1. Toxicology and Substance Abuse Ray Taylor Valencia Community College Department of Emergency Medical Services

2. Notice All rights reserved. All rights reserved. Slide show used with permission only for the purposes of educating emergency medical providers (EMTs and Paramedics) Slide show used with permission only for the purposes of educating emergency medical providers (EMTs and Paramedics) No portion of this presentation may be reproduced, stored in a retrieval system in any form or by any means (including but not limited to electronic, mechanical, photocopying etc.) without prior written permission from the author No portion of this presentation may be reproduced, stored in a retrieval system in any form or by any means (including but not limited to electronic, mechanical, photocopying etc.) without prior written permission from the author

3. Topics Epidemiology Epidemiology Poison Control Centers Poison Control Centers Routes of Toxic Exposure Routes of Toxic Exposure General Principles of Toxicology Assessment and Management General Principles of Toxicology Assessment and Management Ingested Toxins Ingested Toxins Inhaled Toxins Inhaled Toxins Surface-Absorbed Toxins Surface-Absorbed Toxins Specific Toxins Specific Toxins Injected Toxins Injected Toxins Substance Abuse and Overdose Substance Abuse and Overdose Alcohol Abuse Alcohol Abuse

4. Epidemiology Over 4 million poisonings occur annually. Over 4 million poisonings occur annually. 10% of ED visits and EMS responses involve toxic exposures. 10% of ED visits and EMS responses involve toxic exposures. 70% of accidental poisonings occur in children under 6 years old. 70% of accidental poisonings occur in children under 6 years old. 80% of attempted suicides involve a drug overdose. 80% of attempted suicides involve a drug overdose.

5. Poison Control Centers Poison Control Poison Control National network of specially trained providers. National network of specially trained providers. Typically regional or statewide. Typically regional or statewide. Accessed by telephone. Accessed by telephone. Contact poison control early. Contact poison control early. Assist in determining potential toxicity. Assist in determining potential toxicity. Advise on prehospital treatment. Advise on prehospital treatment. Advise the receiving facility and medical direction. Advise the receiving facility and medical direction.

6. Routes of Toxic Exposure Ingestion Ingestion Common agents: Common agents: Household products Household products Petroleum-based agents Petroleum-based agents Cleaning agents Cleaning agents Cosmetics Cosmetics Drugs, plants, or foods Drugs, plants, or foods Absorption occurs in the stomach and small intestine. Absorption occurs in the stomach and small intestine.

7. Routes of Toxic Exposure Inhalation Inhalation Common agents: Common agents: Toxic gases, vapors, fumes, aerosols Toxic gases, vapors, fumes, aerosols Carbon monoxide, ammonia, chlorine Carbon monoxide, ammonia, chlorine Tear gas, freon, nitrous oxide, methyl chloride Tear gas, freon, nitrous oxide, methyl chloride Carbon tetrachloride Carbon tetrachloride Absorption occurs via the capillary- alveolar membrane in the lungs. Absorption occurs via the capillary- alveolar membrane in the lungs.

8. Inhaled poisoning Injury is directly proportional to the concentration of the chemical in the air Injury is directly proportional to the concentration of the chemical in the air Solubility of chemical also influences injury Solubility of chemical also influences injury Soluble chemicals i.e.: chlorine and anhydrous ammonia cause injuries early (upper airways) Soluble chemicals i.e.: chlorine and anhydrous ammonia cause injuries early (upper airways) Insoluble chemicals i.e.: nitrogen dioxide need to metabolize before injury occurs (alveoli and bronchioles) Insoluble chemicals i.e.: nitrogen dioxide need to metabolize before injury occurs (alveoli and bronchioles) Injury is directly proportional to the concentration of the chemical in the air Injury is directly proportional to the concentration of the chemical in the air Solubility of chemical also influences injury Solubility of chemical also influences injury Soluble chemicals i.e.: chlorine and anhydrous ammonia cause injuries early (upper airways) Soluble chemicals i.e.: chlorine and anhydrous ammonia cause injuries early (upper airways) Insoluble chemicals i.e.: nitrogen dioxide need to metabolize before injury occurs (alveoli and bronchioles) Insoluble chemicals i.e.: nitrogen dioxide need to metabolize before injury occurs (alveoli and bronchioles)

9. InhalantsInhalants Classifications of toxic gases Classifications of toxic gases Simple asphyxiants Simple asphyxiants lowers O 2 concentrations lowers O 2 concentrations ie: Methane, propane, other inert gases ie: Methane, propane, other inert gases Chemical asphyxiants Chemical asphyxiants systemic toxicity systemic toxicity ie: Carbon Monoxide, cyanide ie: Carbon Monoxide, cyanide Irritants or corrosives Irritants or corrosives cellular destruction on contact cellular destruction on contact ie: chlorine, ammonia ie: chlorine, ammonia Classifications of toxic gases Classifications of toxic gases Simple asphyxiants Simple asphyxiants lowers O 2 concentrations lowers O 2 concentrations ie: Methane, propane, other inert gases ie: Methane, propane, other inert gases Chemical asphyxiants Chemical asphyxiants systemic toxicity systemic toxicity ie: Carbon Monoxide, cyanide ie: Carbon Monoxide, cyanide Irritants or corrosives Irritants or corrosives cellular destruction on contact cellular destruction on contact ie: chlorine, ammonia ie: chlorine, ammonia

10. General Management Protect yourself !! Scene Safety!!

11. Routes of Toxic Exposure Surface Absorption Surface Absorption Common agents: Common agents: Poison ivy, oak, or sumac Poison ivy, oak, or sumac Organophosphates Organophosphates Absorption occurs through capillaries in the skin. Absorption occurs through capillaries in the skin.

12. Routes of Toxic Exposure Injection Injection Common agents: Common agents: Animal bites or stings Animal bites or stings Intentional injection of illicit drugs Intentional injection of illicit drugs Substance enters directly into the body through a break in the skin. Substance enters directly into the body through a break in the skin.

13. Routes Ingestion - *induce emesis only if Poison Control advises (79.2%) Ingestion - *induce emesis only if Poison Control advises (79.2%) Inhalation - *freon; *chlorine most often (5.1%) Inhalation - *freon; *chlorine most often (5.1%) Surface Absorption - *pesticides; *organophosphates (6.3%) Surface Absorption - *pesticides; *organophosphates (6.3%) - ophthalmic absorption (5.3%) Injection – most common for anaphylaxis (3.1%) Injection – most common for anaphylaxis (3.1%) 5% have antidotes 5% have antidotes

14. General Principles of Toxicologic Assessment and Management Standard Toxicologic Emergency Procedures Standard Toxicologic Emergency Procedures Recognize a poisoning promptly. Recognize a poisoning promptly. Assess the patient thoroughly to identify the toxin and measures required to control it. Assess the patient thoroughly to identify the toxin and measures required to control it. Initiate standard treatment procedures. Initiate standard treatment procedures. Protect rescuer safety. Protect rescuer safety. Remove the patient from the toxic environment. Remove the patient from the toxic environment. Support ABCs. Support ABCs. Decontaminate the patient. Decontaminate the patient. Administer antidote if one exists. Administer antidote if one exists.

15. General Assessment Scene Size-up Scene Size-up Be alert to the potential for violence. Be alert to the potential for violence. Look for signs of hazardous material involvement. Look for signs of hazardous material involvement. Enter a hazardous materials scene only if properly trained and equipped to do so. Enter a hazardous materials scene only if properly trained and equipped to do so. Initial Assessment Initial Assessment Airway and respiratory compromise are common in toxicologic emergencies. Airway and respiratory compromise are common in toxicologic emergencies. Manage life-threatening conditions. Manage life-threatening conditions.

16. General Assessment History, Physical Exam, and Ongoing Assessment History, Physical Exam, and Ongoing Assessment Identify the toxin and length of exposure. Identify the toxin and length of exposure. Contact poison control and medical direction according to local policy. Contact poison control and medical direction according to local policy. Complete appropriate physical exams. Complete appropriate physical exams. Monitor vital signs closely. Monitor vital signs closely.

17. General Treatment Decontamination Decontamination Reduce intake of the toxin. Reduce intake of the toxin. Remove the individual from the toxic environment. Remove the individual from the toxic environment. Reduce absorption of toxins in the body. Reduce absorption of toxins in the body. Use gastric lavage and activated charcoal. Use gastric lavage and activated charcoal. “The treatment for pollution is dilution.” “The treatment for pollution is dilution.” Enhance elimination of the toxin. Enhance elimination of the toxin. Use cathartics (defecation). Use cathartics (defecation).

18. General Treatment Antidotes Antidotes Useful only if the substance is known. Useful only if the substance is known. Rarely 100% effective. Rarely 100% effective. Must be used in conjunction with other therapies to ensure effectiveness. Must be used in conjunction with other therapies to ensure effectiveness.

19. General Treatment

20. Suicidal Patients and Protective Custody Suicidal Patients and Protective Custody Involve law enforcement. Involve law enforcement. Involve medical direction. Involve medical direction. Know local procedures and laws. Know local procedures and laws. Laws for protective custody vary widely. Laws for protective custody vary widely.

21. Ingested Toxins Assessment Assessment History History What was ingested? What was ingested? When was it ingested? When was it ingested? How much was ingested? How much was ingested? Did you drink any alcohol? Did you drink any alcohol? Have you attempted to treat yourself? Have you attempted to treat yourself? Have you been under psychiatric care? Why? Have you been under psychiatric care? Why? What is your weight? What is your weight?

22. Ingested Toxins Physical Exam Physical Exam Skin Skin Eyes Eyes Mouth Mouth Chest Chest Circulation Circulation Abdomen Abdomen Exposure to Multiple Toxins Exposure to Multiple Toxins Suicide attempt, experimentation Suicide attempt, experimentation

23. Ingested Toxins Management Management Contact poison control/medical direction. Contact poison control/medical direction. Prevent aspiration. Prevent aspiration. Administer fluids and drugs. Administer fluids and drugs. IV access IV access Use of D 50 W, naloxone, and thiamine Use of D 50 W, naloxone, and thiamine Decontamination Decontamination Do NOT induce vomiting. Do NOT induce vomiting.

24. Inhaled Toxins Assessment Assessment History and Physical Exam History and Physical Exam Evaluate the scene. Evaluate the scene. Central nervous system effects include dizziness, headache, confusion, seizure, hallucinations, coma. Central nervous system effects include dizziness, headache, confusion, seizure, hallucinations, coma. Respiratory effects include cough, hoarseness, stridor, dyspnea, retractions, wheezing, chest pain or tightness, crackles, rhonchi. Respiratory effects include cough, hoarseness, stridor, dyspnea, retractions, wheezing, chest pain or tightness, crackles, rhonchi. Cardiac effects include dysrhythmias. Cardiac effects include dysrhythmias.

25. Inhaled and Surface Absorbed Toxins Management Management Ensure your personal safety. Ensure your personal safety. Do not enter a hazardous scene unless properly trained and equipped to do so. Do not enter a hazardous scene unless properly trained and equipped to do so. Remove the patient from the environment. Remove the patient from the environment. Remove the patient’s contaminated clothing. Remove the patient’s contaminated clothing. Perform the initial assessment, history, and physical exam. Perform the initial assessment, history, and physical exam. Initiate supportive measures. Initiate supportive measures. Contact poison control and medical direction according to local protocol. Contact poison control and medical direction according to local protocol.

26. Specific Toxins

27. Cyanide Exposure Exposure Fast-acting toxin Fast-acting toxin Usually ingested or absorbed Usually ingested or absorbed Signs and Symptoms Signs and Symptoms Burning sensation in the mouth and throat Burning sensation in the mouth and throat Headache, confusion, and combativeness Headache, confusion, and combativeness Hypertension and tachycardia Hypertension and tachycardia Seizures and coma Seizures and coma Pulmonary edema Pulmonary edema

28. Cyanide Management Management Ensure rescuer safety. Ensure rescuer safety. Initiate supportive care. Initiate supportive care. Administer antidote: Administer antidote: Cyanide antidote kit Cyanide antidote kit amyl nitrite amyl nitrite sodium nitrite sodium nitrite sodium thiosulfate sodium thiosulfate Hydroxocobalamin Hydroxocobalamin (Cyanokit) (Cyanokit)

29. Carbon Monoxide Exposure Exposure Inhaled colorless, odorless gas, infinity 200-250x Inhaled colorless, odorless gas, infinity 200-250x Poorly ventilated heating systems Poorly ventilated heating systems Confined spaces Confined spaces Signs and Symptoms Signs and Symptoms Headache Headache Nausea and vomiting Nausea and vomiting Confusion or other altered mental status Confusion or other altered mental status Tachypnea Tachypnea

30. Carbon Monoxide Management Management Ensure rescuer safety. Ensure rescuer safety. Remove the patient from the contaminated area. Remove the patient from the contaminated area. Initiate supportive measures. Initiate supportive measures. High-flow, high- concentration oxygen High-flow, high- concentration oxygen Hyperbaric therapy Hyperbaric therapy

31. Cardiac Medications Exposure Exposure Commonly due to dosage errors Commonly due to dosage errors Signs and Symptoms Signs and Symptoms Nausea, vomiting, headache, dizziness, confusion Nausea, vomiting, headache, dizziness, confusion Profound hypotension, cardiac dysrhythmias Profound hypotension, cardiac dysrhythmias Bronchospasm, pulmonary edema Bronchospasm, pulmonary edema Management Management Standard toxicologic emergency procedures Standard toxicologic emergency procedures Antidotes Antidotes

32. Caustic Substances Exposure Exposure Typically occurs by ingestion or surface absorption. Typically occurs by ingestion or surface absorption. Acids Acids Cause significant damage at sites of exposure. Cause significant damage at sites of exposure. Are rapidly absorbed into the bloodstream. Are rapidly absorbed into the bloodstream. Alkalis Alkalis Slower onset of symptoms allows for longer contact and more extensive tissue damage. Slower onset of symptoms allows for longer contact and more extensive tissue damage.

33. Caustic Substances Signs and Symptoms Signs and Symptoms Facial burns Facial burns Pain in the lips, tongue, throat, or gums Pain in the lips, tongue, throat, or gums Drooling, trouble swallowing Drooling, trouble swallowing Hoarseness, stridor, or shortness of breath Hoarseness, stridor, or shortness of breath Shock from bleeding, vomiting Shock from bleeding, vomiting Management Management Perform standard toxicologic emergency procedures. Perform standard toxicologic emergency procedures. Maintain an adequate airway. Maintain an adequate airway. Do not neutralize!!! Do not neutralize!!!

34. Hydrofluoric Acid Exposure Exposure Highly toxic; used to clean and etch glass. Highly toxic; used to clean and etch glass. Signs and Symptoms Signs and Symptoms Burning at site of contact. Burning at site of contact. Confusion, palpitations, muscle cramps. Confusion, palpitations, muscle cramps. Management Management Perform standard toxicologic emergency procedures. Perform standard toxicologic emergency procedures. Irrigate and immerse the affected area. Irrigate and immerse the affected area. Transport immediately for definitive care. Transport immediately for definitive care.

35. Hydrocarbons Compounds of Carbon and Hydrogen Compounds of Carbon and Hydrogen May be ingested, inhaled, or adsorbed May be ingested, inhaled, or adsorbed Signs and Symptoms Signs and Symptoms Burns due to local contact Burns due to local contact Wheezing, dyspnea, hypoxia, pneumonitis Wheezing, dyspnea, hypoxia, pneumonitis Headache, dizziness, slurred speech, ataxia, obtundation, cardiac dysrhythmias Headache, dizziness, slurred speech, ataxia, obtundation, cardiac dysrhythmias Foot and wrist drop with numbness and tingling Foot and wrist drop with numbness and tingling Management Management Standard toxicologic emergency procedures Standard toxicologic emergency procedures

36. Contaminated Food Bacteria, Viruses, and Toxic Chemicals Bacteria, Viruses, and Toxic Chemicals Bacterial toxins Bacterial toxins Exotoxins (affect cell metabolism) and enterotoxins (kills cells by destroying cell membrane) Exotoxins (affect cell metabolism) and enterotoxins (kills cells by destroying cell membrane) Seafood poisonings Seafood poisonings Signs and Symptoms Signs and Symptoms Nausea, vomiting, diarrhea, and abdominal pain Nausea, vomiting, diarrhea, and abdominal pain Facial flushing and respiratory distress Facial flushing and respiratory distress

37. Contaminated Food Treatment Treatment Perform assessment. Perform assessment. Collect samples of the suspect food source. Collect samples of the suspect food source. Maintain the airway and support breathing. Maintain the airway and support breathing. Intubate and assist ventilations if indicated. Intubate and assist ventilations if indicated. Administer high-flow, high-concentration oxygen. Administer high-flow, high-concentration oxygen. Establish IV access. Establish IV access. Consider medications. Consider medications. Antihistamines, antiemetics. Antihistamines, antiemetics.

38. Poisonous Plants and Mushrooms Decorative Plants Decorative Plants Common source of accidental poisoning in children Common source of accidental poisoning in children Signs and Symptoms Signs and Symptoms Excessive salivation, lacrimation, diaphoresis, abdominal cramps, nausea, vomiting, diarrhea, and altered mental status Excessive salivation, lacrimation, diaphoresis, abdominal cramps, nausea, vomiting, diarrhea, and altered mental status Treatment Treatment Follow treatment guidelines for contaminated food. Follow treatment guidelines for contaminated food.

39. Injected Toxins General Principles of Management General Principles of Management Protect rescuers. Protect rescuers. Remove the patient from danger. Remove the patient from danger. Identify the organism that caused the injury. Identify the organism that caused the injury. Perform an initial assessment and rapid physical exam. Perform an initial assessment and rapid physical exam. Prevent or delay absorption of the poison. Prevent or delay absorption of the poison. Initiate supportive measures as indicated. Initiate supportive measures as indicated. Watch for anaphylactic reactions. Watch for anaphylactic reactions. Transport the patient rapidly. Transport the patient rapidly. Contact poison control and medical direction. Contact poison control and medical direction.

40. Insect Bites and Stings Insect Stings Insect Stings Signs and Symptoms Signs and Symptoms Localized pain, redness, swelling, skin wheal. Localized pain, redness, swelling, skin wheal. Idiosyncratic reactions Idiosyncratic reactions Observe for signs of an allergic reaction. Observe for signs of an allergic reaction. Localized pain, redness, swelling, skin wheal Localized pain, redness, swelling, skin wheal Generalized flushing of the skin or itching Generalized flushing of the skin or itching Tachycardia, hypotension, bronchospasm, laryngeal edema, facial edema, uvular swelling Tachycardia, hypotension, bronchospasm, laryngeal edema, facial edema, uvular swelling

41. Insect Bites and Stings Insect Stings Insect Stings Treatment Treatment Wash the area. Wash the area. Remove stingers, if present. Remove stingers, if present. Use care not to disturb the venom sac. Use care not to disturb the venom sac. Apply cool compresses to the injection site. Apply cool compresses to the injection site. Observe for and treat allergic reactions and/or anaphylaxis. Observe for and treat allergic reactions and/or anaphylaxis.

42. Spider Bites Two types common to US Two types common to US Black Widow and Brown Recluse Black Widow and Brown Recluse Types of reactions to bites Types of reactions to bites neurotoxic reaction (Black Widow) neurotoxic reaction (Black Widow) local tissue necrosis (Brown Recluse) local tissue necrosis (Brown Recluse) Two types common to US Two types common to US Black Widow and Brown Recluse Black Widow and Brown Recluse Types of reactions to bites Types of reactions to bites neurotoxic reaction (Black Widow) neurotoxic reaction (Black Widow) local tissue necrosis (Brown Recluse) local tissue necrosis (Brown Recluse)

43. Insect Bites and Stings Brown Recluse Brown Recluse Found primarily in the South and Midwest Found primarily in the South and Midwest Features Features “Fiddleback” “Fiddleback” 1” body, long thin legs 1” body, long thin legs Painless bite Painless bite Halo bleb to necrosis Halo bleb to necrosis Debride – steroid/xylocaine; Benadryl Debride – steroid/xylocaine; Benadryl

44. Insect Bites and Stings Brown Recluse Spider Bite Brown Recluse Spider Bite Signs and Symptoms Signs and Symptoms Localized, white-ringed macule. Localized, white-ringed macule. Progresses to localized pain, redness, and swelling over next 8 hours. Progresses to localized pain, redness, and swelling over next 8 hours. Chills, fever, nausea, vomiting, and joint pain may also develop. Chills, fever, nausea, vomiting, and joint pain may also develop.

45. Insect Bites and Stings Brown Recluse Spider Bite Brown Recluse Spider Bite Signs and Symptoms Signs and Symptoms Tissue necrosis develops over subsequent days and weeks. Tissue necrosis develops over subsequent days and weeks. Treatment Treatment Follow general treatment guidelines. Follow general treatment guidelines. Provide supportive care. Provide supportive care.

46. Black Widow Adult female injects venom with pincer-like teeth Adult female injects venom with pincer-like teeth No pain after mild bite, then lymph nodes draining site become painful No pain after mild bite, then lymph nodes draining site become painful Within 1 st ½ hour, local erythema, sweating & piloerection at wound site Within 1 st ½ hour, local erythema, sweating & piloerection at wound site Over next few hrs white, blanched plaque visible @ center and lymphangitis Over next few hrs white, blanched plaque visible @ center and lymphangitis Cramping muscle spasms to thighs, lumbar region, abdomen or thorax *due to excessive release of neurotransmitters Cramping muscle spasms to thighs, lumbar region, abdomen or thorax *due to excessive release of neurotransmitters Musculature becomes hypertonic & abdominal rigidity, trismus, opisthotonus Musculature becomes hypertonic & abdominal rigidity, trismus, opisthotonus

47. Black Widow Respirations shallow, tachy, irregular Respirations shallow, tachy, irregular Dysarthria, hoarseness Dysarthria, hoarseness Priapism & ejaculation possible Priapism & ejaculation possible Pain produced by tissue hypoxia from muscular spasm and vasoconstriction Pain produced by tissue hypoxia from muscular spasm and vasoconstriction Venom causes depletion of acetylcholine at motor nerve endings & provokes release of catecholamines at adrenergic nerve endings Venom causes depletion of acetylcholine at motor nerve endings & provokes release of catecholamines at adrenergic nerve endings *Calcium gluconate, 10 ml of 10% solution, may repeat X1 for pain/antivenin & MS for pain if not relieved by calcium/IV diazepam *Calcium gluconate, 10 ml of 10% solution, may repeat X1 for pain/antivenin & MS for pain if not relieved by calcium/IV diazepam

48. Black Widow Hourglass on abdomen (ventral) Hourglass on abdomen (ventral) Egg cases spiked Egg cases spiked golf ball golf ball Under chairs, in garages, machines Under chairs, in garages, machines Bite can look like puncture Bite can look like puncture

49. Insect Bites and Stings Black Widow Spider Bite Black Widow Spider Bite Treatment Treatment Follow general treatment guidelines. Follow general treatment guidelines. Provide supportive care. Provide supportive care. Consider using muscle relaxants to relieve severe muscle spasms. Consider using muscle relaxants to relieve severe muscle spasms. Diazepam 2.5–10 mg IV or 0.1–0.2 mg/kg of a 10% calcium gluconate solution IV Diazepam 2.5–10 mg IV or 0.1–0.2 mg/kg of a 10% calcium gluconate solution IV

50. Scorpions Nocturnal arachnids – love shoes, boots, under rocks, logs Nocturnal arachnids – love shoes, boots, under rocks, logs Venom injection structure located in a bulb-like enlargement at the tip of its long tail Venom injection structure located in a bulb-like enlargement at the tip of its long tail Venom acts on CNS by affecting cardiac & respiratory centers – directly cardiotoxic Venom acts on CNS by affecting cardiac & respiratory centers – directly cardiotoxic

51. Scorpions Initial burning & tingling – progresses to numbness, *slurred speech, restlessness, muscle twitching, salivation, *abdominal cramping, nausea & vomiting and seizures Initial burning & tingling – progresses to numbness, *slurred speech, restlessness, muscle twitching, salivation, *abdominal cramping, nausea & vomiting and seizures Management – constricting band wound site to occlude lymph flow only, avoid analgesics which may increase toxicity & potentiate the venom’s effect on A/W control Management – constricting band wound site to occlude lymph flow only, avoid analgesics which may increase toxicity & potentiate the venom’s effect on A/W control

52. Florida Scorpion

53. Tick Bites Normally not an emergency Normally not an emergency Treatment would include tick removal and transport Treatment would include tick removal and transport Normally not an emergency Normally not an emergency Treatment would include tick removal and transport Treatment would include tick removal and transport

54. Snakebites Pit Viper Bites Pit Viper Bites Venom destroys proteins and other tissue components. Venom destroys proteins and other tissue components. Coral Snake Bites Coral Snake Bites Venom is a neurotoxin that results in paralysis. Venom is a neurotoxin that results in paralysis.

55. Pit Viper Bites

56. Copperhead

57. Milk Snake (not Copperhead)

58. Eastern Diamondback

59. Facial pits – 1 behind eye & nostril on each side of head Elliptical pupil, broad V-shaped head, characteristic color pattern

60. E. Hognose (Adder)

61. Eastern Hognose - Good

62. FL Diamondback Rattlesnake

63. FL Canebrake Rattlesnake

64. Pigmy/Pygmy Rattlesnake

65. FL Cottonmouth

66. Cottonmouth - Bad

67. Pit Viper Bites Treatment Treatment Keep the patient supine. Keep the patient supine. Immobilize the injured limb and maintain it in a neutral position. Immobilize the injured limb and maintain it in a neutral position. Shock management Shock management Apply high-flow, high-concentration oxygen Apply high-flow, high-concentration oxygen Pulse oximetry Pulse oximetry Capnography Capnography

68. Pit Viper Bites Treatment Treatment Monitor the ECG Monitor the ECG Establish IV access. Establish IV access. Transport. Transport. DO NOT apply constricting bands, ice, cold packs, tourniquets, or electrical stimulation to the wound. DO NOT apply constricting bands, ice, cold packs, tourniquets, or electrical stimulation to the wound.

69. Coral Snake Bites Signs and Symptoms Signs and Symptoms Localized numbness, weakness, drowsiness, ataxia, slurred speech, excessive salivation, paralysis of the tongue and larynx Localized numbness, weakness, drowsiness, ataxia, slurred speech, excessive salivation, paralysis of the tongue and larynx Drooping of the eyelids, double vision, dilated pupils, abdominal pain, nausea, vomiting, loss of consciousness, seizures, respiratory failure, hypotension Drooping of the eyelids, double vision, dilated pupils, abdominal pain, nausea, vomiting, loss of consciousness, seizures, respiratory failure, hypotension

70. Coral Snake Bites Treatment Treatment Treat similarly to a pit viper Treat similarly to a pit viper Shock management Shock management

71. Red touch Yellow

72. Kill a Fellow

73. FL Scarlet Kingsnake Red touch Black Venom Lack

74. Corn Snake - Good

75. Happy Gator

76. Unhappy Gator Victim

77. Marine Animal Injection Signs and Symptoms Signs and Symptoms Intense local pain and swelling Intense local pain and swelling Nausea and vomiting Nausea and vomiting Dyspnea Dyspnea Tachycardia Tachycardia Hypotension or shock in severe cases Hypotension or shock in severe cases Treatment Treatment Deactivate with Heat Catfish – hot soapy water Urchins – do not attempt to remove Man o’War – remove tentacle(s) Ammonia

78. Thank you!