1. Poisoning and Overdose Emergencies
CHAPTER 21
Poisoning and Overdose Emergencies

2. Key Term
Poison
Any substance that can harm the body by altering cell structure or function.

3. Key Term
Toxin
A poisonous substance secreted by bacteria, plants or animals

4. General Information
Reactions to poisons are different for all persons, but they are the most severe in the ill and the elderly.
Effects and extent of damage depend upon:
Patient’s age
Patient’s weight
Patient’s general health

5. Key Term Systemic Poisons
These poisons cause harm to the entire body or an entire body system

6. Four Types of Poisoning
INHALATION
INJECTION
Drugs
Sprays
Cleaning Fluid
INGESTION
ABSORPTION
Lye
Household
Cleaners
Drain Cleaners
Rat Poison
Insecticides

7. Key Term Ingested Poisons
Poisons that are swallowed (i.e. acetaminophen, acids/alkalis, antihistamines, aspirin, food poisoning, insecticides, petroleum products, plants, etc…

8. Signs & Symptoms of Ingested Poison/Overdose
History of ingestion
Nausea (most common)
Vomiting (most common)
Diarrhea

9. Signs & Symptoms of Ingested Poison/Overdose
Altered mental status
Abdominal pain
Chemical burns around mouth
Unusual breath odor
Difficulty breathing

10. Gather information. Remove pills, tablets or fragments with gloves from patient’s mouth, as needed, without injuring oneself.

11. Consult medical direction.
Administer activated charcoal?

12. Transport the patient – bring all containers,
bottles, labels, etc… of poison agents to
receiving facility. Position patient for
vomiting. Save all vomitus. Have suction
equipment ready.

13. Information to Gather What substance involved?
Get exact name and spelling.
Bring container, if possible and safe.
When did exposure occur?
Reaction times of poisons are different. Try to find out as closely as possible the time of ingestion.

14. Information to Gather How much did you ingest? Over what time period?
Counting the tablets left in a new container.
Amount spilled on the floor.
If you can’t be exact, give the maximum possible amount.
Over what time period?
Has the patient been taking the medication and then overdosed?
Is this a new medication, and the patient overdosed?

15. Information to Gather What interventions taken?
Any home remedies?
What is patient’s estimated weight?
Estimate your patient’s weight because it can be critical in the treatment process.
Any effects on patient?
Nausea/vomiting, altered mental status, abdominal pain, diarrhea, chemical burns around the mouth and nose, unusual breath odors

16. Inhaled, Injected and Absorbed Poisons

17. Key Term Inhaled Poisons
Poisons that are breathed in (i.e. carbon monoxide, ammonia, chlorine, volatile chemicals); chemicals that change easily from liquid to gas – industrial solvents

18. Signs & Symptoms of Inhaled Poisons
Nausea (most common)
Vomiting (most common)
Difficulty breathing
Chest pain
Cough
Hoarseness

19. Signs & Symptoms of Inhaled Poisons
Dizziness
Headache
Confusion
Seizures
Altered mental status
History of inhalation; MOI

20. Carbon Monoxide
Most common inhaled poison (motor vehicle exhaust, fire suppression, faulty heaters)
Colorless, odorless, tasteless gas
Prevents normal carrying of red blood cells
Death can occur as hypoxia becomes severe

21. Carbon Monoxide Inhalation
Signs and
Symptoms
(resemble flu)
Nausea
Vomiting
Headache
Dizziness
Difficulty breathing
Cyanosis
Altered mental status
Unconsciousness
Cherry red lips VERY UNCOMMON.

22. Smoke Inhalation Substances found in smoke can burn the skin
Irritate the eyes
Injure the airway
Cause respiratory arrest
Cause cardiac arrest

23. Smoke Inhalation Signs and Symptoms Difficulty breathing Coughing
(can be delayed or
Immediate and
severe)
Difficulty breathing
Coughing
Breath has “smoky” smell or odor of chemicals involved at the scene
Black (carbon) residue in patients mouth and nose
Black (carbon) residue in sputum coughed up by patient
Nose hairs singed in superheated air

24. Have trained rescuers remove patient from poisonous environment
Have trained rescuers remove patient from poisonous environment. DO NOT go unless you have proper apparatus and training.

25. Establish an open airway
Establish an open airway. Give oxygen, if not already done in the initial assessment.
Give by NRB at 15 lpm.

26. Maintain airway and administer oxygen.

27. Remove contaminated clothing.

28. Consult medical direction.

29. Transport the patient. Bring all containers
bottles, labels, etc… of poison agents to
receiving facility if you can safely
transport them.

30. Information to Gather What substance involved?
Get exact name and spelling.
Bring container, if possible and safe.
When did exposure occur?
Try to find out what the earliest and latest possible times of exposure were.

31. Information to Gather Over how long a period did the exposure occur?
The longer the exposure, the more likely the poison was inhaled
Patient interventions…
Did someone ventilate the area?
Did someone remove the patient from the area?
When did this happen?

32. Information to Gather Any effects on patient?
Nausea/vomiting, difficulty breathing, chest pain, coughing, hoarseness, dizziness, headache, confusion, seizures, or altered mental status

33. Key Term
Injected Poisons
Poisons that are inserted through the skin.

34. Signs & Symptoms of Injected Poisons Weakness Dizziness Chills Fever
Nausea
Vomiting

35. Emergency Care of Injected Poisons
Secure airway; administer oxygen.
Be alert for vomiting.
Bring all containers, bottles, labels, etc… of poison agents to receiving facility if you can safely transport them.

36. Key Term Absorbed Poisons
Poisons that are taken into the body through unbroken skin.

37. Signs & Symptoms of Absorbed Poisons History of exposure
Liquid or powder on patient’s skin
Burns
Itching
Irritation
Redness
Difficulty Breathing

38. Remove patient from source without
contaminating yourself.

39. Brush powders from patient, and irrigate
Remove contaminated clothing and other articles. Be sure to protect oneself.
Brush powders from patient, and irrigate
with water for at least 20 minutes.

40. Irrigate with clear water for at least
20 minutes.

41. Emergency Care of Eye Absorption
Irrigate with clean water for at least 20 minutes and continue en route if possible.

42. Acids and Alkalis
Neutralizing acids or alkalis with solutions (vinegar or baking soda) should not be done.
DO NOT mix acids with alkalis – you may think it could neutralize the reaction, but the reaction produces heat and skin could be futher damaged.

43. Information to Gather What substance involved?
Get exact name and spelling.
When did exposure occur?
How much substance was the patient exposed to?
How large an area of skin was covered?

44. Information to Gather Over what time period? Patient interventions…
The longer the substance was on the patient’s skin, the more likely it was absorbed.
Patient interventions…
Did someone attempt to wash the poison off? With what?
Did anyone attempt to neutralize the substance?

45. Information to Gather Any effects on patient?
Liquid or powder on the patient’s skin, burns, itching, irritation and redness
BE ALERT FOR CONTACT LENSES

46. Airway Management in Poisoning/Overdose
When treating a poisoned or overdosed patient, be prepared for deterioration, vomiting, and the need to secure airway.

47. Use of Activated
Charcoal

48. Key Term Activated Charcoal
A substance that adsorbs (one substance becoming attached to the surface of another) many poisons and prevents them from being absorbed by the body

49. Trade Names: SuperChar, InstaChar, LiquiChar, Actidose
Generic Name: Activated Charcoal

50. Activated Charcoal Indication Contraindications Poisoning by mouth
Altered mental status
Ingestion of acid or alkali (i.e. oven cleaners, drain cleaners, toilet bowl cleaners, lye, etc…)
Patient unable to swallow
Patient who swallowed gasoline while siphoning

51. Activated Charcoal Medication Form
Pre-mixed in water, commonly grams in plastic bottle
Avoid powder form in the field

52. Activated Charcoal Dosage Adults and children: Adult: Pediatric:
1 gram activated charcoal/kg of body weight
Adult:
25-50 grams
Pediatric:
grams

53. Activated Charcoal Administration 1. Consult medical direction.
2. Shake container thoroughly.
3. Since medication looks like mud, patient may need to be persuaded to drink it.
A covered container and a straw may improve patient compliance since the patient cannot see the medication this way.
If patient takes a long time to drink the medication, the charcoal will settle and will need to be shaken or stiffed again.
Record activity and time.

54. Activated Charcoal Actions
Binds to certain poisons; prevents absorption by body
This is not an antidote (a substance that will neutralize the poison or its effects
It will reduce/prevent the amount of poison available for the body to absorb
Does not work with all poisons (again DO NOT use with acids and alkalis)
Not all brands of activated charcoal are the same; some bind much more poison that others, so consult medical direction about the brand to use

55. Activated Charcoal Side Effects
Black stools
Some patients, particularly those who have ingested poisons that cause nausea, may vomit
If patient vomits, the dose should be repeated once
The EMT-Basic should be prepared for the patient to vomit or further deteriorate
Reassessment
Strategies

56. Syrup of Ipecac Facts Causes vomiting in most people with one dose
Takes minutes to work
On average, it removes less than 1/3 of stomach contents
Because of its slowness, it’s relatively ineffective
Can cause aspiration of vomit into lungs

57. Syrup of Ipecac Indication Contraindications Poisoning by mouth
Altered mental status
Ingestion of acid or alkali (i.e. oven cleaners, drain cleaners, toilet bowl cleaners, lye, etc…)
Patient unable to swallow

58. Syrup of Ipecac
Medication
Form
Liquid
Contact Medical Control
Dosage

59. Syrup of Ipecac Administration Reassessment Strategies
Obtain order from medical direction either on-line or off-line
Record activity and time
Reassessment Strategies
Should be prepared for the patient to vomit or further deteriorate

60. Antidote versus Dilution
A substance that will neutralize the poison or its effects
Only a few genuine antidotes exist, and they only work with a small number of poisons
Dilution
Thinning down or weakening by mixing with something else
Usually used with ingested poisons
Should use water or milk
Adult dosage should be 1-2 glasses
Pediatric dosage should be ½ to 1 glass

61. Alcohol
and
Substance Abuse

62. Alcohol Abuse Emergencies can result from:
Due to the effect of the alcohol just consumed
Resulting from the cumulative effects of years of alcohol abuse
Provide care for the patient suffering from alcohol abuse/overdose the same as you would for any other patient

63. Effects of Alcohol Immediate effect is CNS depression
Injuries and falls
Derangements of blood sugar (chronic abusers)
Poor nutrition (chronic abusers)
Potential for considerable GI bleeding (chronic abusers)
Having a heart attack
Hypoglycemia
If combined with other depressants (antihistamines/tranquilizers) effects are exacerbated

64. Signs & Symptoms of Alcohol Abuse
Odor of alcohol on patient’s breath/clothing
Swaying/Unsteadiness of movement
Slurred speech, rambling thoughts and incoherent words/phrases
Flushed appearance
Nausea and vomiting
Poor coordination
Slowed reaction time
Blurred vision
Confusion
Hallucination (visual/auditory)
Lack of memory
Altered mental status – decreased level of consciousness
All of these signs & symptoms could be serious medical problems as well!

65. Signs & Symptoms of Alcohol Withdrawal
Confusion/Restlessness
Unusual behavior
Hallucination
Gross Tremor (obvious shaking) of the hands
Profuse sweating
Seizures

66. Problems Associated with Alcohol Withdrawal
Patients may suffer from delirium tremens (DT’s).
A severe reaction that can be a part of alcohol withdrawal. It is characterized by sweating, trembling, anxiety, and hallucinations.
All patients with DT’s must be transported to a medical facility ASAP
Can be fatal.

67. Special Circumstances with Alcohol Abuse
Some conditions may make the patient appear to be intoxicated when he/she is not. Don’t let the presence of alcohol or the signs/symptoms of alcohol abuse override suspicions of other medical problems/injuries
Diabetes
Epilepsy
Head Injuries
High Fever
Hypoxia

68. Emergency Care of Alcohol Overdose
A patient under the influence of alcohol cannot make an informed refusal of treatment or transport!
You must treat by implied consent!!!
The condition may worsen as alcohol is absorbed into the blood stream (i.e. head injuries can lead to subdural hematomas)

69. Substance Overdose
A chemical substance that is being taken for other than therapeutic (medical) reasons
Most common substances are:
Uppers & Downers
Narcotics
Hallucinogens
Volatile Chemicals

70. Uppers
Uppers – Stimulants such as amphetamines that affect the CNS to excite the user, relieve fatigue or to create the feeling of well-being
Include caffeine, cocaine, & amphetamines
Signs and Symptoms
Excitement
Increased heart rate
Increased breathing rate
Rapid speech
Dry mouth
Dilated pupils
Sweating
Complaint of having gone without sleep for long periods

71. Downers
Downers – Have a depressant effect on the CNS; relaxing agent, sleeping pill, tranquilizer; produces a sense of euphoria and sometimes hallucinations
Includes Rohypnol, barbiturates, GHB, etc…
Signs and symptoms
Sluggish
Sleepy patient lacking typical coordination of body and speech
Decreased pulse (often to point of a true emergency)
Decreased respiration (often to point of a true emergency)
Stupor

72. Narcotics
Drugs capable of producing stupor or sleep often used to relieve pain and to quiet coughing; intense state of relaxation and well-being
Include heroin, codeine, & oxycodone
Opiate Triad
Coma
Pinpoint Pupils
Respiratory Depression
Signs and symptoms
Decreased heart rate, respiratory rate and skin temperature
Pinpoint pupils
Relaxed muscles
Profuse sweating
Patient is sleepy and doesn’t want to do anything

73. Hallucinogens
Mind-affecting drugs that act on the nervous system to produce an intense state of excitement or a distortion of the user’s perceptions
Include PCP, LSD, & ecstasy
Signs and symptoms
Increased heart rate
Dilated pupils
Flushed face
Patient often “sees” and “hears” things
Patient has little concept of time
Patient may not be aware of true environment
Patient may become aggressive or timid

74. Volatile Chemicals
Give an initial “rush” then act as a depressant on the CNS
Include glue, cleaning fluid, model cement, typing correction fluid, propane, etc…
Signs and symptoms
Dazed or showing temporary loss of contact with reality
Develop coma
Linings of nose/mouth may show swollen membranes
Patient complains of “funny numb feeling” or “tingling” inside head
Changes in heart rhythm

75. Emergency Care of Substance Overdose
Ensure scene safety; restrain patient if needed.
Assess for respiratory compromise.
Monitor level of consciousness.
Continued…

76. Emergency Care of Substance Overdose
Monitor vital signs.
Treat for shock.
Assess for injuries.
Transport.