4 primary methods of entry
Ingestion
Inhalation
Injection
Absorption
Assessment clues pointing towards ingestion:
Stained fingers, lips, or tongue
Sudden onset of stomach cramps w/, w/o n/v/d
Empty pill bottles
Plant partially chewed
Management of ingestion toxicology
Immediately assess ABCs Activated charcoal or syrup of ipecac Prompt transport to ED Possible IV access Provide aggressive vent support and CPR if ingestion of opiate, sedative or barbiturate
Assessment clues pointing towards inhalation
Rapid onset of s/s
Management of inhalation toxicology
Scene Safety Consult poison control or local hazardous materials team members Remove clothing Take any containers with you High concentration of oxygen Iv access Pulse ox Call ALS backup early
Why should you never pull a shirt over the pt’s head?
The toxin can be introduced in the eye, nose or mouth. Always cut or unbutton.
Management of injection posioning
Monitor airway Administer high-flow oxygen Be alert for n/v Transport promptly Take all containers with you
s/s of absorption poisoning
Hx of exposure
Liquid or powder of skin
Burns, itching, irritation or redness of skin
Typical odors of the substance
Management of absorption poisoning
Avoid contamination
Remove irritating or corrosive substances from pt
Cut off all clothing
Brush off as much powder, flush skin with running water, and then wash with soap and water
Irrigates eyes for 20 minutes if needed
Obtain material SDS
Prompt transport
Continue irrigation and oxygen if possible while enroute
Why should you never flush off dry powder?
Water can activate a chemical reaction.
What type of chemicals react violently with water?
Phosphorus or elemental sodium
Major toxidromes
Stimulants Narcotics Sympathomimetics Cholinergic Anticholinergics
s/s of stimulant toxidrome
Restlessness Agitation Incessant talking Insomnia Anorexia Dilated pupils Tachycardia Tachypnea HTN or hypotension Paranoia Seizures Cardiac arrest
Examples of stimulant toxidromes
Amphetamine Methamphetamine Cocaine Diet aids Nasal decongestants
s/s of narcotic toxidrome
Pinpoint pupils
Marked respiratory depression
Drowsiness
Stupor Coma
Examples of narcotic toxidromes
Heroin Morphine Hydromorphone Fentanyl Oxycodone
s/s of sympathomimetic toxidromes
Hypertension Tachycardia Dilated pupils Agitation Seizures Hyperthermia
Examples of sympathomimetic toxidromes
Epi
Albuterol
Cocaine
Methamphetamine
s/s of sedative-hypnotic toxidrome
Drowsiness Disinhibition Ataxia Slurred speech Mental confusion Resp. depression Progressive CNS depression Hypotension
Examples of sedative-hypnotic toxidrome
Diazepam
Secobarbital
Flunitrazepam
s/s of cholinergic toxidrome
SLUDGEM
Examples of cholinergic toxidromes
Diazonin
Orthene
Parathion
Nerve gas
s/s anticholinergic toxidrome
Tachycardia Hyperthermia Dry skin Dry mucous membranes Dilated pupils Blurred vision Sedation Agitation Seizures Coma Delirium
Examples of anticholinergic toxidromes
Atropine Antihistamines Jimsonweed Antipsychotics Scopolamine
Antagonist
Affinity for a cell receptor preventing the cell from responding.
Potentation
Enhances the effect of one drug by another
Synergism
The total effect of two drugs are greater than the sum of the independent effects of the two.
Dosage of activated charcoal
1g/kg
Adults : 25-50
Children : 12.5 - 12.5
Contraindications of activate charcoal
Ingested acid, alkali, or petroleum product
Decreased LOC
Cannot protect their airways
Unable to swallow
Minor alcohol withdrawal s/s
Restlessness Anxious Sleeping disturbances Agitation Tremors
Major ETOH withdrawal s/s
Increased BP
Vomiting
Hallucinations
Delirium tremens
What is delirium tremens?
Delirium resulting in tremors, restlessness, weakness, fever, diaphoresis, disorientation, hallucinations, confusion, hypotension, seizures, and possibly death.
Medical conditions alcoholics are more susceptible to
Subdural hematoma GI bleeding Pancreatitis Hypoglycemia Burns Hypothermia Seizures Dysrhythmias Cancer Esophageal varices
Management of ETOH-related condistions
Establish and maintain airway
Gag reflex present left lateral recumbent w/ suction ready
Non gag reflex - airway adjunct and vent BVM
High-concentration oxygen
Vascular access
Asses blood sugars
Suspect internal bleeding if s/s shock
How can you protect a patient with DTs from injury?
Keep pt calm Administer oxygen via nasal cannula Vascular access Manage hypotension w/ infusion of nl saline Reassess breath sounds Maintain ongoing dialogue
When do withdrawal seizures typically occur?
w/in 12-48 hours of last drink
Narcotic
Drug that produces sleep or AMS
Two classifications of narcotics
Opiate - natural drugs derived from opium
Opioid - synthetics
Examples of common narcotics
Morphine Codein Heroin Fentanyl Oxycodone Meperidine Propoxyphene Dextromethorphan
Pathophysiology of narcotics
Major effects on the CNS by binding with receptor sites in the brain and other tissues
Naloxone dosage
0.4 - 2mg
What should you do before administering Naloxone?
Place OPA or NPA and vet w/ BVM
Onset of effects of snorting cocaine and smoking cocaine.
Nasal : effects w/ 1-2 minutes and peaks in 20-30 minutes
Inhalation : onset 8-10 seconds and does not last as long
What potentially fatal complications can occur with cocaine use?
Lethal dysrhythmias AMI Seizures CVA Apnea Hyperthermia
Management of stimulant OD
Maintain max oxygen levels
Prevent seizures w/ adequate sedation
Monitor serial vital signs
IV access
Manage hypotension w/ fluid infusion of nl saline
Call ALS backup for medication administration of benzo
Smoking marijuana results in
Bronchodilation Slight tachycardia Euphoria Drowsiness Decreased short-term memory Diminished motor coordination Increased appetite Bloodshot eyes
Management of marijuana use
Supportive care
Adverse effects of spice
Psychosis Hallucinations Tachycardia Vomiting Renal problems Seizures
Management of spice OD
Supportive care w/ fluids and airway maintenance.
Call ALS if seizures occur for medication administration
Treatment for PCP or ketamine OD
Secure the patient well Assess ABCDEs Manage life threats Administer oxygen IV access Safe transport to facility Call ALS for benzo administration to help calm agitated pt
Treatment for mescaline or psilocybin mushrooms OC
Pay attention to ABCDEs Administer oxygen therapy Monitor vital signs Provide positive psychological support Provide safe transport IV access
Mild to moderate barbiturate intoxication s/s
Similar to ETOH intoxication Drowsiness Decreased inhibitions Ataxia Mental confusion Staggering gait
Increased doses of barbiturate intoxication s/s
Lethargic
Low level of responsiveness or unresponsiveness
Effects of beznodiazepines
Sedation
Reduction of anxiety
Relaxation of striated muscle
s/s benzodiazepines OD
AMS Drowsiness Confusion Slurred speech Ataxia General incoordination
Withdrawal s/s of benzodiazepines
Tachycardia
Tremulousness
Confusion
Seizures
What medical conditions are commonly treated with benzodiazepines?
Anxiety, seizures, ETOH withdrawal
What medical conditions are commonly treated with barbiturates?
Sleep aids, antianxiety, seizures
Management of sedative-hypnotic OD
Airway management first priority
Administer high-concentration oxygen
IV access
Shock - rapid infusion of 20-mL/kg bolus of nl saline and repeated doses up to 2L PRN
s/s of cardiac drug OD
Hypotension Weakness or confusion N/V Rhythm disturbance Headache Difficulty breathing
Management of cardiac drug OD
Patent airway Adequate vent Administer high-flow oxygen IV access Sequential fluid boluses of nl saline for HTN Contact medical control
Major classes of cardiac drugs
Antidysrhythmics Beta-blockers Calcium-channel blockers Cardiac-channel blockers Cardiac glycosides Angiotensin-converting enzyme inhibitors
s/s tricyclic antidepressant OD
AMS Dysrhythmias Dry mouth Blurred vision or dilated pupils Urinary retention Constipation Pulmonary edema
Management of TCAs OD
Maintain airway. Insert advanced airway if deterioration
Call ALS for cardiac monitoring, intubation, and medication administration.
Administer high-flow supplemental oxygen
IV access
Administer activated charcoal per medical control
Manage hypotension with boluses of nl saline
Assess blood sugars. Administer dextrose 50% in water.
Early and late s/s of MOAI OD
Hyperactivity
Sinus tachycardia
Hyperventilation
Nystagmus
Chest pain Palpitations HTN Diaphoresis Agitate or combative behavior Hyperthermia Hallucinations
Management of MAOI OD
Establish and maintain airway
Administer high-flow oxygen or provided positive pressure vent
IV access
Consider activate charcoal if recommended by medical control
Treat HTN with fluid boluses of nl saline
Call ALS for seizures to administer medications
s/s SSRI OD
N/V Sinus tachycardia Sedation Tremors Dilated pupils Agitation BP changes Seizures Hallucinations
Management of SSRI OD
Establish and maintain airway Administer high-flow oxygen IV access Call ALS PRN Consider single dose of activated charcoal
s/s lithium OD
N/V
Hand tremors
Excessive thirst
Slurred speech
Ataxia Muscle weakness Incoordination Blurred vision Hyperreflexia Seizures Coma
Management of lithium OD
Establish and maintain airway, insert advanced airway if needed.
Administer high-flow oxygen
IV access
Administer serial boluses of nl saline if hypotensive
s/s NSAID OD
Headache AMS Behavioral changes Seizures Bradydysrythmias Hypotension ABD pain N/V
Management of NSAID OD
Establish and maintain airway, insert advanced airway if needed
Administer high-flow oxygen
IV access
Administer fluid bolus of nl saline if hypotensive
Consider ALS if hypotension continues
s/s salicylates OD
N/V ABD pain Diaphoresis Hyperpnea Tinnitus Pulmonary edema Acid-base disturbances
Metabolic acidosis
Respiratory alkalosis-metabolic acidosis
Management of salicylates OD
Establish and maintain airway, insert advanced airway PRN
Administer high-flow oxygen
IV access
Administer serial boluses of nl saline if hypotensive
Monitor CO2 levels
One dose of activated charcoal after consulting medical control
Management of APAP OD
Administer high-flow oxygen
IV access
Recent ingestions - consider activate charcoal after medical control consult
s/s GHB OD
CNS depression
Disinhibition
Passivity
Antegrade amnesia
Management of GHB
Establish and airway management, insert an advanced airway if needed
Carefully monitor LOC
Assist breathing as necessary and administer high-flow oxygen
IV access
Provide rapid transport
Pathophysiology of organophosphate poisoning
Overstimulate normal body functions controlled by parasympathetic nerves.
Management of organophosphate
Decontaminate and remove all clothing Establish and maintain the airway Suction PRN Administer high-flow oxygen IV access Call ALS for medication administration and cardiac monitoring. Transport immediately
Management of CO poisoning
Remove pt from environment
Establish and maintain airway, insert advanced airway PRN
Administer high0flow oxygen with tight-fitting nonrebreather
IV access
Keep patient quiet and rest
Monitor LOC
Management of lead poisoning
Establish and maintain airway, inserting an advanced airway
Administer high-flow oxygen
IV access with saline or hep lock
Only administer fluids if hypotensive
s/s lead poisoning
AMS Mood changes Memory deficit Sleep disturbances Headache Seizures Ataxia ABD pain Renal insufficiency HTN Gout Anemia
Management of iron poisoning
ABCs
s/s iron poisoning
ABD pain
Vomiting
Diarrhea
Hypotension
s/s chlorine gas poisoning
Burning sensation of eyes, nose, and through with slight cough.
Chest tightness Choking Paroxysmal cough Headache N/V Diffuse wheezing Cyanosis Crackles Shock Seizures Loss of conscious
Management of chlorine gas poisoning
Remove from exposure
Prioritize breathing
Irrigate burning or itching eyes with water
s/s food poisoning
Abd pain and cramping
N/V/D
Management of food poisoning
Establish and maintain the airway, inserting advanced airway PRN
Administer high flow oxygen
IV access
Fluid boluses w/ nl saline if hypotensive
Call ALS for backup PRN
