Chapter 28 Toxicology Certain images and/or photos in this presentation are the copyrighted property of ArtToday, Inc. and are being used with permission under license. These images and/or photos may not be copied or downloaded without permission from ArtToday, Inc. Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Objectives Image source: Microsoft clipart

What Is a Poison? Poison Poisoning Toxin Antidote Poison Control Center A poison is any substance taken into the body that interferes with normal body function. Poisoning is exposure to a substance that is harmful in any dosage. A toxin is a poisonous substance. An antidote is a substance that neutralizes a poison. A Poison Control Center (PCC) is a medical facility that provides free telephone advice to the public and medical professionals in case of exposure to poisonous substances. In the United States, the national telephone number is 1-800-222-1222 (toll-free). This number is staffed 24 hours a day, 7 days a week, 365 days a year by pharmacists, physicians, nurses, and poison information providers. A PCC is an excellent resource that is often used by EMS personnel.

Routes of Entry A poison may be a solid, liquid, spray, or gas. Toxins enter the body in four ways—ingestion, inhalation, injection, or absorption.

Toxidromes Signs, symptoms, and characteristics that often occur together in toxic exposures Categories Sympathomimetic Cholinergic Anticholinergic Opioid Sedative/hypnotic Signs, symptoms, and characteristics that often occur together in toxic exposures are called toxidromes.

Sympathomimetic Toxidrome Signs/Symptoms Examples Agitation Rapid breathing Increased heart rate Increased blood pressure Fever Seizures Sweating Amphetamines, methamphetamines Cocaine Phencyclidine (PCP) Ecstasy Caffeine Pseudoephedrine

Cholinergic Toxidrome Signs/Symptoms Examples Altered mental status Decreased or increased heart rate SLUDGEM Salivation Lacrimation (tearing) Urination Defecation Gastrointestinal distress Emesis (vomiting) Miosis (pupil constriction) Organophosphate and carbamate insecticides Some mushrooms Nerve agents Sarin gas

Anticholinergic Toxidrome Signs/Symptoms Examples Confusion Hallucinations Agitation Coma Blurred vision Warm, flushed, dry skin Dilated pupils Antihistamines Benadryl Jimson weed Tricyclic antidepressants Amitriptyline (Elavil) Desipramine (Norpramin) Nortriptyline (Aventyl, Pamelor)

Opioid (Narcotic) Toxidrome Signs/Symptoms Examples Altered mental status Coma Slow or absent breathing Slow heart rate Low blood pressure Constricted pupils Morphine Codeine Heroin Diphenoxylate (Lomotil) Meperidine (Demerol) Methadone (Dolophine) Propoxyphene (Darvon)

Sedative/Hypnotic Toxidrome Signs/Symptoms Examples Slurred speech Hallucinations Confusion Coma Respiratory depression Low blood pressure Pupil dilation or constriction Blurred vision Dry mouth Decreased temperature Staggering walk Barbiturates Phenobarbital Benzodiazepines Diazepam (Valium) Alcohol GHB (a date-rape drug or “liquid x”)

Commonly Misused and Abused Substances

Key Terms Substance abuse Substance misuse Tolerance Addiction Withdrawal Overdose Substance abuse is the deliberate, persistent, and excessive self-administration of a substance in a way that is not medically or socially approved. Recreational use of substances is considered intentional abuse. Substance misuse is the self-administration of a substance for unintended purposes, or for appropriate purposes but in improper amounts or doses, or without a prescription for the person receiving the medication. Tolerance occurs when an individual requires progressively larger doses of a drug to achieve the desired effect. Addiction is a psychological and physical dependence on a substance that has gone beyond voluntary control. Withdrawal is the condition produced when an individual stops using or abusing a drug to which she is physically or psychologically addicted. An overdose is an intentional or unintentional overmedication or ingestion of a toxic substance. Commonly misused and abused substances include stimulants, depressants, hallucinogens, and designer drugs.

Increase mental and physical activity May produce violent behavior Stimulants Examples Cocaine Amphetamines, methamphetamines PCP Caffeine Nicotine Increase mental and physical activity May produce violent behavior

Depressants Examples Alcohol Barbiturates Narcotics (opiates) Benzodiazepines

Slows mental and physical activity Depressants Alcohol Slows mental and physical activity Affects judgment, vision, reaction time, and coordination In large quantities, can cause death Alcohol slows mental and physical activity. It affects judgment, vision, reaction time, and coordination. When approaching the patient who has ingested alcohol, observe the scene for evidence of trauma. In large quantities, alcohol can cause death.

Do not assume the patient is intoxicated. Depressants Alcohol Signs and symptoms of misuse or abuse can mimic those of other medical conditions Do not assume the patient is intoxicated. Signs and symptoms of alcohol misuse or abuse can mimic those of medical conditions, such as a diabetic emergency, epilepsy, drug reaction, or CNS infection. In addition, alcohol abuse can often mask potentially lethal conditions such as a head injury. Do not assume the patient is intoxicated. Carefully assess the patient for the presence of other injuries or illnesses. Perform a blood glucose test (if permitted by state and local protocol).

Alcohol withdrawal syndrome Delirium tremens (DTs) Depressants Alcohol Alcohol withdrawal syndrome Delirium tremens (DTs) Alcohol withdrawal syndrome occurs 6 to 48 hours after a chronic alcoholic reduces or stops his alcohol consumption. Signs and symptoms of alcohol withdrawal include tremors (“the shakes”), anxiety, irritability, inability to sleep, sweating, nausea, vomiting. The patient must be monitored closely by healthcare professionals or delirium tremens (DTs) can occur. DTs usually begin 24 to 72 hours after a chronic alcoholic reduces or stops alcohol consumption. The diagnosis of DTs is made when symptoms of alcohol withdrawal progress beyond the usual symptoms of withdrawal. DTs are potentially fatal. Signs and symptoms of DTs include those of alcohol withdrawal plus altered mental status (confusion, visual and/or auditory hallucinations, severe agitation), seizures, increased heart rate, increased blood pressure, and elevated body temperature. Symptoms may be present for several days. In general, seizures associated with alcohol withdrawal occur 6 to 48 hours after the last drink.

Depressants Barbiturates Prescribed to relieve anxiety, promote sleep, control seizures, and relax muscles Examples Secobarbital (Seconal) Phenobarbital (Luminal) Particularly dangerous when combined with alcohol Barbiturates are prescribed to relieve anxiety, promote sleep, control seizures, and relax muscles. Examples of barbiturates include pentobarbital (Nembutal), secobarbital (Seconal), amobarbital (Amytal), and phenobarbital (Luminal). Street names for these drugs include yellow jackets, reds, blues, Amy’s, rainbows, Barbs, downers, goof balls, and stumblers. Barbiturates are particularly dangerous when combined with alcohol. Overdose can produce respiratory depression, coma, and death. Withdrawal can cause anxiety, tremors, nausea, fever, convulsions, and death.

Depressants Narcotics Prescribed drugs used to relieve moderate to severe pain, control diarrhea, and suppress cough Narcotics include: Opium Opium derivatives Man-made compounds that produce opium-like effects Depressants are prescribed drugs used to relieve moderate to severe pain, control diarrhea, and suppress cough. Narcotics include opium, opium derivatives, and synthetic compounds that produce opium-like effects. Overdose can result in respiratory depression, constricted (pinpoint) pupils, shock, and death. Withdrawal can cause tearing, nasal congestion, headache, joint pain, dilated pupils, abdominal cramps, increased heart rate, chills, fever, gooseflesh, tremors, loss of appetite, vomiting, diarrhea, sweating, confusion, and intense agitation.

Depressants Benzodiazepines Prescribed medications used: To control anxiety and stress To aid sleep To relax muscles For sedation To control seizures Overdose can result in respiratory depression and death Benzodiazepines are prescribed medications used to control anxiety and stress, aid sleep, and relax muscles. They are also used for sedation and to control seizures. These drugs vary widely in their onset, indications, potency, and duration of effect. Overdose can result in respiratory depression and death. Respiratory depression may be especially significant if benzodiazepines are taken in combination with alcohol or other drugs. Withdrawal can cause anxiety, tremors, nausea, fever, seizures, and death.

Produce changes in mood, thought, emotions, and self-awareness Hallucinogens Examples Lysergic acid diethyl amine (LSD) PCP (angel dust) Mescaline Produce changes in mood, thought, emotions, and self-awareness Can also cause disruptive behavior that can make the user dangerous to himself and others Hallucinogens include lysergic acid diethyl amine (LSD), PCP (angel dust), and mescaline. (Street names include “buttons” “mess” “peyote.”) These drugs produce changes in mood, thought, emotions, and self-awareness. Signs and symptoms of hallucinogen misuse and abuse include flushed face, sudden mood changes, fear, and anxiety. They can also cause hallucinations, profound depression, and irrational and disruptive behavior that can make the user dangerous to himself and others.

Can be injected, smoked, snorted, or ingested Designer Drugs Variations of federally controlled substances that have high abuse potential Can be injected, smoked, snorted, or ingested Signs and symptoms unpredictable Overdose occurs frequently Designer drugs are variations of federally controlled substances that have high abuse potential (such as narcotics and amphetamines). These drugs are produced by persons ranging from amateurs to highly skilled chemists (called “cookers”) and sold on the street. Designer drugs can be injected, smoked, snorted, or ingested. Signs and symptoms of designer drug misuse and abuse are unpredictable and depend on the drug that is being chemically altered. Because designer drugs are often much stronger than the original form of the drug, overdose occurs frequently. Fentanyl (Sublimaze), a narcotic analgesic, is 1 drug used to make designer narcotics. Street names include "china white," "synthetic heroin," "Persian white," and "Mexican brown." Signs and symptoms of misuse or abuse include respiratory depression and mental status depression. Designer amphetamines include “Ecstasy." The chemical name for Ecstasy is MDMA—methylenedioxymethamphetamine. It is also called "Adam," "XTC," and “Love Drug.” Signs and symptoms of misuse or abuse include increased heart rate, sweating, agitation, erratic mood swings, and increased blood pressure.

Patient Assessment

When responding, you may or may not know the substance(s) involved Scene Size-Up When responding, you may or may not know the substance(s) involved Remember scene safety in all circumstances Observe the patient’s environment for clues: Unusual odors Smoke or flames Open medicine cabinet Open or overturned containers Syringes or other drug paraphernalia When responding to a call involving a possible toxic exposure, you may or may not know the substance(s) involved. For example, a 9-1-1 caller may tell the dispatcher that her toddler ate rat poison, or that a teenager took an overdose of sleeping pills. On the other hand, the 9-1-1 dispatcher may not have any information available from the caller other than an “unresponsive person” or a person who “is not acting right.” Remember scene safety in all circumstances. Protecting yourself and your crew must be your primary concern so that you are not injured or poisoned. Use appropriate protection or have trained rescuers remove the patient from the poisonous environment. Call for additional resources if needed. On arrival at the scene, observe the patient’s environment for clues as to the source of the poisoning, such as: Unusual odors Smoke or flames Open medicine cabinet Open or overturned containers Syringes or other drug paraphernalia

Primary Survey Mental Status Many toxic exposures result in mental status changes Anticipate seizures Many toxic exposures result in mental status changes. For example, sedatives and alcohol cause CNS depression. Agitation or violent behavior may be caused by CNS stimulants, such as cocaine, amphetamines, and PCP. Some substances can cause CNS stimulation or depression, depending on the dose ingested. Some toxins can cause visual or auditory hallucinations and personality changes. Seizures are a complication of toxic exposures and should be anticipated. Any toxic exposure that results in mental status changes increases the patient’s risk of problems with his ABCs.

Use airway adjuncts, suction as needed Primary Survey Airway Look Burns around the mouth Blisters of the lips or mucous membranes Difficulty swallowing or drooling Listen Stridor Hoarseness Use airway adjuncts, suction as needed When assessing the patient’s airway, look for burns around the mouth and blisters of the lips or mucous membranes. Note if the patient has trouble swallowing or is drooling. Excessive salivation is one of the signs associated with organophosphate insecticide exposure. Listen for stridor and hoarseness. If any of these signs are present, the patient is at risk of an airway obstruction. You may need to use airway adjuncts, such as an oral or nasal airway to keep the patient’s airway open. Because some substances increase airway secretions and others cause nausea and vomiting, have suction equipment within arm’s reach while the patient is in your care.

Primary Survey Breathing Be prepared to provide positive-pressure ventilation Narrowing of lower airway may cause wheezing Many toxic exposures affect breathing. For instance, substances that can cause a decreased respiratory rate include sedatives, narcotics, and depressants such as alcohol. Substances that can cause an increased respiratory rate include aspirin, amphetamines, methamphetamines, caffeine, cocaine, PCP, and carbon monoxide. Be prepared to provide positive-pressure ventilation. Narrowing of the lower airway because of swelling, mucus, or spasms of the bronchi may cause wheezing.

Primary Survey Circulation Toxic exposures can affect heart rate and blood pressure Increased or decreased heart rate Irregular heart rhythm Increased or decreased blood pressure Shock Toxic exposures can also affect the victim’s heart rate and blood pressure. Drugs that stimulate the sympathetic division of the autonomic nervous system will result in an increased heart rate. For instance, expect to see an increased heart rate if the patient has been exposed to amphetamines, cocaine, and Ecstasy. When taken in excess, alcohol and some prescribed heart medications are examples of substances that can cause a decreased heart rate. Some plants such as lily of the valley, foxglove, and oleander contain substances that can slow the heart rate. An irregular heart rhythm and shock are complications of toxic exposures and should be anticipated.

Primary Survey Priority Patients Patients who give a poor general impression Patients experiencing difficulty breathing Patients with signs and symptoms of shock Unresponsive patients with no gag reflex or cough Responsive patients who are unable to follow commands Establish patient priorities. Priority patients include the following: Patients who give a poor general impression Patients experiencing difficulty breathing Patients with signs and symptoms of shock Unresponsive patients with no gag reflex or cough Responsive patients who are unable to follow commands If a patient with a suspected toxic exposure has any of the above findings, provide initial emergency care and transport immediately to the closest appropriate medical facility, with Advanced Life Support (ALS) backup if available.

Vital signs and physical exam findings (toxidrome) can provide clues Secondary Survey SAMPLE history Who, what, where, when, why, how Vital signs and physical exam findings (toxidrome) can provide clues Image source: Microsoft clipart The patient’s vital signs and physical exam findings (toxidrome) can provide clues to help you identify the substance involved.

Common Signs and Symptoms of Poisoning Altered mental status Difficulty breathing Headache Nausea Vomiting Diarrhea Chest or abdominal pain Sweating Seizures Burns around the mouth Burns on the skin

Emergency Care Have trained rescuers remove patient from source of poison Follow decontamination procedures Maintain an open airway Give oxygen Call a Poison Control Center as needed Bring containers, labels, or other evidence to receiving facility Save vomitus Anticipate complications Ongoing assessments Have trained rescuers remove the patient from the source of the poison. Follow proper decontamination procedures, if necessary, and prepare the ambulance to receive the patient. Methods used for decontamination will depend on the toxin and type of exposure. Establish and maintain an open airway. Remove pills, tablets, or fragments with gloves from the patient’s mouth, as needed, without injuring oneself. Be alert for vomiting and have suction ready. Pills or fragments need to be transported to the hospital with the patient so that Emergency Department personnel can identify any unknown substances. Pills should be placed in a zip-closure bag and properly labeled. Give oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 liters per minute (L/min) if not already done. If the patient’s breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered. Call a Poison Control Center for advice about decontamination procedures and patient care as needed. Do not delay transport to contact a Poison Control Center. If the patient has ingested a poison (and is awake), consult medical direction about giving activated charcoal. If the patient is unresponsive or seizing, consult medical direction about checking the patient’s blood sugar. If possible, bring all containers, labels, and other evidence of suspected poisons to the receiving facility. If the patient vomits, save the vomitus in a container (such as a portable suction unit) and transport it to the receiving facility for analysis. Anticipate complications, including: Seizures Vomiting Shock Agitation Irregular heart rhythm When ALS personnel arrive at the scene (or when transferring patient care at the receiving facility), pass on any patient information that you have gathered. You should include what the patient looked like when you first arrived on the scene, the care you gave, and the patient’s response to your care. If the patient is stable, perform ongoing assessments every 15 minutes while the patient is in your care. If the patient is unstable, perform ongoing assessments every 5 minutes.

Ingested Poisons

Signs and symptoms are related to: Ingested Poisons Signs and symptoms are related to: The drug ingested The amount ingested The length of time since the ingestion Image source: Microsoft clipart Most toxic exposures that you will respond to are ingested poisons. In some cases, they will be the result of intentional overdoses. Since the patient’s signs and symptoms are related to the drug ingested, the amount ingested, and the length of time since the ingestion, try to find out this information as quickly as possible. For example, how many pills were in the bottle before they were ingested? How many are left in the bottle? If the patient took a prescription medication, when was the prescription last filled? Ingestions sometimes involve liquids. Attempt to obtain information about the product from the container’s label. When possible, take the label with you to the hospital.

Ingested Poisons Emergency care: Remove pills, tablets from patient’s mouth Maintain an open airway Give oxygen Consult medical direction about giving activated charcoal Bring containers, labels, and other evidence of suspected poisons to receiving facility Transport Using gloves, remove pills, tablets, or fragments from the patient’s mouth, as needed, without injuring yourself. Establish and maintain an open airway. Be alert for vomiting; have suction ready. When indicated (and if trauma is not suspected), position the patient in the recovery position to reduce the risk of aspiration. Give oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient’s breathing is inadequate, provide positive-pressure ventilation with 100% oxygen. Assess the adequacy of the ventilations delivered. Consult medical direction about giving activated charcoal. Bring all containers, labels, and other evidence of suspected poisons to the receiving facility. Transport the patient to the closest appropriate facility, keeping the patient warm. En route to the receiving facility, reassess (including vital signs) as often as indicated. Carefully document all patient care information on a prehospital care report (PCR).

Activated Charcoal Activated charcoal can only bind a drug that is not yet absorbed from the gastrointestinal tract If the patient is alert and cooperative, medical direction may instruct you to give the patient activated charcoal. Activated charcoal binds (adsorbs) with many (but not all) chemicals, slowing down or blocking absorption of the chemical in the gastrointestinal (GI) tract. Activated charcoal is produced by heating wood pulp to high temperatures and then “activating” it with steam or strong acids. This process creates tiny pores on each particle of charcoal that increase its surface area. With this large surface area, activated charcoal will bind many ingested toxins. However, charcoal can only bind a drug that is not yet absorbed from the GI tract.

Activated Charcoal Actions Acts as an adsorbent Binds with many (but not all chemicals) Slows down or blocks absorption of the chemical Activated charcoal binds many toxic substances in the GI tract to prevent them from being absorbed and then carries them out of the GI tract. Activated charcoal does not bind well to some substances such as some pesticides (malathion), cyanide, strong caustics (acids and bases), iron, mercury, ethanol, methanol, and petroleum products (such as gasoline, turpentine, and kerosene).

Activated Charcoal Indications/Dosage Some ingested poisons Dosage 1 gram of activated charcoal per kilogram of body weight Usual adult dose: 25 to 50 grams Usual infant/child dose: 12.5 to 25 grams If ordered by medical direction (and approved by your state and local EMS system), you may give activated charcoal for some ingested poisons. The dosage of activated charcoal for adults and children is 1 gram of activated charcoal per kilogram of body weight. The usual adult dose is 25 to 50 grams. The usual dose for an infant or child 12.5 to 25 grams. If the activated charcoal is not premixed, mix the appropriate dosage in a glass of water (8 ounces) to produce a thick slurry.

Activated Charcoal Contraindications Patient has an altered mental status Patient is unable to swallow Medical direction does not give authorization Patient has ingested acids or alkalis Contraindications of activated charcoal include the following: The patient has an altered mental status. The patient is unable to swallow. Medical direction does not give authorization. The patient has ingested acids or alkalis. Examples of acids include rust removers, phenol, and battery acid. Examples of alkalis include ammonia, household bleach, and drain cleaner.

Inhaled Poisons

Inhaled Poisons Examples Carbon monoxide Carbon dioxide Chlorine Ammonia Propane Cyanide Freon Tear gas Hair spray Cleaning fluids Correction fluid Nail polish remover Glue, rubber cement Paint, paint thinner Lighter fluid Room deodorizers Felt marker pens

Sudden sniffing death syndrome Inhalants “Huffing” “Sniffing” Sudden sniffing death syndrome Inhalants are household and commercial products that can be abused by intentionally breathing the product’s gas or vapors for its mind-altering effects. Inhalant use is called "huffing" or "sniffing." According to the National Institute on Drug Abuse (NIDA), sudden sniffing death syndrome (SSDS) can occur when a person sniffs highly concentrated amounts of the chemicals in solvents or aerosol sprays. Death occurs within minutes because of heart failure. This syndrome is particularly associated with the abuse of butane, propane, and chemicals in aerosols.

Inhaled Poisons Signs/Symptoms Signs and symptoms depend on: The substance inhaled The amount inhaled The extent and duration of exposure Signs and symptoms of an inhalation exposure depend on the substance inhaled, the amount inhaled, and the extent and duration of exposure. A person who experiences a toxic exposure in a confined space, such as a closed room or garage, is more likely to experience more severe signs and symptoms than a person exposed in an open area. In general, the longer and more concentrated the exposure, the more risk of the incident being fatal.

Inhaled Poisons Signs and symptoms: History of inhalation of toxic substance Altered mental status Difficulty breathing Chest pain/discomfort Cough Hoarseness Dizziness Headache Confusion Seizures

Inhaled Poisons Emergency care: Have trained rescuers remove patient from poisonous environment Ensure scene safety Removed and discard contaminated clothing Maintain open airway Give oxygen Bring containers/labels to receiving facility Transport Have trained rescuers remove the patient from the poisonous environment. After making sure the scene is safe to enter and you are properly equipped, remove the patient’s contaminated clothing. Discard contaminated clothing in an appropriate container. Establish and maintain an open airway. Be alert for vomiting; have suction ready. When indicated (and if trauma is not suspected), position the patient in the recovery position to reduce the risk of aspiration. Give oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient’s breathing is inadequate, provide positive-pressure ventilation with 100% oxygen. Assess the adequacy of the ventilations delivered. Contact medical direction or a Poison Control Center to help determine potential toxicity. If relevant, bring all containers, labels, and other evidence of suspected poisons to the receiving facility. Transport the patient to the closest appropriate facility. En route to the receiving facility, reassess (including vital signs) as often as indicated. Carefully document all patient care information on a PCR.

Injected Poisons

Poisons that can be injected include: Injected Poisons Poisons that can be injected include: Bee, wasp, and ant venom Spider, tick, and scorpion venom Snake venom Drugs Image source: Microsoft clipart Poisons that can be injected include: Bee, wasp, and ant venom Spider, tick, and scorpion venom Snake venom Drugs

Abnormal heart rate or rhythm Nausea Vomiting Injected Poisons Signs and symptoms: Weakness Dizziness Chills Fever Abnormal heart rate or rhythm Nausea Vomiting Signs and symptoms are related to the substance injected, the amount injected, and the length of time since the exposure occurred. Be alert for signs and symptoms of anaphylaxis.

Injected Poisons Emergency care: Remove patient (and rescuers) from environment Maintain an open airway Give oxygen Contact medical direction/Poison Control Center to help determine potential toxicity Bring containers/labels to receiving facility Monitor for anaphylaxis Transport Remove the patient (and rescuers) from the environment if repeated stings or bites are likely. Establish and maintain an open airway. Be alert for vomiting; have suction ready. Give oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient’s breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered. Contact medical direction/Poison Control Center to help determine potential toxicity. If applicable, bring all containers, labels, and other evidence of suspected poisons to the receiving facility. Monitor the patient closely for signs and symptoms of anaphylaxis. If the patient has severe respiratory distress or signs of shock and has been prescribed an epinephrine auto-injector (or if you are authorized to carry it), contact medical direction and request an order to give epinephrine or assist the patient in taking it. Transport the patient to the closest appropriate facility or rendezvous with an ALS unit en route. En route to the receiving facility, reassess (including vital signs) as often as indicated. Carefully document all patient care information on a PCR.

Absorbed Poisons

Examples of poisons that can be absorbed include: Absorbed Poisons Examples of poisons that can be absorbed include: Toxins from plants Poison ivy, poison oak, and poison sumac Pesticides Fertilizers Cocaine Chemical warfare agents Toxins can enter the body by absorption through the eye, skin, or mucous membranes. Examples of poisons that can be absorbed include the following: Toxins from plants such as poison ivy, poison oak, and poison sumac Pesticides Fertilizers Cocaine Chemical warfare agents

Absorbed Poisons Signs and symptoms: History of exposure Liquid or powder on patient’s skin Burns Itching Irritation Redness Absorbed Poisons – Signs and Symptoms History of exposure Liquid or powder on patient’s skin Burns Itching Irritation Redness

Absorbed Poisons Emergency care: Remove patient from source of the poison Remove powder or residue from patient’s skin Remove/discard contaminated clothing Maintain open airway, give oxygen If present, brush powder off the patient If exposure involves patient’s eye, flush affected eye with clean water Transport Remove the patient from the source of the poison. Remove any powder or residue from the patient’s skin carefully. While wearing chemical protective clothing and gloves, remove the patient’s contaminated clothing and jewelry. Dispose of contaminated clothing in an appropriate container. Establish and maintain an open airway. Give oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient’s breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered. If the exposure involves the patient’s skin and the poison is in powder form, brush the powder off the patient, then continue as for other absorbed poisons. Be careful not to brush the chemical onto unaffected areas. If the poison is in liquid form, irrigate the skin with clean water for at least 20 minutes (and continue en route to the receiving facility if possible). Pay particular attention to skin creases and fingernails. Do not apply grease or ointments to the affected area. If the exposure involves the patient’s eye, flush the affected eye with clean water 2 or 3 inches from the eye for at least 20 minutes. Ask the patient to blink often while flushing. If only 1 eye is involved, be careful not to contaminate the unaffected eye. Do not allow the patient to rub his eyes. Continue en route to the receiving facility if possible. When flushing is complete, cover both eyes with moistened dressings or eye pads. Contact medical direction/Poison Control Center to help determine potential toxicity. If applicable, bring all containers, bottles, labels, and other evidence of suspected poisons to the receiving facility. Transport the patient to the closest appropriate facility. En route to the receiving facility, reassess (including vital signs) as often as indicated. Carefully document all patient care information on a PCR.

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