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Chapter 21 Poisoning and Overdoses Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 1 Case History You are dispatched to a poisoning and find a 5-year-old girl who is suspected of having ingested a large quantity of acetaminophen (Tylenol) tablets. The mother shows you an empty bottle, but the child appears perfectly normal and has normal vital signs. The child is alert and oriented. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2 Introduction Poison A substance that usually kills, injures, or impairs an organism through its chemical action Overdose Drugs, taken in excess or in combination with other agents, to the point where poisoning occurs Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3 Incidence More than 5 million poisonings occur each year in U.S. Most occur in children <5 years of age. Poisonings cause more than 10,000 deaths. Other causes Drug abuse Suicide Animal or insect bites Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4 Poison Control Centers Provide access to experts in toxicology. Staffed 24 hours a day. Coordinate emergency response Provide advice to patients at home Refer people to area hospitals with poisoning care capabilities Advise EMTs, physicians, and nurses Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5 Types of Poisonings Ingested Injected Inhaled Absorbed Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6 Cardinal Rules Treat the patient, not poison. Protect self and bystanders. Look for clues of trauma. Maintain a high level of suspicion. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7 Scene Size-up Survey the scene to protect yourself and bystanders. Dangers Toxic gases Absorbed toxins Do not enter without adequate protection. Only trained hazmat rescuers should enter. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8 Initial Assessment What is your general impression? Findings indicate any trauma? Is the patient awake and responsive? Airway, Breathing, Circulation Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9 Focused History What is the poison? How was it taken? Was it ingested, inhaled, absorbed, or injected? When was it taken? How much was taken? Over what period of time? Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10 Focused History Is there any other evidence at the scene (e.g., commercial products, pills)? Were any other interventions attempted? Vomiting Dilution Activated charcoal Syrup of ipecac Antidote How much does the patient weigh? Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11 Perform a Focused Physical Examination Skin Pupils Breath sounds Abdomen Mental status Vital signs Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12 Emergency Medical Care Remove patient from poisonous environment. Ensure patent airway and administer oxygen. Be alert for vomiting. Bring all poison agents to hospital. Containers Bottles Labels Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13 Ingested Poisons – Signs and Symptoms History of ingestion Nausea Vomiting Diarrhea Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14 Ingested Poisons – Signs and Symptoms Altered mental status Abdominal pain Chemical burns around the mouth Different breath odors Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15 Odors Smell Possible Poison Acetone (sweet, fruity) Ethanol, isopropyl alcohol, diabetic Alcohol Alcohol, isopropyl alcohol Disinfectants Creosol and phenol Rotten eggs Hydrogen sulfide Garlic Insecticides Stale tobacco Nicotine Wintergreen Methyl salicylate Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16 Emergency Medical Care Remove poison from patient’s mouth using gloves. Consult medical direction. Activated charcoal Bring all containers (bottles, labels, etc.,) to hospital. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17 Types of Ingestions Sedative-hypnotics Antianxiety agents Opioids Psychiatric medications Stimulants Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18 Types of Ingestions – Sedative-Hypnotics Barbiturates Secobarbital (Seconal) Pentobarbital (Nembutal) Benzodiazepines Diazepam (Valium) Chlordiazepoxide (Librium) Chlorazepate (Tranxene) Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19 Types of Ingestions – Sedative-Hypnotics Others Methaqualone (Quaalude) Ethchlorvynol (Placidyl) Chloral hydrate (Noctec) Mebrobamate (Miltown) Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20 Toxic Effects – Sedative-Hypnotics Altered mental status Respiratory depression and arrest Most toxic when combined with alcohol Support of ABCs is critical. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21 Types of Ingestions Opioids (Narcotics) Central nervous system depressant Examples • Heroin • Morphine • Percocet • Percodan Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22 Toxic Effects/Management – Opioids (Narcotics) Toxic effects and signs and symptoms Altered (depressed) mental status Respiratory depression Pinpoint pupils Track marks Management Support ABCs Administration of naloxone (Narcan) by ALS providers or hospital Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23 Ingested Substances Stimulants Cause increased excitability (e.g., amphetamines) Alcohol Heart and lung drugs Analgesics Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24 Inhaled Poisons – Signs and Symptoms History of inhalation of toxic substance Dizziness Headache Difficulty breathing Chest pain Confusion Cough Seizures Hoarseness Altered mental status Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25 Poisonous Gases Simple asphyxiants Carbon dioxide Small hydrocarbon molecules Chemical asphyxiants Irritant gases Organophosphates Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26 Toxic Injection – Signs and Symptoms Weakness Dizziness Chills Fever Nausea Vomiting Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27 Absorbed Poisons – Signs and Symptoms History of exposure Liquid or powder on patient’s skin Burns Itching Irritation Redness Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28 Emergency Medical Care Skin Powder Remove contaminated clothing. Protect self from contamination. Brush powder off patient. Irrigate for at least 20 minutes. Continue en route to facility, if possible . Liquid Irrigate for at least 20 minutes. Continue en route to facility, if possible. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29 Medication Name Generic Activated charcoal Trade SuperChar™ InstaChar™ Actidose™ LiquiChar™ Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30 Activated Charcoal Indications Poisoning by mouth Contraindications Altered mental status Ingestion of acids or alkalis Inability to swallow Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31 Medication Form Medication is pre-mixed in water. Plastic bottle containing 125 grams activated charcoal Powder should be avoided in field. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32 Dosage Adults and children Usual adult dose 1 gram activated charcoal/kg of body weight 25 - 50 grams Usual infant/child dose 12.5 - 25 grams Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33 Actions Charcoal binds to certain poisons. Binding action prevents absorption. Not all brands are the same. Some bind much more poison Consult medical direction about the brand to use. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34 Side Effects Black stool Some patients may vomit. If the patient vomits, repeat dose one time. Reassessment strategies Prepare for vomiting and deterioration of patient’s condition. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35
