1. Breathing
Pulse Oximetry
By observation and oximetry (monitor the saturation of pt’s Hb)
Ventilatory failure…..most common cause of death in poisoned patients:…………..mechanical ventilation
Hypoxia……brain damage, cardiac arrhythmias, and cardiac arrest
Hypercarbia…elevated CO2 in the blood ...acidosis (may contribute to arrhythmias)
LOOK for mental status, chest movement, respiratory rate
LISTEN for air escaping during exhalation, sound of obstruction
FEEL for the flow of air, chest wall for crepitus (crunching sound)
ASSESS tracheal position, auscultation of all lung fields (listening to the internal sounds of the body , usually using stethoscope)
Oximetry is a procedure used to measure the oxygen saturation in the blood (on a fingertip)

3. Circulation
Should be assessed by contineous monitoring of the pulse rate, blood pressure, urinary output, and valuation of peripheral perfusion.
Check skin color, temperature, capillary refill
Management: stop major external bleeding
Begin continuous ECG monitoring

4. Altered mental status
A decreased level of consciousness is the most common serious complication of drug overdose or poisoning
Coma sometimes represents a postictal phenomenon after a drug- or toxin-induced seizure
Coma may also be caused by brain injury associated with infarction or intracranial bleeding
Coma frequently is accompanied by respiratory depression, which is a major cause of death
May be complicated by hypotension, hypothermia, hyperthermia, and rhabdomyolysis
Postictal state: altered state of consciousness after the patient has had seizures

5. Disability How to assess the level of consciousness ??? by AVPU method
A…..ALERT
V…..responds to VERBAL stimuli
P…..responds to PAINFUL stimuli
U…..UNRESPONSIVE
Size and reactivity of pupils
Movement of upper and lower extremities

6. The DONT Cocktail Administer supplemental oxygen
Every patient with altered mental status should receive a challenge with concentrated Dextrose unless a rapid bedside blood sugar test demonstrates that the patient is not hypoglycemic.
Adults: 50% dextrose, 50 mL (25 g) IV.
Children: 25% dextrose, 2 mL/kg (0.5g/kg) IV

7. The DONT Cocktail
Thiamine: is a cofactor in a number of metabolic pathways allowing aerobic metabolism to produce ATP and, Important in normal neuronal conduction
Alcoholic or malnourished patients should receive 100mg of thiamine IM or in the IV infusion solution to prevent or treat Wernicke's syndrome.(type of brain disorder , bleeding of the lower section of the brain ….brain damage ….affect vision, coordenation, and balance)

8. The DONT Cocktail
The opioid antagonist Naloxone may be given as IV (may also be given intramuscularly) to all patients with CNS depression and respiratory depression.
If artificially ventilated…..not immediately necessary
0.4 mg IV, if there is no response within 1–2 minutes, give naloxone, 2 mg IV
If there is still no response and opioid overdose is highly suspected give naloxone, 10–20 mg IV

9. Exposure
Remove clothes and other items that interferes with a full evaluation

10. History Route of exposure (e.g. ingestion, inhalation, intravenous)
Historical data should include the amount and type of toxin
Route of exposure (e.g. ingestion, inhalation, intravenous)
Also ask about prior suicide attempts or psychiatric history
If the patient is a female in reproductive years, ask about pregnancy and obtain pregnancy test

11. Identify the toxicant SAMPLE
S: substance, amount, time, correlate symptom
A: allergies, age, gender, wt
M: medication (including prescription drugs, OTC medication, vitamins, and herbal preparation)
P: past diseases, substance abuse or intentional ingestion
L: last meal….influence absorption
E: events leading to current condition

12. Odors Acetone Isopropyl alcohol Ethanol Bitter almonds Cyanide Garlic
Arsenic
Organophosphates
Rotten eggs
Sulfide
Not absolute… the odor may be subtle and may be obscured by the smell of emesis or by other ambient odors. In addition, the ability to smell an odor may vary

13. Blood Pressure

14. hypertension
Sympathomimetics
Amphetamines
Cocaine
MAOI
Nicotine

15. hypotension Antipsychotic Beta blockers Calcium channel blockers
Ethanol
Nitrates
Opioids
Sedative-hypnotics
Tricyclic antidepressants (with tachycardia)

16. Pulse

17. tachycardia Amphetamines Atropine Antihistamines Caffeine Cyanide
Nitrates

18. bradycardia Beta blockers Calcium channel blockers Clonidine Digitalis
Mushrooms
Organophosphates
Sedative hypnotics

19. RESPIRATION

20. Hyperventilation Salicylates Carbon monoxide Ethylene glycol
Rapid respirations are typical of toxins that produce metabolic acidosis or cellular asphyxia. (a condition of severely deficient supply of oxygen).
Salicylates
Carbon monoxide
Ethylene glycol
Hydrocarbons

21. Hypoventilation
Anesthetics
Cyanide
Ethanol
Sedative hypnotics
Opioids

22. TEMPERATURE HYPERTHERMIA (>40°C): Sympathomimetics Amphetamines
MAOI
Anticholinergic
Drugs producing seizures or muscular rigidity
Antipsychotic may cause muscular rigidity!

23. TEMPERATURE HYPOTHERMIA (<32°C):
CNS depressants (barbiturates, opioids, ethanol)
Hypoglycemic agents
Drugs that cause vasodilation
…..(especially if accompanied by cold environment)
N.B: commonly accompanied by hypotension and bradycardia

24. Eye findings Miosis:(constriction of the pupil) Cholinergic Clonidine
Insecticides
Narcotics
Phenothiazines

25. Eye findings Mydriasis dilation of the pupil):
Anticholinergic
Sympathomimetic
Withdrawal states
Nystagmus: (involuntary or voluntary in rare cases eye movement)
Horizontal……phenytoin, alcohol, barbiturates
Both vertical & horizontal: strongly suggest phencyclidine poisoning

26. OTHERS
Absent bowel sounds: paralytic ileus……anticholinergic intoxication or perforation coz of acid ingestion
Hyperactive bowel sounds, abdominal cramping and diarrhea….organophosphates
Determine if bladder distention (stretched) and urinary retention exist…..anticholinergic intoxication
Skin appearance: red, white, blue, warm, cool, dry, moist, piloerection which is erection of the hair of the skin (opioid withdrawal)

27. Inhalation exposure
Irritant gases exposure!! mainly in industry, but also after mixing cleansing agents at home, or smoke inhalation in structural fires
Health care providers should protect themselves from contamination
Eg.: “organophosphate, fumes of H2S, cyanide, ammonia, formaldehyde”

28. Inhalation exposure Bronchodilators Treatment:
Immediate removal from hazardous environment
100% humidified O2
Assisted ventilation
Bronchodilators
Observe for noncardiogenic pulmonary edema. Early signs and symptoms include “dyspnea, tachypnea, hypoxemia”
Monitor arterial blood gases or oximetry, chest x- ray, and pulmonary function