Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Paramedic Care: Principles & Practice Volume 3 Medical Emergencies

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Topics Epidemiology Poison Control Centers Routes of Toxic Exposure General Principles of Toxicologic Assessment and Management Ingested Toxins Inhaled Toxins Surface-Absorbed Toxins Specific Toxins Injected Toxins Substance Abuse and Overdose Alcohol Abuse

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Epidemiology Over 4 million poisonings occur annually 10% of ED visits and EMS responses involve toxic exposures 70% of accidental poisonings occur in children under 6 years old 80% of attempted suicides involve a drug overdose

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Poison Control Centers Poison Control –National network of specially trained providers –Typically regional or statewide –Accessed by telephone Contact Poison Control Early –Assist in determining potential toxicity –Advise on prehospital treatment –Advise the receiving facility and medical direction

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ingestion –Common agents: Household products Petroleum-based agents Cleaning agents Cosmetics Drugs, plants, or foods –Absorption occurs in the stomach and small intestine Routes of Toxic Exposure

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Routes of Toxic Exposure Inhalation –Rapid absorption of the toxic agent through the alveolar-capillary membrane –Irritates pulmonary passages, causing extensive edema and destroying tissue –Causative agents can appear as gases, vapors, fumes, or aerosols

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Common Inhaled Poisons Toxic gases Carbon monoxide Ammonia Chlorine Freon Toxic vapors, fumes, or aerosols Carbon tetrachloride Methyl chloride Tear gas Mustard gas Nitrous oxide

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Routes of Toxic Exposure Surface Absorption –Entry of a toxic substance through the skin or mucous membranes –Causes Plants Chemical Organophosphates ©The Stock Connection

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Routes of Toxic Exposure Injection –Results in both immediate and delayed effects Immediate Local effects Anaphylaxis Delayed As toxin is absorbed –Most poisonings by injection result from the bites and stings of insects and animals

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Principles of Toxicologic Assessment and Management

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Principles of Toxicologic Assessment and Management Standard Toxicologic Emergency Procedures –Recognize a poisoning promptly –Assess the patient thoroughly to identify the toxin and measures required to control it –Initiate standard treatment procedures Protect rescuer safety Remove the patient from the toxic environment Support ABCs Decontaminate the patient Administer antidote if one exists

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Assessment Scene Size-up –Be alert to the potential for violence. –Look for signs of hazardous material involvement. Enter a hazardous materials scene only if properly trained and equipped to do so. Initial Assessment –Airway and respiratory compromise are common in toxicologic emergencies. –Manage life-threatening conditions.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Assessment History, Physical Exam, and Ongoing Assessment –Identify the toxin and length of exposure –Contact poison control and medical direction according to local policy –Complete appropriate physical exams –Monitor vital signs closely

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Treatment Initiate supportive treatment Decontamination –Reduce intake of the toxin Remove the individual from the toxic environment –Reduce absorption of toxins in the body Use of Ipecac is no longer indicated except in extreme circumstances Use gastric lavage and activated charcoal –Enhance elimination of the toxin Use cathartics

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Use of Ipecac: All of the Following Must Apply There is no contraindication to the use of ipecac syrup; and There is a significant risk of serious toxicity in the victim; and There is no alternative therapy available effective to decrease gastrointestinal absorption (e.g., activated charcoal); and

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Use of Ipecac: All of the Following Must Apply There will be a delay greater that 1 hour before the patient will arrive at the emergency department; and Ipecac syrup can be administered within 30–90 minutes of the ingestion; and Ipecac syrup administration will not adversely affect more definitive treatment that might be provided at a hospital.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Treatment Antidotes –Useful only if the substance is known –Rarely 100% effective –Must be used in conjunction with other therapies to ensure effectiveness

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Treatment Suicidal Patients and Protective Custody –Involve law enforcement –Involve medical direction –Know local procedures and laws Laws for protective custody vary widely

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ingested Toxins Assessment –History What was ingested? When was it ingested? How much was ingested? Did you drink any alcohol? Have you attempted to treat yourself? Have you been under psychiatric care? Why? What is your weight?

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ingested Toxins Physical Exam –Skin –Eyes –Mouth –Chest –Circulation –Abdomen Exposure to Multiple Toxins –Suicide attempt –Experimentation

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ingested Toxins Management –Contact poison control/medical direction –Prevent aspiration –Administer fluids and drugs IV access Use of D 50 W, naloxone, and thiamine Decontamination –Do NOT induce vomiting

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Inhaled Toxins Assessment –History and Physical Exam Evaluate the scene Central nervous system effects Dizziness, headache, confusion, seizure, hallucinations, coma Respiratory effects Cough, hoarseness, stridor, dyspnea, retractions, wheezing, chest pain or tightness, crackles, rhonchi Cardiac effects Dysrhythmias

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Inhaled Toxins Management –Ensure your personal safety. Do not enter a hazardous scene unless properly trained and equipped to do so. –Remove the patient from the environment. Remove the patient’s contaminated clothing. –Perform the initial assessment, history, and physical exam. –Initiate supportive measures. –Contact poison control and medical direction according to local protocol.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Surface-Absorbed Toxins Assessment and Management –Ensure your personal safety. Do not enter a hazardous scene unless properly trained and equipped to do so. –Remove the patient from the environment. Remove the patient’s contaminated clothing. –Perform the initial assessment, history, and physical exam. –Initiate supportive measures. –Contact poison control and medical direction according to local protocol.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Specific Toxins Toxidromes –Similar toxins typically have similar signs and symptoms –In some cases it may be difficult to identify a specific toxin

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Carbon Monoxide Number one cause of poisoning in industrialized countries Inhaled colorless, odorless gas –Poorly ventilated heating systems –Confined spaces

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Carbon Monoxide Sources –Endogenous Normal breakdown of hemoglobin May increase with disease states –Exogenous Product of combustion –Methylene chloride © 2007 fortworthfire.com

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Carbon Monoxide Pathophysiology –CO competes with oxygen for the oxygen- binding sites on hemoglobin Affinity is approximately 200–250 times that of oxygen –The amount of hemoglobin that is saturated with oxygen is steadily diminished –Can be removed only via degradation of carboxyhemoglobin Administration of oxygen Hyperbaric therapy

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Carbon Monoxide Effects of CO Exposure –Central Nervous System Headache, dizziness, confusion, seizures, and ultimately coma Long-term cognitive and psychiatric disorders –Cardiovascular Chest pain, hypotension with tachycardia, cardiac dysrhythmias, myocardial ischemia and ultimately ventricular fibrillation –Respiratory Pulmonary edema –Other body systems and functions Metabolic derangements Multiple Organ Dysfuntion Syndrome

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Carbon Monoxide Summary of effects of CO exposure –Limits oxygen transport –Inhibits oxygen transfer –Causes tissue inflammation –Causes reduced cardiac function –Increases activation of nitric oxide –Causes vasodilation –Induces free-radical formation

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Carbon Monoxide At-risk populations –Extremes of age –Patients with heart disease –Pregnant women –Patients with a decreased oxygen-carrying capacity –Patients with chronic respiratory conditions

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Carbon Monoxide Signs and Symptoms –Often vague and nonspecific Mimics viral illness, coronary syndrome, or migraine –Symptoms may be acute or chronic –Symptoms worsen with significant exposure Cherry-red skin color is unreliable and usually a late indicator of CO poisoning

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Carbon Monoxide CO Detection –Home use –Hand-held detectors –CO oximetry

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Carbon Monoxide Management –Ensure rescuer safety –Remove the patient from the contaminated area –Initiate supportive measures High-flow, high- concentration oxygen Monitor CO levels –Hyperbaric therapy Courtesy of NASA

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cyanide Colorless gas that has a faint, bitter-almond odor Cyanide-containing products are routinely used in certain manufacturing processes

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cyanide Sources –Product of combustion Plastics, wool, silk, synthetic rubber, polyurethane, and asphalt Found in routine firefighting operations –Ingested, inhaled, or absorbed –Long-term sodium nitroprusside therapy Pathophysiology –Effectively stops energy production by the cell –Cell shifts from aerobic to anaerobic metabolism

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cyanide CO and Cyanide Poisoning –The effects of CO and cyanide are cumulative Signs and Symptoms –Burning sensation in the mouth and throat –Headache, confusion, combative behavior –Hypertension and tachycardia followed by hypotension and further dysrhythmias –Seizures and coma –Pulmonary edema

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cyanide Management –Ensure rescuer safety –Initiate supportive care –Administer antidote: Lilly Antidote Kit Pasadena Antidote Kit Cyanokit ® Courtesy © Dey, L.P. © Jeff Forster

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiac Medications Exposure –Commonly due to dosage errors Signs and Symptoms –Nausea, vomiting, headache, dizziness, confusion –Profound hypotension, cardiac dysrhythmias –Bronchospasm, pulmonary edema Management –Standard toxicologic emergency procedures –Antidotes

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Caustic Substances Caustic substances are either acids or alkalis –Acids pH < 2 Cause significant damage at sites of exposure Are rapidly absorbed into the bloodstream –Alkalis pH > 12 Slower onset of symptoms allows for longer contact and more extensive tissue damage

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Caustic Substances Signs and Symptoms –Facial burns –Pain in the lips, tongue, throat, or gums –Drooling, trouble swallowing –Hoarseness, stridor, or shortness of breath –Shock from bleeding, vomiting Management –Perform standard toxicologic emergency procedures –Maintain an adequate airway May require cricothyrotomy

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hydrofluoric Acid Extremely toxic –Can be lethal despite the appearance of only moderate burns Inactivated only when it comes in contact with cations deep in body tissues © Fundamental Photographs, NYC © David Effron, MD

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hydrofluoric Acid Signs and Symptoms –Burning at site of contact –Trouble breathing –Confusion, palpitations, muscle cramps Management –Perform standard toxicologic emergency procedures –Irrigate and immerse the affected area in cool water with magnesium sulfate, calcium salts, or benzethonium chloride –Transport immediately for definitive care

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hydrocarbons Compounds of Carbon and Hydrogen –May be ingested, inhaled, or adsorbed Signs and Symptoms –Burns due to local contact –Wheezing, dyspnea, hypoxia, pneumonitis –Headache, dizziness, slurred speech, ataxia, obtundation, cardiac dysrhythmias –Foot and wrist drop with numbness and tingling Management –Standard toxicologic emergency procedures

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Tricyclic Antidepressant Include amitriptyline, amoxapine, doxepin, nortriptyline, imipramine, clomipramine –TCAs have a narrow therapeutic index –Safer agents available Signs and Symptoms of Toxicity –Dry mouth, blurred vision, urinary retention, constipation

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Tricyclic Antidepressants Signs and Symptoms of Severe Toxicity –Confusion, hallucinations, hyperthermia –Respiratory depression, seizures –Tachycardia, hypotension, cardiac dysrhythmias Management –Perform standard toxicologic emergency procedures –Monitor and treat cardiac dysrhythmias –Avoid use of flumazenil, which may precipitate seizures

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Tricyclic Antidepressant Overdose Algorithm Click here to view the Tricyclic Antidepressant Overdose Algorithm.here

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ MAO Inhibitors Infrequently Prescribed Antidepressant –High mortality with overdose because of drug’s action –Interacts with many other medications Signs and Symptoms –Headache, agitation, restlessness, tremor –Nausea, severe hypertension, hyperthermia –Palpitations and tachycardia Progresses to bradycardia, hypotension, coma, and death Management –Standard toxicologic emergency procedures

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Newer Antidepressants Trazodone, Bupropion, and SSRIs Signs and Symptoms –Drowsiness, tremor, nausea, vomiting, tachycardia

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Newer Antidepressants Serotonin syndrome –Cognitive Effects: mental confuson, hypomania, hallucinations, agitation, headache, coma –Autonomic Effects: shivering, sweating, fever, hypertension, tachycardia, nausea, diarrhea –Somatic Effects: myoclonus/clonus, hyperreflexia, tremor Management –Standard toxicologic emergency procedures

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Re-Uptake Inhibitors Click here to view an animation on re-uptake inhibitors.here

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ SSRI Overdose Algorithm Click here to view the SSRI Overdose Algorithm.here

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Lithium Prescribed to treat bipolar disorder –Narrow therapeutic index Signs and Symptoms –Thirst, dry mouth, tremors, muscle twitching, and increased reflexes –Confusion, stupor, seizures, coma, nausea, vomiting, diarrhea, bradycardia, and dysrhythmias Treatment –Standard toxicologic emergency procedures Activated charcoal not effective with lithium

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Salicylates Common Overdose Drug –Includes aspirin, oil of wintergreen Signs and Symptoms –Tachypnea, hyperthermia, confusion, lethargy, coma, cardiac failure, and dysrhythmias, metabolic acidosis –Abdominal pain, vomiting, pulmonary edema, ARDS Treatment –Standard toxicologic emergency procedures Activated charcoal indicated

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Acetaminophen Common OTC Antipyretics and Analgesics Signs and Symptoms Treatment –Standard toxicologic emergency procedures Gradual recovery or progressive liver failure 4–14 daysStage 4 Liver function disruption72–96 hoursStage 3 Abdominal pain, decreased urine, elevated liver enzymes 24–48 hoursStage 2 Nausea, vomiting, weakness, and fatigue 1/2 hour – 24 hours Stage 1

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Acetominophen Overdose Algorithm Click here to view the Acetominophen Overdose Algorithm.here

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Nonprescription Pain Medications Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) –Include ibuprofen, keterolac, naproxen sodium Signs and Symptoms –Headache, tinnitus, nausea, vomiting, abdominal pain, drowsiness –Dyspnea, wheezing, pulmonary edema, swelling of extremities, rash, itching Treatment –Standard toxicologic emergency procedures

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Theophylline Bronchodilator Prescribed for Chronic Respiratory Problems Signs and Symptoms –Agitation, tremors, seizures, cardiac dysrhythmias, nausea, and vomiting Management –Standard toxicologic emergency procedures Repeated doses of activated charcoal are indicated Treat cardiac dysrhythmias

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Metals Iron –Overdose of dietary supplement –Signs and Symptoms Vomiting (with hematemesis), diarrhea, abdominal pain, shock, liver failure, bowel scarring and obstruction, metabolic acidosis with tachypnea –Treatment Standard toxicologic emergency procedures Activated charcoal not indicated

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Metals Lead and Mercury –Overdose often results from chronic environmental exposure Paints, glazes, industrial use, thermometers –Signs and Symptoms Headache, irritability, confusion, coma, memory disturbances, tremors, weakness, agitation, abdominal pain –Treatment Standard toxicologic emergency procedures Activated charcoal not indicated

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Contaminated Food Bacteria, Viruses, and Toxic Chemicals –Bacterial toxins Exotoxins and enterotoxins –Seafood poisonings Signs and Symptoms –Nausea, vomiting, diarrhea, and abdominal pain –Facial flushing and respiratory distress

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Contaminated Food Treatment –Perform assessment –Collect samples of the suspect food source –Maintain the airway and support breathing Intubate and assist ventilations if indicated Administer high-flow, high-concentration oxygen –Establish IV access –Consider medications Antihistamines, antiemetics

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Poisonous Plants and Mushrooms Decorative Plants –Common source of accidental poisoning in children Signs and Symptoms –Excessive salivation, lacrimation, diaphoresis, abdominal cramps, nausea, vomiting, diarrhea, and altered mental status Treatment –Follow treatment guidelines for contaminated food © Leonard Lee Rue III/ Photo Researchers, Inc.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Injected Toxins General Principles of Management –Protect rescuers –Remove the patient from danger –Identify the organism that caused the injury –Perform an initial assessment and rapid physical exam –Prevent or delay absorption of the poison –Initiate supportive measures as indicated –Watch for anaphylactic reactions –Transport the patient rapidly –Contact poison control and medical direction

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Insect Bites and Stings Hymenoptera most common –Includes bees, wasps, hornets, and ants Signs and Symptoms –Localized pain, redness, swelling, skin wheal Idiosyncratic reactions –Observe for signs of an allergic reaction Localized pain, redness, swelling, skin wheal Generalized flushing of the skin or itching Tachycardia, hypotension, bronchospasm, laryngeal edema, facial edema, uvular swelling

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Insect Bites and Stings Insect Stings –Treatment Wash the area Remove stingers, if present Use care not to disturb the venom sac Apply cool compresses to the injection site Observe for and treat allergic reactions and/or anaphylaxis

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Insect Bites and Stings Africanized Honey Bees –“Killer Bees” –Much more aggressive than their European counterparts –Attack in groups –Triggers © Nature Picture Library

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Africanized Honey Bees Management –Personnel should don appropriate protective equipment –Approached with a hose line using water and a fog pattern Ideally use foam –Proprietary systems BeeAlert 

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Insect Bites and Stings Brown Recluse Spider Bite –Found primarily in the South and Midwest –Lives in dark, dry locations –Violin-shaped marking on the back “Fiddleback”

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Brown Recluse Spider Bite –Signs and Symptoms Localized, white-ringed macule Progresses to localized pain, redness, and swelling over next 8 hours Chills, fever, nausea, vomiting, and joint pain may also develop Insect Bites and Stings © Scott and White Hospital and Clinic

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Brown Recluse Spider Bite –Signs and Symptoms Tissue necrosis develops over subsequent days and weeks –Treatment Follow general treatment guidelines Provide supportive care © Scott and White Hospital and Clinic Insect Bites and Stings

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Insect Bites and Stings Black Widow Spider Bite –Signs and Symptoms Immediate pain, redness, and swelling Progressive muscle spasms of all large muscle groups Nausea, vomiting, sweating, seizures, paralysis, and altered level of consciousness

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Insect Bites and Stings Black Widow Spider Bite –Treatment Follow general treatment guidelines Provide supportive care 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

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Scorpion Stings –Signs and Symptoms Localized burning and tingling sensation Slurred speech, restlessness, muscle twitching, salivation, nausea, vomiting, and seizures –Treatment Follow general treatment guidelines Apply constricting band Insect Bites and Stings

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Snakebites Two families of venomous snakes –Crotalidae Pit Viper Bites Cottonmouth, rattlesnakes, and copperhead –Elapidae Coral Snake Bites Characteristic yellow-banded red and black rings “Red touch yellow, kill a fellow; red touch black, venom lack”

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pit Vipers Copperhead - Animals Animals/Earth Scenes Rattlesnake - © National Geographic Image Collection Cottonmouth snake - © Nature Picture Library

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pit Viper Bites Contains enzymes that are capable of destroying proteins and most other tissue –Will produce infarction and tissue necrosis Most deaths from pit viper bites occur from 6 to 30 hours after the bite

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pit Viper Bites Treatment –Keep the patient supine –Immobilize the injured limb and maintain it in a neutral position –Apply high-flow, high-concentration oxygen –Establish IV access –Transport –DO NOT apply constricting bands, ice, cold packs, tourniquets, or electrical stimulation to the wound

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Coral Snake Bites Contains some of the enzymes found in pit viper venom Neurotoxin –Coral snake venom primarily affects nervous tissue May result in respiratory and skeletal muscle paralysis

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Coral Snake Bites Signs and Symptoms –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 Treatment –Treat similarly to a pit viper bite Wash the wound with large amounts of water and maintain the immobilized extremity at the level of the heart

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Coral Snake Bites Management –Wash the wound with copious amounts of water –Apply a compression bandage and keep the extremity at the level of the heart –Immobilize the limb with a splint –Start an IV using crystalloid fluid –Transport the patient to the emergency department for administration of antivenin

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Coral Snake Bites DO NOT –Apply ice, cold pack, or Freon sprays to the wound –Incise the wound –Apply electrical stimulation from any device in an attempt to retard or reverse venom spread

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Marine Animal Injection Injection of toxins from marine life can result from: –Stings of jellyfish, corals, and the bony spines of animals such as sea urchins and stingrays Stingray

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Marine Animal Injection Signs and Symptoms –Intense local pain and swelling –Nausea and vomiting –Dyspnea –Tachycardia –Hypotension or shock in severe cases Treatment –Establish and maintain the airway –Apply a constricting band above the site –Apply heat or hot water –Inactivate or remove any stingers

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Marine Animal Injection Management –Establish and maintain the airway –Apply a constricting band between the wound and the heart no tighter than a watchband to occlude lymphatic flow only –Apply heat or hot water (110°–113°F) –Inactivate or remove any stingers

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ciguatera Poisoning Illness caused by eating fish that contain toxins produced by a marine microalgae Poisoning primarily occurs from predator reef fish –Barracuda, moray eel, grouper, amberjack, and parrotfish Heavybeak parrotfish (Photo Researchers, Inc.)

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ciguatera Poisoning Signs and Symptoms –Gastrointestinal Nausea, vomiting, diarrhea, and abdominal pain –Neurologic Profound weakness, paresthesias, severe pruritus, tooth pain or the feeling that teeth are loose, pain on urination, and blurred vision –Cardiovascular Hypotension, bradycardia (slowed heartbeat), or dysrhythmia

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ciguatera Poisoning Management –Symptoms usually go away in days or weeks but can last for years –Treat patient for presenting symptoms

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Substance Abuse and Overdose Addiction –Habituation –Physiological dependence –Psychological dependence –Tolerance Withdrawal Drug Overdose

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Common Drugs of Abuse Drugs Used for Sexual Purposes –Ecstasy (MDMA) Signs and symptoms include anxiety, nausea, tachycardia, and hypertension, followed by relaxation and euphoria Provide supportive care –Rohypnol (“Date Rape Drug”) Potent benzodiazepine, illegal in the U.S. Treat as a benzodiazepine overdose and sexual assault victim

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Alcohol Abuse Physiologic Effects –CNS depressant –Alcoholism Susceptible to methanol or ethylene glycol ingestion –Peripheral vasodilation, diuresis General Alcoholic Profile –Drinks early in the day, alone, or secretly –Binges, blackouts, GI problems, “green tongue syndrome,” chronic flushing of face and palms –Cigarette burns, tremulousness, and odor of alcohol

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Consequences of Chronic Alcohol Ingestion –Poor nutrition –Alcohol hepatitis –Liver cirrhosis, pancreatitis –Sensory loss in hands/feet –Loss of balance and coordination –Upper GI hemorrhage –Hypoglycemia –Falls (fractures and subdural hematoma) Alcohol Abuse

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cirrhosis Click here to view an animation on cirrhosis.here

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Alcohol Abuse Withdrawal Syndrome –Delirium Tremens (DTs) –Signs and Symptoms Coarse tremor of hands, tongue, eyelids Nausea, vomiting, general weakness, anxiety Tachycardia, sweating, hypertension, hallucinations, irritability or depressed mood, poor sleep Increased sympathetic tone, orthostatic hypotension

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Alcohol Abuse Withdrawal Syndrome –Treatment Establish and maintain the airway Determine if other drugs are involved Establish IV access Lactated Ringer’s or normal saline Consider medications 25g D 50 W if hypoglycemic 100mg thiamine IV or IM Transport, maintaining a sympathetic attitude, and reassure the patient

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Summary Epidemiology Poison Control Centers Routes of Toxic Exposure General Principles of Toxicologic Assessment and Management Ingested Toxins Inhaled Toxins Surface-Absorbed Toxins Specific Toxins Injected Toxins Substance Abuse and Overdose Alcohol Abuse

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ.

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Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ.

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