Chapter 22 - Toxicology

Introduction

• Every day, we come into contact with potentially poisonous things.

• — poisoning affects over 2 million people each year.

• Chronic poisoning is — —.

• Deaths caused by poisoning are fairly rare.

  • Poisoning in children has decreased steadily since the 1960s due to child-resistant caps.

  • Deaths caused by chronic poisoning in adults have been rising as a result of drug —-.

acute, more common, abuse

Identifying the Patient and the Poison

• Toxicology is the study of toxic or poisonous substances.

  • Poison: any substance whose chemical action can —- body structures or —- body function

  • Toxin: a — substance produced by —-, —, or — 

  • Substance abuse: the —- of any substance to produce a —- effect.

  • Overdose: a toxic —- of a drug.

• Your primary responsibility to the patient is to recognize that a poisoning has occurred.

  • Pay attention to your surroundings. 

  • Very —- amounts of some poisons can cause considerable damage or death.

damage, impair, poisonous, bacteria, animals, plants, misuse, desired, dose, small

Identifying the Patient and the Poison

• The signs and symptoms of poisoning —- according to the specific agent.

• If possible, ask the patient:

  • — substance did you take?

  • — did you take it (or become exposed to it)?

  • How — did you ingest?

  • Did you have anything to — or — before or after you took it?

  • Has anyone given you an antidote or any substance —- since you ingested it? 

  • How much do you —-?

• Try to determine the —- of the poison.

  • Look around the immediate area for clues.

  • Take any suspicious material with you.

  • Containers at the scene can provide critical information.

• If the patient vomits, —- the contents for —- fragments and try to bring some vomitus in a separate bag to the hospital 

• Note and document anything unusual that you see. 

vary, what, when, much, eat drink, orally, weigh, nature, examine, pill 

How Poisons Enter the Body

• How you provide treatment depends on —- the poison got into the patient’s body. 

• Four routes to consider:

  • Inhalation

  • Absorption

  • Ingestion

  • Injection

• All four routes can lead to life-threatening conditions. 

• This most common route is —— (80%) 

how, ingestion 

Inhaled Poisons

• Move the patient into —- air immediately.

• The patient may require supplemental —.

• If you suspect the presence of a toxic gas, call for specialized resources such as the —- team.

• Some patients may need —- by the hazmat team after removal from the toxic environment.

• All patients who have inhaled poison require —- transport.

  • Be prepared to use supplemental oxygen.

  • Make sure a —- unit is available.

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

  • Exhaust fumes contain high levels of — —.

fresh, oxygen, hazmat, decontamination, immediate, suctioning, c carbon monoxide,

Absorbed and Surface Contact Poisons

• Can affect the patient in many ways:

  • Skin, mucous membrane, or eye damage

  • Chemical burns

  • Rashes or lesions

  • Systemic effects

• It is important to distinguish between contact —- and contact —-

  • Contact burn = — tissue damage

  • Contact absorption = absorbed through the skin into the —- ( —- effects).

• Signs and symptoms include:

  • A history of exposure

  • Liquid or powder on a patient’s skin

  • Burns

  • Itching

  • Irritation

  • Redness of skin

  • Typical odors of the substance

burns, absorption, local, bloodstream, systemic 

Absorbed and Surface Contact Poisons

• Emergency treatment:

  • Avoid contaminating —- or others.

  • — the substance from patient as rapidly as possible.

• Remove all contaminated —-.

• Flush and wash the skin.

• If dry powder has been spilled

  • —- —- the powder

  • Flood the area with —- for 15 to 20 minutes

  • — skin with soap and water. 

• If liquid has been spilled onto the skin, —- for 15 to 20 minutes.

• If a chemical agent is introduced to the eyes, —- them quickly and thoroughly. 

• Many chemical burns occur in an industrial setting.

  • Safety showers and specific protocols for handling surface burns may be available. 

  • Hazmat team should be available to assist you. 

  • After decontamination, promptly transport to the ED for definitive care.

  • Obtain material —- — —.

yourself, remove, clothing, brush off, water, wash, flood, irrigate, safety data sheets 

Ingested Poisons

• About 80% of poisoning is by —-.

  • Liquids

  • Household cleaners

  • Contaminated food

  • Plants

  • Drugs

• Usually accidental in —- and deliberate in —

• Signs and symptoms include —- around the mouth, —- pain, —-, cardiac dysrhythmias, and seizures.

• Treat signs and symptoms and notify the —- center and — — of the patient’s condition.

• Consider whether there is — poison remaining in the gastrointestinal tract and whether you can safely and effectively —- its absorption. 

• Some EMS systems allow EMTs to administer —- —-.

• Always immediately assess the —- of every patient who has been poisoned. 

mouth, children, adults, burns, GI, vomiting, poison, medical control, unabsorbed, prevent, activated charcoal, ABCs

Injected Poisons

• Exposure includes intravenous — —- and — by insects, arachnids, and reptiles. 

• Usually absorbed —- into the body or cause intense —- tissue destruction 

• Cannot be diluted or removed from the body in the field

• Signs and symptoms may include weakness, dizziness, fever/chills, unresponsiveness, and excitability.

• Monitor the airway, provide high-flow oxygen, and be alert for nausea and vomiting.

• Remove rings, watches, and bracelets from areas around the injection site if —- occurs.

drug abuse, envenomation, quickly, local, swelling

Scene Size-up

• Take standard precautions and look for clues:

  • Is there an —- in the room? Is the scene —-? 

  • Are there medication —- lying around? Is there medication —- that might indicate an overdose?

  • Are —- beverage containers present?

  • Are there — or other drug paraphernalia?

  • Is there a suspicious odor that may indicate the presence of a drug laboratory?

odor, safe, bottles, missing, alcoholic, syringes,

Primary Assessment

• Determine the severity of the patient’s condition. 

  • Obtain a general impression.

  • Assess the level of consciousness.

  • Determine any life threats.

  • Do not assume a conscious, alert, and oriented patient is in —— condition.

• Airway and breathing

  • Ensure that the patient has an — airway and adequate —-.

  • If patient has difficulty breathing or an inhalation injury, begin oxygen therapy.

  • Have —— available; these patients are susceptible to vomiting. 

• Circulation

  • Assess the pulse and skin condition.

  • Will vary depending on the —- involved

• Transport decision

  • Consider prompt transport for patients with obvious alterations in the XABCs or for patients you have determined have a poor general impression.

  • Everyone who is exposed to the hazardous material must be thoroughly decontaminated by the hazmat team —- leaving the scene. 

stable, open, ventilation, suction, substance, before

History Taking

• Investigate the chief complaint.

  • If your patient is responsive, begin with an evaluation of the exposure and the SAMPLE history.

  • If your patient is unresponsive, obtain the history from other sources.

• In addition to SAMPLE, ask the following questions:

  • — is the substance involved?

  • — did the patient become exposed to it?

  • — — did the patient ingest or what was the level of exposure?

• Questions (cont’d):

  • Over what period did the patient take or was exposed to the substance?

  • Has the patient or a bystander performed any intervention?

  • How much does the patient weigh?

what, when, how much 

Secondary Assessment

• Physical examinations

  • Focus on the area of the body involved with the poisoning or the —- of exposure.

  • A general review of —- body systems may help to identify systemic problems.

• A complete set of baseline — —- is important.

route, all, vital signs

Reassessment

• Reassess the adequacy of the XABCs.

• Repeat vital signs; compare them with the baseline set. 

• Evaluate your interventions.

  • Every 15 minutes for a stable patient

  • Every 5 minutes or —-, for a patient who has consumed a harmful or lethal dose

• Treatment

  • Supporting the —— is your most important task.

  • Contact medical control or a poison center to discuss treatment options.

  • Manage airborne exposures with oxygen.

  • Remove contact exposures with —-.

  • Consider —- —- for ingestions.

• Communication and documentation

  • Report as much information as you have about the poison or chemical to the hospital.

  • Bring the material — — — to the hospital if the poisoning occurred in a work setting.

constantly, ABCs,, water, activated charcoal safety data sheet

Emergency Medical Care

• Ensure scene safety.

• Remove tablets or fragments from the patient’s —-.

• — or — the poison from the patient’s skin.

• Assess and maintain the patient’s —.

• Provide oxygen and perform assisted ventilations if necessary.

• Treat for —— and transport the patient promptly to the nearest hospital.

mouth, flood brush, ABCs, shock

Emergency Medical Care

• Some EMS systems allow EMTs to give activated charcoal by —-. 

• Activated charcoal —- to specific toxins, which are then carried out of the body in the —-. 

• Contraindicated in patients who have ingested

  • —- poisons

  • —

  • — or —

  • — or —

  • — acids or — solvents 

  • A decreased —- and cannot protect their —-

• If local protocol permits, you may carry a premixed suspension of 50 g of activated charcoal.

  • The usual dose for an adult or child is —- per —- of body weight.

• Before you give a patient charcoal, obtain approval from —- —.

  • Shake the bottle vigorously.

  • You may need to convince the patient to drink it, but never force it.

  • Record the —- when you administered activated charcoal.

  • If the patient refuses activated charcoal, document the refusal and transport the patient for further evaluation.

• Side effects are —- and — stools.

• If the patient has ingested a poison that causes nausea, he or she may —- after taking charcoal.

mouth, binds, stool, alkali, cyanide, ethanol methanol, iron lithium, mineral, organic, LOC airway, 1g, 1 kg medical control, time, constipation black, vomit

Specific Poisons

• Over time, a person who routinely misuses a substance may need —- amounts of it to achieve the —- result.

  • This is called developing a —-.

  • A person with an —- has an overwhelming need to continue using the substance, at whatever cost.

  • Almost —- substance can be abused.

• The importance of safety awareness and standard precautions cannot be overemphasized.

  • Known drug abusers have a fairly high incidence of serious and undiagnosed infections, including —- and —-.

increasing same, tolerance, addiction, any, HIV hepatitis

Alcohol

• Many calls for service have a connection to alcohol use.

• Alcohol can damage the —-, whether thorough —- overuse or occasional —- use (— drinking).

• Binge use can be —— damaging than chronic use, depending on the frequency of the binging and the surrounding circumstances.

liver, chronic, heavy, binge, more,

Alcohol

• Alcohol is a powerful —- —-.

  • — activity and excitement (Sedative) 

  • Induces — (hypnotic) 

  • Dulls the sense of —-, slows —, and reduces — —

  • May cause —- and —- behavior and lack of —

  • Alcohol —- the effects of other drugs and is commonly taken with other substances.

• If a patient exhibits signs of serious CNS depression, provide respiratory —-.

  • May cause —-

• Patients may experience frightening —-, or — — (DTs).

• DTs are characterized by:

  • Agitation and restlessness

  • Fever

  • Sweating

  • Tremors

  • Confusion/disorientation

  • Delusions/hallucinations

  • Seizures

CNS depressant, decreases, sleep, awareness, reflexes, reaction time, aggressive, inappropriate, coordination, increases support, vomiting, hallucinations, delirium tremens, 

Opioids

• An opioid is a type of — medication used to relieve —.

• An opiate is a subset of the opioid family, and refers to —, —- opioids.

• Named for the — in — —, from which — and — are derived

• — opioid drugs are among the most commonly abused drugs in the United States.

• Some people become — dependent on opioids after taking an appropriate medical prescription.

narcotic, pain, natural nonsynthetic, opium, poppy seeds, codeine morphine, prescription, physically

Opioids

• These agents are — — and can cause severe respiratory —- and then cardiac —- if not treated promptly.

  • — develops quickly.

  • Some users may require massive doses to experience the same high.

  • Often cause nausea and vomiting

  • May lead to —

• Although seizures are uncommon, they can occur. 

• Patients typically appear sedated or unconscious and cyanotic with —- pupils (—-)

• — reverses the effects of opiate or opioid overdose. 

  • Can be given intravenously, intramuscularly, or intranasally 

  • In many EMS systems, EMTs administer naloxone by the — route. 

  • Should only be used when the patient has — respirations or is —

  • In some areas, lay people are permitted to administer naloxone.

  • Find out from bystanders if the patient was given naloxone.

CNS depressants, depression, arrest tolerance, hypotension pinpoint, miosis, naloxone, intranasal, agonal, apneic,

Sedative-Hypnotic Drugs

• Barbiturates and benzodiazepines are —— —-. 

  • — the level of consciousness. 

  • Patient may appear drowsy, peaceful, or intoxicated.

• These agents are generally taken by —.

  • Occasionally, they are dissolved in water and —-.

  • IV sedative-hypnotic drugs quickly induce —-.

  • These drugs may be given to people as a “knock-out” drink.

  • Treatment is to ensure airway is —, — ventilation, and provide prompt transport.

CNS depressants, alter, mouth, injected tolerance, patent, assist,

Abused Inhalants

• These agents are —-.

  • Acetone, toluene, xylene, hexane

  • Found in —-, —- compounds, paint —, and lacquers

  • — and halogenated hydrocarbons are also abused.

  • Commonly abused by teenagers

• Always use special care.

  • Halogenated hydrocarbon solvents can make the heart —- to the patient’s own —-.

  • Keep patients from —- or — themselves.

  • Use a —- to move the patient, give oxygen, and transport to the hospital.

inhaled, glues, cleaning, thinners, gasoline, hypsensitive, adrenaline, struggling, exerting, stretcher,  

Hydrogen Sulfide

• Hydrogen sulfide 

  • A highly toxic, —-, and —- gas with a distinctive — —- odor

  • Affects —- organs, but it has the most impact on the — and —.

  • Used to commit —-

  • If you suspect the presence of a toxic gas, wait for a —- team to tell you the scene is safe.

• Signs and symptoms: 

  • Nausea and vomiting, confusion, dyspnea, a loss of consciousness, seizures, shock, coma, and cardiopulmonary arrest

• Once the patient has been —-, management is largely supportive. 

  • Monitor and assist the patient’s respiratory and cardiovascular functions.

  • Provide rapid transport.

colorless, flammable, rotten egg, all, lungs CNS, suicide, hazmat, decontaminated

Sympathomimetics

• CNS —- that mimic the effects of the sympathetic nervous system

• Produce an —- state.

  • Frequently cause —, —-, and — pupils

  • Includes —-, methamphetamines, phentermine hydrochloride, and Benzedrine

  • Designer drugs, such as MDMA, are also frequently abused.

  • Commonly taken by mouth; also injected by drug abusers

• Cocaine may be taken in a number of different ways.

  • Can be —- through all mucous membranes and even across the —

  • Immediate effects include excitement and euphoria and last less than an hour.

  • Smoked crack is the most —-.

• Acute overdose is a genuine emergency.

  • Patients have a high risk of —-, cardiac —-, and —-. 

  • Patients may experience —- or paranoia.

  • Do not leave the patient unattended.

  • Provide prompt transport.

stimulants, excited, hypertension, tachycardia, dilated, amphetamines, absorbed, skin, potent, seizures, dysrhythmias, stroke, hallucinations

Synthetic Cathinones (Bath Salts)

• An emerging class of drugs —- to MDMA.

• Produce —-, increased mental clarity, and sexual arousal. 

  • Most users of this drug snort or insufflate the powder —-. 

  • Effects reportedly last as long as 48 hours. 

• Adverse effects include: 

  • Teeth grinding, appetite loss, muscle twitching, lip-smacking, confusion, gastrointestinal conditions, paranoia, headache, elevated heart rate, and hallucinations

• Keep the patient calm and transport. 

• Consider ALS assistance.

similar, euphoria, nasally

Marijuana

• Marijuana is abused throughout the world.

  • — is the chemical in the marijuana plant that produces its —-.

  • Produces euphoria, relaxation, and drowsiness

  • Impairs — — memory and the capacity to do —- thinking

  • Could progress to depression and confusion

• With very high doses, patients may experience —- or become very — or —.

  • Reassure the patient and transport with a minimum amount of excitement.

• Marijuana is often used as a vehicle to get other drugs into the body.

• Several states have legalized the recreational use of marijuana, and others allow for the medical use of marijuana and products that contain THC.

  • “Edibles” infused with marijuana

  • Ingestion can lead to —- —- syndrome.

• Synthetic marijuana or “Spice” 

  • A variety of herbal incense or smoking blends that resemble THC and produce a similar high

  • Powerful and unpredictable effects may result, ranging from simple euphoria to complete loss of consciousness.

THC, high, short term, complex, hallucinations, anxious, paranoid, cannabinoid hyperemesis,

Hallucinogens

• Hallucinogens alter a person’s —- perceptions.

  • Classic example is LSD. 

• These agents:

  • Cause —- hallucinations

  • Intensify vision and hearing

  • Generally separate the user from —-

• Patients experiencing a “bad trip” have —-, —, anxiety, and paranoia.

• Use a calm, professional manner.

• Provide emotional support.

• Do not use —- unless you or the patient is in danger of injury.

• Watch the patient carefully throughout transport and do not leave unattended.

• Request ALS assistance when appropriate.

sensory, visual, reality, hypertension, tachycardia, restraints, 

Anticholinergic Agents

• Have properties that —- the parasympathetic nerve.

• Anticholinergic toxidrome 

  • Mnemonic = (5 phrases) 

  • Hyperthermia, blurred vision, decreased sweating an dry mouth, flushed skin, and delirium and confusion 

• Common drugs include atropine, Benadryl, jimsonweed, and amitriptyline.

• Some —- —- have significant anticholinergic effects.

• Death from these agents can be —.

  • The patient can go from “normal” to seizure and death within —- minutes.

  • Transport immediately.

  • Consider ALS backup.

block

hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter 

tricyclic antidepressants

rapid, 30 

Cholinergic Agents

• — normal body functions that are controlled by the parasympathetic nerves. 

  • Include “— —” designed for chemical warfare and —- insecticides

• Use the mnemonic DUMBELS to remember the signs and symptoms:

  • Stands for ———

• Or, you can use SLUDGEM:

  • Stands for ——

overstimulate, nerve gases, organophosphates

diarrhea, urination, miosis, bradycardia bronchospasm bronchorrhea, emesis, lacrimation, seizures salvation sweating

salivation and sweating, lacrimation, urination, defecation drooling diarrhea, gastric upset and cramps, emesis, muscle twiching and miosis

Cholinergic Agents

• The most important consideration is to avoid exposure —-.

  • — may take priority over immediate transport.

  • — team will provide decontamination and contain the exposure chemical. 

  • After decontamination:

    • — the secretions in the mouth and trachea.

    • Provide airway support.

• Antidote kit may be available.

  • DuoDote Auto-Injector

  • The kit consists of a single auto-injector containing —- and —.

  • If a known exposure to nerve agents with manifestation of signs and symptoms has occurred, use the antidote kit on —-. 

yourself, decontamination, hazmat, suction, atropine, pralidoxime , yourself

Miscellaneous Drugs

• Accidental or intentional overdose with cardiac medications has become common.

  • Children 

  • Older patients

• Signs and symptoms depend on the —- ingested.

• Contact the poison center as soon as possible.

• — poisoning remains a potentially lethal condition.

  • Ingesting too many aspirin may result in:

    • Nausea

    • Vomiting

    • Hyperventilation

    • Ringing in the ears

  • Patients with this problem have:

    • Anxiety

    • Confusion

    • Tachypnea

    • Hyperthermia

    • Danger of having seizures

• Overdosing with —— is also very common.

• Some alcohols, including methyl alcohol (—-) and —- —-, are even more toxic than ethyl alcohol (drinking alcohol)

substance, aspirin, acetaminophen, methanol, ethylene glycol

Food Poisoning

• Almost always caused by eating food contaminated by —-

• Two main types:

  • Organism —- may cause disease.

  • Organism may produce —- that cause disease.

• One organism that produces direct effects of food poisoning is the -—- bacterium.

• Causes salmonellosis

  • Characterized by severe —- symptoms within —- hours of ingestion, including nausea, vomiting, abdominal pain, and diarrhea

  • Proper cooking kills bacteria, and proper cleanliness in the kitchen prevents the contamination of uncooked foods.

bacteria, itself, toxins, Salmonella, GI, 72,  

Food Poisoning

• The more common cause of food poisoning is the ingestion of powerful —— produced by bacteria, often in —-.

  • The bacterium —— is quick to grow and produce toxins in food.

  • Foods left — are a common vehicle.

  • Symptoms usually within start 2 to 3 hours or as long as 8 to 12 hours after ingestion.

• The most severe form of toxin ingestion is ——.

  • Can result from eating improperly —— food

  • Symptoms are ——:

    • Blurring of vision

    • Weakness

    • Difficulty in speaking and breathing

• Do not try to determine the specific cause of acute GI problems.

  • Gather as much history as possible from the patient.

  • When two or more persons have the same illness, take along the suspected —-.

toxins, leftovers, staphylococcus, unrefrigerated, botulism, canned, neurologic, food

Plant Poisoning

• There are tens of thousands of cases of plant poisoning annually.

  • Many household plants are poisonous if ingested.

  • Symptoms can range from localized irritation to cardiovascular effects 

• It is impossible to memorize every plant or poison, let alone their effects.

  • Assess the patient’s airway and vital signs.

  • Notify the regional poison center.

  • — the plant to the emergency department.

take,

Which of the following questions is of LEAST pertinence for the EMT to ask a patient who intentionally overdosed on a medication?

“How much do you weigh?”

“How much did you ingest?”

“What substance did you take?”

“Why did you take the medication?”

why did you take the medication

A 30-year-old male who ingested an unknown substance begins to vomit. You should:

collect the vomitus and bring it to the hospital.

apply a bag-mask device.

analyze the vomitus and try to identify the poison.

suction his oropharynx for no longer than 30 seconds.

Explanation: If the patient vomits, examine the contents for pill fragments. Ensure that you are wearing proper personal protective equipment for this activity. Note and document anything unusual that you see. You should try to collect the vomitus in a separate plastic bag so that it can be analyzed at the hospital.

collect the vomitus and bring it to the hospital 

When caring for a patient with a surface contact poisoning, it is important to remember to:

prevent contamination of the patient.

avoid contaminating yourself or others.

let the hospital remove the surface poison.

immediately flush dry chemicals with water.

Explanation: Other thing to do is remove the irritating or corrosive substance from the patient as rapidly as possible….. Dry chemicals must be brushed from the body prior to flushing with water.

avoid contaminating yourself or others 

Most poisonings occur via the _________ route. (80%)

injection

ingestion

inhalation

absorption

ingestion 

How much activated charcoal should you administer to a 55-pound child who swallowed a bottle of aspirin?

12.5 g

25 g

2 g/kg

50 g

Explanation

The usual dose of activated charcoal for adults and children is —- of charcoal per —- of body weight

To convert a patient’s weight from pounds to kilograms, simply —- the weight in pounds by

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.

25g 

1g, 1 kg, divide, 2.2

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:

addiction. 

dependence. 

tolerance. 

drug abuse.

Explanation: addiction is a physiologic or psychologic dependance on a potentially harmful drug. Dependence is the physiologic or psychologic need to use a drug. Drug abuse is the deliberate use of an illegal drug or too much of a prescribed drug 

tolerance 

 

Which of the following effects does drinking alcohol NOT produce?

Induction of sleep

Slowing of reflexes

Inappropriate behavior

Increased sense of awareness

explanation: alcohol (ethyl alcohol) is both a sedative (decrease activity and excitement) and hypnotic (induces sleep). It could potentially cause aggressive or inappropriate behavior 

increased sense of awareness 

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:

cocaine.

an opioid. 

a stimulant drug. 

methamphetamine.

explanation: opioids depress the CNS and when taken in excess can cause respiratory depression, bradycardia, and hypotension. Another sign is constricted/pinpoint pupils (miosis)

an opioid 

The mnemonic DUMBELS can be used to recall the signs and symptoms of a cholinergic drug poisoning. The “E” in DUMBELS stands for:

emesis. 

erythema. 

ecchymosis. 

elevated blood pressure.

emesis 

Food poisoning is almost always caused by eating food that contains:

fungi.

viruses.

bacteria.

protozoa.

bacteria