1. Slide 1 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Poisoning and Overdoses Chapter 21

2. Slide 2 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Case History You are dispatched to a poisoning and find a 5-year-old girl who is suspected of having ingested a large quantity of acetaminophen (Tylenol) tablets. The mother shows you an empty bottle, but the child appears perfectly normal and has normal vital signs. The child is alert and oriented. You are dispatched to a poisoning and find a 5-year-old girl who is suspected of having ingested a large quantity of acetaminophen (Tylenol) tablets. The mother shows you an empty bottle, but the child appears perfectly normal and has normal vital signs. The child is alert and oriented.

3. Slide 3 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Introduction  Poison  A substance that usually kills, injures, or impairs an organism through its chemical action  Overdose  Drugs, taken in excess or in combination with other agents, to the point where poisoning occurs

4. Slide 4 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Incidence  More than 5 million poisonings occur each year in U.S.  Most occur in children <5 years of age.  Poisonings cause more than 10,000 deaths.  Other causes  Drug abuse  Suicide  Animal or insect bites

5. Slide 5 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Poison Control Centers  Provide access to experts in toxicology.  Staffed 24 hours a day.  Coordinate emergency response  Provide advice to patients at home  Refer people to area hospitals with poisoning care capabilities  Advise EMTs, physicians, and nurses

6. Slide 6 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Types of Poisonings  Ingested  Injected  Inhaled  Absorbed

7. Slide 7 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Cardinal Rules  Treat the patient, not poison.  Protect self and bystanders.  Look for clues of trauma.  Maintain a high level of suspicion.

8. Slide 8 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Scene Size-up  Survey the scene to protect yourself and bystanders.  Dangers  Toxic gases  Absorbed toxins  Do not enter without adequate protection.  Only trained hazmat rescuers should enter.

9. Slide 9 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Initial Assessment  What is your general impression?  Findings indicate any trauma?  Is the patient awake and responsive?  Airway, Breathing, Circulation

10. Slide 10 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Focused History  What is the poison?  How was it taken?  Was it ingested, inhaled, absorbed, or injected?  When was it taken?  How much was taken?  Over what period of time?

11. Slide 11 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Focused History  Is there any other evidence at the scene (e.g., commercial products, pills)?  Were any other interventions attempted?  Vomiting  Dilution  Activated charcoal  Syrup of ipecac  Antidote  How much does the patient weigh?

12. Slide 12 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Perform a Focused Physical Examination  Skin  Pupils  Breath sounds  Abdomen  Mental status  Vital signs

13. Slide 13 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Emergency Medical Care  Remove patient from poisonous environment.  Ensure patent airway and administer oxygen.  Be alert for vomiting.  Bring all poison agents to hospital.  Containers  Bottles  Labels

14. Slide 14 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Ingested Poisons – Signs and Symptoms  History of ingestion  Nausea  Vomiting  Diarrhea

15. Slide 15 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Ingested Poisons – Signs and Symptoms  Altered mental status  Abdominal pain  Chemical burns around the mouth  Different breath odors

16. Slide 16 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Odors SmellPossible Poison Acetone (sweet, fruity)Ethanol, isopropyl alcohol, diabetic AlcoholAlcohol, isopropyl alcohol DisinfectantsCreosol and phenol Rotten eggsHydrogen sulfide GarlicInsecticides Stale tobaccoNicotine WintergreenMethyl salicylate

17. Slide 17 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Emergency Medical Care  Remove poison from patient’s mouth using gloves.  Consult medical direction.  Activated charcoal  Bring all containers (bottles, labels, etc.,) to hospital.

18. Slide 18 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Types of Ingestions  Sedative-hypnotics  Antianxiety agents  Opioids  Psychiatric medications  Stimulants

19. Slide 19 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Types of Ingestions – Sedative-Hypnotics  Barbiturates  Secobarbital (Seconal)  Pentobarbital (Nembutal)  Benzodiazepines  Diazepam (Valium)  Chlordiazepoxide (Librium)  Chlorazepate (Tranxene)

20. Slide 20 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Types of Ingestions – Sedative-Hypnotics  Others  Methaqualone (Quaalude)  Ethchlorvynol (Placidyl)  Chloral hydrate (Noctec)  Mebrobamate (Miltown)

21. Slide 21 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Toxic Effects – Sedative-Hypnotics  Altered mental status  Respiratory depression and arrest  Most toxic when combined with alcohol  Support of ABCs is critical.

22. Slide 22 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Types of Ingestions Opioids (Narcotics)  Central nervous system depressant  Examples Heroin Heroin Morphine Morphine Percocet Percocet Percodan Percodan

23. Slide 23 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Toxic Effects/Management – Opioids (Narcotics)  Toxic effects and signs and symptoms  Altered (depressed) mental status  Respiratory depression  Pinpoint pupils  Track marks  Management  Support ABCs  Administration of naloxone (Narcan) by ALS providers or hospital

24. Slide 24 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Ingested Substances  Stimulants  Cause increased excitability (e.g., amphetamines)  Alcohol  Heart and lung drugs  Analgesics

25. Slide 25 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Inhaled Poisons – Signs and Symptoms  History of inhalation of toxic substance  Difficulty breathing  Chest pain  Cough  Hoarseness  Dizziness  Headache  Confusion  Seizures  Altered mental status

26. Slide 26 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Poisonous Gases  Simple asphyxiants  Carbon dioxide  Small hydrocarbon molecules  Chemical asphyxiants  Irritant gases  Organophosphates

27. Slide 27 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Toxic Injection – Signs and Symptoms  Weakness  Dizziness  Chills  Fever  Nausea  Vomiting

28. Slide 28 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Absorbed Poisons – Signs and Symptoms  History of exposure  Liquid or powder on patient’s skin  Burns  Itching  Irritation  Redness

29. Slide 29 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Emergency Medical Care  Skin  Remove contaminated clothing.  Protect self from contamination.  Powder  Brush powder off patient.  Irrigate for at least 20 minutes.  Continue en route to facility, if possible.  Liquid  Irrigate for at least 20 minutes.  Continue en route to facility, if possible.

30. Slide 30 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Medication Name  Generic  Activated charcoal  Trade  SuperChar™  InstaChar™  Actidose™  LiquiChar™

31. Slide 31 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Activated Charcoal  Indications  Poisoning by mouth  Contraindications  Altered mental status  Ingestion of acids or alkalis  Inability to swallow

32. Slide 32 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Medication Form  Medication is pre-mixed in water.  Plastic bottle containing 125 grams activated charcoal  Powder should be avoided in field.

33. Slide 33 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Dosage  Adults and children  1 gram activated charcoal/kg of body weight  Usual adult dose  25 - 50 grams  Usual infant/child dose  12.5 - 25 grams

34. Slide 34 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Actions  Charcoal binds to certain poisons.  Binding action prevents absorption.  Not all brands are the same.  Some bind much more poison  Consult medical direction about the brand to use.

35. Slide 35 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Side Effects  Black stool  Some patients may vomit.  If the patient vomits, repeat dose one time.  Reassessment strategies  Prepare for vomiting and deterioration of patient’s condition.