POISONS


Identifying the Patient and the Poison

- a poison is any substance that when introduced into the body in substantial amounts causes harm.
- a poison can be something as simple as water if consumed in excess or it can be something like inhaled cyanide which takes very minute amounts to kill.
- poisons work by altering cell metabolism in such a way that is causes harm.
- poisons may act acutely, such as a heroin overdose, or over years such as with alcohol abuse.
- signs and symptoms are an important clue to identifying a patient that has been poisoned. Ingested poisons, for example, may result in injury to the mouth.
- if a patient vomits, collect the vomitus and bring it to the hospital so that it can be examined. In addition, if you suspect overdose of pills or medicines, brings those to the hospital as well.



How Poisons Get Into the Body

- poisons are introduced into the body in one of four ways:

      ingestion
      injection
      inhalation
      absorption (contact)

  Ingested Poisons
   

- approximately 80% of all poisoning is by mouth; ingested products include household products, food, plants and in the majority of cases... drugs.

- children are poisoned most frequently and the most common products they are poisoned with are household products.

- if an ingested poison is suspected the EMT's job is to first assess Airway, Breathing, Circulation and Disability (ABCD). If this appears stable, you should attempt to remove as much poison as possible. This can be accomplished in several ways but a common method used in many EMS agencies is activated charcoal.

- activated charcoal is a suspension of charcoal that binds (adsorbs) to the ingested poison and carries it through the body minimizing and limiting absorption through the GI tract.

 

  Inhaled Poisons
   

- inhaled poisons include several substances including natural gas -- the most common accidental inhaled poison -- pesticides, chlorine, smoke and others.

- all patients should be moved into an environment where there is fresh air. Supplemental oxygen should also be provided for those suspected of inhaling a poison. .

- signs and symptoms may include burning or watery eyes, sore throat, cough, hoarseness, respiratory distress, stridor, pulmonary edema, seizures and altered mental status. Remember, signs and symptoms need not be immediate... therefore, if an inhaled poison is suspected, ALL patients require transport to the hospital.

- EMT's should be prepared to use Basic Life Support (BLS) skills.


  Injected Poisons
   

- injected poisonings are almost always the result of substance abuse. Heroin and cocaine top the list... but injected poisons can also be the result of bites and stings.

- signs and symptoms (s/s) vary in every patient but common s/s include weakness, dizziness, altered mental status, excitability, or unresponsiveness.

- injected poisons are difficult for EMT's to treat since dilution is difficult. Some medications can be given in certain circumstances that counteract the effects of some drug-induced poisoning but quick transport to the hospital is the key to effective treatment.

- EMT's should be prepared to use Basic Life Support (BLS) skills.


  Contact (Absorbed) Poisons
   


- chemicals that contact the skin, mucus membranes or eyes have the potential to cause severe damage. Alkalis, acids and hydrocarbons are some of the most destructive.

- signs and symptoms (s/s) of such poisonings include a history suggestive of this, irritated skin, erythema of the skin or bullae (blisters) present on the skin. .

- emergency treatment involves removing the offending chemical by first, preventing self-contamination and secondly diluting with copious amounts of water. If the patient is wearing clothing -- REMOVE IT. Flush with water for 10 minutes if contact is on the skin.

- if the patient has chemical exposure in the eyes irrigation should be at least 10 minutes for acid substances and 20 minutes for alkali substances. If you are unsure, irrigate for 20 minutes.

- the only time irrigation is contraindicated is if a potential harmful reaction may occur from contact with water. Examples include phosphorous and elemental sodium.

- provide prompt transport to the emergency department. Irrigate while in route if necessary.


Emergency Medical Care
      "the solution to pollution is dilution.
                                                          Hercules, 5000 bn

- the key to emergency medical care is diluting the poisoned substance so much that it lacks the ability to cause harm.
- treatment then focuses on support i.e. assessing and maintaining ABCD.
- in circumstances where charcoal is indicated, the usual adult dosage is 25 - 50g, and the usual pediatric dose is 12.5 - 25g. If a small child is involved, the dose is 1g of charcoal per kg of body weight.
- charcoal is CONTRAINDICATED in patients that have ingested acids, alkalis or petroleum products, or those patients who have a decreased level of consciousness (LOC).
- side effects of charcoal ingestion include abdominal pain, diarrhea, constipation and black stools. Vomiting is a serious side effect that can occur due to the risk of aspiration into the lungs.

 

SPECIFIC POISONS
   
  Alcohol (EtOH)
   

- most commonly abused drug in the United States contributing to more than 200,000 deaths each year.
- EtOH is a powerful CNS depressant that sedates (to decrease the activity of) and is a hypnotic (induces sleep).
- EtOH dulls the senses, slows reflexes, reduces reaction time, and reduces coordination.
- signs and symptoms include any of the above and CNS depression. Periods of CNS depression may result in a patient vomiting without even knowing s/he has vomited... so ALWAYS PROTECT THE AIRWAY in these patients.
- a patient with EtOH withdrawl may experience delirium tremors (DT's) -- syndrome characterized by restlessness, fevers, sweating, chills, delusions, hallucinations, agitation and seizure activity.
- overall treatment for patients suspected of EtOH abuse is to dilute with oral or IV fluid and to provide BLS support. Protect the airway by having suction devices ready and turing patients to their side.

 

  Opioids
   

- named so due to its origin from the poppy seed. Include such drugs and medicines as heroin, codeine, and morphine, demerol, dilaudid, percocet, vicodin and methodone.
- these substances are CNS depressants and result in severe CNS depression.
- s/s include "sedated" patients, occasionally they are cyanotic and have pinpoint pupils.
- treatment includes supporting ABC, administering supplemental oxygen, being prepared for vomiting and dilution with IV fluids.
- an antidote for narcotics include a powerful narcotic-antagonist called Narcan -- usually administered by paramedics -- that will reverse the "high" in as little as two-minutes.


  Sedative Hypnotic Drugs
   

- includes a category of drugs and medicines categorically known as barbiturates and benzodiazepines.
- these substances are CNS depressants and alter level of conscious.
- s/s are similar to EtOH intoxication.
- these substances are lethal when used in combination with alcohol (EtOH).
- these drugs are also touted to be given to people as "knock-out" drugs or "date rape drugs." Rohypnol is one such example.
- general treatment for such individuals is airway support, ventilatory assistance, and transport to the emergency department for continued ventilatory support. Always administer supplemental oxygen.
- an antidote -- romazicon -- can be administered by paramedics.


  Inhalants
   

- s/s are similar to the CNS effects seen with sedative-hypnotic but the route is via inhalation vs. ingestion or infection.
- common inhalants include acetone, hexane (found in glues), paint thinner, hydrocarbons (found in gasoline or other petroleum products), propellants found in aerosol sprays.
- drowsiness is a common finding, but seizures can also occur with the use of this substance.
- patients that inhale hydrocarbons can make the heart sensitive to the patients own adrenaline putting them a risk for sudden cardiac death; try to keep such patients from struggling or exerting themselves.
- treatment should always include supplemental high-flow oxygen and use stretches to move these patients.
- transport to a hospital is always recommended.

 

  Sympathomimetics
   

- these are CNS stimulants (substances that produce an excited state) causing hypertension (HTN), tachycardia and dilate the pupils. |
- examples include amphetamines, methamphetamines, phentermine, caffeine, phenylpropanolamine (nasal decongestants), and pseudoephedrine (nasal decongestants).
- cocaine and crack are the classic sympathomimetics though recently ecstasy -- a so-called "designer drug" -- has become increasingly abused in certain areas of the United States.
- designer drugs can be ingested, inhaled and injected.
- s/s include disorganized behavior, restlessness, delusions, paranoia. Effects of the medication last less than one hour usually.
- the risk of cardiac arrhythmia and stroke is also high -- particularly with cocaine or crack. EMT's may see extremes of HTN and seizures.
- treatment includes oxygen, IV establishment if possible and be prepared to suction and protect the airway.

 

  Marijuana
   

- it is estimated that as many as 20 million people use marijuana daily in the United States.
- s/s normally include euphoria, drowsiness, hallucinations and relaxation.
- marijuana normally impairs short-term memory and complex thinking, but usually doesn't result in a hospital admission or an ambulance transport.
- exceptions include the patient who is hallucinating and is paranoid or anxious.
- marijuana is a "gateway drug" -- a drugs that is used as vehicle for additional and oftentimes more harmful drugs.

 

  Hallucinogens
   

- hallucinogens alter one's sense of perception.
- two common hallucinogens include LSD and PCP.
- s/s include visual hallucinations and intensify auditory and visual senses.
- many of the hallucinogens have sympathomimetic properties therefore treatment usually invokes a calm manner and providing emotional support.

 

  Anticholinergics
   

- these drugs block the parasympathetic nervous system.
- common medications include benadryl and tricyclic antidepressants.
- s/s include tachycardia, agitation and pupil dilation. Serious side effects include cardiac arrhythmia's and seizures.
- treatment for such serious side effects include sodium bicarbonate intravenously otherwise monitoring is necessary in a hospital environment.

 

  Cholinergics
   

- cholinergic agents are the "nerve gases" used in chemical warfare.
- the mechanism by which they act upregulate the parasympathetic nervous system.
- normally found in insecticides or some wild mushrooms.
- s/s are easily remembered by the acronym SLUDGE
     - salivation
     - lacrimation
     - urination
     - defecation
     - GI irritation
     - eye constriction
- patients exposed to cholinergic actions frequently require decontamination by HAZMAT units.
- treatment include IV atropine and aggressive airway support.

 

 
Others
    - two of the more common medications that can lead to lethal conditions include aspirin (ASA) and tylenol (acetaminophen - APAP).
- over-ingestion of ASA can result in nausea and vomiting and tinitus (ringing in the ears). Serious side effects include lowering the pH of the body to lethal levels resulting in tachyarrhthymias or kidney failure.
- over-ingestion of APAP leads to liver failure... the problem is, it may not be apparent for over a week and the patient may be symptom free until that time. If information about the overdose is obtained early enough, a antidote may minimize and in some cases prevent liver failure.

 

Food Poisoning
- there are two main types. In one type, the organism is responsible for the disease process; in the other type, the organism produces a toxin which then causes the disease.

- Salmonella is one example in which the organism causes the disease process.
- s/s of salmonellosis is characterized by nausea, vomiting, abdominal pain, diarrhea, fever and generalized weakness. It occurs within 72 hours of eating and is common when eating improperly cooked poultry.

- Staphylococcus is an example where the organism produces a toxin that causes the disease process.
- s/s include nausea, vomiting, and diarrhea starting within 2-3 hours after ingestion of the offending organism.
- this type of poisoning commonly occurs when eating food that are prepared in advance and kept unrefrigerated.
- treatment includes supportive care until IV fluids and medications can be administered.


Plant Poisoning
- thousands of cases each year due to contact or ingestion.
- though it is impossible to memorize all plants that can cause harm, two common offending organisms are listed below -- poison ivy and poison oak.


poison ivy

poison oak


- treatment include maintaining an open airway and monitor vital signs, notifying the regional Poison Control Center (PCC) below to identify the plant, taking the patient and the plant to the Emergency Department and transporting the patient to the hospital.



Poison Control Center
- the PCC is the best resource for any poisoning.
- all PCC can be found at the following link: http://www.aapcc.org/findyour.htm
- the 800# is: 1-800-222-1222

      

 

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