Chapter 21 Toxicology

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

poisoning call Scene size-up

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.

Activated charcoal dose

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 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.

Hallucinogens

These agents: a. Cause visual hallucinations b. Intensify vision and hearing c. Generally separate the user from reality 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.

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. 3. Alcohol increases the effects of many other drugs and is commonly taken with other substances. 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. 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

n situations where a patient may have an inhalation injury (typically carbon monoxide and/or cyanide poisoning),

place the patient on high-flow oxygen regardless of the pulse oximetry reading.

toxin

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 or chronic effects.

Emergency care for a patient who has been poisoned may include actions that range from

reassuring an anxious parent to performing CPR. 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.

All patients who have inhaled poison require

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

signs symptoms of drugs

see image

Salmonellosis is characterized by

severe gastrointestinal symptoms within 72 hours of ingestion, including nausea, vomiting, abdominal pain, and diarrhea. Patients may be systemically ill with fever and generalized weakness. 2. Proper cooking kills bacteria, and proper cleanliness in the kitchen prevents the contamination of uncooked foods.

Toxicology

study of toxic or poisonous substances

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.

Substance abuse

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.

opioid

type of narcotic medication used to relieve pain These agents are CNS depressants and can cause severe respiratory depression and then cardiac arrest if not treated promptly. a. Tolerance develops quickly, so some users may require massive doses to experience the same high. b. These drugs often cause nausea and vomiting and may lead to the development of hypotension. c. Although seizures are uncommon, they can occur. d. Patients typically appear sedated or unconscious and cyanotic with pinpoint pupils. i. Pinpoint pupils are the most commonly accepted sign of opiate abuse.

methyl alcohol and ethylene glycol

will cause severe tachypnea, blindness, renal failure, and eventually death. b. Immediate transport to the emergency department is essential.

Synthetic cathinones (bath salts)

1. An emerging class of drugs similar to MDMA. 2. Sold as bath salts to escape the legal restrictions imposed on illicit drugs. a. Brand names include Ivory Wave and Cloud Nine. 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.

Sedative-hypnotic drugs

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. 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. c. IV sedative-hypnotic drugs quickly induce tolerance, so the person requires increasingly larger doses. 3. These drugs may be given to people as a "knock-out" drink, or "Mickey Finn," to incapacitate them without their knowledge. 4. Generally, your treatment is to ensure airway is patent, assist ventilations, and provide prompt transport.

poisoning call 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.

poisoning call Primary assessment

1. Determine the severity of the patient's condition. 2. Airway and breathing 3. Circulation 4. Transport decision

food poisoning 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.

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. 4. Used to commit suicide; referred to as chemical or detergent suicide a. If you approach an enclosed vehicle with an unconscious patient inside, be alert for warning signs, as well as containers, buckets, or pots. b. If you suspect the presence of a toxic gas, wait for a HazMat team to tell you the scene is safe. 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

Try to determine the nature of the poison.

1. Look around the immediate area for an 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 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.

Inhaled poisons

1. Move the patient into fresh air immediately. 2. The patient may require supplemental oxygen. 3. If you suspect the presence of a toxic gas, call for specialized resources such as the HazMat team. 4. A self-contained breathing apparatus is necessary to protect yourself from poisonous fumes. 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.

There are two main types of food poisoning.

1. The organism itself may cause disease. 2. The organism may produce toxins that cause disease.

Abused inhalants

1. These agents are inhaled instead of ingested or injected. 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. a. These are commonly abused by teenagers. b. The effective dose and the lethal dose are very close, making these extremely dangerous drugs. 3. Take special care in dealing with a patient who may have used inhalants. a. Halogenated hydrocarbon solvents can make the heart hypersensitive to the patient's own adrenaline. b. Even the action of walking may cause a fatal ventricular dysrhythmia. c. Try to keep such patients from struggling with you or exerting themselves. 4. Use a stretcher to move the patient, give oxygen, and transport the patient to the hospital.

Ingested poisons Signs and symptoms include

burns around the mouth, gastrointestinal pain, vomiting, cardiac dysrhythmias, and seizures.

Cholinergic agents

1. These agents overstimulate normal body functions that are controlled by the parasympathetic nerves. 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 The most important consideration is to avoid exposure yourself. a. Decontamination may take priority over immediate transport. 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. a. Most common is the DuoDote Auto-injector. b. The kit consists of a single auto-injector containing atropine and pralidoxime. c. If a known exposure to nerve agents or organophosphates with manifestation of signs and symptoms has occurred, use the antidote kit on yourself.

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. Common drugs include atropine, Benadryl, jimsonweed, and amitriptyline (Elavil). a. With the exception of jimsonweed, these medications usually are not abused drugs. 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. 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.

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

poisoning call 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.

Signs and symptoms of absorbed poisons include:

A history of exposure Liquid or powder on a patient's skin Burns Itching Irritation Redness of the skin in light-skinned people Typical odors of the substance

Ingested poisons examples

About 80% of poisoning is by mouth. a. Liquids b. Household cleaners c. Contaminated food d. Plants e. Drugs

treatment Injected poisons

Monitor the airway, Provide high-flow oxygen for any patient with respiratory distress or signs of hypoxia (SpO2 level 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 to the emergency department is essential. Take all containers, bottles, and labels with the patient to the hospital.

Ingested poisons treatment

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. 7. Some EMS systems allow EMTs to administer activated charcoal. 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, to a patient who has ingested an opioid, a sedative, or a barbiturate, each of which can cause depression of the central nervous system (CNS) and slow breathing.

If you believe a patient has been poisoned, immediately provide the poison center with all relevant information:

When the poisoning occurred Evidence found at the scene A description of the suspected poison, including the amount involved The patient's size, weight, and age

narcotic

a drug that produces sleep or altered mental consciousness.

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.

poisoning call Circulation

a. Assess the pulse and skin condition. b. You will find variations depending on the substance involved.

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. Remove all contaminated clothing. 6. Flush and wash the skin. a. If dry powder has been spilled, brush off the powder, 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

poisoning call 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

four routes of poisoning

a. Inhalation b. Absorption (surface contact) c. Ingestion d.Injection

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 hydrogen sulfide gas chemicals or detergent in a tightly sealed vehicle as a type of gas chamber. c. When you open the door, you may be overcome as well. d. Contact HazMat responders and have them remove the victim.

poisoning call 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.

poisoning call History taking 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

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

poisoning call 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.

Inhaled poisons 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.

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. d. After decontamination, promptly transport to the ED for definitive care. e. Obtain material safety data sheets and transport with the patient. i. If not immediately available, have the company fax them to the hospital.

Absorbed and surface contact 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

poisoning call History taking 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?

Ingested poisons Signs and symptoms vary greatly with the:

a. Type of poison b. Age of the patient c. Time that has passed since the ingestion

Injected poisons Signs and symptoms include:

a. Weakness b. Dizziness c. Fever d. Chills e. Unresponsiveness f. Excitability

poisoning 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?

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

Sympathomimetics Examples include

amphetamines, methamphetamines, phentermine hydrochloride, and amphetamine sulfate (Benzedrine). a. Designer drugs, such as MDMA (ecstasy or Molly), are also frequently abused in certain areas of the United States.

poison

any substance whose chemical action can damage body structures or impair body function.

Sympathomimetics are

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. Irritability Anxiety Fear Lack of concentration Seizures Paranoia Delusions

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.

Patients in alcohol withdrawal may experience

experience frightening hallucinations, or delirium tremens (DTs). 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 These conditions may develop after a person stops drinking or when alcohol consumption levels are decreased suddenly. c. Provide prompt transport. d.Reassure the patient and provide necessary care and emotional support

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.

Severe, acute alcohol ingestion may cause

hypoglycemia.

Aspirin poisoning Ingesting too many may result in:

i. Nausea ii. Vomiting iii. Hyperventilation iv. Ringing in the ears Patients with this problem frequently have: i. Anxiety ii. Confusion iii. Tachypnea iv. Hyperthermia v. Danger of having seizures

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. c.The patient's condition can be life threatening; you must act quickly

Acute cocaine overdose is an emergency because

is a genuine emergency. a. Patients have a high risk of seizures, cardiac dysrhythmias, and stroke. b. Patients may be experiencing hallucinations or paranoia, placing you at risk. 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.

Naloxone (Narcan)

is an antidote that reverses the effects of opiate or opioid overdose. a. Can be given by the intravenously, intramuscularly, or intranasally b. In many EMS systems, EMTs administer naloxone by the intranasal route. i. Atomized through the nares into the nasal mucosa 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.

Your primary responsibility to the patient who has been poisoned is

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. 2. Very small amounts of some poisons can cause considerable damage or death. 3. If you suspect that ingestion or exposure to a toxic substance has occurred, notify medical control and begin emergency treatment at once.

Synthetic opioids include

meperidine, hydromorphone, oxycodone, hydrocodone, and methadone.

Most often, you will not be administering a specific antidote because

most poisons do not have one.

The phone number of your regional poison center is typically listed

n the inside cover of your local phone book or on the American Association of Poison Control Centers (AAPCC) website. The Poison Help hotline is 1-800-222-1222 (available 24 hours a day, 7 days a week).

The medication antidote most commonly available to prehospital providers is

naloxone (Narcan), which is used to reverse the effects of an opioid overdose.

Hydrogen sulfide Signs and symptoms include

nausea and vomiting, confusion, dyspnea, a loss of consciousness, seizures, shock, coma, and cardiopulmonary arrest.