CHAPTER 21 Poisoning and Overdose Emergencies. Poison K ey Term Any substance that can harm the body by altering cell structure or function

CHAPTER 21

Poisoning and Overdose Emergencies

Poison

Key Term

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

Toxin

Key Term

A poisonous substance secreted by A poisonous substance secreted by bacteria, plants or animalsbacteria, plants or animals

General Information

Reactions to poisons are different for all persons, but they are the most severe in the ill and the elderly.

Effects and extent of damage depend upon:

Patient’s age

Patient’s weight

Patient’s general health

Systemic Poisons

Key Term

These poisons cause harm to the These poisons cause harm to the entire body or an entire body systementire body or an entire body system

Four Types of PoisoningFour Types of Poisoning

INHALATION INJECTION

INGESTION ABSORPTION

Drain Cleaners

Rat Poison

Lye

Sprays Cleaning Fluid

Drugs

Household Cleaners

Insecticides

Ingested Poisons

Key Term

Poisons that are swallowed (i.e. Poisons that are swallowed (i.e. acetaminophen, acids/alkalis, acetaminophen, acids/alkalis, antihistamines, aspirin, food antihistamines, aspirin, food poisoning, insecticides, petroleum poisoning, insecticides, petroleum products, plants, etc…products, plants, etc…

History of ingestion

Nausea (most common)

Vomiting (most common)

Diarrhea

Signs & Symptoms of Ingested Poison/Overdose

Signs & Symptoms ofIngested Poison/Overdose

Altered mental status

Abdominal pain

Chemical burns around mouth

Unusual breath odor

Difficulty breathing

Gather information. Remove pills, Gather information. Remove pills, tablets or fragments with gloves from tablets or fragments with gloves from patient’s mouth, as needed, without patient’s mouth, as needed, without injuring oneself.injuring oneself.

Consult medical direction.Consult medical direction.Administer activated charcoal?Administer activated charcoal?

Transport the patient – bring all containers,Transport the patient – bring all containers,bottles, labels, etc… of poison agents to bottles, labels, etc… of poison agents to receiving facility. Position patient for receiving facility. Position patient for vomiting. Save all vomitus. Have suction vomiting. Save all vomitus. Have suction equipment ready.equipment ready.

Information to Gather

What substance involved?

Get exact name and spelling.

Bring container, if possible and safe.

When did exposure occur?

Reaction times of poisons are different. Try to find out as closely as possible the time of ingestion.


How much did you ingest?

Counting the tablets left in a new container.

Amount spilled on the floor.

If you can’t be exact, give the maximum possible amount.

Over what time period? Has the patient been taking the medication and then overdosed?

Is this a new medication, and the patient overdosed?


What interventions taken?

Any home remedies?

What is patient’s estimated weight?

Estimate your patient’s weight because it can be critical in the treatment process.

Any effects on patient?

Nausea/vomiting, altered mental status, abdominal pain, diarrhea, chemical burns around the mouth and nose, unusual breath odors

Inhaled, Injected

and AbsorbedPoisons

Inhaled Poisons

Key Term

Poisons that are breathed in (i.e. Poisons that are breathed in (i.e. carbon monoxide, ammonia, carbon monoxide, ammonia, chlorine, volatile chemicals); chlorine, volatile chemicals); chemicals that change easily from chemicals that change easily from liquid to gas – industrial solventsliquid to gas – industrial solvents

Signs & Symptoms of Inhaled Poisons

Nausea (most common)

Vomiting (most common)


Chest pain

Cough

Hoarseness

Dizziness

Headache

Confusion

Seizures


History of inhalation; MOI

Signs & Symptoms of Inhaled Poisons

Most common inhaled poison (motor vehicle exhaust, fire suppression, faulty heaters)

Colorless, odorless, tasteless gas

Prevents normal carrying of red blood cells

Death can occur as hypoxia becomes severe

Carbon Monoxide

Carbon Monoxide Inhalation

Nausea

Vomiting

Headache

Dizziness


Cyanosis


Unconsciousness

Signs andSymptoms(resemble flu)

Cherry red lips VERY UNCOMMON.

Substances found in smoke can burn the skin

Irritate the eyes

Injure the airway

Cause respiratory arrest

Cause cardiac arrest

Smoke Inhalation

Smoke Inhalation


Coughing

Breath has “smoky” smell or

odor of chemicals involved at the

scene

Black (carbon) residue in patients

mouth and nose

Black (carbon) residue in sputum

coughed up by patient

Nose hairs singed in superheated

air

Signs andSymptoms(can be delayed orImmediate and severe)

Have trained rescuers remove patient Have trained rescuers remove patient from poisonous environment. DO NOT from poisonous environment. DO NOT go unless you have proper apparatus go unless you have proper apparatus and training.and training.

Establish an open airway. Give oxygen, if Establish an open airway. Give oxygen, if not already done in the initial assessment.not already done in the initial assessment.

Give by NRB at 15 lpm.Give by NRB at 15 lpm.

Maintain airway and administer oxygen.Maintain airway and administer oxygen.

Remove contaminated clothing.Remove contaminated clothing.

Consult medical direction.Consult medical direction.

Transport the patient. Bring all containersTransport the patient. Bring all containersbottles, labels, etc… of poison agents to bottles, labels, etc… of poison agents to

receiving facility if you can safelyreceiving facility if you can safelytransport them.transport them.




Bring container, if possible and safe.


Try to find out what the earliest and latest possible times of exposure were.


Over how long a period did the exposure occur?

The longer the exposure, the more likely the poison was inhaled

Patient interventions… Did someone ventilate the area?

Did someone remove the patient from the area?

When did this happen?



Nausea/vomiting, difficulty breathing, chest pain, coughing, hoarseness, dizziness, headache, confusion, seizures, or altered mental status

Injected Poisons

Key Term

Poisons that are inserted through Poisons that are inserted through the skin.the skin.

Signs & Symptoms ofInjected Poisons

Weakness

Dizziness

Chills

Fever

Nausea

Vomiting

Emergency Care of Injected Poisons

Secure airway; administer oxygen.

Be alert for vomiting.

Bring all containers, bottles, labels, etc… of poison agents to receiving facility if you can safely transport them.

Absorbed Poisons

Key Term

Poisons that are taken into the body Poisons that are taken into the body through unbroken skin.through unbroken skin.

Signs & Symptoms ofAbsorbed Poisons

History of exposure

Liquid or powder on patient’s skin

Burns

Itching

Irritation

Redness

Difficulty Breathing

Remove patient from source withoutRemove patient from source withoutcontaminating yourself.contaminating yourself.

Remove contaminated clothing and other Remove contaminated clothing and other articles. Be sure to protect oneself.articles. Be sure to protect oneself.

Brush powders from patient, and irrigatewith water for at least 20 minutes.

Irrigate with clear water for at leastIrrigate with clear water for at least20 minutes.20 minutes.

Emergency Care of Eye Absorption

Irrigate with clean water for at least 20 minutes and continue en route if possible.

Acids and Alkalis

Neutralizing acids or alkalis with solutions (vinegar or baking soda) should not be done.

DO NOT mix acids with alkalis – you may think it could neutralize the reaction, but the reaction produces heat and skin could be futher damaged.





How much substance was the patient exposed to?

How large an area of skin was covered?


Over what time period?The longer the substance was on the patient’s skin, the more likely it was absorbed.

Patient interventions… Did someone attempt to wash the poison off? With what?

Did anyone attempt to neutralize the substance?



Liquid or powder on the patient’s skin, burns, itching, irritation and redness

BE ALERT FOR CONTACT LENSES

When treating a poisoned or overdosed patient, be prepared for deterioration, vomiting, and the need to secure airway.

Airway Management in Poisoning/Overdose

Use ofUse ofActivatedActivatedCharcoalCharcoal

Activated Charcoal

Key Term

A substance that adsorbs (one A substance that adsorbs (one substance becoming attached to the substance becoming attached to the surface of another) many poisons surface of another) many poisons and prevents them from being and prevents them from being absorbed by the bodyabsorbed by the body

Trade Names: SuperChar, InstaChar,Trade Names: SuperChar, InstaChar,LiquiChar, ActidoseLiquiChar, Actidose

Generic Name: Generic Name: Activated Activated CharcoalCharcoal

Activated Charcoal

Indication Poisoning by mouth

Contraindications Altered mental status

Ingestion of acid or alkali (i.e. oven cleaners, drain cleaners, toilet bowl cleaners, lye, etc…)

Patient unable to swallow

Patient who swallowed gasoline while siphoning

Pre-mixed in water,

commonly 12.5

grams in plastic

bottle

Avoid powder form

in the field

Activated Charcoal

MedicationForm

Adults and children: 1 gram activated charcoal/kg of body weight

Adult: 25-50 grams

Pediatric: 12.5-25 grams

Activated Charcoal

Dosage

1. Consult medical direction.

2. Shake container thoroughly.

3. Since medication looks like mud, patient may need to

be persuaded to drink it.

4. A covered container and a straw may improve patient

compliance since the patient cannot see the

medication this way.

5. If patient takes a long time to drink the medication, the

charcoal will settle and will need to be shaken or

stiffed again.

6. Record activity and time.

Activated CharcoalAdministration

Activated Charcoal

Actions Binds to certain poisons;

prevents absorption by body This is not an antidote (a substance that

will neutralize the poison or its effects

It will reduce/prevent the amount of

poison available for the body to absorb

Does not work with all poisons (again

DO NOT use with acids and alkalis)

Not all brands of activated charcoal are

the same; some bind much more poison

that others, so consult medical direction

about the brand to use

The EMT-Basic should be

prepared for the patient to

vomit or further deteriorate

Activated Charcoal

SideEffects

Black stools

Some patients, particularly those who

have ingested poisons that cause

nausea, may vomit

If patient vomits, the dose should be

repeated once

ReassessmentReassessment

StrategiesStrategies

Syrup of Ipecac

Facts

Causes vomiting in most people with one dose

Takes 15-20 minutes to work

On average, it removes less than 1/3 of stomach contents

Because of its slowness, it’s relatively ineffective

Can cause aspiration of vomit into lungs

Syrup of Ipecac

Indication Poisoning by mouth

Contraindications Altered mental status

Ingestion of acid or alkali (i.e. oven cleaners, drain cleaners, toilet bowl cleaners, lye, etc…)

Patient unable to swallow

Liquid

Syrup of Ipecac

MedicationForm

Contact Medical ControlDosage

Obtain order from

medical direction either

on-line or off-line

Record activity and

time

Syrup of Ipecac

Administration

Should be prepared for the patient to

vomit or further deteriorate

Reassessment Strategies

A substance that will neutralize the poison

or its effects

Only a few genuine antidotes exist, and

they only work with a small number of

poisons

Antidote versus Dilution

Antidote

Thinning down or weakening by mixing with

something else

Usually used with ingested poisons

Should use water or milk

Adult dosage should be 1-2 glasses

Pediatric dosage should be ½ to 1 glass

Dilution

AlcoholAlcoholandand

Substance AbuseSubstance Abuse

Alcohol AbuseEmergencies can result from:

Due to the effect of the alcohol just consumed

Resulting from the cumulative effects of years of alcohol abuse

Provide care for the patient suffering from alcohol abuse/overdose the same as you would for any other patient

Effects of Alcohol Immediate effect is CNS depression

Injuries and falls

Derangements of blood sugar (chronic abusers)

Poor nutrition (chronic abusers)

Potential for considerable GI bleeding (chronic abusers)

Having a heart attack

Hypoglycemia

If combined with other depressants (antihistamines/tranquilizers) effects are exacerbated

Signs & Symptoms of Alcohol Abuse

Odor of alcohol on patient’s breath/clothing

Swaying/Unsteadiness of movement

Slurred speech, rambling thoughts and incoherent words/phrases

Flushed appearance

Nausea and vomiting

Poor coordination

Slowed reaction time

Blurred vision

Confusion

Hallucination (visual/auditory)

Lack of memory

Altered mental status – decreased level of consciousness

All of these signs & symptoms could be serious medical problems as well!

Signs & Symptoms of Alcohol Withdrawal

Confusion/Restlessness

Unusual behavior

Hallucination

Gross Tremor (obvious shaking) of the hands

Profuse sweating

Seizures

Problems Associated withAlcohol Withdrawal

Patients may suffer from delirium tremens (DT’s).

A severe reaction that can be a part of alcohol withdrawal. It is characterized by sweating, trembling, anxiety, and hallucinations.

All patients with DT’s must be transported to a medical facility ASAP

Can be fatal.

Special Circumstances with Alcohol Abuse

Some conditions may make the patient appear to be intoxicated when he/she is not. Don’t let the presence of alcohol or the signs/symptoms of alcohol abuse override suspicions of other medical problems/injuries

Diabetes

Epilepsy

Head Injuries

High Fever

Hypoxia

Emergency Care ofAlcohol Overdose

A patient under the influence of alcohol cannot make an informed refusal of treatment or transport!

You must treat by implied consent!!!

The condition may worsen as alcohol is absorbed into the blood stream (i.e. head injuries can lead to subdural hematomas)

Substance Overdose

A chemical substance that is being taken for other than therapeutic (medical) reasons

Most common substances are: Uppers & Downers Narcotics Hallucinogens Volatile Chemicals

UppersUppers – Stimulants such as amphetamines that affect the CNS to excite the user, relieve fatigue or to create the feeling of well-being

Include caffeine, cocaine, & amphetamines

Signs and Symptoms

Excitement

Increased heart rate

Increased breathing rate

Rapid speech

Dry mouth

Dilated pupils

Sweating

Complaint of having gone without sleep for long periods

Downers

Downers – Have a depressant effect on the CNS; relaxing agent, sleeping pill, tranquilizer; produces a sense of euphoria and sometimes hallucinations

Includes Rohypnol, barbiturates, GHB, etc…

Signs and symptoms

Sluggish

Sleepy patient lacking typical coordination of body and speech

Decreased pulse (often to point of a true emergency)

Decreased respiration (often to point of a true emergency)

Stupor

NarcoticsDrugs capable of producing stupor or sleep often used to relieve pain and to quiet coughing; intense state of relaxation and well-being

Include heroin, codeine, & oxycodone

Opiate Triad

Coma

Pinpoint Pupils

Respiratory Depression

Signs and symptoms

Decreased heart rate, respiratory rate and skin temperature

Pinpoint pupils

Relaxed muscles

Profuse sweating

Patient is sleepy and doesn’t want to do anything

HallucinogensMind-affecting drugs that act on the nervous system to produce an intense state of excitement or a distortion of the user’s perceptions

Include PCP, LSD, & ecstasy

Signs and symptoms

Increased heart rate

Dilated pupils

Flushed face

Patient often “sees” and “hears” things

Patient has little concept of time

Patient may not be aware of true environment

Patient may become aggressive or timid

Volatile ChemicalsGive an initial “rush” then act as a depressant on the CNS

Include glue, cleaning fluid, model cement, typing correction fluid, propane, etc…

Signs and symptoms

Dazed or showing temporary loss of contact with reality

Develop coma

Linings of nose/mouth may show swollen membranes

Patient complains of “funny numb feeling” or “tingling” inside head

Changes in heart rhythm

Emergency Care ofSubstance Overdose

Ensure scene safety; restrain patient if needed.

Assess for respiratory compromise.

Monitor level of consciousness.

Continued…

Emergency Care ofSubstance Overdose

Monitor vital signs.

Treat for shock.

Assess for injuries.

Transport.

Documents

CHAPTER 21 Poisoning and Overdose Emergencies. Poison K ey Term Any substance that can harm the body by altering cell structure or function