EMT Chap 21 Toxicology

Cholinergics (nerve gas, organophosphates)

-airway compromise SLUDGEM S Salivation, sweating L Lacrimation U Urination D Defecation, drooling, diarrhea G Gastric upset and Cramps E Emesis M Muscle twitching

sympathomemetics (epi, albuterol, cocaine, meth)

-hypertension -tachycardia -dilated pupils -Agitation or seizures -hyperthermia

Opiodes/Opiates

-hypoventilation -respiratory arrest -pinpoint pupils -sedation or coma -hypotension

sedative-hypnotics (diazepam)

-slurred speech -sedation or coma -hypoventilation -hypotension

anticholinergics (atropine)

-tachycardia -hyperthermia -hypertension -dilated pupils -dry skin -sedation -decreased bowel sounds

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). 5. 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.

Scene-size up in toxicological emergencies

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 e. 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 4. Signs and symptoms include burns around the mouth, gastrointestinal pain, vomiting, 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. 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.

1.Which of the following questions is of LEAST pertinence for the EMT to ask a patient who intentionally overdosed on a medication? A."How much do you weigh?" B."How much did you ingest?" C."What substance did you take?" D."Why did you take the medication?"

D."Why did you take the medication?"

7.Which of the following effects does drinking alcohol NOT produce? A.Induction of sleep B.Slowing of reflexes C.Inappropriate behavior D.Increased sense of awareness

D.Increased sense of awareness

Poisonous plants include

Dieffenbachia (A), Mistletoe (B), Castor Bean (C), Nightshade (D), Foxglove (E), Rhododendron (F) Jimsonweed (G), Death camas (H), Poison ivy (I), Poison oak (J), Pokeweed (K), Rosary pea (L), Poison sumac (M)

Botulism

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.

Signs & Symptoms

The signs and symptoms of poisoning vary according to the specific agent. 1. The presence of injuries at the patient's mouth strongly suggests the ingestion (swallowing) of a poison.

5.How much activated charcoal should you administer to a 55-pound child who swallowed a bottle of aspirin? A.12.5 g B.25 g C.2 g/kg D.50 g

The usual dose of activated charcoal for adults and children is 1 g of charcoal per kg of body weight. To convert a patient's weight from pounds to kilograms, simply divide the weight in pounds by 2.2. Therefore, a 55-pound child should receive 25 g of activated charcoal (55 [pounds] ÷ 2.2 = 25 [kg]). The average pediatric dosing range for activated charcoal is 12.5 to 25 g. 25 g

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.

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.

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. c. The patient's condition can be life threatening; you must act quickly. 2. Signs and symptoms include: a. Weakness b. Dizziness c. Fever d. Chills e. Unresponsiveness f. Excitability 3. Monitor the airway, provide high-flow oxygen, and be alert for nausea and vomiting. 4. Remove rings, watches, and bracelets from areas around the injection site if swelling occurs.

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. 2. 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.

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

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.

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. 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. 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. 5. Patients in alcohol withdrawal may experience frightening hallucinations, or 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. 5. Patients in alcohol withdrawal may experience frightening hallucinations, or delirium tremens (DTs).

Marijuana

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. 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. 4. Several states have legalized the recreational use of marijuana, and others allow for the medical use of marijuana and products that contain THC. 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. 5. Synthetic marijuana or "Spice" refers to a variety of herbal incense or smoking blends that resemble THC and produce a similar high. a. Powerful and unpredictable effects may result, ranging from simple euphoria to complete loss of consciousness.

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. 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. 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. 8. 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. c. When you open the door, you may be overcome as well. d. Contact HazMat responders and have them remove the victim.

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, and amphetamine sulfate (Benzedrine). 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 3. Cocaine may be taken in a number of different ways. 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. 4. Acute overdose 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.

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.

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 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 5. 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.

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 2. It is important to distinguish between contact burns and contact absorption. 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 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, 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. 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. 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.

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. 1. Most often, you will not be administering a specific antidote 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. 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 for Toxicology

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. Treat for shock, if necessary, and transport the patient promptly to the nearest appropriate hospital. D. 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. 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 4. Before you give a patient charcoal, obtain approval from medical control. a. Shake the bottle vigorously to mix the suspension. b. You may need to convince the patient to drink it, but never force it. 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. 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.

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. 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. 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. b. Always wear appropriate protective equipment. 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. 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

2.A 30-year-old male, who ingested an unknown substance, begins to vomit. You should: A.collect the vomitus and bring it to the hospital. B.apply a bag-valve mask. C.analyze the vomitus and try to identify the poison. D.suction his oropharynx for no longer than 30 seconds.

A.collect the vomitus and bring it to the hospital.

9.The mnemonic DUMBELS can be used to recall the signs and symptoms of a cholinergic drug poisoning. The "E" in DUMBELS stands for: A.emesis. B.erythema. C.ecchymosis. D.elevated blood pressure.

A.emesis.

Delirium tremens (DTs)

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. 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. 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. 5. Patients in alcohol withdrawal may experience frightening hallucinations, or delirium tremens (DTs).

Naloxone (Narcan)

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.

8.A 21-year-old male was found unconscious in an alley. Your initial assessment reveals that his respirations are slow and shallow, and his pulse is slow and weak. Further assessment reveals that his pupils are bilaterally constricted. His presentation is MOST consistent with an overdose of: A.cocaine. B.an opioid. C.a stimulant drug. D.methamphetamine.

B.an opioid.

3.When caring for a patient with a surface contact poisoning, it is important to remember to: A.prevent contamination of the patient. B.avoid contaminating yourself or others. C.let the hospital remove the surface poison. D.immediately flush dry chemicals with water.

B.avoid contaminating yourself or others.

4.Most poisonings occur via the _________ route. A.injection B.ingestion C.inhalation D.absorption

B.ingestion

10.Food poisoning is almost always caused by eating food that contains: A.fungi. B.viruses. C.bacteria. D.protozoa.

C.bacteria.

6.After taking Vicodin for 2 years for chronic pain, a 40-year-old woman finds that her usual dosage is no longer effective and goes to the doctor to request a higher dosage. This is an example of: A.addiction. B.dependence. C.tolerance. D.drug abuse.

C.tolerance.

Intro

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. B. Acute poisoning affects 2 million people each year. C. Chronic poisoning is more common. 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.

Toxicology

Recognition and management of: • Carbon monoxide poisoning • Nerve agent poisoning • How and when to contact a poison control center

Toxicology

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 or chronic effects. 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.

Recognize that poisoning has occured

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. 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.

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?

DTs 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. d. Reassure the patient and provide necessary care and emotional support.