EMT Chapter 23 Poisoning and Overdose Emergencies

Body mass in kilogram
divide by 2.2

How to know if a patient has been poisoned
Once on or in the body, poisons can do damage in a variety of ways. A poison may act as a corrosive or irritant, destroying skin and other body tissues. A poisonous gas can act as a suffocating agent, displacing oxygen in the air. Some poisons are systemic poisons, causing harm to the entire body or to an entire body system. These poisons can critically depress or overstimulate the central nervous system, cause vomiting and diarrhea, prevent
red blood cells from carrying oxygen, or interfere with the normal biochemical processes in the body at the level of the cell. The actual effect and extent of damage is dependent on the nature of the poison, on its concentration, and sometimes on how it enters the body. These factors vary in importance depending on the patient’s age, weight, and general health.

ingested poisons
(poisons that are swallowed) can include many common household and industrial chemicals, medications, improperly prepared or stored foods, plant materials, petroleum products, and agricultural products made specifically to control rodents, weeds, insects, and crop diseases.

inhaled poisons
(poisons that are breathed in) take the form of gases, vapors, and sprays. Again, many of these substances are in common use in the home, industry, and agriculture. Such poisons include carbon monoxide (from car exhaust, wood-burning stoves, and furnaces), ammonia, chlorine, insect sprays, and the gases produced from volatile liquid chemicals (volatile means “able to change very easily from a liquid into a gas”; many industrial solvents are volatile).

Absorbed Poisons
(poisons taken into the body through unbroken skin) may or may not damage the skin. Many are corrosives or irritants that will injure the skin and then be slowly absorbed into body tisues and the bloodstream, possibly causing widespread damage. Others are absorbed into the bloodstream without injuring the skin. Examples of these poisons include insecticides and agricultural chemicals. Contact with a variety of plant materials and certain forms of marine life can lead to skin damage and possible absorption into tissues under the skin.

injected poisons
(poisons inserted through the skin) enter the body through a means that penetrates the skin.The most common injected poisons include illicit drugs injected with a needle and venoms injected by snake fangs or insect stingers.

Assessment and care for alcohol abuse
Since alcohol abuse patients often vomit, take Standard Precautions, including gloves, mask, and protective eyewear as necessary. To provide basic care for the intoxicated patient and the patient suffering alcohol withdrawal, follow these steps:
1. Stay alert for airway and respiratory problems. Be prepared to perform airway maintenance, suctioning, and positioning of the patient should the patient lose consciousness, seize, or vomit. Help the patient so that vomitus will not be aspirated. Have a rigid-tip suction device ready. Provide oxygen and assist respirations as needed.
2. Assess for trauma the patient may be unaware of because of his intoxication. 3. Be alert for changes in mental status as alcohol is absorbed into the bloodstream. Talk
to the patient in an effort to keep him as alert as possible.
4. Monitor vital signs.
5. Treat for shock.
6. Protect the patient from self-injury. Use restraint as authorized by your EMS system.
Request assistance from law enforcement if needed. Protect yourself and your crew.
7. Stay alert for seizures.
8. Transport the patient to a medical facility.

— Assessment and care for substance abuse

Describe the ways in which poisons can enter the
body. (pp. 547-548)

Identify potential dangers to EMS providers and
others at scenes where poisoning, alcohol abuse,
or substance abuse is involved. (pp. 546-567)

Collect key elements in the history of a patient
who has been poisoned. (pp. 549, 554, 558)

Describe the use of activated charcoal in the
management of ingested poisons. (pp. 550-553)

Explain the management of patients who have
ingested a poison. (p. 553)

Develop a plan for managing patients who have
inhaled poisons. (pp. 554-558)

Develop a plan for managing patients who
have absorbed poisons through the skin.
(pp. 558-559, 560)

Describe the health risks associated with alcohol
abuse. (p. 561)

Recognize the signs and symptoms of alcohol
abuse and alcohol withdrawal. (pp. 561-562)

Recognize signs, symptoms, and health risks
associated with abuse of substances, including
stimulants, depressants, narcotics, volatile
chemicals, and hallucinogens. (pp. 563-566)

Given a variety of scenarios, develop a treatment
plan for patients with emergencies related to
alcohol and substance abuse. (pp. 562-563, 566-567)

absorbed poisons, p. 548
1. Detect and treat immediately life-threatening problems in the primary assessment.
Evaluate the need for prompt transport of critical patients.
2. Perform a secondary assessment; obtain vital signs. This includes removing contami-
nated clothing while protecting oneself from contamination.
3. Remove the poison by doing one of the following:
• Powders. Brush powder off the patient, then continue as for other absorbed poisons.
• Liquids. Irrigate with clean water for at least 20 minutes and continue en route if
• Eyes. Irrigate with clean water for at least 20 minutes and continue en route if possible.
4. Transport the patient with all containers, bottles, MSDS sheets, and labels from the
5. Perform reassessment en route.

activated charcoal, p. 551

antidote, p. 553
a substance that will neutralize the
poison or its effects.

delirium tremens (DTs),
p. 562

dilution, p. 552
thinning down or weakening by mixing with something else. Ingested poisons are sometimes diluted by drinking water or milk.

downers, p. 564

hallucinogens, p. 565

ingested poisons, p. 547

inhaled poisons, p. 547
1. Remove the patient from the source of the poison. 2. Establish an open airway.
3. Insert an oropharyngeal or nasopharyngeal airway and administer high-concentration oxygen by 4. Gather the patient’s history, take baseline vital signs, and expose the chest for auscultation.
5. Contact medical direction. 6. Transport the patient.

injected poisons, p. 548

Analgesics that are interchangeable with opiods (also include heroine, marijuana, cocaine, and amphetamines)

poison, p. 546
any substance that can harm the body
by altering cell structure or functions.

toxin, p. 546
a poisonous substance secreted by
bacteria, plants, or animals.

uppers, p. 563

volatile chemicals, p. 565

withdrawal, p. 562

Ingested Poisons
1. Quickly gather information.
2. Call medical direction on the scene or en route to the
3. If directed, administer activated charcoal. You may
wish to administer the medication in an opaque cup
that has a lid with a hole for a straw.
4. Position the patient for vomiting and save all vomitus.
Have suction equipment ready.
When a patient has ingested a poison, it provides another reason to avoid mouth-to-mouth contact. Provide ventilations through a pocket face mask or other barrier devic

A poison is any substance that can harm the body
The harm it can cause can result in a medical emergency
“All things are poison and nothing is without poison, only the dose permits something not to be poisonous.” Paracelsus

Effects of a Poison
Harm to body based on nature of poison, concentration, route of entry, patient’s age and health. Damage to skin and tissues from contact. Suffocation. Localized or systemic damage to body systems.
Dependent on: 1. Nature of poison 2. Concentration 3. How poison enters the body 4. Patient’s age, weight, and general health

Toxins may not only damage exposed skin, but may enter the body and damage tissues and organs. Some poisons may directly impact the central nervous system, either depressing or overstimulating it. Gases such as carbon monoxide interfere with red blood cells’ ability to carry oxygen. Other gases that are not themselves toxic can displace oxygen, leading to suffocation.

Classification of Poisons (By Routes of Entry) A+III

Four routes involve poisons, blood-borne pathogens, drugs, and weapons of mass destruction.
Ingested-common household and industrial chemicals, medications, improperly prepared or stored foods, plant materials, petroleum products, agricultural products. Inhaled-Gases, vapors, and sprays common in home, industry, and agriculture. Includes carbon monoxide, ammonia, chlorine, insect sprays, and gases from volatile liquid chemicals many industrial solvents). Absorbed-Corrosives or irritants that may or may not damage skin before being absorbed into body tissues and bloodstream. Insecticides, agricultural chemicals, plant materials and certain forms of marine life. Injected-Most commonly illicit drugs injected with a needle and venoms injected by snake fangs or insect stingers.

Ingested Poison
Child: may accidentally eat or drink a toxic substance
Adult: often an accidental or deliberate medication overdose

Medications may not be just prescription. Use “PORCH” acronym during assessment:
Prescription, Over the counter, Recreational, Compliance (taking as prescribed?), Herbal/supplemental (includes vitamins). OTC and herbal supplements can be just as toxic as prescription medications. Elderly persons may forget when they took their medications, causing them to possibly take their daily dose twice. Children may also ingest waterless hand cleaners after their use.

Common Ingested Poisons
Petroleum products

Assessment: Ingested Poisons
What substance was involved?
Look for container; check labels
Transport with patient to hospital
When did exposure occur?
Quick-acting poison requires faster treatment
ER personnel need to know for appropriate testing and treatment
How much was ingested?
Estimate missing pills by looking at prescription label
Over how long a time?
Treatments may vary
Was medication taken for very first time?
Was medication being taken chronically?
What interventions have been taken?
Treatments indicated on label,
Other home remedies (syrup of ipecac)
What is patient’s weight?
Rate of onset of toxic effects is related to weight
What effects has patient experienced?
Nausea, vomiting, altered mental status, abdominal pain, diarrhea, chemical burns around mouth, unusual breath odors

Food Poisoning
Can be caused by improperly handled or prepared food
Symptoms: nausea, vomiting, abdominal cramps, diarrhea, fever
May occur within hours of ingestion, or a day or two later

Treatment Food Poisoning
Activated Charcoal

Activated Charcoal
Works through adsorption, allowing substances to attach to its surface
Not an antidote: prevents or reduces amount of poison absorbed by body

Contraindications for Activated Charcoal
Inability to swallow
Altered mental status
Acid/Alkali/gasoline ingestion
Food poisoning

Inhaled Poisons
While many gases are toxic, others kill via oxygen displacement, where the gas replaces the oxygen in the environment, leading to suffocation. The gas itself (such as nitrogen) may be harmless, but the lack of oxygen is deadly.
Common Types:
Carbon monoxide
Agricultural chemicals and pesticides
Carbon dioxide

Assessment: Inhaled Poisons
What substance is involved (exact name)?
When did exposure occur?
Over how long did exposure occur?
What interventions has anyone taken?
Remove patient?
Ventilate area?
What effects is patient experiencing?
Move patient from unsafe environment using trained and equipped personnel
Detect/treat life threatening injuries
Open airway; provide high flow oxygen
History, physical exam, vital signs
Transport with all containers, bottles, and labels
Reassessment en route

Carbon Monoxide (CO) Poisoning
Can be caused by improper venting of fireplaces, portable heaters, generators Colorless, odorless, tasteless gas created by combustion Common cause of death during winter and power outages
If the CO poisoning is the result of a malfunctioning heater or poorly vented fireplace, everyone in the home or building may be affected. Commonly accepted idea that patients exposed to CO have cherry-red lips is not true.

Treatment: CO Poisoning
High flow oxygen is appropriate treatment, but CO bonds to red blood cells much more strongly than oxygen does
Can take several hours or days to “wash” CO from bloodstream

Smoke Inhalation
Smoke from burning materials can contain poisonous and toxic substances, including CO, ammonia, chlorine, cyanide
Substances can irritate skin and eyes, damage lungs, and progress to respiratory or cardiac arrest

Signs and Symptoms: Smoke Inhalation
Difficulty breathing
“Smoky” or chemical smell on breath
Black (carbon) residue in mouth, nose or sputum
Singed nasal or facial hair

Treatment: Smoke Inhalation
Move patient to safe area
Maintain airway; provide high flow oxygen
Monitor patient closely—airway burns may lead to swelling of airway
The body’s reaction to toxic gases and foreign matter in the airway can often be delayed. Convince all smoke inhalation patients that they must be seen by a physician, even if they are not yet feeling serious effects.

“Detergent Suicides”
Method of suicide started in Japan and becoming more common in the U.S.
Mix two easily-obtained chemicals to release hydrogen sulfide gas
Commonly released inside enclosed space such as a car
A source of acid, such as a strong household cleaner, and a source of sulfur, often a pesticide, when mixed together will quickly release significant amounts of toxic hydrogen sulfide gas. Often the victim will leave notes warning others of the hazardous gas.

Absorbed Poisons
Can be absorbed through skin
May or may not cause damage to skin
Patient may require decontamination prior to treatment

Treatment: Absorbed Poisons
Assess for immediate life threats
History, physical exam, vital signs
Brush off powder, then irrigate
Irrigate skin and eyes for at least 20 minutes and during transport
Transport with all containers
Reassessment en route

Injected Poisons
Illicit drugs

Treatment: Injected Poisons
May not know substance
Contact poison control

Poison Control Centers
Excellent resource
Information on poisons, signs and symptoms, and treatments
Follow local protocol for contact procedures

Alcohol and Substance Abuse
Alcohol and substance abuse are both safety threats to the EMT. Assure good safety habits when dealing with these types of patients.
Alcohol might disrupt the assessment of a patient with altered mental status. See many patients whose conditions are caused either directly or indirectly by alcohol or substance abuse
Abuse of alcohol and other drugs crosses all geographic and economic boundaries

Alcohol Abuse
Potent drug affects central nervous system
Can be addictive
Emergencies may result from recent consumption or years of abuse
Treat patients as any others
Abuse can lead to or worsen other medical conditions
Alcohol often consumed with other drugs, which can result in a serious medical emergency
Impaired patients can be uncooperative or combative
Contact law enforcement if safety concern

Assessment: Alcohol Abuse
Many medical conditions mimic alcohol intoxication
Intoxicated patients may also have medical problems
All patients receive full assessment regardless of suspicion of intoxication Remember that diabetes, epilepsy, head injuries, high fevers, hypoxia, and other medical problems may make the patient appear to be intoxicated. This can also include many traumatic injuries such as blood loss and head injury.

Signs and Symptoms: Alcohol Abuse
Alcohol odor on breath
Unsteady on feet
Slurred, rambling speech
Flushed, complaining of being warm
Poor coordination
Blurred vision
Confusion/altered mental status

delirium tremens (DTs)
Abrupt cessation of drinking may cause some alcoholics to suffer from delirium tremens (DTs)
Can be serious, resulting in tremors, hallucinations, and seizures

Signs and Symptoms: Alcohol Withdrawal
Confusion and restlessness
Unusual behavior, demonstrating “insane” behavior
Hallucinations, gross tremor of hands, profuse sweating, anxiety
Alcohol can be a respiratory depressant. The patient may not be a reliable source of information. Try to seek other sources such as bystanders, family, medical bracelets, or law enforcement. Be on the alert for signals—such as depressed vital signs—that the patient has mixed alcohol and drugs.

Patient Care: Alcohol Abuse
Vomiting common; standard precautions are essential
Keep suction ready
Stay alert for airway and respiratory problems
Monitor vital signs
Gather history from patient, bystanders
Stay alert for seizures

Substance Abuse
Any chemical substance taken for other than therapeutic (medical) reasons
Includes illicit drugs, prescription medications, industrial chemicals

Commonly abused substances
can be classified as uppers, downers, narcotics, hallucinogens, or volatile chemicals.

Stimulants that affect the nervous system
May be snorted, smoked, or injected

Central nervous system depressants
Rohypnol (Roofies)

Used to relieve pain or help with sleep
Heroin, codeine, morphine
OD characterized by coma, pinpoint pupils, and respiratory depression

Create intense state of excitement and distorted perception
LSD, PCP, some mushrooms, XTC

Volatile Chemicals
Produce vapors that are inhaled
Initial “rush,” then can act as central nervous system depressant

Assessment: Substance Abuse
May be difficult
Patient’s level of consciousness
Patient may have taken more than one type of drug
Patient may be uncooperative or combative
Be aware of a possibility of contaminated needles and the presence of chemicals

Signs and Symptoms: Uppers
People who abuse these drugs display excitement, increased pulse and breathing rates, rapid speech, dry mouth, dilated pupils, sweating, and the complaint of having gone without sleep for long periods. Repeated high doses can produce a “speed run.” The patient will be restless, hyperactive, and usually very apprehensive
and uncooperative.

Signs and Symptoms: Downers
People who abuse these drugs are sluggish, sleepy patients lacking typical coordination of body and speech. Pulse and breathing rates are low, often to the point of a true emergency.

Signs and Symptoms: Narcotics
People who abuse these drugs have a reduced rate of pulse and rate and depth of breathing, which is often seen with a lowering of skin temperature. The pupils are constricted, often pinpoint in size. The muscles are relaxed and sweating is profuse. The patient is very sleepy and does not wish to do anything. In overdoses, coma is common. Respiratory arrest or cardiac arrest may rapidly develop.

Signs and Symptoms: Hallucinogens
Rapid pulse
Dilated pupils
Flushed face
Seeing or hearing things (Hallucinations)

Signs and Symptoms: Volatile Chemicals
Swollen membranes in nose or mouth
Numbness or tingling sensation inside head
Changes in heart rhythm
May be residue of chemical on face or in bag

Treatment: Substance Abuse
Be aware of possible airway problems and respiratory distress
Provide oxygen and assist respirations as needed
Treat for shock
Talk to patient to keep them calm and cooperative
Perform physical exam
Look for evidence of injection sites (“track marks”)
Transport as soon as possible
Consult with medical control on further treatment
Follow local protocol concerning consideration for restraint

Perform primary assessment and immediately treat life-threatening problems. Ensure an open airway. Administer high-concentration oxygen if the poison was inhaled or injected.

Perform a history and physical exam, including baseline vital signs. Find out if the poison was ingested, inhaled, absorbed, or injected; what substance was involved; how much poison was taken in, when, and over how long a period; what interventions others have already done; and what effects the patient experienced.

Consult medical direction. As directed, administer activated charcoal, water, or milk for ingested poisons.

Remove patient who has inhaled poison from the environment and administer high-concentration oxygen; remove poisons from skin by brushing off or diluting.

Transport patient with all containers, bottles, and labels from substance.

Reassess patient en route.

Carefully document all information about poisoning, interventions, and patient’s responses.

Safety is always the first concern when dealing with a poisoning or substance-abuse patient.

Poisonings are generally classified by route of exposure. Effects vary greatly, depending upon type of poison and method of entrance into body.

EMTs must use thorough assessment, including scene clues, to help identify the nature and severity of poisoning.

Poison control centers offer a wealth of resources to assist in assessment and treatment of poisoning patient.

Alcohol is a common underlying issue with patients. In some patients it may be the most significant problem.

The effects of substance abuse can vary greatly, based on the type of substance. Determining the type of drug ingested can shed light on effects to come.

What are potential risks to the responder on a poisoning or overdose call?

What are the routes of entry into the body?

What are some things EMS can do to prevent poisonings, especially in children?

In a poisoned patient, perform a primary assessment and im-
mediately treat life-threatening problems. Ensure an open
airway. Administer high-concentration oxygen if the poison
was inhaled or injected.
Next, perform a secondary assessment, including baseline vi-
tal signs. Find out if the poison was ingested, inhaled, ab-
sorbed, or injected; what substance was involved; how much
poison was taken in; when and over how long a period expo-
sure took place; what interventions others have already
done; and what effects the patient experienced.

referring to alcohol or drug withdrawal in which the patient’s body reacts severely when deprived of the abused substance.

1. Name four ways in which a poison can be taken into the body.
Poison can be ingested, inhaled, absorbed, and injected into the body.

2. What is the sequence of assessment steps in cases of poisoning?
The sequence of assessment steps in cases of poisoning is: detect and treat immediately life-threatening problems in the primary assessment, perform a history and physical exam, assess baseline vital signs, consult medical direction, and transport the patient with all containers and labels from the substance. Reassess the patient en route.

3. What information must you gather in a case of poisoning before contacting medical direction?
Gather the following information about a poisoning case before contacting medical direction:
• What substance was involved?
• When did the exposure occur?
• How much was ingested?
• Over how long a period did the ingestion occur?
• What interventions have the patient, family, or well-meaning bystanders taken?
• What is the patient’s estimated weight?
• What effects is the patient experiencing from the ingestion?

4. What are the emergency care steps for ingested poisoning?
Emergency care steps for an ingested poisoning include gathering whatever information is available about the poison and contacting medical direction on the scene or en route. Administer activated charcoal as directed by medical control, and position the patient for vomiting. Have suction equipment readily available and never discard vomitus until it can be inspected by the receiving facility personnel or physician.

5. What are the emergency care steps for inhaled poisoning?
For absorbed poisoning?
Emergency care steps for an inhaled poisoning include removing the patient from the source of the poison, establishing an open airway, and inserting an OPA or NPA.Administer high-concentration oxygen by nonrebreather mask. Gather the patient’s history, take vital signs, expose the chest for auscultation, and contact medical direction. Transport. Emergency care steps for an absorbed poisoning include removing the patient from the source of the poison while avoiding your own cross-contamination. Always brush
powders from the patient, being careful not to abrade the patient’s skin. Remove contaminated clothing. Irrigate with clear water for at least 20 minutes while catching contaminated water and disposing of it safely. Contact medical direction and transport.

Prevent the patient from brushing at his jeans. Making sure that you are wearing protective gloves, brush off as much of the powder that remains on his hands and other body areas as possible. Do not try to rinse contaminated areas with water or any other “neutralizing” substance. Remove the patient’s jeans and any other clothing or jewelry that might be contaminated with the pesticide.Transport him immediately, bringing along the pesticide container and its labels.

A class of drugs that affect the nervous system and changes many normal body activities legally used for pain relief is:

1 gram/kg
What is the usual dosage of activated charcoal?

The dosage of activated charcoal is 1 gram/kg of body weight.
The dosage of activated charcoal is 1 gram/kg of body weight. The usual adult dose is 25-50 grams and the usual pediatric dose is 12.5-25 grams.

illicit drugs
The most common injected poisons include illicit drugs injected with a needle and venoms injected by snake fangs or insect stingers.
The most commonly injected poisons include snake and insect venom and:

What is the patient’s estimated weight?
Your patient has ingested a potentially dangerous amount of a medication. One question you should ask is:

volatile chemical.
Cleaning fluid, glue, model cement, and solutions used to correct typing mistakes are commonly abused volatile chemicals, which can cause an initial “rush” in the user, followed by a depressant effect on the nervous system. A substance that provides an initial “rush” followed by a depressant effect on the nervous system is a:

Syrup of ipecac has been used less in recent years because:
it removes, on the average, less than one third of the stomach contents. Vomiting induced with syrup of ipecac removes, on the average, less than one third of the stomach contents. If the patient has ingested a massive amount of a poison or medication, a toxic amount may remain in the system.

The most important part of treatment for an absorbed poison is:
irrigating the skin with large amounts of clean water. The best treatment for an absorbed poison is to flush the skin with large amounts of clean water. Attempting to neutralize the substance can do more harm than good, causing a great deal of heat, resulting in burning. Activated charcoal does nothing for absorbed poisons, only for ingested ones. Warming the patient to make him perspire will open the skin’s pores and allow more of the poison to be absorbed.

What treatment is normally advised for patients who have ingested a mild poison that does not, according to online medical direction, warrant care at a medical facility?
Dilution with water or milk

Not all poisons are toxins. Toxins are poisons that are:
produced by living organisms. Many living organisms are capable of producing a toxin, a substance that is poisonous to humans. Examples are plants, bacteria, and jellyfish.

Activated charcoal is manufactured to have more ____ than ordinary charcoal.
surface area
Ordinary charcoal adsorbs some substances, but activated charcoal is different because it has been manufactured to have many cracks and crevices. As a result, activated charcoal has an increased amount of surface area available to which poisons can bind.

Carbon monoxide poisoning is extremely serious because carbon monoxide:
Carbon monoxide is undetectable without special equipment. It takes the place of oxygen on red blood cells, causing hypoxia. Long exposure, even at low levels, can cause serious effects.

Activated charcoal is given to patients who have ingested a poison or overdose because it:
Activated charcoal works through adsorption, the process of one substance becoming attached to the surface of another. It binds with many poisons, reducing the amount of poison available for the body to absorb.

What should you be most concerned with when treating a child who ingested a caustic chemical and is beginning to vomit?
Aspiration of the chemical.
Ingested poisons pose a significant danger to patients due to the potential for regurgitation and aspiration. Caustic chemicals, for example, will cause much more damage to the delicate tissues of the lungs than to the lining of the stomach.

When arriving at the scene of an inhaled poisoning, your first priority is:
keeping yourself safe. As with any emergency response, your first priority is your personal safety. You can help no one if you become a victim.

What is the usual dosage of activated charcoal?
1 gram/kg

A class of drugs that affect the nervous system and changes many normal body activities legally used for pain relief is:

The two most common side effects of bronchodilators are patient jitteriness and
Since many bronchodilators also have an effect on the heart, an increased heart rate and patient jitteriness are common side effects of treatment.

determine whether the patient has recently taken anything
to treat erectile dysfunction, such as sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), or similar medication. If so, he should not take
If so, he should not take nitroglycerin because of the possi-
bility of a serious negative interaction with these drugs.

causes a dilation of blood vessels, a drop in the patient’s blood pres-
sure is always a potential side effect of administration. If this should occur, you may also need to lay the patient flat as you contact medical direction again for advice.

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