9/18/2012 Chapter 15 Poisoning and Overdosesems.jbpub.com/henry/emt/docs/PPT_Lectures/Chapter_015.pdf · 9/18/2012 10 28 Ingested Poisons ... Sudden death from acute cardiac dysrhythmia

9/18/2012

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Chapter 15

Poisoning and Overdoses

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Learning Objectives

List ways poisons enter the body

List signs/symptoms associated with poisoning

Know emergency medical care for possible overdose

Know steps in emergency medical care for suspected poisoning

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Learning Objectives

Establish relationship between patient with poisoning/overdose and airway management

State generic, trade names, indications, contraindications, medication form, dose, administration, actions, side effects, reassessment strategies for activated charcoal

Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company

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Learning Objectives

Recognize need for medical direction in poisoning/overdose

Know rationale for administering activated charcoal

Know rationale for contacting medical direction early in prehospital management of poisoning/overdose patient

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Introduction

Patients with poisonings/overdoses Positive pressure ventilation

Signs of threat to life

Provide life support as needed

Maintain airway

Gather clues to identify substance

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Introduction

Poison Substance that kills, injures/impairs organism

through chemical action

Toxicology Study of poisons

Overdose Self-administered drugs taken in excess or in

combination with other agents


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Incidence

According to the AAPCC, more than 2 million poisonings each year

Unreported overdoses

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Poison Control Centers

Provide information about: Toxins

Management of poisoned victims

Antidotes

Services provided: Access to toxicology experts 24/7 by phone

Emergency response coordination

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Types of Exposure

Ingestion Swallow through GI tract

Inhalation CO most frequent toxin

Wear PPE


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Types of Exposure

Absorption Through skin

Injection Fastest onset - poisons injected directly into

bloodstream

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Assessment

Maintain high level of suspicion

Must have good scene assessment Look for patterns of multiple exposures

Do not jeopardize yourself if exposure possibility

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Assessment

Bring medications and poisons to hospital

Report noticeable odors that give clue to toxin

Search for clues of trauma

Treat patient, not poison

Management


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Assessment

Scene size-up Survey scene

Protect yourself/bystanders from inadvertent poisoning

• Take adequate protection

Wear PPE

Only trained rescuers should remove patient

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Assessment

Scene size-up Eye exposure & skin contamination

• Remove toxin immediately

• Remove contaminated clothing

• Flood contaminated skin with soap & water to minimize contact

Follow local protocols

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Assessment

Initial (primary) assessment Get general impression

Evaluate for traumatic injury

Check airway & breathing

Remove pills, tablets, pills from mouth with gloved hand

Protect & support c-spine

Check pulse

Check skin for perfusion


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Assessment

Initial assessment Patient history

• Ask about pill bottles/containers

• Information needed Poison name

Route taken

When

Amount

Time period

Interventions attempted

Patient weight

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Assessment

Focused assessment Review mental status

• If unconscious, use alert, verbal, painful, unresponsive (AVPU)

If unable to swallow:• Transport

• Protect airway

• Ensure adequate ventilations

Document findings

Look for signs of injury

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Assessment


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Management

Management Maintain open airway

Provide ventilation & O2

Prevent further absorption • Depends on exposure type

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Management

Management Prevent further absorption

• Activated charcoal

Absorbent material that binds most toxins

Keeps toxins in GI tract until eliminated

Dose: 1 g/kg body weight

Premixed is thick, souplike slurry

Sweeteners used for children

No harm if patient can swallow & can protect airway

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Management

Management Prevent further absorption

• Induction of vomiting

Syrup of ipecac not recommended, except for plant ingestion

Contraindicated for certain drugs/poisons or patients


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Skill 15-1:Administering Activated Charcoal

Obtain order from medical direction

Shake container thoroughly

Measure proper amount of solution per medical direction

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Skill 15-1:Administering Activated Charcoal

Obtain patient cooperation Cover drink; provide

straw

Reshake if patient takes too long

Record activity, time

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Management

Treat signs & symptoms Few poisons have antidotes available

• Counteracts effects of poison

Provide supportive care


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Management

Transport If unconscious/deteriorating mental status

• Protect airway

• Continuously assess for respiratory support

• Place in recovery position

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Management

Emotions & poisoned patient AMS from emotional events/physical effects

Suicidal

Parents may feel guilt

Maintain professional approach

Do not antagonize patient

Do not label patient

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Management

Patients who refuse medical attention May insist they want to die/be left alone

• Do not abandon

• Encourage them to go to hospital

• Call police for protective custody, if necessary


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Ingested Poisons

History & physical examination Suspect poison from history or physical

examination

Patient may give history of poisoning or signs may be noted on exam

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Ingested Poisons

History & physical examinationSigns/symptoms

• Pupils constricted or dilated• Heart rate fast or slow• Mental status agitated or depressed• Seizures, coma• BP high or low• Skin dry or moist• Body temperature alterations• Nausea, vomiting, diarrhea, abdominal pain

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Ingested Poisons

History & physical examination History may help clarify chief complaint

• Ask patient/bystanders what patient may have taken

• Establish ingestion time

• Ask if pills were taken at once or more and more at repeated intervals

• Ask the amount ingested

Possible alterations in consciousness


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Ingested Poisons

History & physical examination Perform physical examination

• Note positive/negative findings:

Pupil size

Skin condition

Presence/absence of breath odors

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Ingested Poisons

Types of ingested poisons Sedative-hypnotics & antianxiety agents

• Commonly prescribed

• Sedatives – calm, reduce activity and excitement

• Hypnotics - induce sleep

• Toxic effects:

Respiratory depression

Mental status depression

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Ingested Poisons

Types of ingested poisons Opioids

• CNS depressant

• Alter pain perception

• Overdose signs:

Reduced respirations

Reduced mental status

Pinpoint pupils


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Ingested Poisons

Types of ingested poisons Stimulants

• Amphetamines

• Methylphenidate

• MDMA

• Cocaine

• PCP

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Ingested Poisons


• Overdose signs Increased HR

Increased BP

Chest pain

Anxiety

Delirium

Paranoia

Psychotic & violent behavior

Sudden death from acute cardiac dysrhythmia

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Ingested Poisons


• Assess need for cardiorespiratory support

• Be conservative

To gain compliance, reassure patient

Maintain verbal contact with patient

Do not judge

Avoid restraints


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Ingested Poisons


• Overdose can cause: Myocardial infarction

Bleeding in brain

Convulsions

Coma

Respiratory depression

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Ingested Poisons

Types of ingested poisons Alcohol

• Most frequently abused drug

• Depressant effect in high doses

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Ingested Poisons


• Slows reflexes

• Suppresses inhibitions

• Causes uncoordinated movements

• Causes unpredictable behavior

• Acute intoxication can be lethal

• Patient may choke on vomit


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Ingested Poisons


• Withdrawal causes DTs Tremors

Weakness

Nausea

Hallucinations

Seizures

Cardiovascular collapse

Death

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Ingested Poisons

Types of ingested poisons Chronic alcoholic

• Assessment CAGE

• Physical findings Slender extremities with distended abdomen

Bruises

Jaundice from failing liver

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Ingested Poisons


• Management Treat symptomatically

Dress open wounds

Administer O2 if short of breath

Transport


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Ingested Poisons

Types of ingested poisons Prescription drugs

• Suicidal patients take any available medications

• Circulatory & respiratory drugs cause wide range of symptoms Alterations in heart rate, rhythm

BP changes

Dysrhythmias

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Ingested Poisons

Types of ingested poisons Analgesics

• OTC pain relievers widely available, often used

• Few early symptoms present after overdose

Aspirin overdose

Acetaminophen overdose

• Patient should receive further evaluation

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Ingested Poisons

Types of ingested poisons Commercial & industrial products

• Ingestion of hydrocarbons, caustics, insecticides, household products

• Caustics

Acids

Alkalis

• Dilute

• Do not induce vomiting

• Follow local protocols


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Ingested Poisons

Types of ingested poisons Methanol & ethylene glycol

• Initially cause signs of mild inebriation/no findings

• Left untreated, can lead to coma, death

• Methanol

• Ethylene glycol

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Ingested Poisons

Types of ingested poisons Methanol & ethylene glycol

• Ingestion Causes severe acid formation in blood when products

break down

To delay effects, administer ethyl alcohol

Patient may hyperventilate

Need hospital care and possible dialysis

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Ingested Poisons

Types of ingested poisons Insecticides

• Contain organophosphates Overstimulation of secretions

Bronchoconstriction

Muscle weakness

In excess, death by respiratory muscle paralysis or pulmonary oversecretion and bronchoconstriction


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Ingested Poisons


• Outpouring of secretions from most body openings, includes: Vomiting

Salivation

Sweating

Lacrimation (tearing)

Urination

Diarrhea

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Ingested Poisons


• Findings Small pupils

Low HR

Respiratory distress

• Antidote

Atropine

Pralidoxime

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Ingested Poisons


• Prehospital treatment

O2

Ventilatory support

Rapid transport

• May be absorbed through skin

Remove contaminated clothing

Flush skin with soap & water

• Wear PPE


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Ingested Poisons

Types of ingested poisons Food poisoning

• Causes Bacteria

Toxins produced by bacteria

Viruses

Improperly cooked or canned food

Fecal bacteria by food handlers

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Ingested Poisons


• Symptoms Abdominal pain

Nausea

Vomiting

Diarrhea

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Ingested Poisons


• Botulism Most severe type of food poisoning

Flulike symptoms with double vision

Difficulty moving eyes & swallowing

Descending (from head to toe) weakness

Paralysis

Respiratory arrest


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Ingested Poisons


• Poisonous mushroom consumption GI disturbances

Hallucinations

Delirium

Symptoms often delayed

Supportive care

Bring available mushroom or fragments to hospital for I.D.

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Ingested Poisons

Types of ingested poisons Plants

• Adverse effects on GI, circulatory, and neurologic systems

• Severe skin and mucous membrane irritation

• Dieffenbachia

Household plant

Causes severe irritation and swelling in the mouth if ingested

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Inhaled Poisons

Rescue considerations & precautions Always approach with consideration of safety

Avoid inhaling fumes

Only trained rescuers enter contaminated area or closed space

Victims should be moved from toxic environment to fresh air ASAP

• Ventilatory support

• Humidified supplemental O2


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Inhaled Poisons

Rescue considerations & precautionsCarbon monoxide

• Lethal & poisonous

• Management 100% O2

In severe cases, hyperbaric O2 treatment

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Inhaled Poisons

Rescue considerations & precautions Poisonous gases

• Possible asphyxiation/death

• Simple asphyxiants

• CO2

• Small hydrocarbon molecules

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Inhaled Poisons


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Inhaled Poisons

Rescue considerations and precautions Poisonous gases

• Chemical asphyxiants

Attach to molecules in body essential to respiration

Carbon monoxide

Cyanide

Hydrogen sulfide

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Inhaled Poisons

Rescue considerations & precautions Irritant gases

• Causes inflammatory damage to airway, bronchconstriction

• Most soluble agents (ammonia, sulfur dioxide, hydrogen chloride react almost immediately

• Low-solubility agents (phosgene, nitrogen oxides) are less likely to react immediately

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Inhaled Poisons

Rescue considerations and precautions Organophosphates

• Spraying of fields/gardens with insecticides can result in inhalation

• Initial symptoms Visual problems

Bronchoconstriction

Excessive pulmonary secretion


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Absorbed Poisons

Skin damaged by corrosive, caustic agents Causes severe chemical burns

Findings:• History of exposure

• Liquid or powder on patient’s skin

• Burns

• Itching

• Irritation

• Redness

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Absorbed Poisons

Skin damaged by corrosive, caustic agents, severe chemical burns Remove contaminated clothing

Flood skin, then wash with soap and water

Irrigate eyes with water for more than 20 min; continue en route

Call PCC

Wear PPE

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Injected Poisons

Cause most rapid onset of drug effects

Often self-administered overdoses

Bites, stings result in venom poisoning


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Drugs of Abuse

Legal/illegal drugs

Repeated self-administration

Tolerance

Dependency

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Drugs of Abuse

Most common - alcohol Withdrawal symptoms

• Shakes

• Tremors

• Seizures

• Possible DTs

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Drugs of Abuse

Other drugs of abuse Heroin

Cocaine, PCP, amphetamines

LSD

Ecstasy

Prescription drugs


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Drugs of Abuse

EMT contact often involves: Overdose

Behavioral emergency

Trauma caused by overdose

Must treat psychological & physical manifestations simultaneously

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Summary

Poisons enter body by ingestion, inhalation, injection, absorption

Scene size-up anticipates hazards to EMS personnel/bystanders from exposure to toxin/secondary contamination Prevent through PPE

Only trained rescuers remove patients from toxic environment

Decontaminate victims

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Summary

Signs/symptoms of poisoning Extreme stimulation

Inhibition of most organ systems, depending on toxin involved


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Summary

Emergency care for patients with poisoning/overdose focuses on: Preventing injury to EMS personnel/bystanders

Adequate airway

Ventilations

Oxygenation

Preventing further absorption

Gathering evidence of poisoning

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Summary

During history, important questions to ask include Substance involved

Amount taken

Over what period of time

Interventions performed before arrival

Patient’s weight

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Summary

Prevent further absorption by removing contaminated clothing while protecting yourself from contamination; brush any powder off before irrigation Irrigate skin with clean water/soap & water for at

least 20 min; continue en route

At scenes of possible inhaled exposures, trained rescuers remove patients from poisonous environment


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Summary

For patients with inhaled toxins, remove to fresh air, administer supplemental O2

Under medical direction, administer activated charcoal to prevent absorption of ingested poisons (approximately 1 g/kg body weight)

Contraindications to activated charcoal include AMS, inability to swallow, ingestion of acids/alkalis

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Summary

Consider ALS intercept for victims of opioid & organophosphate overdose because lifesaving antidotes may be carried by ALS personnel

Opioid overdose recognized by classic presentation of depressed mental status, depressed respirations, pinpoint pupils

Organophosphate overdose may be recognized by overstimulation of secretions, bronchoconstriction, muscle weakness

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Questions?


Documents

9/18/2012 Chapter 15 Poisoning and Overdosesems.jbpub.com/henry/emt/docs/PPT_Lectures/Chapter_015.pdf · 9/18/2012 10 28 Ingested Poisons ... Sudden death from acute cardiac dysrhythmia