POISONING/OVERDOSE

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INTRODUCTION  

Optimal patient care requires that the EMT-I understand the possible signs and symptoms and field management of poisonings and overdoses.  The following topics will be discussed during this lesson:

 

·        Common routes of toxic exposure

 

·        General assessment principles for the toxic exposure/drug overdose victim

 

·        General field management of the conscious and unconscious overdose patient

 

·        Signs and symptoms of specific toxic exposures

 

·        Contraindication to vomiting

 

·        Transport decisions for the toxic exposure/drug overdose patient

 

 

LESSON OBJECTIVES

At the end of this lesson the participants will be able to:

 

1.         Name 4 common routes that drugs/poisons enter the body.

 

2.         Discuss general assessment principles relative to the toxic exposure/drug overdose victim.

 

3.         Verbalize the field management principles for the conscious toxic exposure/drug overdose victim.

 

4.         Discuss the field management of the unconscious toxic exposure/drug overdose victim.

 

5.         State the signs/symptoms and field management for specific toxic exposures/overdoses.

 

6.         Understand the contraindication for inducing vomiting.

 

7.         Discuss transport decisions for the toxic exposure/drug overdose patient.

 

 

SKILLS

None

 

 

KEY VOCABULARY

The following terms will be used during this lesson:

 

·        Antidote - a substance that neutralizes a poison or the effects of a poison

 

·        Ingestion - the entrance of a substance into the body by the gastrointestinal route

 

·        Inhalation - the entrance of substances into the body by the respiratory system

 

·        Injection - the entrance of a substance into the body by a break in the skin

 

·        Overdose - a dose of a drug in excess of that usually prescribed - may be intentional or unintentional

 

·        Poisoning - adverse effects of plants, food, chemicals, or pharmaceutical agents on the body

 

·        Toxicology - the study of poisons

 

KEY CONCEPTS 

The following section provides information and space for taking notes on the key concepts discussed by the instructor.

 

 

COMMON ROUTES OF TOXIC EXPOSURE

Ingestion

·        Household products

·        Cosmetics

·        Petroleum based products

·        Cleaning agents

·        Medications

·        Plants

·        Foods

 

 

Inhalation

·        Carbon Monoxide

·        Smoke

·        Toxic fumes

·        Cleaning fluids and household sprays

·        Nitrous oxide

·        Tear gas

·        Pepper spray

Injection

·        Venom

·        Medications

·        Marine animal bites

·        Spider bites

 

Absorption

·        Insecticides

·        Plants

·        Medications

·        Household products

 

 

SPECIFIC EXPOSURES/OVERDOSES

Narcotic Overdose

Routes of toxic exposure:

·        Ingestion (Lomotil, Methodone, Percodan, Codeine, Darvon)

·        Injected (Morphine, Heroin, Demerol)

 

Signs and symptoms:

·        Altered LOC

·        Pupil constriction

·        Respiratory depression

·        Hypotension

·        Nausea/vomiting

 

Specific Field Treatment

·        Narcan (ALS Procedure)

 

Depressant Overdose

Routes:

·        Ingestion (barbiturates, sedatives, tricyclics, alcohol,                  benzodiazapines)

·        Injection (narcotics, sedatives)

 

Signs and symptoms

·        Altered LOC

·        Respiratory depression

·        Loss of motor coordination

·        Slurred speech

·        Bradycardia

·        Hypotension

 

Specific Field Treatment

·        Narcan (ALS Procedure) for suspected narcotic overdose

·        Sodium Bicarbonate (ALS Procedure) for suspected tricyclic      overdose

 

 

Stimulant/Hallucinogen/Euphoric Agents Overdose

Routes:

·        Inhalation (cocaine, marijuana)

·        Ingestion (LSD, PCP)

·        Injection (cocaine, amphetamines)

 

 

Signs and symptoms

·        Euphoria

·        Dry mouth

·        Exhilaration

·        Nystagmus

·        Hot flashes

·        Hyperactivity

·        Twitching and seizures

·        Hypertension

·        Tachycardia

·        Dysrhythmias

·        Dilated pupils

·        Hallucinations

·        Aggression and increased strength

 

 

Specific Field Treatment:

·        Protect yourself and the patient

·        Calm environment

·        Position of Comfort

·        Restraint use may be necessary

 

 

Organophosphates (pesticides) Exposure

Routes

·        Absorption (usually accidental while spraying)

·        Ingestion (usually intentional)

·        Inhalation (may be accidental or intentional)

 

Signs and Symptoms:

 (SLUDGE) --massive parasympathetic response

·        Salivation

·        Lacrimation (tearing)

·        Urination

·        Diarrhea

·        Gastrointestinal distress

·        Emesis

·        Bradycardia (from parasympathetic response)

·        Tachycardia (if nicotinic receptors are stimulated)

·        Seizures

 

Specific Field Treatment:

·        Atropine (ALS Procedure)

·        Valium (ALS Procedure) for active tonic/clonic seizures

 

Methanol (automotive products and cooking fuel)

Routes:

·        Ingestion (often ingested by alcoholics trying to get                      intoxicated)

 

Signs and symptoms

·        Abdominal pain

·        Nausea/vomiting

·        Inebriation

·        Tachypnea

·        Blindness (as little as 4ml.)

·        Death (as little as 10ml.)

 

Specific Field Treatment:

·        Sodium Bicarb. (ALS Procedure) may be ordered for lactic acidosis

 

Ethylene glycol (polishes, paint, coolant, and antifreeze)

Routes:

·        Ingestion

·        Inhalation (“huffing” and “snorting”)

 

Signs and Symptoms:

·        Often odorless

·        Abdominal pain/Nausea/vomiting

·        Signs of intoxication

·        Tachypnea/Hypernea/Coma

·        Renal damage or lung damage

 

Specific Field Treatment:

·        Sodium Bicarb. (ALS Procedure) may be ordered for lactic        acidosis

 

Hydrocarbons (Petroleum products)

Routes:

·        Ingestion

·        Inhalation

 

Signs and symptoms

·        Coughing

·        Choking

 

Specific Field Treatment:

·        Do not induce vomiting

·        Fowlers position

 

Toxic Inhalation

Routes:

·        Inhalation (Smoke, Chlorine, CO2, Ammonia, Sulfur                 Dioxide)

 

Signs and Symptoms:

·        Dyspnea/tachypnea

·        Coughing

·        Hoarseness

·        Stridor

·        Chest pain/Tightness

·        Wheezing/Rales

·        Nausea/Vomiting

·        Altered LOC

 

Specific Field Treatment:

·        Albuterol for wheezing (ALS procedure)

·        High fowlers position (usually)

 

Carbon Monoxide (odorless, tasteless gas)

Routes:

·        Inhalation

 

Signs and symptoms:

·        Headache/Nausea/Vomiting

·        Confusion to coma

·        Tachypnea/Flushed skin

Specific Field Treatment

·        High Flow O2 (the CO molecule has a high affinity for                hemoglobin and binds more readily than O2)

·        Patients are often transported to hyperbaric chambers

 

Ammonia

Routes:

·        Inhalation

 

Signs and symptoms:

·        Coughing

·        Choking

·        Respiratory collapse

·        Eye irritation

·        Nausea, vomiting, and abdominal pain

·        Seizures

 

Specific Field Treatment:

·        Seizure precautions

 

Caustic Substances (acids and alkalis)

Routes:

·        Ingestion

 

Signs and symptoms:

·        Oral burning

·        Drooling

 

 

Specific Field Treatment:

·        Do NOT induce vomiting

 

Poisonous Plants

Routes:

·        Ingestion (small children)

·        Injection

 

Signs and symptoms (vary with type of plant):

·        Pain

·        Swelling

·        Itching

·        Abdominal cramps, nausea, diarrhea

·        Excess salivation/drooling

 

 

Specific Field Treatment:

·        Bring the plant (leaf, stem, and flower if able)

·        Treat the symptoms

 

Phenothiazines

Routes:

·        Ingestion (Haldol, Compazine)

·        Injection ( Compazine, Thorazine)

·        Absorption

 

Signs and symptoms:

·        Extrapyramidal effects (Dystonic reaction)

·        Eye deviation

·        Head deviation

·        Difficulty speaking (thick tongue)

·        Involuntary leg and/or arm twitching

·        This is not a seizure and not necessarily an overdose

 

Specific Field Treatment:

·        Benadryl IV (ALS Procedure)

 

CONTRAINDICATIONS FOR VOMITING

Coma (agents that may reduce LOC)

·        Sedatives (Seconal, Xanax, Dalmane, Halcion)

·        Tricyclics (Elavil, Tofranil, Triavil)

·        Benzodizapines (Valium, Librium, Ativan)

·        Alcohol

·        Narcotics (Demerol, Morphine, Codeine)

Convulsions

·        Tricyclics (Elavil, Triavil, Tofranil)

·        Salicylates (Excedrin, Bayer, Bufferin, Aspirin)

·        Sedatives (Seconal, Xanax, Dalmane, Halcion)

·        Cocaine (Crack, Rock)

 

Caustic Substances

·        Acids (Hydrochloric acid)

·        Alkalis (Lye)

 

Hydrocarbons

·        Petroleum products

 

 

 

INITIAL ASSESSMENT AND FOCUSED HISTORY AND DETAILED PHYSICAL EXAMINATION  OF THE TOXIC EXPOSURE/OVERDOSE PATIENT

 

Initial Assessment

1).  Assess environment:  (may need to manipulate the environment)

·        Safety of rescuers and environment

  • Environmental factors
    • Patient location (home, street, convalescent, etc.)
    • Medications (may offer clues to past medical history)
    • Witnesses (may help to explain circumstances)
  • Protect the victim from further exposure
  • Remove clothing if it is a source of contaminant

 

2).  Airway :  determine responsiveness and patency of airway

·        Is it open?

·        Patients may be altered or unconscious and unable to protect     or maintain their airway

 

3).  Breathing:

·        Assess for rate, rhythm and tidal volume

 

4).  Circulation:

·        Palpate for pulse noting: rate/rhythm/quality

·        Tachydysrhythmias may indicate stimulant overdose

·        Bradydysrthymias may indicate organophosphates

·        Assess capillary refill

 

5). Skin signs:  assess color, temperature and moisture

·        Check for areas of chemical burning or irritation

·        Skin color may indicate the type of exposure (flushing may

Indicate anticholinergic substances, cyanosis indicates lack of oxygen)
 
 

 

 

 

 

 

 


6).  Assess Neurological Status:

·        Assess level of consciousness (Glasgow Coma Scale), and neuro       deficits

·        Many toxic substances will cause altered mental status.

·        Remember to rule out all possible causes of altered mental status      (AEIOUTIPS)

 

7).  Determine chief complaint:

 

 

 

GOLDEN RULE: 

Bring all containers to the hospital with the patient, if possible.

 

 

Focused History and Detailed Physical Examination

 

1).  Elicit history of chief complaint or problem (PQRST)

  • P   provoking factor- “What were you doing?”
  • Q   Quality- “How do you feel?”
  • R   Region- “Where does it hurt?”

                  Radiation- “Does the pain go anywhere else?”

                  Reoccurrence-“Has this happened before?”

  • S   Severity- “How bad is the pain?”
  • T   Time- “When did it start?”
 
 

 

 

 

 

 

 

 

 

 

 

2).  Elicit personal history (HAM)

  • H   medical history/under a doctors care
  • A   allergies/age
  • M   medications-current over the counter and prescription                                              

 
 
 

 

 

 

 

 

 

 


3). Vital Signs:

·        Blood Pressure—may be normal or low

·        Pulse—rate and quality (pulses present and equal in all extremities)

o       Toxins may cause dysrhythmias

o       Rate may be fast, slow, or absent

o       Quality may be normal, pounding, weak, thready

·        Heart rhythm (dysrhythmias may be an indication of poor perfusion or a result of poor perfusion)

·        Respirations—rate, depth, tidal volume, and lung sounds

(present, absent, or abnormal)

o       Many toxins affect the respiratory center

o       Rate may be fast, slow or absent

o       Tidal volume may be normal, shallow, or deep

o       Lung sounds may have wheezes, rales, or rhonchi

·        Pupils—pupillary size and reaction to light

 

 

4).  Special Questions:

·        Type of exposure?

·        Time of exposure?

·        Number of people exposed?

·        Quantity of substance exposed to?

·        Any vomiting?

·        Any “home remedies” attempted (ie. milk, ipecac, etc.)?

·        Is this a suicide attempt?

 

 

5).  Pertinent Body Check:

  • Medical or minor trauma—perform body check pertinent to chief complaint

 
 
 

 

 

 

 

 


Head to Toe Examination:

·        General appearance:  pallor, cyanosis, obese, wasting, flushed,   visible trauma

·        CNS: agitated, hallucinating, withdrawn, seizures, headache,        dizziness

·        Pupils:  dilation and constriction are common with various poisons

·        Eyes: nystagmus, blurring, and impaired vision are common with various poisons

·        Skin irritation:  may be from exposure or allergy

·        Tracts or puncture wounds may indicate envenomation or injection

·        Medic alert tags may indicate pertinent past medical history

 

GENERALIZED FIELD MANAGEMENT OF TOXIC EXPOSURES/OVERDOSE

 

Conscious patients

BLS procedures:

·        Ensure scene safety and remove the victim

·        Maintain airway

·        Flush to remove surface toxins if applicable

·        Position of comfort or shock position if hypotensive

·        Monitor vital signs, airway, and LOC, high flow O2 by mask

 

 

ALS procedures

·        Advanced airway management prn

·        Venous access (large bore if hypotensive)

·        Monitor

·        Fluid challenge if hypotensive

·        Contact poison control

·        Transport (Bring containers)

·        Activated charcoal

·        Albuterol if wheezing

 

Unconscious Patients

BLS procedures

·        Ensure scene safety and remove the victim

·        Maintain airway (suction available for vomiting)

·        Left lateral position

·        Flush to remove surface contaminants if applicable

·        Shock position if hypotensive

·        High flow oxygen by mask

·        Evaluate for other causes (AEIOUTIPS)

·        Assist with ALS procedures

 

ALS procedures

·        Advanced airway prn

·        Venous access

·        Glucometer

·        Monitor

·        Fluid challenge if hypotensive

·        Narcan

·        Dextrose if Glucometer <80

·        Specific medications for toxic substances

·        Contact poison control/Transport (Bring containers)

 

 

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