene, xylene, and hexane. b. Found in glues, cleaning compounds, paint thinners, and lacquers 2. Gasoline and various halogenated hydrocarbons such as Freon, used as propellants in aerosol sprays, are also abused as inhalants. - none of these are medications - they temporarily displace oxygen in the brain and cause a rush of euphoria a. These are commonly abused by teenagers/young adults chasing and alc like high - bc they are cheap and relatively easy to obtain in hardware stores b. The effective dose and the lethal dose are very close, making these extremely dangerous drugs. - long term abuse can lead to permanent brain damage 3. Take special care in dealing with a patient who may have used inhalants. - effects range from mild drowsiness to coma - unlike other sedative-hypnotics they can cause seizures - lack of oxygen can cause loss of brain function a. Halogenated hydrocarbon solvents can make the heart hypersensitive to the patient's own adrenaline - high risk for sudden cardiac death because of ventricular fibrillation b. Even the action of walking may release enough adrenaline cause a fatal ventricular dysrhythmia. c. Try to keep such patients from struggling with you or exerting themselves. - oxygen if signs of respiratory distress 4. Use a stretcher to move the patient, give oxygen, and transport the patient to the hospital - monitor vitals on route

Opioids

1. A narcotic is a drug that produces sleep or altered mental consciousness. 2. An opioid is a type of narcotic medication used to relieve pain. a. An opiate is a subset of the opioid family, and refers to natural, nonsynthetic opioids. 3. Opioids are named for the opium in poppy seeds, from which codeine and morphine are derived. 4. Synthetic opioids include meperidine, hydromorphone, oxycodone, hydrocodone, and methadone. a. Prescription opioid drugs are among the most commonly abused drugs in the United States. b. Some people become physically dependent on opioids after taking an appropriate medical prescription. c. The death rate from heroin overdoses tripled between 2010 and 2013 (to 44,000 deaths). 4. These agents are CNS depressants and can cause severe respiratory depression and then cardiac arrest if not treated promptly. - when administered IV they produce a characteristic high or "kick" a. Tolerance develops quickly, so some users may require massive doses to experience the same high. - in general emergency medical conditions caused by opioids are respiratory depression, including a decreased volume of inspired air and decreased respirations which can lead to cardiac arrest b. These drugs often cause nausea and vomiting and may lead to the development of hypotension. c. Although seizures are uncommon, they can occur. - an overdose can result in the patient experiencing a comatose condition d. Patients typically appear sedated or unconscious and cyanotic with pinpoint pupils. i. Pinpoint pupils are the most commonly accepted sign of opiate abuse. - patients who inject into veins are at a higher risk of HepC and HIV

Scene size-up

1. A well-trained dispatcher can obtain important information pertaining to a poisoning call, including: a. Proper protection needed b. Information pertaining to the MOI/NOI c. Number of patients involved d. Additional resources needed e. Whether trauma is involved 2. Take standard precautions and look for clues that might indicate the substance involved. 3. Ask yourself the following questions: a. Is there an odor in the room? If so, is the scene safe? b. Are there medication bottles lying around the patient and the scene? If so, is there medication missing that might indicate an overdose? c. Are there alcoholic beverage containers present? d. Are there syringes or other drug paraphernalia on the scene? e. Is there a suspicious odor and/or drug paraphernalia present that may indicate the presence of a drug laboratory? 4. Keep a constant eye on the surroundings, and keep an open mind when questioning the patient or bystanders to avoid mistaken conclusions.

Ingested poisons

1. About 80% of poisoning is by mouth. a. Liquids b. Household cleaners c. Contaminated food d. Plants (common in children who like to explore and bite various plants) e. in most cases Drugs 2. Ingested poisoning is usually accidental in children and deliberate in adults. 3. Signs and symptoms vary greatly with the: a. Type of poison b. Age of the patient c. Time that has passed since the ingestion - small children may cry if the poison is an acid or alkaline - often causes burns around the mouth 4. Signs and symptoms include burns around the mouth, gastrointestinal pain, vomiting before or after arrival, cardiac dysrhythmias, and seizures. 5. Treat signs and symptoms and notify the poison center and medical control of the patient's condition. a. If patient has altered mental status, protect the patient from aspirating on vomit. 6. Consider whether there is unabsorbed poison remaining in the gastrointestinal tract and whether you can safely and effectively prevent its absorption. - some chemicals react with water - small amounts can usually be flushed safely with large amounts of water, larger amounts can give off toxic fumes and explode when wet - call for HazMat, and read warnings and placards 7. Some EMS systems allow EMTs to administer activated charcoal. - although every poison will result in a specific set of signs and symptoms goes with ABCs 8. You should always immediately assess the airway, breathing, and circulation (ABCs) of every patient who has been poisoned. - be prepared to provide aggressive ventilatory support and CPR if necessary if the patient ingested a CNS depressant

Miscellaneous drugs

1. Accidental or intentional overdose with cardiac medications has become common. a. Children may ingest them thinking they are candy. b. Older patients may forget and take a second dose of their medication. c. Signs and symptoms depend on the medication ingested. d. These drugs may cause bleeding, cardiac dysrhythmias, unconsciousness, and even cardiac arrest. e. Contact the poison center as soon as possible. f. You may be ordered to administer activated charcoal. 2. Aspirin poisoning remains a potentially lethal condition. a. Ingesting too many may result in: i. Nausea ii. Vomiting iii. Hyperventilation iv. Ringing in the ears b. Patients with this problem frequently have: i. Anxiety ii. Confusion iii. Tachypnea iv. Hyperthermia v. Danger of having seizures 3. Overdosing with acetaminophen and medications that contain acetaminophen is also common. a. Among the top 25 substances with the largest number of fatalities due to poisoning b. Overdose, unintentional or intentional, must be treated promptly and aggressively. c. Accidental acetaminophen overdose is as serious as intentional overdose. i. Patient is unaware of the continuous exposure to the toxin and massive liver failure may not be apparent for a full week. d. Gathering information at the scene is very important. 4. Some alcohols, including methyl alcohol and ethylene glycol, are even more toxic than ethyl alcohol (drinking alcohol). a. Both will cause severe tachypnea, blindness, renal failure, and eventually death. b. Immediate transport to the emergency department is essential.

Some EMS systems allow EMTs to give activated charcoal by mouth.

1. Activated charcoal binds to specific toxins and prevents their absorption by the body; the toxins are then carried out of the body in the stool. (adsorption) 2. Activated charcoal is not indicated for patients: a. Who have ingested alkali poisons, cyanide, ethanol, iron, lithium, methanol, mineral acids, or organic solvents b. Who have a decreased level of consciousness and cannot protect their airway 3. If local protocol permits, you will likely carry plastic bottles of premixed suspension, each containing up to 50 g of activated charcoal. a. Some common trade names are InstaChar, Actidose, and LiquiChar. b. The usual dose for an adult or child is 1 g of activated charcoal per kilogram of body weight. i. 30 to 100 g for adults ii. 15 to 30 g for children younger than 13 4. Before you give a patient charcoal, obtain approval from medical control. - consider amount of toxin/patient's condition - in most cases it should be given within one hour to exposure a. Shake the bottle vigorously to mix the suspension - it looks like mud - place it in a covered container with a straw b. You may need to convince the patient to drink it, but never force it - PTs may not tolerate the gritty texture c. Shake the container frequently to keep the medication mixed. d. Once the patient has finished, discard the container. e. Record the time when you administered activated charcoal. f. If the patient refuses activated charcoal, document the refusal and your attempts to counsel the patient, and transport the patient for further evaluation. - as you asses the patient be prepared vomiting, nausea and possible airway conditions 5. Side effect of ingesting activated charcoal are constipation and black stools. 6. If the patient has ingested a poison that causes nausea, he or she may vomit after taking activated charcoal and the dose will have to be repeated. - preparing a large plastic bag as a bib will help in case the patients vomits

Synthetic cathinones (bath salts)

1. An emerging class of drugs similar to MDMA. - made with methylenedioxypyrovaleroone (MDVP) 2. Sold as bath salts to escape the legal restrictions imposed on illicit drugs. a. Brand names include Ivory Wave and Cloud Nine. - don't confuse with Epson salt (magnesium sulfate) 3. Cathinones produce euphoria, increased mental clarity, and sexual arousal. a. Most users of this drug snort or insufflate the powder nasally. b. Effects reportedly last as long as 48 hours. 4. Adverse effects include teeth grinding, appetite loss, muscle twitching, lip smacking, confusion, gastrointestinal conditions, paranoia, headache, elevated heart rate, and hallucinations. 5. Keep the patient calm and transport. 6. Consider ALS assistance; some of these patients may require chemical restraint to facilitate safe transport.

Reassessment

1. Continually reassess the adequacy of the patient's ABCs. 2. Repeat vital signs; compare them with the baseline set. 3. Evaluate the effectiveness of interventions you have provided. a. Every 15 minutes for a stable patient b. Every 5 minutes, or constantly, for a patient who has consumed a harmful or lethal dose 4. Treatment a. Supporting the ABCs is your most important task. b. Contact medical control or a poison center to discuss treatment options. c. Dilute airborne exposures with oxygen. d. Remove contact exposures with copious amounts of water unless contraindicated. e. Consider activated charcoal for ingested poisons. 5. Communication and documentation a. Report as much information as you have about the poison or chemical to the hospital. b. If the poisoning or exposure occurred in a work setting, bring, or have the company fax, the material data sheet to the hospital.

Primary assessment

1. Determine the severity of the patient's condition. a. Obtain a general impression of the patient. b. Assess his or her level of consciousness. c. Determine any life threats. d. Do not assume a conscious, alert, and oriented patient is in stable condition. 2. Airway and breathing a. Quickly ensure that the patient has an open airway and adequate ventilation. b. If the patient has any difficulty breathing, begin oxygen therapy. c. If the patient may have an inhalation injury, place the patient on high-flow oxygen regardless of the pulse oximetry reading. d. Consider inserting an airway adjunct in unresponsive patients. e. Have suction available; these patients are susceptible to vomiting. f. You may have to assist ventilations with a BVM because some substances act as depressants. 3. Circulation a. Assess the pulse and skin condition. b. You will find variations depending on the substance involved. 4. Transport decision a. Consider prompt transport for patients with obvious alterations in the ABCs or for patients you have determined have a poor general impression. b. Everyone who is exposed to the hazardous material must be thoroughly decontaminated by the HazMat team before leaving the scene.

Injected poisons

1. Exposure by injection includes intravenous drug abuse and envenomation by insects, arachnids, and reptiles. a. Injected poisons are usually absorbed quickly into the body or cause intense local tissue destruction. b. They cannot be diluted or removed from the body in the field bc they absorb too quickly c. The patient's condition can be life threatening; you must act quickly. - take the time at the scene to make thorough notes about the nature of the poisoning - use this info to state the type/amount of the substance, time and route if exposure - emergency staff will appreciate this 2. Signs and symptoms include: a. Weakness b. Dizziness c. Fever d. Chills e. Unresponsiveness f. Excitability 3. If you suspect rapid absorption has occurred, Monitor the airway, provide high-flow oxygen for respiratory distress and hypoxia (Spo2 less than 94%, cyanosis), and be alert for nausea and vomiting. 4. Remove rings, watches, and bracelets from areas around the injection site if swelling occurs. - prompt transport is essential, take all containers, bottles and labels to the hospital

Your primary responsibility to the patient who has been poisoned is to recognize that a poisoning has occurred.

1. For your own safety, you must pay attention to your surroundings or you could also become exposed to the same substance. a. The where, what, and how of the toxic exposure is important. - never approach a scene until the area is deemed safe 2. Very small amounts of some poisons can cause considerable damage or death. - never let your guard down 3. If you suspect that ingestion or exposure to a toxic substance has occurred, notify medical control and begin emergency treatment at once.

Hallucinogens

1. Hallucinogens alter a person's sensory perceptions. a. The classic hallucinogen is lysergic acid diethylamide (LSD). b. Abuse of PCP is relatively uncommon among young adults. c. PCP is a dissociative anesthetic that is easily synthesized and highly potent. - its effectiveness by oral, nasal, pulmonary and IV methods makes it easy to add to other street drugs - its dangerous bc it causes severe behavioral changed making ppl inflict injury on themselves 2. These agents: a. Cause visual hallucinations b. Intensify vision and hearing c. Generally separate the user from reality - pt axpects a pleasurable altered sensory state however it is usually terrifying 3. Patients experiencing a "bad trip" have: a. Hypertension b. Tachycardia c. Anxiety d. Paranoia 4. Your care is the same as that for a patient who has taken a sympathomimetic. a. Use a calm, professional manner. b. Provide emotional support. c. Do not use restraints unless you or the patient is in danger of injury. d. Watch the patient carefully throughout transport and do not leave unattended. e.Request ALS assistance when appropriate

Hydrogen sulfide

1. Hydrogen sulfide is a highly toxic, colorless, and flammable gas with a distinctive rotten-egg odor. 2. Poisoning usually occurs by inhalation. 3. Hydrogen sulfide affects all organs, but it has the most impact on the lungs and CNS. - occurs naturally in sewers, swamps, volcanoes, crude petroleum, 4. Used to commit suicide; referred to as chemical or detergent suicide - started in Japan and came to America via the internet - patient may place a warning sign a. If you approach an enclosed vehicle with an unconscious patient inside, be alert for warning signs, as well as containers, buckets, or pots. - don't enter a scene where a toxic gas is present b. If you suspect the presence of a toxic gas, wait for a HazMat team to tell you the scene is safe. - workers in industrial settings may experience low level exposure to hydrogen sulfide over a long period of time - this leads to eye, nose, throat irritation, headaches, bronchitis - chronic exposure may decrease ability to smell the gas - exposed to high levels of the gas - nausea, vomiting, confusion, dyspnea, loss of consciousness, 5. Signs and symptoms include nausea and vomiting, confusion, dyspnea, a loss of consciousness, seizures, shock, coma, and cardiopulmonary arrest. - there is no antidote, HazMat must quickly remove patient 6. Once the patient has been decontaminated, management is largely supportive. a. Monitor and assist the patient's respiratory and cardiovascular functions. b. Provide rapid transport.

History taking

1. Investigate the chief complaint. a. Obtain the patient's medical history (can be performed en route). b. If your patient is responsive, begin with an evaluation of the exposure and the SAMPLE history. c. If the patient is unresponsive, attempt to obtain the history from other sources: i. Coworkers ii. Bystanders iii. Friends iv. Family members v. Medical identification jewelry vi. Wallet cards 2. SAMPLE history a. The SAMPLE history guides you in what to focus on as you continue to assess the patient's complaints; the physical examination and vital signs tell you what is happening to the patient's body. b. In addition to the SAMPLE history, ask the following questions: i. What is the substance involved? ii. When did the patient ingest or become exposed to the substance? iii. How much did the patient ingest or what was the level of exposure? iv. Over what period did the patient take or was exposed to the substance? v. Has the patient or a bystander performed any intervention? Has the intervention helped? vi. How much does the patient weigh?

Try to determine the nature of the poison

1. Look around the immediate area for clues - overturned bottle, a needle or syringe, scattered pills, chemicals, remains of food or drink items, or even an overturned or damaged plant. 2. Place any suspicious material in a plastic bag and take it with you. 3. Containers at the scene can provide critical information, such as: a. Name and concentration of the drug b. Ingredients c. Number of pills originally in the bottle d. Name of the manufacturer e. Prescribed dose - this information can help department physicians determine how much has been ingested/specific treatment - a food container that lists name/location of vendor/restaurant can save someone's life 4. If the patient vomits, examine the contents for pill fragments. 5. Wear proper personal protective equipment. 6. Note and document anything unusual that you see.

Alcohol

1. Many calls for service have a connection to alcohol use. a. 1 in 10 deaths among working-age adults in the United States can be attributed to excessive alcohol use. b. Alcohol can damage the liver, whether thorough chronic overuse or occasional heavy use (binge drinking). c. Binge use can be more damaging than chronic use, depending on the frequency of the binging and the surrounding circumstances. - binge use has increased more than 17% - many people dismiss the dangers of alcohol 2. Alcohol is a powerful CNS depressant. a. It is a sedative (decreases activity and excitement) and a hypnotic (induces sleep). b. In general, alcohol dulls the sense of awareness, slows reflexes, and reduces reaction time. c. It may also cause aggressive and inappropriate behavior and lack of coordination. d. A person who appears intoxicated may have other medical problems as well. i. Look for signs of head trauma, mental illness, toxic reactions, or uncontrolled diabetes. ii. Severe acute alcohol ingestion may cause hypoglycemia. e. Assume that all intoxicated patients are experiencing a drug overdose and require a thorough examination by a physician. - I many states a patient impaired in any way - mental illness, medical condition, intoxication cannot legally refuse transport 3. Alcohol increases the effects of many other drugs and is commonly taken with other substances. - OTC drugs, antihistamines, diet meds can cause serious complications if taken with alcohol 4. If a patient exhibits signs of serious CNS depression, provide respiratory support. a. Depression of the respiratory system can also cause emesis, or vomiting - making respiratory support difficult b. The vomiting may be very forceful or even bloody (hematemesis) because large amounts of alcohol irritate the stomach. c. Internal bleeding should also be considered if the patient appears to be in shock. - blood may not clot efficiently in a patient who has a prolonged history of alcohol abuse - drug abuse is becoming increasingly more common in teens - likely because of peer pressure - older teens who have developed a tolerance will give people too much drugs and cause them to overdose - reassure teens ur there to help and not get them in trouble - they will lie to avoid trouble - many teens also attempt suicide, never judge 5. Patients in alcohol withdrawal may experience frightening hallucinations, or delirium tremens (DTs). - 1-7 days after a person stops drinking or their alc consumption levels decrease suddenly DTs may develop - a PT with an otherwise clear mental state may see or hear things - such visual and auditory hallucinations precede DTs a more serious complication a. The syndrome is characterized by: i. Agitation and restlessness ii. Fever iii. Sweating iv. Tremors v. Confusion and/or disorientation vi. Delusions and/or hallucinations vii. Seizures b. These conditions may develop after a person stops drinking or when alcohol consumption levels are decreased suddenly. c. Provide prompt transport after you have completed your assessment and completed necessary care - patient experiencing DTs is extremely ill - treat seizures as normal - don't restrain patient but protect them from self-harm - difficulty breathing - treat with oxygen - watch carefully for vomiting, have suction ready - hypovolemia may develop as a result of sweating, fluid loss, insufficient fluid intake, vomiting associated with DTs - if u see signs of shock, clear airway, and turn patients head to one side to minimize chance of aspiration d. PTs may not respond appropriately to suggestions or conversations, they're often confused and frightened, remain calm and relaxed - Reassure the patient and provide necessary care and emotional support.

Inhaled poisons

1. Move the patient into fresh air immediately. 2. depending on length of exposure - patient may require supplemental oxygen. 3. If you suspect the presence of a toxic gas, call for specialized resources such as the HazMat team. - never approach a contaminated PT unless you have specialized HazMat training and appropriate PPE 4. A self-contained breathing apparatus is necessary to protect yourself from poisonous fumes. - if u don't have the proper training or equipment defer to people who do 5. Some patients may need decontamination by the HazMat team after removal from the toxic environment. a. The patient's clothing should be removed in this process because it may contain trapped gases that can be released, exposing you to the substance. - you cannot render care until this is done and no danger to you exists - Carbon monoxide - colorless/odorless, produces severe hypoxia without damaging/irritating the lungs - Chlorine - very irritating to tissues, cause airway obstruction and pulmonary edema 6. The patient may have the following signs and symptoms: burning eyes, sore throat, cough, chest pain, hoarseness, wheezing, respiratory distress, dizziness, confusion, headache, or stridor in severe cases. - may have seizures and AMS - most inhaled poisons can be treated by removing the PT, fresh air and oxygen - some inhaled poisons cause ongoing damage, even after removal from direct exposure - damage may not be evident for several hours - may take 2-3 days for intensive care to restore normal lung function 7. All patients who have inhaled poison require immediate transport to an emergency department. a. Be prepared to use supplemental oxygen via a nonrebreathing mask and/or ventilatory support with a BVM, if necessary. b. Pulse oximetry readings may not be accurate with inhaled poisons. c. Make sure a suctioning unit is available in case the patient vomits. - alternative heating systems in poorly ventilated systems - increase in carbon monoxide poisonings

Sympathomimetics

1. Sympathomimetics are CNS stimulants that mimic the effects of the sympathetic (fight-or-flight) nervous system. a. These stimulants frequently cause hypertension, tachycardia, and dilated pupils. b. A stimulant is an agent that produces an excited state. 2. Examples include amphetamines, methamphetamines, phentermine hydrochloride (appetite suppressant), and amphetamine sulfate (Benzedrine - weight control, narcolepsy, chronic fatigue syndrome) - caffeine and phenylpropanolamine (nasal decongestant) - mild sympathomimetics a. Designer drugs, such as MDMA (ecstasy or Molly), are also frequently abused in certain areas of the United States. b. Commonly taken by mouth; they are also injected by drug abusers - commonly taken because they make the patient "feel good" improve task performance, suppress appetite, prevent sleepiness - may produce irritability, anxiety, fear, lack of concentration, seizures - paranoia and delusions are common symptoms 3. Cocaine (crystal, snow, freebase, rock, gold dust, blow and lady) may be taken in a number of different ways. - is one of the most addictive substances known - classically inhaled through the nose into the nasal mucosa - damages tissue causes nosebleeds, ultimately destroys the septum - injected IV or subcutaneously (skin popping) a. It can be absorbed through all mucous membranes and even across the skin. b. Immediate effects include excitement and euphoria and last less than an hour. c. Smoked crack produces the most rapid means of absorption and, therefore, the most potent effect. - crack is pure cocaine, melts at 93% vaporizes slightly higher so is easily smoked - reaches capillary network of the lungs and can be absorbed in seconds - immediate outflow of blood from the heart speeds drug to the brain, its effect is felt at once 4. Acute overdose is a genuine emergency. a. Patients have a high risk of seizures, cardiac dysrhythmias, and stroke. - BP can be as high as 250/150 b. Patients may be experiencing hallucinations or paranoia, placing you at risk. - "cocaine bugs" pts thinks bugs are under the skin - poisoned patients may be paranoid c. Law enforcement officers should restrain the patient if necessary. d. Do not leave the patient unattended during transport. 5. Patients need prompt transport to the ED. Give supplemental oxygen and be ready to provide suctioning.

Cholinergic agents

1. These agents overstimulate normal body functions that are controlled by the parasympathetic nerves. - used in chemical warfare, organophosphate insecticides, 2. Includes "nerve gases" designed for chemical warfare and organophosphate insecticides. a. Poisoning results in: i. Excessive salivation or drooling ii. Mucus membrane oversecretion iii. Runny nose iv. Excessive urination v. Tearing of the eyes vi. Uncontrolled diarrhea vii. Abnormal heart rate 3. The signs and symptoms of cholinergic drug poisoning are easy to remember with the mnemonic DUMBELS: a. Diarrhea b. Urination c. Miosis (constriction of the pupils) d. Bradycardia, bronchospasm, bronchorrhea (discharge of mucus from the lungs) e. Emesis (vomiting) f. Lacrimation (tearing) g. Seizures, salivation, sweating 4. Alternatively, you can use the mnemonic SLUDGEM: a. Salivation, sweating b. Lacrimation c. Urination d. Defecation, drooling, diarrhea e. Gastric upset and cramps f. Emesis g. Muscle twitching/miosis - patients may have brady cardia 5. The most important consideration is to avoid exposure yourself. a. Decontamination may take priority over immediate transport bc they cling to clothing and skin i. In many jurisdictions, the HazMat team will provide decontamination and contain the exposure chemical. b. Your priorities after decontamination are to: i. Decrease the secretions in the mouth and trachea. ii. Provide airway support. 6. Antidote kits may be available - developed by the military a. Most common is the DuoDote Auto-injector. b. The kit consists of a single auto-injector containing 2 mg atropine (dry up secretions) and 600mg pralidoxime (reverse nerve agents' effects on NS) c. If a known exposure to nerve agents or organophosphates with manifestation of signs and symptoms has occurred, use the antidote kit on yourself - receive training on how to use them

Anticholinergic agents

1. These are medications that have properties that block the parasympathetic nerve. 2. The classic picture of a person who has taken too much of an anticholinergic medication is "hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as a hatter." 3. In other words, they will exhibit hyperthermia, dilated pupils, dry skin/mucosa membranes reddened skin, agitated/delirium 3. Common drugs with an anticholinergic effect include atropine, Benadryl, jimsonweed, and amitriptyline (Elavil). a. With the exception of jimsonweed, these medications usually are not abused drugs may be taken to cause an intentional overdose 4. It is often difficult to distinguish between an anticholinergic overdose and a sympathomimetic overdose. Both groups of patients may be agitated and have tachycardia and dilated pupils. - as safer antidepressants are added to the market u can expect to see fewer overdoses - tricyclic antidepressant overdoses may cause more serious life-threatening effects bc the meds may block the electrical conduction system - lethal cardiac dysthymias 5. Some tricyclic antidepressants have significant anticholinergic effects. a. Death from these agents can be rapid—the patient can go from appearing "normal" to seizure and death within 30 minutes. b. The seizures and dysrhythmias are best treated in the hospital. c. Transport immediately; consider calling for ALS backup en route.

Absorbed and surface contact poisons

1. These poisons can affect the patient in many ways. a. Skin, mucous membrane, or eye damage b. Chemical burns c. Rashes or lesions d. Systemic effects - acids, alkali, and some petroleum (hydrocarbons) are very destructive 2. It is important to distinguish between contact burns and contact absorption. - some substances are absorbed into the bloodstream through the skin and produce systematic effects - other substances such as poison ivy and poison oak cause an itchy rash without being dangerous to the PTS health - absorption of toxic substances through the skin is a common problem in the agriculture/manufacturing industries - most solvents, insecticides, herbicides and pesticides are toxic and easily absorbed through the skin 3. Signs and symptoms of absorbed poisoning include: a. A history of exposure b. Liquid or powder on a patient's skin c. Burns d. Itching e. Irritation f. Redness of the skin in light skinned people g. Typical odors of the substance 4. Emergency treatment for a typical contact poisoning includes: a. Avoid contaminating yourself or others. b. While protecting yourself, remove the substance from the patient as rapidly as possible. 5. Remove all contaminated clothing. 6. Flush and wash the skin. a. If dry powder has been spilled, brush off the powder (avoid creating a dust cloud), then flood the area with water for 15 to 20 minutes, then wash skin with soap and water. b. If liquid has been spilled onto the skin, flood for 15 to 20 minutes. c. If a chemical agent is introduced to the eyes, irrigate them quickly and thoroughly, from the bridge of the nose outward to avoid contaminating the other eye - u can use a nasal cannula - initiate this on scene and continue during transport - may have to help the patient keep their eyes open 7. Many chemical burns occur in an industrial setting. a. Safety showers and specific protocols for handling surface burns may be available. b. A HazMat team should be available to assist you. c. Ensure you, your team members, and the exposed patient are thoroughly decontaminated - failure to do so can contaminate the entire emergency department d. After decontamination, promptly transport to the ED for definitive care. e. Obtain material safety data sheets from the industrial sites and transport with the patient. i. If not immediately available, have the company fax them to the hospital.

Secondary assessment

1. You may not have time to conduct a secondary assessment. 2. Physical examinations a. Focus on the area of the body involved with the poisoning or the route of exposure. b. Once the ABCs have been addressed and managed in the primary assessment, conducting a thorough physical examination will provide additional information on the exposure. c. A general review of all body systems may help to identify systemic problems. 3. A complete set of baseline vital signs is important. a. Many poisons produce no outward indications of the seriousness of the exposure. b. Alterations in the level of consciousness, pulse, respirations, blood pressure, and skin are the more sensitive indicators that something serious is wrong.

How Poisons Enter the Body

A. Emergency care for a patient who has been poisoned may include actions that range from reassuring an anxious parent to performing CPR. - definitive care can only be provided at the hospital so transport promptly 1. Most often, you will not be administering a specific antidote (substance that counteracts the effects of a particular poison) because most poisons do not have one. a. The medication antidote most commonly available to prehospital providers is naloxone (Narcan), which is used to reverse the effects of an opioid overdose. - ALS may be able to offer more 2. Definitive treatment can only be provided at the ED, so transport promptly. 3. The most important treatment you can perform for a poisoning is diluting and/or physically removing the poisonous agent. 4. How you provide treatment depends on how the poison got into the patient's body in the first place. 5. The four routes to consider are: a. Inhalation b. Absorption (surface contact) c. Ingestion d. Injection 6. All four routes of poisoning can lead to serious and possibly life-threatening conditions. a. Take care to treat patients appropriately. b. Keep yourself safe from harm. 7. If you are uncertain how to treat a patient who has been poisoned or exposed to a specific substance, find the container, if possible, and contact medical control and/or the poison control center before you proceed.

Emergency Medical Care

A. Ensure scene safety. 1. Follow standard precautions. 2. Perform external decontamination. B. Remove tablets or fragments from the patient's mouth and wash or brush the poison from the patient's skin. C. Treatment focuses on support. 1. Assess and maintain the patient's ABCs. 2. Provide oxygen and perform assisted ventilations if necessary. 3. Keep the patient warm, treat for shock, if necessary, and transport the patient promptly to the nearest appropriate hospital.

Introduction

A. Every day, we come into contact with things that are potentially poisonous. 1. Almost any substance may be a poison in certain circumstances. 2. Different doses can turn even a remedy into a poison—for example, aspirin - safe if taken in the recommended dose but if too much is taken it can cause death B. Acute poisoning affects 2 million people each year. C. Chronic poisoning is more common - long term abuse of meds, alc, and tabacco D. Deaths caused by poisoning are fairly rare. 1. Rates of death as the result of poisoning in children have decreased steadily since the 1960s due to child-resistant caps. 2. Deaths caused by chronic poisoning in adults have been rising as a result of drug abuse. - as an EMT u must recognize acute/chronic poisonings have a variety of signs and symptoms - cannot stop chronic substance abuse but might be able to save a life in acute poisonings simply by airway management, and symptomatic treatment - drugs can work tother to increase adverse effects and prevent a drug from working as expected

Food Poisoning

A. Food poisoning is almost always caused by eating food contaminated by bacteria. B. There are two main types of food poisoning. 1. The organism itself may cause disease. 2. The organism may produce toxins that cause disease. C. One organism that produces direct effects of food poisoning is the Salmonella bacterium. 1. Salmonellosis is characterized by severe gastrointestinal symptoms within 72 hours of ingestion, including nausea, vomiting, abdominal pain, and diarrhea. 2. Proper cooking kills bacteria, and proper cleanliness in the kitchen prevents the contamination of uncooked foods. D. The more common cause of food poisoning is the ingestion of powerful toxins produced by bacteria, often in leftovers. 1. The bacterium Staphylococcus is quick to grow and produce toxins in food. 2. Foods left unrefrigerated are a common vehicle. 3. Results in sudden GI symptoms, including nausea, vomiting, and diarrhea 4. Symptoms usually start within 2 to 3 hours after ingestion or as long as 8 to 12 hours after ingestion. E. The most severe form of toxin ingestion is botulism. 1. Botulism can result from eating improperly canned food. a. The spores of Clostridium bacteria grow and produce a toxin. 2. The symptoms are neurologic. a. Blurring of vision b. Weakness c. Difficulty in speaking and breathing 3. Often fatal, symptoms may develop within the first 24 hours after ingestion or as long as 4 days later. F. In general, do not try to determine the specific cause of acute gastrointestinal problems. 1. Gather as much history as possible from the patient. 2. Transport him or her promptly to the hospital. 3. When two or more persons in one group have the same illness, you should take along some of the suspected food.

Specific Poisons

A. Over time, a person who routinely misuses a substance may need increasing amounts of it to achieve the same result. 1. This is called developing a tolerance to the substance. 2. A person with an addiction has an overwhelming desire or need to continue using the substance, at whatever cost, with a tendency to increase the dose. 3. Almost any substance can be abused - including laxatives, nasal decongestants, vitamins and food B. The importance of safety awareness and standard precautions in caring for victims of drug abuse cannot be overemphasized. 1. Known drug abusers have a fairly high incidence of serious and undiagnosed infections, including HIV and hepatitis. a. These patients may bite, spit, hit, or otherwise injure you while intoxicated - u can come into contact with their blood and body fluids b. Always wear appropriate protective equipment. - professional and calm demeaner can diffuse a frightening situation - safety of yourself and team is most important c. Expect the unexpected and remember: the drug user, not the drug, can pose the greatest threat.

Plant Poisoning

A. There are tens of thousands of cases of plant poisoning annually. 1. Many household plants are poisonous if ingested. 2. Some cause local skin irritation. 3. Some can affect the circulatory system, the gastrointestinal tract, or the CNS. B. It is impossible to memorize every plant and poison, let alone their effects. 1. You can and should do the following: a. Assess the patient's airway and vital signs. b. Notify the regional poison center for assistance in identifying the plant. c. Take the plant to the emergency department. d. Provide prompt transport. C. Irritation of the skin and/or mucous membranes is a problem with the common houseplant called dieffenbachia. 1. When chewed, a single leaf may irritate the lining of the upper airway enough to cause difficulty swallowing, breathing, and speaking. 2. Emergency medical treatment includes: a. Maintaining an open airway b. Giving oxygen c. Transporting the patient promptly to the hospital for respiratory support

Identifying the Patient and the Poison

Toxicology is the study of toxic or poisonous substances. 1. A poison is any substance whose chemical action can damage body structures or impair body function. 2. A toxin is a poisonous substance produced by bacteria, animals, or plants that acts by changing the normal metabolism of cells or destroying them. a. Toxins can have acute (injection of heroin - respiratory arrest) or chronic effects (years of substance abuse - weakened immune system) 3. Substance abuse is the misuse of any substance to produce a desired effect. a. A common complication of substance abuse is overdose, when a patient takes a toxic dose of a substance.

Naloxone (Narcan) is an antidote that reverses the effects of opiate or opioid overdose.

a. Can be given by the intravenously, intramuscularly, or intranasally - IV is the best route however that is difficult in chronic users - these patients have venous scarring called track marks from repeated use of needles in peripheral veins - IN is preferred over IM because no needle is used b. In many EMS systems, EMTs administer naloxone by the intranasal route. i. Atomized through the nares into the nasal mucosa - be aware that the drug can cause harm ii. Should only be used when the patient has agonal respirations or is apneic c. Place an oropharyngeal airway and ventilate the patient using a BVM prior to administering naloxone. i. Adequate ventilation decreases the risk of permanent brain damage related to hypoxia. ii. As the level of consciousness rises, the patient will react to the presence of the oropharyngeal airway and you will have to remove it to prevent aspiration. d. In some areas, lay people are permitted to administer naloxone; find out from bystanders if the patient was given naloxone. -Ventilations is an important treatment in these patients - if they're unresponsive and in cardiac arrest - begin chest compressions and prepare AED - administer naloxone - if still unresponsive - continue CPR prepare AED - repeat Narcan after 4 mins preform defibrillation as soon as possible

Some patients use inhaled poisons to commit suicide in a vehicle.

a. Leaving a car engine running in an enclosed garage can cause the exhaust fumes, which contain high levels of carbon monoxide, to cause the patient to lose consciousness and eventually stop breathing. b. A recent variation involves using chemicals or detergent in a tightly sealed vehicle as a type of gas chamber - people mix household chemicals to produce hydrogen sulfide gas which is quickly fatal c. When you open the door, you may be overcome as well. d. Contact HazMat responders and have them remove the victim if u suspect this occurred - if multiple ppl are down with no MOI/NOI be suspicious think mass casualty - especially true if multiple ppl have AMS - toxic fumes are often odorless/colorless and seem harmless such as sewer gas - incapacitated EMTS help no one