Chapter 19 Toxicology

Chronic poisoning
most common. Caused by abuse of medications, tobacco, alcohol, drugs

toxicology
study of toxic or poisonous substances.
A poison is any substance whose chemical action can damage body structures or impair body function.
Substance abuse is the misuse of any substance to produce a desired effect.
An overdose is a toxic dose of a drug.

primary responsibility
to recognize that a poisoning has occurred.
Very small amounts of some poisons can cause considerable damage or death.
If you suspect poisoning, notify medical control and begin emergency treatment.

signs and symptoms
vary according to the specific agent.
Presence of such injuries at the patient’s mouth suggests the ingestion of a poison.
If possible, ask the patient:
What substance did you take?
When did you take it (or become exposed to it)?
How much did you ingest?
What actions have been taken?
How much do you weigh?

determine the nature of the poison
Look around the immediate area for clues.
Place any suspicious material in a plastic bag and take it with you.
Containers at the scene can provide critical information.
If the patient vomits, examine the contents for pill fragments.
Wear proper personal protective equipment.
Collect the vomitus in a plastic bag

How Poisons Get Into the Body
The most important treatment you can perform is diluting and/or physically removing the poisonous agent.
Most often, you will not be administering an antidote.
How you provide treatment depends on how the poison got into the body

How Poisons Get Into the Body: Four avenues to consider
Inhalation
Absorption
Ingestion
Injection

Inhaled Poisons
Move the patient into fresh air immediately.
The patient may require supplemental oxygen.
Use self-contained breathing apparatus to protect yourself from poisonous fumes
Some patients may need decontamination after removal from the toxic environment.
All patients who have inhaled poison require immediate transport.
Take containers, bottles, labels when transporting the patient to the hospital

inhaled poisons cont’d
Patients sometimes attempt to commit suicide in a vehicle.
Exhaust fumes contain high levels of carbon monoxide
When you open the door, you may be overcome as well.
Contact hazardous materials responders and have them remove the victim

Absorbed and Surface Contact Poisons
Can affect the patient in many ways:
Skin damage
Chemical burns
Rashes
Systemic effects
It is important to distinguish between contact burns and contact absorption

Absorbed and Surface Contact Poisons:Signs and symptoms include
A history of exposure
Liquid or powder on a patient’s skin
Burns
Itching
Irritation
Typical odors of the substance

Absorbed and Surface Contact Poison:Emergency treatment
Avoid contaminating yourself or others.
While protecting yourself, remove substance from patient as rapidly as possible.
Remove all contaminated clothing.
Flush and wash the skin.
If the patient has a chemical agent in the eyes, irrigate them quickly and thoroughly. (be sure water runs from bridge outward)
5 to 10 minutes for acid substances
15 to 20 minutes for alkalis
Many chemical burns occur in an industrial setting.
Wash the substance off immediately.
Obtain material safety data sheets

Absorbed and Surface Contact Poison:Emergency treatment cont’d
The only time you should not irrigate with water is when the poison reacts violently with water. (phosphorus, elemental sodium)
Brush the chemical off.
Remove contaminated clothing.
Apply a dry dressing to the burn area

Ingested Poisons
About 80% of poisoning is by mouth.
Drugs
Liquids
Household cleaners
Contaminated food
Plants
Usually accidental in children and deliberate in adults

Ingested Poisons : signs and symptoms vary
Type of poison
Age of the patient
Time that has passed since ingestion

ingested poisons: goals
Goal is to rapidly remove as much poison as possible from the GI tract.
Further care will be provided at the emergency department.

ingested poisons: treatment
In the past, syrup of ipecac was used to induce vomiting.
Generally not used today
Many EMS systems use activated charcoal.
Comes as a suspension that binds to the poison in the stomach and carries it out of the system

Injected Poisons
Usually the result of drug abuse, such as heroin or cocaine
Signs and symptoms may include:
Weakness
Dizziness
Fever/chills
Unresponsiveness
Excitability

Injected poisons: treatmen
Injected poisons are impossible to dilute or remove.
Usually absorbed quickly into the body
Can cause intense local tissue destruction
Monitor the airway, provide high-flow oxygen, be alert for nausea and vomiting, and transport promptly

Scene Size-up
Assess the scene to ensure your safety.
Determine:
Number of patients involved
Need for additional resources
Whether spine stabilization is required
Use the appropriate PPE

MOI/NOI
Mechanism of injury/nature of illness
Dispatcher may specify
If not, look for clues and ask yourself the following questions:
Are there medication bottles lying around?
Are there alcoholic beverage containers?
Are there syringes or drug paraphernalia?
Is there an unpleasant or odd odor?
Do I see anything suggesting a drug lab

Primary assessment
Form a general impression.
Assess the patient’s LOC.
Determine any life threats.
Do not be fooled into thinking that a conscious, alert, and orientated patient is in stable condition

Primary assessment: airway and breathing
Ensure that the patient has an open airway and adequate ventilation.
Do not hesitate to begin oxygen therapy.

Primary assessment: circulation
Assess the patient’s circulatory status and pulse and skin condition.

Primary assessment: transport decision
A delay on the scene is rarely indicated.
Consider decontamination of the patient before transport depending on the poison that the patient was exposed to.
Decontamination is especially important when transporting in a helicopter

History Taking
Investigate the chief complaint.
If your patient is responsive, begin with an evaluation of the exposure and the SAMPLE history.
If your patient is not responsive, obtain this history from friends, family members, medical jewelry, or cards in his or her wallet
SAMPLE history
Guides you in what to focus on as you continue to assess the patient’s complaints
Also, ask the following questions:
What is the substance involved?
When did the patient become exposed to it?
What was the level of exposure?
Over what period did the patient take the substance?
Has the patient or a bystander performed any intervention?
How much does the patient weigh?

Secondary Assessment: Physical examinations
Focus on the area of the body involved with the poisoning or the route of exposure

Secondary Assessment:Vital signs
Vital signs
Many poisons produce no outward indications of the exposure’s seriousness.
Look for alterations in the LOC, pulse, respirations, blood pressure, and skin

Reassessment
Reassess the adequacy of the ABCs.
Evaluate your interventions.
Repeat the assessment of vital signs:
Every 15 minutes for a stable patient
Every 5 minutes, or constantly, for a patient who has consumed a harmful or lethal dose

Reassessment: interventions
Supporting the ABCs is your most important task.
Dilute airborne exposures with oxygen.
Remove contact exposures with water.
Consider activated charcoal for ingestions.
Contact medical control or a poison center to discuss treatment options

Reassessment:Communication and documentation
Report as much information about the poison as possible to the hospital.
Bring, or have the company fax, the material data sheet to the hospital if the poisoning occurred in a work setting

Emergency Medical Care
Ensure scene safety.
Follow standard precautions.
Perform external decontamination.
Remove tablets or fragments from the patient’s mouth.
Wash or brush the poison from the patient’s skin.
Assess and maintain the patient’s ABCs.
Provide oxygen and perform assisted ventilations if necessary.
If approved by medical control, give activated charcoal
You will likely carry plastic bottles of premixed suspension, each containing up to 50 g of activated charcoal.
Insta-Char, Actidose, Liqui-Char
The usual dose for an adult or child is 1 g per kilogram of body weight.
Before you give a patient charcoal, obtain approval from medical control

Emergency Medical Care contraindications
Activated charcoal is not indicated for patients:
Who have ingested an acid, an alkali, or a petroleum product
Who have a decreased LOC and cannot protect their airway
Who are unable to swallow

Specific Poisons
Over time, a person who routinely misuses a substance may need increasing amounts of it to achieve the same result.
This is called developing a tolerance.
Almost any substance can be abused

Specific Poisons
The importance of safety awareness and standard precautions cannot be stressed enough.
Known drug abusers have a fairly high incidence of serious and undiagnosed infections, including HIV and hepatitis.
Always wear the appropriate PPE.
Expect the unexpected
drug user not drug poses greatest threat.

Alcohol
Most commonly abused drug in the United States
Kills more than 200,000 people each year
One of the greatest national health problems
Alcohol abuse can result in many long-term effects.
Most common effect is liver damage
90% of heavy drinkers will develop some level of hepatitis.
10% to 20% of alcoholics will develop cirrhosis

Alcohol cont’d
Alcohol is a powerful CNS depressant.
Decreases activity and excitement
Also induces sleep
Dulls the sense of awareness, slows reflexes, and reduces reaction time
May cause aggressive and inappropriate behavior and lack of coordination
Alcohol is commonly not the only drug taken
If a patient exhibits signs of serious CNS depression, you must provide respiratory support.
May cause vomiting
Patients may experience frightening hallucinations, or delirium tremens (DTs).

alcohol: delirium tremens (DTs)
Agitation and restlessness
Fever
Sweating
Tremors
Confusion and/or disorientation
Delusions and/or hallucinations
Seizures

Opioids
Named for the opium in poppy seeds, origin of heroin, codeine, and morphine
Many addicts may have started using opioids with an appropriate medical prescription.

Opioids cont’d
These agents are CNS depressants and can cause severe respiratory depression.
Tolerance develops quickly.
Some users may require massive doses to experience the same high.
Often cause nausea and vomiting
May lead to hypotension

Opioids cont’d
Patients typically appear sedated or unconscious and cyanotic with pinpoint pupils.
Treatment includes supporting the airway and breathing.
Open the airway, give supplemental oxygen, and be prepared for vomiting.
Narcotic antagonists are the only antidote

Sedative-Hypnotic Drugs
Barbiturates and benzodiazepines are easy to obtain and relatively cheap.
Patient may appear drowsy, peaceful, or intoxicated.
In general, these agents are taken by mouth.
Occasionally, the capsules are suspended or dissolved in water and injected.
Your treatment is to provide airway clearance, ventilatory assistance, and prompt transport.
The antidote (flumazenil) may be administered in the hospital.

Abused Inhalants
These agents are inhaled instead of ingested or injected.
Acetone, toluene, xylene, hexane
Found in glues, cleaning compounds, paint thinners, and lacquers
Gasoline and halogenated hydrocarbons are also abused.
Commonly abused by teenagers

Abused inhalants cont’d
Always use special care.
Halogenated hydrocarbon solvents can make the heart hypersensitive to the patient’s own adrenaline.
Even the action of walking may cause a fatal ventricular arrhythmia.
Use a stretcher to move the patient, give oxygen, and transport to the hospital

Sympathomimetics
CNS stimulants that mimic the effects of the sympathetic (fight-or-flight) nervous system
A stimulant is an agent that produces an excited state.
Frequently cause hypertension, tachycardia, and dilated pupils
Designer drugs are frequently abused in certain areas of the United States.

Sympathomimetics: cocaine
Cocaine may be taken in a number of different ways.
Can be absorbed through all mucous membranes and even across the skin
Effects last less than an hour
Smoked crack is the most potent
Cocaine is one of the most addicting substances known.
Acute overdose is a genuine emergency.
Severe agitation can lead to tachycardia and hypertension.
Patients may be paranoid.
Do not leave the patient unattended.
Provide prompt transport.

Marijuana
Marijuana is abused throughout the world.
Produces euphoria, relaxation, and drowsiness
Impairs short-term memory and the capacity to do complex thinking
Could progress to depression and confusion
Marijuana use rarely necessitates transport to the hospital.
Except for a patient who is hallucinating, very anxious, or paranoid
Reassure the patient and transport with a minimum amount of excitement.
Marijuana is often used as a vehicle to get other drugs into the body.

Hallucinogens
Hallucinogens alter a person’s sensory perceptions
Cause visual hallucinations
Intensify vision and hearing
Generally separate the user from reality
Patients experiencing a “bad trip” will be hypertensive, tachycardic, anxious, and paranoid.

Hallucinogens: treatment
Use a calm, professional manner.
Provide emotional support.
Do not use restraints unless you or the patient is in danger of injury.
Watch the patient carefully throughout transport.
Provide reassurance.

Anticholinergic Agents
“Hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as a hatter.”
These medications have properties that block the parasympathetic nerve.
Common drugs include atropine, Benadryl, and Jimson weed

Anticholinergic Agents
Death from these agents can be rapid.
The patient can go from appearing “normal” to seizure and death within 30 minutes.
Transport immediately.
Seizures and arrhythmias are best treated in the hospital

Cholinergic Agents
Include “nerve gases” designed for chemical warfare, insecticides, and some types of wild mushrooms.
Overstimulate normal body functions that are controlled by the parasympathetic nerves
Salivation
Mucus secretion
Urination
Crying
An abnormal heart rate

Cholinergic Agents: DUMBELS
Use the mnemonic DUMBELS to remember the signs and symptoms:
Defecation
Urination
Miosis
Bronchorrhea
Emesis
Lacrimation
Salivation

Cholinergic Agents: SLUDGE
Or, you can use SLUDGE:
Salivation
Lacrimation
Urination
Defecation
Gastrointestinal irritation
Eye constriction/emesis

Cholinergic Agents: treatment
The most important consideration is to avoid exposure yourself.
Decontamination may take priority over immediate transport.
After decontamination:
Decrease the secretions in the mouth and trachea.
Provide airway support.
Antidote kits may be available.
Mark I kit, DuoDote kit
Indications include a known exposure to nerve agents or organophosphates with manifestation of signs and symptoms.
The kit consists of an auto-injector of atropine and one of 2-PAM chloride

Miscellaneous Drugs
Accidental or intentional overdose with cardiac medications has become common.
Children may ingest them thinking they are candy.
Signs and symptoms depend on the medication ingested.
You will likely be given an order to administer activated charcoal

Miscellaneous Drugs cont’d
Aspirin poisoning remains a potentially lethal condition
Ingesting too many may result in:
Nausea
Vomiting
Hyperventilation
Ringing in the ears
Patients with this problem are frequently:
Anxious
Confused
Tachypneic
Hyperthermic
In danger of having seizures

Miscellaneous Drugs cont’d
Overdosing with acetaminophen is also very common.
Be extremely careful in dealing with a child who has ingested a poison.
Some alcohols, including methyl alcohol and ethylene glycol, are even more toxic than ethyl alcohol (drinking alcohol).

Food Poisoning
Two main types:
Organism itself may cause disease
Organism may produce toxins that cause disease
One organism that produces direct effects of food poisoning is the Salmonella bacterium
Causes salmonellosis
Characterized by severe GI symptoms within 72 hours of ingestion, including nausea, vomiting, abdominal pain, and diarrhea
Proper cooking kills bacteria, and proper cleanliness in the kitchen prevents the contamination of uncooked foods.

Food Poisoning cont’d
The more common cause of food poisoning is the ingestion of powerful toxins produced by bacteria, often in leftovers.
The bacterium Staphylococcus is quick to grow and produce toxins in food.
Foods prepared with mayonnaise, when left unrefrigerated, are a common vehicle

Food poisoning: botulism
The most severe form of toxin ingestion.
Can result from eating improperly canned food
Symptoms are neurologic:
Blurring of vision
Weakness
Difficulty in speaking and breathing

Plant Poisoning
Assess the patient’s airway and vital signs.
Notify the regional poison center.
Take the plant to the emergency department.
Provide prompt transport.

plant poisoning cont’d
Irritation of the skin and/or mucous membranes is a problem with the common houseplant called dieffenbachia.
Maintain an open airway.
Give oxygen.
Transport the patient promptly to the hospital for respiratory support.

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