9/18/2012
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Chapter 15
Poisoning and Overdoses
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Learning Objectives
List ways poisons enter the body
List signs/symptoms associated with poisoning
Know emergency medical care for possible overdose
Know steps in emergency medical care for suspected poisoning
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Learning Objectives
Establish relationship between patient with poisoning/overdose and airway management
State generic, trade names, indications, contraindications, medication form, dose, administration, actions, side effects, reassessment strategies for activated charcoal
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Learning Objectives
Recognize need for medical direction in poisoning/overdose
Know rationale for administering activated charcoal
Know rationale for contacting medical direction early in prehospital management of poisoning/overdose patient
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Introduction
Patients with poisonings/overdoses Positive pressure ventilation
Signs of threat to life
Provide life support as needed
Maintain airway
Gather clues to identify substance
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Introduction
Poison Substance that kills, injures/impairs organism
through chemical action
Toxicology Study of poisons
Overdose Self-administered drugs taken in excess or in
combination with other agents
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Incidence
According to the AAPCC, more than 2 million poisonings each year
Unreported overdoses
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Poison Control Centers
Provide information about: Toxins
Management of poisoned victims
Antidotes
Services provided: Access to toxicology experts 24/7 by phone
Emergency response coordination
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Types of Exposure
Ingestion Swallow through GI tract
Inhalation CO most frequent toxin
Wear PPE
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Types of Exposure
Absorption Through skin
Injection Fastest onset - poisons injected directly into
bloodstream
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Assessment
Maintain high level of suspicion
Must have good scene assessment Look for patterns of multiple exposures
Do not jeopardize yourself if exposure possibility
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Assessment
Bring medications and poisons to hospital
Report noticeable odors that give clue to toxin
Search for clues of trauma
Treat patient, not poison
Management
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Assessment
Scene size-up Survey scene
Protect yourself/bystanders from inadvertent poisoning
• Take adequate protection
Wear PPE
Only trained rescuers should remove patient
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Assessment
Scene size-up Eye exposure & skin contamination
• Remove toxin immediately
• Remove contaminated clothing
• Flood contaminated skin with soap & water to minimize contact
Follow local protocols
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Assessment
Initial (primary) assessment Get general impression
Evaluate for traumatic injury
Check airway & breathing
Remove pills, tablets, pills from mouth with gloved hand
Protect & support c-spine
Check pulse
Check skin for perfusion
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Assessment
Initial assessment Patient history
• Ask about pill bottles/containers
• Information needed Poison name
Route taken
When
Amount
Time period
Interventions attempted
Patient weight
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Assessment
Focused assessment Review mental status
• If unconscious, use alert, verbal, painful, unresponsive (AVPU)
If unable to swallow:• Transport
• Protect airway
• Ensure adequate ventilations
Document findings
Look for signs of injury
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Assessment
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Management
Management Maintain open airway
Provide ventilation & O2
Prevent further absorption • Depends on exposure type
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Management
Management Prevent further absorption
• Activated charcoal
Absorbent material that binds most toxins
Keeps toxins in GI tract until eliminated
Dose: 1 g/kg body weight
Premixed is thick, souplike slurry
Sweeteners used for children
No harm if patient can swallow & can protect airway
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Management
Management Prevent further absorption
• Induction of vomiting
Syrup of ipecac not recommended, except for plant ingestion
Contraindicated for certain drugs/poisons or patients
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Skill 15-1:Administering Activated Charcoal
Obtain order from medical direction
Shake container thoroughly
Measure proper amount of solution per medical direction
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Skill 15-1:Administering Activated Charcoal
Obtain patient cooperation Cover drink; provide
straw
Reshake if patient takes too long
Record activity, time
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Management
Treat signs & symptoms Few poisons have antidotes available
• Counteracts effects of poison
Provide supportive care
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Management
Transport If unconscious/deteriorating mental status
• Protect airway
• Continuously assess for respiratory support
• Place in recovery position
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Management
Emotions & poisoned patient AMS from emotional events/physical effects
Suicidal
Parents may feel guilt
Maintain professional approach
Do not antagonize patient
Do not label patient
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Management
Patients who refuse medical attention May insist they want to die/be left alone
• Do not abandon
• Encourage them to go to hospital
• Call police for protective custody, if necessary
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Ingested Poisons
History & physical examination Suspect poison from history or physical
examination
Patient may give history of poisoning or signs may be noted on exam
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Ingested Poisons
History & physical examinationSigns/symptoms
• Pupils constricted or dilated• Heart rate fast or slow• Mental status agitated or depressed• Seizures, coma• BP high or low• Skin dry or moist• Body temperature alterations• Nausea, vomiting, diarrhea, abdominal pain
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Ingested Poisons
History & physical examination History may help clarify chief complaint
• Ask patient/bystanders what patient may have taken
• Establish ingestion time
• Ask if pills were taken at once or more and more at repeated intervals
• Ask the amount ingested
Possible alterations in consciousness
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Ingested Poisons
History & physical examination Perform physical examination
• Note positive/negative findings:
Pupil size
Skin condition
Presence/absence of breath odors
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Ingested Poisons
Types of ingested poisons Sedative-hypnotics & antianxiety agents
• Commonly prescribed
• Sedatives – calm, reduce activity and excitement
• Hypnotics - induce sleep
• Toxic effects:
Respiratory depression
Mental status depression
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Ingested Poisons
Types of ingested poisons Opioids
• CNS depressant
• Alter pain perception
• Overdose signs:
Reduced respirations
Reduced mental status
Pinpoint pupils
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Ingested Poisons
Types of ingested poisons Stimulants
• Amphetamines
• Methylphenidate
• MDMA
• Cocaine
• PCP
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Ingested Poisons
Types of ingested poisons Stimulants
• Overdose signs Increased HR
Increased BP
Chest pain
Anxiety
Delirium
Paranoia
Psychotic & violent behavior
Sudden death from acute cardiac dysrhythmia
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Ingested Poisons
Types of ingested poisons Stimulants
• Assess need for cardiorespiratory support
• Be conservative
To gain compliance, reassure patient
Maintain verbal contact with patient
Do not judge
Avoid restraints
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Ingested Poisons
Types of ingested poisons Stimulants
• Overdose can cause: Myocardial infarction
Bleeding in brain
Convulsions
Coma
Respiratory depression
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Ingested Poisons
Types of ingested poisons Alcohol
• Most frequently abused drug
• Depressant effect in high doses
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Ingested Poisons
Types of ingested poisons Alcohol
• Slows reflexes
• Suppresses inhibitions
• Causes uncoordinated movements
• Causes unpredictable behavior
• Acute intoxication can be lethal
• Patient may choke on vomit
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Ingested Poisons
Types of ingested poisons Alcohol
• Withdrawal causes DTs Tremors
Weakness
Nausea
Hallucinations
Seizures
Cardiovascular collapse
Death
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Ingested Poisons
Types of ingested poisons Chronic alcoholic
• Assessment CAGE
• Physical findings Slender extremities with distended abdomen
Bruises
Jaundice from failing liver
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Ingested Poisons
Types of ingested poisons Alcohol
• Management Treat symptomatically
Dress open wounds
Administer O2 if short of breath
Transport
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Ingested Poisons
Types of ingested poisons Prescription drugs
• Suicidal patients take any available medications
• Circulatory & respiratory drugs cause wide range of symptoms Alterations in heart rate, rhythm
BP changes
Dysrhythmias
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Ingested Poisons
Types of ingested poisons Analgesics
• OTC pain relievers widely available, often used
• Few early symptoms present after overdose
Aspirin overdose
Acetaminophen overdose
• Patient should receive further evaluation
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Ingested Poisons
Types of ingested poisons Commercial & industrial products
• Ingestion of hydrocarbons, caustics, insecticides, household products
• Caustics
Acids
Alkalis
• Dilute
• Do not induce vomiting
• Follow local protocols
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Ingested Poisons
Types of ingested poisons Methanol & ethylene glycol
• Initially cause signs of mild inebriation/no findings
• Left untreated, can lead to coma, death
• Methanol
• Ethylene glycol
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Ingested Poisons
Types of ingested poisons Methanol & ethylene glycol
• Ingestion Causes severe acid formation in blood when products
break down
To delay effects, administer ethyl alcohol
Patient may hyperventilate
Need hospital care and possible dialysis
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Ingested Poisons
Types of ingested poisons Insecticides
• Contain organophosphates Overstimulation of secretions
Bronchoconstriction
Muscle weakness
In excess, death by respiratory muscle paralysis or pulmonary oversecretion and bronchoconstriction
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Ingested Poisons
Types of ingested poisons Insecticides
• Outpouring of secretions from most body openings, includes: Vomiting
Salivation
Sweating
Lacrimation (tearing)
Urination
Diarrhea
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Ingested Poisons
Types of ingested poisons Insecticides
• Findings Small pupils
Low HR
Respiratory distress
• Antidote
Atropine
Pralidoxime
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Ingested Poisons
Types of ingested poisons Insecticides
• Prehospital treatment
O2
Ventilatory support
Rapid transport
• May be absorbed through skin
Remove contaminated clothing
Flush skin with soap & water
• Wear PPE
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Ingested Poisons
Types of ingested poisons Food poisoning
• Causes Bacteria
Toxins produced by bacteria
Viruses
Improperly cooked or canned food
Fecal bacteria by food handlers
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Ingested Poisons
Types of ingested poisons Food poisoning
• Symptoms Abdominal pain
Nausea
Vomiting
Diarrhea
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Ingested Poisons
Types of ingested poisons Food poisoning
• Botulism Most severe type of food poisoning
Flulike symptoms with double vision
Difficulty moving eyes & swallowing
Descending (from head to toe) weakness
Paralysis
Respiratory arrest
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Ingested Poisons
Types of ingested poisons Food poisoning
• Poisonous mushroom consumption GI disturbances
Hallucinations
Delirium
Symptoms often delayed
Supportive care
Bring available mushroom or fragments to hospital for I.D.
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Ingested Poisons
Types of ingested poisons Plants
• Adverse effects on GI, circulatory, and neurologic systems
• Severe skin and mucous membrane irritation
• Dieffenbachia
Household plant
Causes severe irritation and swelling in the mouth if ingested
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Inhaled Poisons
Rescue considerations & precautions Always approach with consideration of safety
Avoid inhaling fumes
Only trained rescuers enter contaminated area or closed space
Victims should be moved from toxic environment to fresh air ASAP
• Ventilatory support
• Humidified supplemental O2
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Inhaled Poisons
Rescue considerations & precautionsCarbon monoxide
• Lethal & poisonous
• Management 100% O2
In severe cases, hyperbaric O2 treatment
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Inhaled Poisons
Rescue considerations & precautions Poisonous gases
• Possible asphyxiation/death
• Simple asphyxiants
• CO2
• Small hydrocarbon molecules
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Inhaled Poisons
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Inhaled Poisons
Rescue considerations and precautions Poisonous gases
• Chemical asphyxiants
Attach to molecules in body essential to respiration
Carbon monoxide
Cyanide
Hydrogen sulfide
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Inhaled Poisons
Rescue considerations & precautions Irritant gases
• Causes inflammatory damage to airway, bronchconstriction
• Most soluble agents (ammonia, sulfur dioxide, hydrogen chloride react almost immediately
• Low-solubility agents (phosgene, nitrogen oxides) are less likely to react immediately
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Inhaled Poisons
Rescue considerations and precautions Organophosphates
• Spraying of fields/gardens with insecticides can result in inhalation
• Initial symptoms Visual problems
Bronchoconstriction
Excessive pulmonary secretion
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Absorbed Poisons
Skin damaged by corrosive, caustic agents Causes severe chemical burns
Findings:• History of exposure
• Liquid or powder on patient’s skin
• Burns
• Itching
• Irritation
• Redness
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Absorbed Poisons
Skin damaged by corrosive, caustic agents, severe chemical burns Remove contaminated clothing
Flood skin, then wash with soap and water
Irrigate eyes with water for more than 20 min; continue en route
Call PCC
Wear PPE
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Injected Poisons
Cause most rapid onset of drug effects
Often self-administered overdoses
Bites, stings result in venom poisoning
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Drugs of Abuse
Legal/illegal drugs
Repeated self-administration
Tolerance
Dependency
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Drugs of Abuse
Most common - alcohol Withdrawal symptoms
• Shakes
• Tremors
• Seizures
• Possible DTs
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Drugs of Abuse
Other drugs of abuse Heroin
Cocaine, PCP, amphetamines
LSD
Ecstasy
Prescription drugs
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Drugs of Abuse
EMT contact often involves: Overdose
Behavioral emergency
Trauma caused by overdose
Must treat psychological & physical manifestations simultaneously
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Summary
Poisons enter body by ingestion, inhalation, injection, absorption
Scene size-up anticipates hazards to EMS personnel/bystanders from exposure to toxin/secondary contamination Prevent through PPE
Only trained rescuers remove patients from toxic environment
Decontaminate victims
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Summary
Signs/symptoms of poisoning Extreme stimulation
Inhibition of most organ systems, depending on toxin involved
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Summary
Emergency care for patients with poisoning/overdose focuses on: Preventing injury to EMS personnel/bystanders
Adequate airway
Ventilations
Oxygenation
Preventing further absorption
Gathering evidence of poisoning
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Summary
During history, important questions to ask include Substance involved
Amount taken
Over what period of time
Interventions performed before arrival
Patient’s weight
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Summary
Prevent further absorption by removing contaminated clothing while protecting yourself from contamination; brush any powder off before irrigation Irrigate skin with clean water/soap & water for at
least 20 min; continue en route
At scenes of possible inhaled exposures, trained rescuers remove patients from poisonous environment
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Summary
For patients with inhaled toxins, remove to fresh air, administer supplemental O2
Under medical direction, administer activated charcoal to prevent absorption of ingested poisons (approximately 1 g/kg body weight)
Contraindications to activated charcoal include AMS, inability to swallow, ingestion of acids/alkalis
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Summary
Consider ALS intercept for victims of opioid & organophosphate overdose because lifesaving antidotes may be carried by ALS personnel
Opioid overdose recognized by classic presentation of depressed mental status, depressed respirations, pinpoint pupils
Organophosphate overdose may be recognized by overstimulation of secretions, bronchoconstriction, muscle weakness
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Questions?
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