Chapter 21: Poisoning and Overdose Emergencies

Absorbed poisons

Poisons that are taken into the body through unbroken skin

Acetaminophen

Jaundice is a delayed sign of this poison

Activated Charcoal

A substance that adsorbs many poisons and prevents them from being absorbed into the body

Antidote

A substance that will neutralize the poison or its effects

Delirium Tremens (DTs)

A severe reaction that can be part of alcohol withdrawal, characterized by sweating, trembling, anxiety, and hallucinations; severe can lead to death if untreated

Dilution

Thinning down or weakening by mixing with something else

Dilution

Ingestion poisons are sometimes ___ by drinking water or milk

Downers

Depressants, such as barbiturates, that depress the central nervous system, which are often used to bring on a more relaxed state of mind

Hallucinogens

Mind-affecting or mind-altering drugs that act on the central nervous system to produce excitement and distortion of perceptions

Ingested poisons

Poisons that are swallowed

Inhaled poisons

Poisons that are breathed in

Injected poisons

Poises that are inserted through the skin, for example, by needle, snake fangs, or insect stinger

Narcotics

A class of drugs that affect the nervous system and change many normal body activities

Narcotics

Their legal use if for the relief of pain while their illicit use is to produce an intense state of relaxation

Poison

Any substance that can harm the body by altering cell structure or functions

Toxin

A poisonous substance secreted by bacteria, plants, or animals

Uppers

Stimulants, such as amphetamines, that affect the central nervous system to excite the user

Volatile Chemicals

Vaporizing compounds, such as cleaning fluid, that are breathing in by the abuser to produce a “high”

Withdrawal

Referring to alcohol or drug withdrawal in which the patient’s body reacts severely when deprived of the abused substance

parasympatholytic; speeds up heart rate; breaks down acetylcholine; nerve gas poisons

Purpose of atropine

-Harm to body based on nature of poison, its concentration, route of entry, patient's age, weight, and health

-Damage to skin and tissues from contact

-Suffocation

-Localized or systemic damage to body systems

Effects of poisons

Food Poisoning

Can be caused by improperly handled or prepared food

Nausea, vomiting, abdominal cramps, diarrhea, and fever

Symptoms of food poisoning

Food Poisoning

May occur within hours of ingestion, or a day or two later

Activated Charcoal

Works through adsorption, allowing substances to attach to its surface

Activated Charcoal

Prevents or reduces amount of poison absorbed by body

No

Is activated charcoal an antidote?

1 gram per kilogram of body weight

-Adults – 25-50; Maximum 50 grams

-Children – 12.5 - 25; Maximum 25 grams

Dosages of activated charcoal

Activated Charcoal

Medical direction will determine whether the use of this substance is appropriate.

Activated Charcoal

Many poisons but not all are absorbed by this substance

syrup of ipecac

Traditionally what was preferred treatment for poisoning?

syrup of ipecac

Induces vomiting in most people with one dose

syrup of ipecac

However, has potential to make patient aspirate and only removes less than one-third of stomach contents

 Altered mental status

 Ingestion of acids or alkalis

 Unable to swallow

Contraindications of activated charcoal

1. Take Standard Precautions; Quickly gather information; Avoid mouth-to-mouth contact; Provide ventilations through a pocket face mask or other barrier device

2. Call medical direction on the scene or en route to the hospital

3. If directed, administer activated charcoal. You may wish to administer the medication in an opaque cup that has a lid with a hole for a straw

4. Position the patient for vomiting and save all vomitus. Have suction equipment ready

Steps to take for ingested poisons

Acetaminophen overdose

Overdose of this medication is very slow onset of symptoms

Acetaminophen overdose

Overdose of this medication is toxic to the liver causing pain in the upper right quadrant

200mg/kg

Level of overdose for Acetaminophen

Acetaminophen overdose

Overdose of this medication: Other symptoms nausea/vomiting are not specific; Patient history is the key

Dilution

What is frequently advised for patients who, as determined by medical direction, do not need transport

Water may slow absorption, but milk may soothe stomach upset.

What liquid is best for dilution?

Adult patient should drink one to two glasses of water or milk.

Dilution amount for adult

Children should drink one-half to one full glass of water or milk.

Dilution amount for children

Antidotes

Thought of as substance that will neutralize the poison or its effects; Very few exist

Naloxone

Directly reverses narcotics' depressant effects on level of consciousness and respiratory drive

 Narcotic overdose (opiate)

 Coma of unknown cause

Indications for Naloxone

• Watery eyes

• Runny nose

• Yawning

• Sweating

• Hot and cold flashes

• Dilated pupils

Side effects of Naloxone: mild to moderate withdrawal

• Agitation

• High or low blood pressure

• Cardiac arrhythmias

• Shortness of breath

• Pulmonary edema

• Encephalopathy

• Seizures

• Coma

Side effects of Naloxone: severe withdrawal

Carbon monoxide, Ammonia, Chlorine gas, Agricultural chemicals and pesticides, Carbon dioxide

Common types of inhaled poisons

Difficulty breathing, Chest pain, Coughing, Hoarseness, Dizziness, Headache, confusion, or altered mental status, Seizures

Signs and symptoms of inhaled poisons

- Move patients from an unsafe environment using trained and equipped personnel

- Detect and treat immediately life-threatening problems in primary assessment

- Perform secondary assessment, obtain vital signs

- Administer high-concentration oxygen

- Transport with all containers, bottles, and labels

- Perform reassessment en route

Patient care for inhaled poisons

Carbon Monoxide

Colorless, odorless, tasteless gas created by combustion

Carbon Monoxide

Can be caused by improper venting of fireplaces, portable heaters, generators

Carbon Monoxide

Common cause of death during winter and power outages

Headache, especially "a band around

head"

 Dizziness

 Breathing difficulty

 Nausea

 Cyanosis

 Altered mental status

• In severe cases, unconsciousness

Signs and symptoms of Carbon Monoxide poisoning

Severe Headache, Vomiting, Vertigo, ALOC, Confusion, Syncope, Tachycardia, Seizures, Shock, Apnea, Coma, Death

30% and up of carbon dioxide in the air can lead to what

CO Monitor

Special monitors are needed to detect the presence of carbon monoxide in the environment.

CO Monitor

ToxiRAE carried on all EMS calls in Fairfax County. Attaches to the aide bags.

- Patient may begin to feel shortly after being removed from dangerous environment

- Administer 100 percent oxygen

- Transport to hospital

- Takes time to "wash out" CO from bloodstream

CO Poisoning Treatment

CO binds to hemoglobin very tightly; this means oxygen and carbon dioxide can’t be carried on the hemoglobin like they should be

CO Poisoning in the cell

High flow oxygen is appropriate treatment, but CO bonds to red blood cells much more strongly than oxygen does

-CO has an affinity for red blood cells 250 times that of oxygen

CO Poisoning Treatment

Can take several hours or days to “wash” CO from bloodstream

• May require hyperbaric chamber

 Located at Mount Vernon Hospital

CO Poisoning Treatment

- On room air = 4 hours

-100% oxygen = 30 minutes

Half life of CO

- Fetus contains hemoglobin different from adults

• Much greater affinity for oxygen

• Consequently a much greater affinity for CO

• Resulting in a mother appearing to have mild symptoms while the fetus is in distress

CO Poisoning in infants

Smoke Inhalation

Smoke from burning materials can contain poisonous and toxic substances, including CO, ammonia, chlorine, cyanide.

Smoke Inhalation

Substances can irritate skin and eyes, damage lungs, and progress to respiratory or cardiac arrest.

Difficulty breathing, Coughing, "Smoky" or chemical smell on breath, Black (carbon) residue in mouth nose or sputum, Singed nasal or facial hair

Signs and symptoms of smoke inhalation

 Move patient to safe area.

 Assess patient.

 Maintain airway.

 Provide high-concentration oxygen.

 Monitor patient closely.; Airway burns may lead to swelling of airway.

Treatment of smoke inhalation

"Detergent Suicides"

Method of suicide started in Japan and is becoming more common in the United States.

"Detergent Suicides"

Mix of two easily obtained chemicals to release toxic hydrogen sulfide gas; Commonly released inside enclosed space such as a car

"Detergent Suicides"

Mixing of an acid source and a sulfur source to create hydrogen sulfide gas

-Exposure to fumes may injure EMS personnel.

 Very fast acting, at 700 ppm 2 – 3 breaths are enough to be fatal

 Warning note may be left on the vehicle, but this is not assured.

 May need to treat first as a hazmat scene

Scene safety of Detergent suicides

Absorbed Poisons

Can be absorbed through skin

Absorbed Poisons

May or may not cause damage to skin

Absorbed Poisons

Patient may require decontamination prior to treatment

Remove powder by:

 Brushing off powder

 Irrigating with clean water for at least 20 minutes and during transport

Patient care of powder

-Illicit drugs injected with a needle

-Venom of snakes and insects

Most common injected poisons

Poison control centers

• Excellent resource

• Information on poisons, signs and symptoms, and treatments

• Follow local protocol for contact procedures.

Alcohol and Substance Abuse

Many patients whose conditions are caused either directly or indirectly by alcohol or substance abuse

• Abuse of alcohol and other drugs crosses all geographic and economic boundaries.

Alcohol Abuse

Potent drug affects central nervous system; Can be addictive

Alcohol Abuse

Emergencies may result from recent consumption or years of abuse.

•Treat patients as any others.

• Abuse can lead to or worsen other medical conditions.

- Alcohol odor on breath or clothing

 Swaying or unsteady on feet

 Slurred, rambling speech

 Flushed, complaining of being warm

 Nausea/vomiting

 Poor coordination

 Slowed reaction time

Signs and symptoms of alcohol abuse

Alcohol withdrawal

 Abrupt cessation of drinking may cause some alcoholics to suffer from delirium tremens (DTs).

 Can be serious, resulting in tremors, hallucinations, and seizures

• Confusion and restlessness

• Unusual behavior

• Hallucinations

• Gross tremor of hands

- Profuse sweating

• Seizures

• Hypertension

• Tachycardia

Signs and symptoms of Alcohol withdrawal

Alcohol Abuse

Subdural hematoma likely from falls

Substance Abuse

Includes illicit drugs, prescription medications, industrial chemicals

Uppers

Stimulants that affect the nervous system

Uppers

Stimulants including Cocaine and Amphetamines

 May be snorted, smoked, or injected

• Excitement, restlessness

• Increased pulse and breathing rates

• Sweating

• Hyperthermia

• No sleep for a long time, possibly days

Signs and symptoms of uppers

Dilated pupils, fast heart rate (tachycardia), elevated BP, elevated temp, elevated respirations

Signs of cocaine/crack use

Downers

Central nervous system depressants

Downers

Includes Barbiturates, Rohypnol (roofies), and GHB (gamma hydroxybutyrate / “Georgia Home Boy”)

Sluggishness, poor coordination

• Decreased pulse and respirations

Signs and symptoms of downers

Narcotics

Used to relieve pain or help with sleep

Narcotics

Includes Opiates, Heroin, codeine, morphine, OxyContin (oxycodone)

• Coma (Depressed LOC)

• Pinpoint pupils

• Respiratory depression

Opiate triad

• Reduced rate of pulse and rate and depth

of breathing

• Lethargy (being very sleepy)

• Pinpoint pupils

• Profuse sweating

• Coma

Signs and symptoms of narcotics

Hallucinogens

Create intense state of excitement and distorted perception

Hallucinogens

Include LSD, PCP, XTC

• Rapid pulse

• Dilated pupils

• Flushed face

• Seeing or hearing things

Signs and symptoms of Hallucinogens