1. Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display. 28-1 Chapter 28 Toxicology

2. 28-2 Objectives

3. What Is a Poison? Poison Poisoning Toxin Antidote Poison Control Center 28-3

4. Routes of Entry 28-4

5. Toxidromes Signs, symptoms, and characteristics that often occur together in toxic exposures Categories –Sympathomimetic –Cholinergic –Anticholinergic –Opioid –Sedative/hypnotic 28-5

6. Sympathomimetic Toxidrome Signs/Symptoms Agitation Rapid breathing Increased heart rate Increased blood pressure Fever Seizures Sweating Examples Amphetamines, methamphetamines Cocaine Phencyclidine (PCP) Ecstasy Caffeine Pseudoephedrine 28-6

7. Cholinergic Toxidrome Signs/Symptoms Altered mental status Decreased or increased heart rate SLUDGEM Salivation Lacrimation (tearing) Urination Defecation Gastrointestinal distress Emesis (vomiting) Miosis (pupil constriction) Examples Organophosphate and carbamate insecticides Some mushrooms Nerve agents –Sarin gas 28-7

8. Anticholinergic Toxidrome Signs/Symptoms Confusion Hallucinations Agitation Coma Blurred vision Warm, flushed, dry skin Dilated pupils Examples Antihistamines –Benadryl Jimson weed Tricyclic antidepressants –Amitriptyline (Elavil) –Desipramine (Norpramin) –Nortriptyline (Aventyl, Pamelor) 28-8

9. Opioid (Narcotic) Toxidrome Signs/Symptoms Altered mental status Coma Slow or absent breathing Slow heart rate Low blood pressure Constricted pupils Examples Morphine Codeine Heroin Diphenoxylate (Lomotil) Meperidine (Demerol) Methadone (Dolophine) Propoxyphene (Darvon) 28-9

10. Sedative/Hypnotic Toxidrome Signs/Symptoms Slurred speech Hallucinations Confusion Coma Respiratory depression Low blood pressure Pupil dilation or constriction Blurred vision Dry mouth Decreased temperature Staggering walk Examples Barbiturates –Phenobarbital Benzodiazepines –Diazepam (Valium) Alcohol GHB (a date-rape drug or “liquid x”) 28-10

11. Commonly Misused and Abused Substances 28-11

12. Key Terms Substance abuse Substance misuse Tolerance Addiction Withdrawal Overdose 28-12

13. Stimulants Examples –Cocaine –Amphetamines, methamphetamines –PCP –Caffeine –Nicotine Increase mental and physical activity May produce violent behavior 28-13

14. Depressants Examples –Alcohol –Barbiturates –Narcotics (opiates) –Benzodiazepines 28-14

15. Depressants Alcohol Slows mental and physical activity Affects judgment, vision, reaction time, and coordination In large quantities, can cause death 28-15

16. Depressants Alcohol Signs and symptoms of misuse or abuse can mimic those of other medical conditions Do not assume the patient is intoxicated. 28-16

17. Depressants Alcohol Alcohol withdrawal syndrome Delirium tremens (DTs) 28-17

18. Depressants Barbiturates Prescribed to relieve anxiety, promote sleep, control seizures, and relax muscles Examples –Secobarbital (Seconal) –Phenobarbital (Luminal) Particularly dangerous when combined with alcohol 28-18

19. 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 28-19

20. 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 28-20

21. 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 28-21

22. 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 28-22

23. Patient Assessment 28-23

24. 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 28-24

25. Primary Survey Mental Status Many toxic exposures result in mental status changes Anticipate seizures 28-25

26. 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 28-26

27. Primary Survey Breathing Be prepared to provide positive- pressure ventilation Narrowing of lower airway may cause wheezing 28-27

28. 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 28-28

29. 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 28-29

30. Secondary Survey SAMPLE history –Who, what, where, when, why, how Vital signs and physical exam findings (toxidrome) can provide clues 28-30

31. 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 28-31

32. 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 28-32

33. Ingested Poisons 28-33

34. Ingested Poisons Signs and symptoms are related to: –The drug ingested –The amount ingested –The length of time since the ingestion 28-34

35. 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 28-35

36. Activated Charcoal Activated charcoal can only bind a drug that is not yet absorbed from the gastrointestinal tract 28-36

37. Activated Charcoal Actions Acts as an adsorbent Binds with many (but not all chemicals) Slows down or blocks absorption of the chemical 28-37

38. Activated Charcoal Indications/Dosage Indications –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 28-38

39. 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 28-39

40. Inhaled Poisons 28-40

41. 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 28-41

42. Inhalants “Huffing” “Sniffing” Sudden sniffing death syndrome 28-42

43. Inhaled Poisons Signs/Symptoms Signs and symptoms depend on: –The substance inhaled –The amount inhaled –The extent and duration of exposure 28-43

44. 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 28-44

45. 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 28-45

46. Injected Poisons 28-46

47. Injected Poisons Poisons that can be injected include: –Bee, wasp, and ant venom –Spider, tick, and scorpion venom –Snake venom –Drugs 28-47

48. Injected Poisons Signs and symptoms: –Weakness –Dizziness –Chills –Fever –Abnormal heart rate or rhythm –Nausea –Vomiting 28-48

49. 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 28-49

50. Absorbed Poisons 28-50

51. 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 28-51

52. Absorbed Poisons Signs and symptoms: –History of exposure –Liquid or powder on patient’s skin –Burns –Itching –Irritation –Redness 28-52

53. 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 28-53

54. Questions? 28-54