Poisoning and Overdose Emergencies CHAPTER 21 Poisoning and Overdose Emergencies

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

Key Term Toxin A poisonous substance secreted by bacteria, 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

Key Term Systemic Poisons These poisons cause harm to the entire body or an entire body system

Four Types of Poisoning INHALATION INJECTION Drugs Sprays Cleaning Fluid INGESTION ABSORPTION Lye Household Cleaners Drain Cleaners Rat Poison Insecticides

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

Signs & Symptoms of Ingested Poison/Overdose History of ingestion Nausea (most common) Vomiting (most common) Diarrhea

Signs & Symptoms of Ingested Poison/Overdose Altered mental status Abdominal pain Chemical burns around mouth Unusual breath odor Difficulty breathing

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

Consult medical direction. Administer activated charcoal?

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

Information to Gather How much did you ingest? Over what time period? 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?

Information to Gather 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 Absorbed Poisons

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

Signs & Symptoms of Inhaled Poisons Nausea (most common) Vomiting (most common) Difficulty breathing Chest pain Cough Hoarseness

Signs & Symptoms of Inhaled Poisons Dizziness Headache Confusion Seizures Altered mental status History of inhalation; MOI

Carbon Monoxide 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 Inhalation Signs and Symptoms (resemble flu) Nausea Vomiting Headache Dizziness Difficulty breathing Cyanosis Altered mental status Unconsciousness Cherry red lips VERY UNCOMMON.

Smoke Inhalation Substances found in smoke can burn the skin Irritate the eyes Injure the airway Cause respiratory arrest Cause cardiac arrest

Smoke Inhalation Signs and Symptoms Difficulty breathing Coughing (can be delayed or Immediate and severe) Difficulty breathing 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

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

Establish an open airway Establish an open airway. Give oxygen, if not already done in the initial assessment. Give by NRB at 15 lpm.

Maintain airway and administer oxygen.

Remove contaminated clothing.

Consult medical direction.

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

Information to Gather What substance involved? Get exact name and spelling. Bring container, if possible and safe. When did exposure occur? Try to find out what the earliest and latest possible times of exposure were.

Information to Gather 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?

Information to Gather Any effects on patient? Nausea/vomiting, difficulty breathing, chest pain, coughing, hoarseness, dizziness, headache, confusion, seizures, or altered mental status

Key Term Injected Poisons Poisons that are inserted through the skin.

Signs & Symptoms of Injected 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.

Key Term Absorbed Poisons Poisons that are taken into the body through unbroken skin.

Signs & Symptoms of Absorbed Poisons History of exposure Liquid or powder on patient’s skin Burns Itching Irritation Redness Difficulty Breathing

Remove patient from source without contaminating yourself.

Brush powders from patient, and irrigate Remove contaminated clothing and other articles. Be sure to protect oneself. Brush powders from patient, and irrigate with water for at least 20 minutes.

Irrigate with clear water for at least 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.

Information to Gather What substance involved? Get exact name and spelling. When did exposure occur? How much substance was the patient exposed to? How large an area of skin was covered?

Information to Gather Over what time period? Patient interventions… 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?

Information to Gather Any effects on patient? Liquid or powder on the patient’s skin, burns, itching, irritation and redness BE ALERT FOR CONTACT LENSES

Airway Management in Poisoning/Overdose When treating a poisoned or overdosed patient, be prepared for deterioration, vomiting, and the need to secure airway.

Use of Activated Charcoal

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

Trade Names: SuperChar, InstaChar, LiquiChar, Actidose Generic Name: Activated Charcoal

Activated Charcoal Indication Contraindications Poisoning by mouth 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

Activated Charcoal Medication Form Pre-mixed in water, commonly 12.5 grams in plastic bottle Avoid powder form in the field

Activated Charcoal Dosage Adults and children: Adult: Pediatric: 1 gram activated charcoal/kg of body weight Adult: 25-50 grams Pediatric: 12.5-25 grams

Activated Charcoal Administration 1. Consult medical direction. 2. Shake container thoroughly. 3. Since medication looks like mud, patient may need to be persuaded to drink it. A covered container and a straw may improve patient compliance since the patient cannot see the medication this way. If patient takes a long time to drink the medication, the charcoal will settle and will need to be shaken or stiffed again. Record activity and time.

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

Activated Charcoal Side Effects Black stools Some patients, particularly those who have ingested poisons that cause nausea, may vomit If patient vomits, the dose should be repeated once The EMT-Basic should be prepared for the patient to vomit or further deteriorate Reassessment Strategies

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 Contraindications Poisoning by mouth Altered mental status Ingestion of acid or alkali (i.e. oven cleaners, drain cleaners, toilet bowl cleaners, lye, etc…) Patient unable to swallow

Syrup of Ipecac Medication Form Liquid Contact Medical Control Dosage

Syrup of Ipecac Administration Reassessment Strategies Obtain order from medical direction either on-line or off-line Record activity and time Reassessment Strategies Should be prepared for the patient to vomit or further deteriorate

Antidote versus Dilution 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 Dilution 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

Alcohol and Substance Abuse

Alcohol Abuse Emergencies 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 with Alcohol 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 of Alcohol 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

Uppers Uppers – 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

Narcotics Drugs 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

Hallucinogens Mind-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 Chemicals Give 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 of Substance Overdose Ensure scene safety; restrain patient if needed. Assess for respiratory compromise. Monitor level of consciousness. Continued…

Emergency Care of Substance Overdose Monitor vital signs. Treat for shock. Assess for injuries. Transport.