Poisoning and Overdose

Airway Management in Poisoning/Overdose

• Understand the role of airway management.
• Explain the use of activated charcoal:
  • Indications.
  • Contraindications.
  • Need for medical control approval.

Types of Toxins and Poisons

• Alcohol
• Opiates and opioids
• Sedative hypnotic drugs
• Inhalants
• Hydrogen sulfide
• Sympathomimetics
• Synthetics
• Caffeinated substances
• Marijuana
• Medicinal substances (toxic at high levels)

Poisoning Statistics

• Acute poisoning affects over two million people annually.
• Chronic poisonings (e.g., alcoholism, drug dependency) are more common.
• Poisoning deaths are relatively rare, especially in children since the 1960s due to:
  • Child-resistant caps.
  • Public knowledge campaigns.
  • Child safety locks.
• Chronic poisoning deaths in adults are rising due to drug and alcohol abuse.

Definitions

• Toxicology: The study of toxic or poisonous substances.
• Poison: Any substance causing damage to body structures or impaired function.
• Toxic substance: A poisonous substance.
• Toxic level: Intake of a drug or substance at a toxic amount.

Initial Actions

• Primary job: Recognize potential poisoning.
• Pay attention to surroundings.
• Small amounts of some poisons can be deadly.
• Signs and symptoms vary widely based on the poison.
• Determine the nature of the poison if possible to help treatment.
• Look for clues:
  • Overturned bottles.
  • Needles.
  • Containers.
  • Pills.
  • Chemicals.
  • Buckets, pots, food, or drink items.
  • Damaged plants.
• Take suspicious materials to the hospital for analysis.
• Pill containers provide:
  • Name and concentration of the drug.
  • Ingredients.
  • Pill count.
  • Manufacturer.
  • Prescribed dose.
  • Fill dates and expiration dates.

Patient Questions

• What substance was taken?
• When was it taken or when did exposure occur?
• How much was ingested?
• What was eaten or drunk before/after ingestion?
• Were any antidotes or substances taken orally?
• What is the patient's weight?

Vomit Analysis

• Examine vomit for pill fragments.
• Document unusual findings.

Routes of Poisoning

• Inhalation
• Absorption
• Ingestion
• Injection

Inhaled Poisons

• Remove patient from the environment immediately.
• Provide supplemental oxygen.
• Call for a hazmat team if toxic gas is suspected and do not approach the patient until they have been decontaminated.
• Monitor for respiratory failure.
• Have suction ready.
• Example: Carbon monoxide suicide in a vehicle.
• Look for multiple unconscious patients and consider carbon monoxide poisoning.

Absorbed Poisons

• Can affect skin, mucous membranes, and eyes.
• May cause chemical burns, rashes, lesions, or systemic effects.
• Differentiate between contact burns and contact absorption.
• Signs and symptoms include:
  • Exposure history.
  • Liquid or powder on the skin.
  • Burning, itching, irritation, redness.
  • Unusual odors.
• Avoid contamination.
• Remove the substance and contaminated clothing.
• Flush and wash the skin.
  • For dry powder, brush off then flood with water for 15-20 minutes, then wash with soap and water.
  • For liquids, flood with water for 15-20 minutes (avoid soap).
• For eye exposure, irrigate quickly and thoroughly with sterile water using a nasal cannula.
• Chemical burns often occur in industrial settings.
• Industrial facilities have safety showers and eyewash stations.
• MSDS (Material Safety Data Sheets) should be available.
• Hazmat team assistance is required.

Ingested Poisons

• 80% of poisonings are by mouth.
• Can be liquids, cleaners, contaminated food, plants, or drugs.
• Accidental in children, purposeful in adults.
• Signs and symptoms vary based on the poison, patient age, and time since ingestion.
• Signs of ingestion:
  • Burns around the mouth.
  • GI pain.
  • Vomiting.
  • Cardiac arrhythmias.
  • Seizures.
• Treat signs and symptoms.
• Contact Poison Control and provide available information such as:
  • Household cleaner details
  • Pill information
  • Material Safety Data Sheets
• Confirm remaining unabsorbed poison.
• If the patient has an altered mental status, prepare for potential airway compromise.
• Activated Charcoal:
  • Dosage: 1 gram per kilogram.
    • To convert pounds to kilograms (\frac{pounds}{2.2} = kilograms).
    • Or \frac{pounds}{2} - 10\%.
  • Side effects: Nausea, vomiting, constipation.
  • Function: Absorbs poisons in the stomach and prevents digestion in the small intestine.
  • Requires orders from medical control and suggestions from Poison Control.

Injected Poisons

• Exposure through IV drug abuse, insect bites, or arachnids/reptiles.
• Absorbed quickly into the vascular system.
• Cannot be diluted or removed in the field.
• Monitor airway and prepare for suction.
• Remove rings, watches, and bracelets from the injection area to prevent circulation cut offs.
• Signs and symptoms include:
  • Weakness.
  • Dizziness.
  • Fever.
  • Chills.
  • Unresponsiveness.
  • Excitability (agitation, fight or flight).

Scene Size-Up

• Take standard precautions; safety is paramount.
• Look for strange odors.
• Note medication bottles, missing medications, alcoholic beverage containers, syringes, and paraphernalia.
• Don't assume a conscious/alert patient is stable.
• Consider prompt transport and look for alterations in ABCs.
• Patients may need decontamination before EMS can approach.

Patient Assessment

• Investigate the chief complaint.
• Assess the area of exposure.
• For unresponsive patients, gather history from other sources and look for medical alert tags.
• Ask:
  • What substance was involved?
  • When did exposure occur?
  • How much was ingested or the level of exposure?
  • Over what period was the exposure?
  • Were any interventions performed?
  • What is the patient's weight?
• Focus on the area of exposure and review all body systems to identify systemic problems.
• Look for changes in:
  • Level of consciousness.
  • Pulse.
  • Respirations.
  • Blood pressure.
  • Skin condition.
• Reassess:
  • Stable patients every 15 minutes.
  • Unstable patients every 5 minutes.

Treatment

• Support ABCs.
• Contact medical control or a poison center.
• Manage:
  • Airborne exposures with oxygen.
  • Contact exposures with copious water.
  • Consider activated charcoal for ingestions.
• Report everything to the receiving facility.
• Notify the hospital early and provide as much information as possible, including MSDS.
• Remove pill fragments from mouth if possible (no blind finger sweeps).
• Have the patient rinse their mouth if conscious and alert.
• Wash or brush poison from skin before flooding with water.
• Provide oxygen/assisted ventilation as needed.
• Treat for shock.

Activated Charcoal

• Binds to toxins for excretion through stool.

• Consult Poison Control for appropriate uses.

• Contraindications:

  • Ingested alkali poisons, cyanide, ethanol, iron, lithium, methanol, mineral salts, or organic solvents.
  • Altered mental status.
  • Ingested an emetic.

• Dosage: 1 gram per kilogram.

• Administration:

  • Mix with something to obscure the appearance of the charcoal to improve palatability.
  • Rights of medication administration: Right route, right patient, right medication, right time, dosage, date, and documentation.
  • Suspension: Doesn't thoroughly mix; shake and add water as needed.

• Document if the patient refuses activated charcoal.

• Repeat the dose if the patient vomits.

• Contact medical control to repeat the dose if the patient has already taken some.

Chronic Substance Misuse

• Tolerance: Increasing amounts are needed to achieve the same result.
• Addiction: Overwhelming need to continue using a substance regardless of the cost.
• High incidence of serious and undiagnosed infections (HIV, hepatitis) in drug abusers.

Alcohol Ingestion (Ethanol or ETOH) Poisoning

• Intoxication causes altered mental status, slowed reflexes, and impaired reaction times.
• Eliminated by the liver; chronic overuse damages liver function.
• Binge drinking (heavy use occasionally) can be more damaging than chronic use due to strain on the liver.
• Alcohol is a central nervous system depressant, decreasing activity and excitability.
• Induces sleep and dulls awareness and can cause a lack of coordination.
• May cause aggressive/inappropriate behavior.
• Increases the effects of other drugs; commonly taken with other substances.
• Avoid tunnel vision; altered mental status may be due to mental illness, head injury, other substances, or diabetes.

Treatment

• Provide respiratory support if central nervous system depression is present.
• Suction if vomiting occurs.
• Alcohol withdrawal can cause hallucinations or delirium tremens (DTs).
• DTs symptoms:
  • Agitation.
  • Restlessness.
  • Fever.
  • Sweating.
  • Tremors.
  • Confusion/disorientation.
  • Delusions/hallucinations.
  • Seizures.
• Develops after stopping or decreasing alcohol consumption.
• Transport promptly and provide emotional support.

Opioids

• Narcotic medications relieve pain and can produce sleep or altered level of consciousness.
• Opiates are natural, non-synthetic opioids derived from opium and poppy seeds (codeine and morphine).
• Prescription opioid drugs are commonly used and can cause physical dependence even when prescribed properly.
• Examples: Butorphanol, codeine, fentanyl, heroin, hydrocodone, hydromorphone, morphine, methadone, oxycodone hydrochloride, or oxymorphone.
• Central nervous system depressants cause severe respiratory depression and cardiac arrest.
• Bind to opioid receptors, primarily in the lungs, and result in respiratory depression.
• Tolerance develops quickly, requiring increased doses for desired effects.
• May cause nausea, vomiting, and hypotension.
• Seizures are uncommon.
• Patients appear sedated or unconscious and may be cyanotic with pinpoint pupils.

Naloxone (Narcan)

• Reverses the effects of opioids/opiates.
• Binds to opioid receptors and blocks them, preventing opioid effects.
• Laypeople can administer naloxone, and it is often prescribed alongside opioids.
• Use only when the patient has agonal respirations or is apneic.
• Find out if the patient was given Narcan by bystanders.

Sedative Hypnotic Drugs

• Barbiturates and benzodiazepines are central nervous system depressants that alter the level of consciousness.
• Effects similar to alcohol: drowsiness, peace, and intoxication.
• Taken by mouth but may be dissolved in water or injected.
• IV use quickly induces tolerance.
• May be used as "knockout" or "date rape" drugs.
• Treatment: Ensure patent airway, assist ventilations, and transport promptly.

Abused Inhalants

• Acetone, toluene, xylene, and hexane are found in glue, cleaning supplies, paint thinner, and lacquers.
• Gasoline and halogenated hydrocarbons (Freon) can also be inhaled.
• Signs and symptoms range from mild drowsiness to coma and may cause seizures.
• Halogenated hydrocarbon solvents can make the heart hypersensitive to its own adrenaline.
• Prevent exertion, provide oxygen, and transport promptly.

Hydrogen Sulfide

• Highly toxic, colorless, flammable gas with a rotten egg smell.
• Affects all organs and the central nervous system, especially the lungs and CNS.
• Used in chemical/detergent suicides.
• Look for buckets, containers, or pots in enclosed vehicles or areas.
• If suspected, call hazmat and wait for them.
• Signs and symptoms include:
  • Nausea and Vomiting.
  • Confusion.
  • Dyspnea.
  • Loss of consciousness.
  • Seizures.
  • Shock.
  • Coma.
  • Cardiopulmonary arrest.
• Treatment (after decontamination) is largely supportive:
  • Respiratory and cardiovascular support.
  • Rapid transport.

Sympathomimetics

• Central nervous system stimulants mimic the sympathetic nervous system (fight or flight).
• Produce an excited state with hypertension, tachycardia, and dilated pupils.
• Drug categories include amphetamines, methamphetamines, phentermine hydrochloride, and benzodrine.
• Designer drugs like MDMA are frequently abused.
• Commonly taken by mouth but can be injected.
• Cocaine is also included and can be absorbed through mucous membranes or skin.

Treatment

• Acute overdose can be a genuine emergency with high risk of seizures, arrhythmias, and strokes.
• Patients may experience hallucinations or paranoia.
• Law enforcement may be needed for restraints.
• Transport promptly, provide supplemental oxygen, and prioritize safety.

Synthetic Cathinones (Bath Salts)

• Inhaled or ingested, with effects lasting up to 48 hours.
• Adverse effects include teeth grinding, appetite loss, muscle twitching, lip smacking, confusion, GI conditions, paranoia, headache, tachycardia, and hallucinations.
• Keep the patient calm and consider ALS for chemical or physical restraints if sufficient resources are not available.

Marijuana

• THC (tetrahydrocannabinol) produces euphoria, relaxation, and drowsiness but can impair short-term memory and complex thinking.
• Euphoria can progress to depression and confusion.
• Often laced with other drugs such as Fentanyl.
• Medicinal and recreational usage is legalized in some states, whereas only medicinal use is allowed in other states.
• Edibles are marijuana-infused foods with cannabinoid hyperemesis syndrome when used in high doses.
• It does have many medicinal benefits.
• Synthetic marijuana (Spice) is a variety of herbal incense or smoking blends that resemble THC but can produce powerful and unpredictable effects, ranging from euphoria to coma.

Is marijuana use okay for EMS personnel?

• It is still federally illegal. Your department bills insurance including Medicare and Medicaid, so it is federally illegal for you.
• Testing is common upon hiring and after accidents.

Hallucinogens

• Commonly abused hallucinogens include nutmeg, morning glory, salvia, and DXM.
• Cause visual hallucinations, intensify vision and hearing, and separate the user from reality.
• Patients can have a "bad trip" with paranoia, hypertension, and tachycardia.

Treatment

• Be calm and professional and provide emotional support.
• Avoid restraints unless absolutely necessary.
• Make sure ALS is en route.
  Note: Working festivals and keeping them in a positive state of mind can be the best thing for them.

Anticholinergic Agents

• Block parasympathetic nerves (rest or digest system).
• Symptoms: Hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as a hatter (Arid).
• Common drugs include atropine, Benadryl, jimsonweed, and amyltryptamine.
• Difficult to distinguish from sympathomimetic overdose.
• Tricyclic antidepressants have significant anticholinergic effects and can cause rapid deterioration.
• Transport immediately and consider ALS.

Cholinergic Agents

• Overstimulate normal body functions controlled by parasympathetic nerves.

• Include nerve gases (chemical warfare) and organophosphate insecticides.

• Symptoms:

  • Diarrhea.
  • Urination.
  • Miosis (pupil constriction).
  • Bradycardia.
  • Bronchospasm and bronchorrhea (coughing up fluid/mucus).
  • Emesis.
  • Lacrimation (crying).
  • Seizures.
  • Salivation.
  • Sweating. (SLUDGEM)

• Treatment

  *Scene safety is primary

  • Decontamination.
  • Suctioning.
  • Airway support.
  • DuoDote autoinjector may be available. Note: National Registry Scope of Practice allows DuoDote administration; not covered in Maryland.
    • Atropine and pralidoxime treat cholinergic poisonings.

General Considerations

• Children may ingest anything, while older adults can accidentally overdose by forgetting they took a medication dose.
• Overdoses, whether intentional or accidental, can occur to anyone.
• Signs and symptoms are dependent on what was ingested.
• Contact poison control. Aspirin poisoning can be a potentially lethal condition.
• Ingesting too much can result in nausea, vomiting, hyperventilation, or tinnitus.
• Patients might be anxious, confused, tachypneic, hyperthermic, and they might have seizures.
  *Acetaminophen is another common agent in toxicity.

Alcohols

• Methyl alcohol and ethylene glycol are more toxic than ethyl alcohol.
• Result in severe tachycardia, blindness, renal failure, and eventually death.

Food Poisoning

• Usually caused by eating food contaminated by bacteria or their toxins.
  Somnolosis is characterized by severe gastrointestinal systems within seventy two hours of ingestion, including nausea, vomiting, abdominal pain, and diarrhea.
• Cooking things properly kills the bacteria and makes all the food safe
• Properly storing things and preventing cross-contamination helps prevent the growth of bacteria in the foods
• Common cause: Ingestion of toxins produced by bacteria in leftovers.
  The bacterium staphylococcus is quick to grow and produce toxins in food and results in sudden GI symptoms including nausea, vomiting, and diarrhea.
  *
  The most severe form of toxin ingestion is Botulism, symptoms may develop within the first twenty four hours after ingestion or maybe as long as four days later.
  In general, it's not always our job to determine the cause of GI problems

Plant Poisons

Many household plants are toxic if ingested.

• If known, take a picture of the plant and provide it to Poison Control. Apps, like nature apps, can help identify the plants. Common poisonous plants include: Mistletoe, Castor Bean, Jimsonweed, Pokeweed, Rosary Pea, Nightshade, Foxglove, Rhododendron, Death Comments, Poison Ivy, Poison Oak, and Poison Sumac.

What to do with festival patients taking hallucinogens:*

It's not my job to figure out what they took. It's just my job to make sure they're okay
* For unstable conditions, take them to the ambulance and give them whatever would help their symptoms. But, if the drug isn't deadly and they are open with you, then you can likely manage them without transporting.
* So, like, if the patient took, like, something like LSD or mushrooms, which usually isn't gonna kill you, if they if they were, like, started hyperventilating on the floor thinking they are dying, would you treat would you treat them as if they were dying
*One of my friends went there and he had, like, the greatest time ever and the other one had a terrible time.