Toxicology

Routes of Exposure• Inhalation• Ingestion• Surface absorption• Injection

Treatments• Decontamination• Gastric lavage• Activated charcoal• Whole bowel irrigation• Ipecac • Dialysis• Antidotes

Antidotes• Acetaminophen – Mucomist 140

mg/kg• Benzodiazepine- Flumazenil 0.2 mg q

min• Carbon monoxide- Oxygen• Cyanide- amyl nitrate• Opiates- Naloxone 2-5 mg• Beta Blockers- glucagen • Organophosphates- Atropine

Get a Good History• What?• How much?• When?• Don’t care about the where and why• Any alcohol?

We no longer use the coma cocktail

• Dextrose• Narcan• Thiamine

Surface Absorbed Toxins• Cyanide• Organophosphates• Others• Treat with supporting measures

Carbon Monoxide• Odorless, tasteless gas• Endogenous sources – breakdown of

hemoglobin• Exogenous sources – combustion• Methylene chloride breakdown in

liver• Mild to fatal

Industrial Solvent

Carbon Monoxide• Half life is normally 240 – 360

minutes• With 100 % oxygen, it is 80 minutes• With hyperbaric treatment, 22 minutes

Signs and Symptoms

• Headache• Dizziness• Confusion• Seizures• Coma• Pulmonary edema (extreme)• Metabolic acidosis (extreme)

Cyanide• Gaseous product of combustion

(plastics, wool, silk, rubber, polyurethane, asphalt)

Signs and Symptoms• Burning sensation in mouth and

throat• Headache, confusion, combativeness• Hypertension and tachycardia

followed by hypotension• Seizures and coma• Pulmonary edema• Use Cynokit (hydroxocobalamin)

Cardiac Medications• Bradycardia

– (may not respond to atropine)

Cardiac Meds Antidotes• Beta Blockers – Glucagon• Calcium channel blockers – calcium

chloride– Norvasc, vascor, cardizem, cardene,

procardia, verapamil• Digoxin - Digibond

Caustic Substances• Acids• Bases (alkalis)• Strong acid pH < 2• Strong alkalis ph > 12.5

Acid or Base?

Acid or Base?

Acid or Base

Acid or Base?

Acid or Base?

Acid or Base?

Acid or Base?

Acid or Base?

Acid or Base?

Hydrofluoric Acid• Creates calcium fluoride in tissues• Pulls calcium from bones• Death in less than 2.5 % body surface

area

Alcohol• Rarely seen in prehospital setting

Hydorcarbons• Burns, wheezing, hypoxia, headache,

dizziness, slurred speech, ataxia, dulled reflexes

• Gastric lavage may be useful• Charcoal does not bind to these

Tricyclic Antidepressants• Not as common;

– narrow therapeutic index• Amitriptyline (Elavil), amoxapine,

clomipramine, doxepin, imipramine, nortripyline

Tricyclic OD• Dry mouth, blurred vision, urinary

retention, constipation• Confusion, hallucinations,

hyperthermia, respiratory depression, seizures, tachycardia and hypotension, dysrhythmias

Tricyclic OD• Sodium bicarbonate for significant

cardiac toxicity• If overdose with benzodiazepines, do

not give Flumazenil… seizures!

MAOI• Monoamine Oxidase Inhibitors• Narrow therapeutic index• Multiple drug and food interactions

MAOI• Headache, agitation, restlessness, tremors• Nausea• Palpitations, tachycardia• Hypertension• Hyperthermia• Bradycardia, hypotension, coma, and death

Seratonin Reuptake Inhibitors• Prozac• Luvox• Paxil• Zoloft

Lithium• Treatment of bipolar (manic-

depressive) disorder• Dry mouth, thirst, tremor, muscle

twitching, reflexes, confusion, stupor, seizures, coma, nausea, vomiting, diarrhea, bradycardia, dysrhythmias

Salicylates• Aspirin• 300 mg / kg causes toxicity• Metabolic acidosis• Use charcoal• Bicarb• Dialysis

Acetaminophen• 150 mg / kg is toxic• Death by liverStage 1: ½ hr to 24 hrs n/v weaknessStage 2: 24 – 48 hrs abd pain, decreased urineStage 3:72 – 96 hrs liver disruptionStage 4: 4-14 days Recovery or death

Tylenol Antidote• Mucomyst

Iron• 20 mg/kg is toxic• vomiting, diarrhea• abdominal pain• shock• metabolic acidosis• bowel scarring

Contaminated Food• Shigella• Salmonella• E. Coli• Clostridium

botulinum• Paralytic shellfish

poisoning• Scombroid

(histamine)

• N/V/D and abd pain

• Red Tide • Treat like allergic

reaction

Organophosphate Poisoning• Salivation• Lacrimation• Urination• Diarrhea• GI distress• Emesis

•Treat with atropine

Bites and Stings

Africanized Honeybees

Brown Recluse

Spider Bite

Black Widow

Scorpion Stings• Use constricting band• Do not give analgesics

Venomous Snakes• Pit Vipers• Elapidae (coral snake)

Common Pit Vipers• Cottonmouths• Rattlesnakes• Copperheads

• http://www.flmnh.ufl.edu/herpetology/fl-guide/snakekey.htm

Name the Florida Snake

Florida Racer

Cottonmouth (water moccasin)

Eastern Diamond Back Rattlesnake

Copperhead

Timber Rattlesnake

Pygmy Rattlesnake

Florida Corn Snake

Marine Animal Injection• Heat will relieve pain and inactivate venom• Secondary infection possible

Galerina

Amanita

Any questions?