Poisoning and Overdoses

Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Poisoning and OverdosesPoisoning and Overdoses

Chapter 21Chapter 21


Case HistoryCase History

You are dispatched to a poisoning and find a You are dispatched to a poisoning and find a 5-year-old girl who is suspected of having 5-year-old girl who is suspected of having ingested a large quantity of acetaminophen ingested a large quantity of acetaminophen (Tylenol) tablets. The mother shows you an (Tylenol) tablets. The mother shows you an empty bottle, but the child appears perfectly empty bottle, but the child appears perfectly normal and has normal vital signs. The child normal and has normal vital signs. The child is alert and oriented.is alert and oriented.


IntroductionIntroduction

Poison Poison A substance that usually A substance that usually

kills, injures, or impairs an kills, injures, or impairs an organism through its organism through its chemical actionchemical action

OverdoseOverdose Drugs, taken in excess or in Drugs, taken in excess or in

combination with other combination with other agents, to the point where agents, to the point where poisoning occurs poisoning occurs


IncidenceIncidence

More than 5 million poisonings More than 5 million poisonings occur each year in U.S.occur each year in U.S. Most occur in children <5 years of age.Most occur in children <5 years of age.

Poisonings cause more than 10,000 Poisonings cause more than 10,000 deaths.deaths.

Other causesOther causes Drug abuseDrug abuse SuicideSuicide Animal or insect bitesAnimal or insect bites


Poison Control CentersPoison Control Centers

Provide access to experts in Provide access to experts in toxicology.toxicology.

Staffed 24 hours a day.Staffed 24 hours a day.

Coordinate emergency responseCoordinate emergency response Provide advice to patients at homeProvide advice to patients at home Refer people to area hospitals with Refer people to area hospitals with

poisoning care capabilitiespoisoning care capabilities Advise EMTs, physicians, and Advise EMTs, physicians, and

nursesnurses


Types of PoisoningsTypes of Poisonings

IngestedIngested

InjectedInjected

InhaledInhaled

AbsorbedAbsorbed


Cardinal RulesCardinal Rules

Treat the patient, not Treat the patient, not poison.poison.

Protect self and Protect self and bystanders.bystanders.

Look for clues of trauma.Look for clues of trauma.

Maintain a high level of Maintain a high level of suspicion.suspicion.


Scene Size-upScene Size-up

Survey the scene to protect Survey the scene to protect yourself and bystanders.yourself and bystanders.

DangersDangers Toxic gasesToxic gases Absorbed toxinsAbsorbed toxins

Do not enter without adequate Do not enter without adequate protection.protection. Only trained hazmat rescuers Only trained hazmat rescuers

should enter.should enter.


Initial AssessmentInitial Assessment

What is your general What is your general impression?impression?

Findings indicate any trauma?Findings indicate any trauma?

Is the patient awake and Is the patient awake and responsive?responsive?

AAirway, irway, BBreathing, reathing, CCirculationirculation


Focused HistoryFocused History

What is the poison?What is the poison?

How was it taken?How was it taken? Was it ingested, inhaled, absorbed, or injected?Was it ingested, inhaled, absorbed, or injected?

When was it taken?When was it taken?

How much was taken?How much was taken?

Over what period of time?Over what period of time?


Focused HistoryFocused History

Is there any other evidence at the scene (e.g., Is there any other evidence at the scene (e.g., commercial products, pills)?commercial products, pills)?

Were any other interventions attempted?Were any other interventions attempted? VomitingVomiting DilutionDilution Activated charcoalActivated charcoal Syrup of ipecacSyrup of ipecac AntidoteAntidote

How much does the patient weigh?How much does the patient weigh?


Perform a Perform a Focused Physical ExaminationFocused Physical Examination

SkinSkin PupilsPupils Breath soundsBreath sounds

AbdomenAbdomen Mental statusMental status Vital signsVital signs


Emergency Medical CareEmergency Medical Care

Remove patient from poisonous environment.Remove patient from poisonous environment.

Ensure patent airway and administer oxygen.Ensure patent airway and administer oxygen.

Be alert for vomiting.Be alert for vomiting.

Bring all poison agents to hospital.Bring all poison agents to hospital. ContainersContainers BottlesBottles LabelsLabels


Ingested Poisons – Ingested Poisons – Signs and SymptomsSigns and Symptoms

History of ingestionHistory of ingestion NauseaNausea VomitingVomiting DiarrheaDiarrhea


Ingested Poisons – Ingested Poisons – Signs and SymptomsSigns and Symptoms

Altered mental statusAltered mental status

Abdominal painAbdominal pain

Chemical burns around Chemical burns around the mouththe mouth

Different breath odorsDifferent breath odors


OdorsOdorsSmell Possible Poison

Acetone (sweet, fruity) Ethanol, isopropyl alcohol, diabetic

Alcohol Alcohol, isopropylalcohol

Disinfectants Creosol and phenol

Rotten eggs Hydrogen sulfide

Garlic Insecticides

Stale tobacco Nicotine

Wintergreen Methyl salicylate



Remove poison from patient’s Remove poison from patient’s mouth using gloves.mouth using gloves.

Consult medical direction.Consult medical direction. Activated charcoalActivated charcoal

Bring all containers (bottles, Bring all containers (bottles, labels, etc.,) to hospital.labels, etc.,) to hospital.


Types of IngestionsTypes of Ingestions

Sedative-hypnoticsSedative-hypnotics

Antianxiety agentsAntianxiety agents

OpioidsOpioids

Psychiatric medicationsPsychiatric medications

StimulantsStimulants


Types of Ingestions – Types of Ingestions – Sedative-HypnoticsSedative-Hypnotics

BarbituratesBarbiturates Secobarbital (Seconal)Secobarbital (Seconal) Pentobarbital (Nembutal)Pentobarbital (Nembutal)

BenzodiazepinesBenzodiazepines Diazepam (Valium)Diazepam (Valium) Chlordiazepoxide (Librium)Chlordiazepoxide (Librium) Chlorazepate (Tranxene)Chlorazepate (Tranxene)


Types of Ingestions –Types of Ingestions –Sedative-HypnoticsSedative-Hypnotics

OthersOthers Methaqualone (Quaalude)Methaqualone (Quaalude) Ethchlorvynol (Placidyl)Ethchlorvynol (Placidyl) Chloral hydrate (Noctec)Chloral hydrate (Noctec) Mebrobamate (Miltown)Mebrobamate (Miltown)


Toxic Effects –Toxic Effects –Sedative-HypnoticsSedative-Hypnotics


Respiratory depression Respiratory depression and arrestand arrest

Most toxic when Most toxic when combined with alcoholcombined with alcohol

Support of ABCs is Support of ABCs is critical.critical.


Types of IngestionsTypes of Ingestions Opioids (Narcotics) Opioids (Narcotics)

Central nervous system depressantCentral nervous system depressant ExamplesExamples

• HeroinHeroin

• MorphineMorphine

• PercocetPercocet

• PercodanPercodan


Toxic Effects/Management – Toxic Effects/Management – Opioids (Narcotics) Opioids (Narcotics)

Toxic effects and signs and Toxic effects and signs and symptomssymptoms Altered (depressed) mental statusAltered (depressed) mental status Respiratory depressionRespiratory depression Pinpoint pupilsPinpoint pupils Track marksTrack marks

ManagementManagement Support ABCsSupport ABCs Administration of naloxoneAdministration of naloxone (Narcan) by (Narcan) by

ALS providers or hospitalALS providers or hospital


Ingested SubstancesIngested Substances

StimulantsStimulants Cause increased Cause increased

excitability (e.g., excitability (e.g., amphetamines)amphetamines)

AlcoholAlcohol

Heart and lung drugsHeart and lung drugs

AnalgesicsAnalgesics


Inhaled Poisons – Inhaled Poisons – Signs and SymptomsSigns and Symptoms

History of inhalation of History of inhalation of toxic substancetoxic substance

Difficulty breathingDifficulty breathing

Chest painChest pain

CoughCough

HoarsenessHoarseness

DizzinessDizziness

HeadacheHeadache

ConfusionConfusion

SeizuresSeizures



Poisonous GasesPoisonous Gases

Simple asphyxiantsSimple asphyxiants

Carbon dioxideCarbon dioxide

Small hydrocarbon moleculesSmall hydrocarbon molecules

Chemical asphyxiantsChemical asphyxiants

Irritant gasesIrritant gases

OrganophosphatesOrganophosphates


Toxic Injection – Toxic Injection – Signs and SymptomsSigns and Symptoms

WeaknessWeakness

DizzinessDizziness

ChillsChills

FeverFever

NauseaNausea

VomitingVomiting


Absorbed Poisons – Absorbed Poisons – Signs and SymptomsSigns and Symptoms

History of exposureHistory of exposure

Liquid or powder on patient’s skinLiquid or powder on patient’s skin

BurnsBurns

ItchingItching

IrritationIrritation

RednessRedness



SkinSkin Remove contaminated clothing.Remove contaminated clothing. Protect self from contamination.Protect self from contamination.

PowderPowder Brush powder off patient.Brush powder off patient. Irrigate for at least 20 minutes.Irrigate for at least 20 minutes. Continue en route to facility, if possible .Continue en route to facility, if possible .

Liquid Liquid Irrigate for at least 20 minutes.Irrigate for at least 20 minutes. Continue en route to facility, if possible.Continue en route to facility, if possible.


Medication NameMedication Name

GenericGeneric Activated charcoalActivated charcoal

TradeTrade SuperChar™SuperChar™ InstaChar™InstaChar™ Actidose™Actidose™ LiquiChar™LiquiChar™


Activated CharcoalActivated Charcoal

IndicationsIndications Poisoning by mouthPoisoning by mouth

Contraindications Contraindications Altered mental statusAltered mental status Ingestion of acids or alkalisIngestion of acids or alkalis Inability to swallowInability to swallow


Medication FormMedication Form

Medication is pre-mixed in water.Medication is pre-mixed in water. Plastic bottle containing 125 grams activated Plastic bottle containing 125 grams activated

charcoalcharcoal

Powder should be avoided in field.Powder should be avoided in field.


DosageDosage

Adults and childrenAdults and children 1 gram activated charcoal/kg of body weight1 gram activated charcoal/kg of body weight

Usual adult doseUsual adult dose 25 - 50 grams25 - 50 grams

Usual infant/child doseUsual infant/child dose 12.5 - 25 grams12.5 - 25 grams


ActionsActions

Charcoal binds to certain poisons.Charcoal binds to certain poisons.

Binding action prevents absorption.Binding action prevents absorption.

Not all brands are the same.Not all brands are the same. Some bind much more poisonSome bind much more poison Consult medical direction about the brand to use.Consult medical direction about the brand to use.


Side Effects Side Effects

Black stoolBlack stool

Some patients may vomit.Some patients may vomit. If the patient vomits, repeat dose one time.If the patient vomits, repeat dose one time.

Reassessment strategiesReassessment strategies Prepare for vomiting and deterioration of patient’s Prepare for vomiting and deterioration of patient’s

condition.condition.

Poisoning and Overdoses

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