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Toxicology
MADISON COUNTY EMD
ANDREW SCORDATO EMT-P
Toxic Exposure
 10% of ED visits and EMS responses involve toxic
exposures.
 70% of accidental poisonings occur in children under 6
years old.
 Drug Abuse

In 2010 22.6 million

4.6 million ED visits 46% involved abuse
o
Mortality-100,000- 1 in 4
o
Cost ½ trillion dollars
o
Common Rx’s=Alcohol, Stimulants, Hallucinogens, Prescription
medications
Routes of Exposure
 Inhalation
 Example-Huffing-paint, gasoline, nitrous oxide, Carbon
monoxide, ammonia, chlorine, Tear gas, Freon, methyl
chloride, Carbon tetrachloride

A&P- Capillary exchange

Assessment-Evaluate the scene and respiratory, CNS, cardiac
systems

Management-Safety, Remove Pt. from environment, Poison
Control
Routes
 Ingestion

Examples-prescription medications, Household/Cleaning agents ,
Petroleum-based agents, Cosmetics, plants, or foods

A&P- absorption in stomach and small intestine

AssessmentWhat, When and How much?
 Did you drink any alcohol?
 Have you attempted to treat yourself?
 Have you been under psychiatric care? Why?
 Weight
 Physical exam


Management-ABC use AEIOUTIPS
Routes
 Surface Absorption
 Examples-Poison ivy, Organophosphates, drug
patches=fentanyl, nitro

A&P-Drug and patient dependent

Assessment-Respiratory, Neurologic

Management-Safety, Removal of drug
Routes
 Injection
 Examples-IV drug abuse-Heroin/Steroid users

A&P-Intravenous VS. Intramuscular

Assessment-Physical findings- Sites?

Management-ABC treat with Antidote if possible

Watch for anaphylactic reactions
Poison Control Centers
 Provide detailed information
 24hr staffed
 Id pills and toxicity
 Effects
Toxidromes
 Similar toxins typically have similar signs and
symptoms.

In some cases it may be difficult to identify a specific toxin.
 Types
 Anticholinergic
 Cholinergic
 Hallucinogenic
 Opiate/Narcotic
 Sedative/Hypnotic
 Sympathomimetic
Anticholinergic
 Signs and Symptoms
 Delirium, Flushed Skin, Dilated Pupils, Urinary Retention,
Decreased Bowel Sounds, Memory Loss, SZR, Hyperthermia,
HTN, Tachycardia
 Causes
 Antihistamines
 Scopolamine
 Jimson Weed
 Angel Trumpet
 Benztropine
 CyclicAntidepressants
 Atropine
 “Hot as a Hare, Dry as a Bone, Red as a Beet, Blind
as a Bat”
Cholinergic
 Signs and Symptoms
 Confusion, Weakness, Salivation, Lacrimation, Defecation,
Emesis, Diaphoresis, Muscle Fasciculations , Miosis , SZR,
Bradycardia, Hypothermia, Tachypnea
 Causes
 Organophosphates
 Carbamates
 Mushrooms
 SLUDGE MM
Hallucinogenic
 Signs and Symptoms
 Disorientation, Hallucinations, Visual Illusions, Panic
Reaction, Moist Skin, Hyperactive Bowel Sounds, SZR,
Tachycardia, Tachypnea, HTN
 Causes
 Amphetamines
 Cannabinoids
 Cocaine
 Phencyclidine (PCP)
Sedative/Hypnotic
 Signs and Symptoms
 Coma, Stupor, Confusion, Sedation, Progressive Deterioration
of CNS Function, Apnea
 Causes
 Barbiturates
 Benzodiazepines
 Ethanol
 Anticonvulsants
Opiate/Narcotic
 Signs and Symptoms
 Altered Mental Status, Unresponsiveness, Miosis, Shock,
Shallow & Slow Respiratory Rate, Bradycardia, Hypothermia,
Hypotension
 Causes
 Opiates
 Propoxyphene
 Dextromethorphan
Sympathomimetic
 Signs and Symptoms

Delusions, Paranoia, Diaphoresis, Piloerection, Mydriasis,
Hyperreflexia, SZR, Anxiety , Tachycardia, Bradycardia (if pure
alpha agonist)HTN
 Causes








Cocaine
Amphetamines
Methamphetamine
Phenylpropanolamine
Ephedrine
Pseudoephedrine
Albuterol
Ma huang
Inhaled Toxins
 Carbon Monoxide

Inhaled colorless, odorless gas
Poorly ventilated heating systems
 Confined spaces


Signs and Symptoms
Headache
 N&V
 altered mental status
 Tachypnea


Management
Prev. discussed
 Initiate supportive measures.
 High-flow, high-concentration oxygen
 Hyperbaric therapy

Inhaled
 Hydrocarbons
 Compounds of Carbon and Hydrogen


May be ingested, inhaled, or adsorbed
Signs and Symptoms
Burns due to local contact
 Wheezing, dyspnea, hypoxia, pneumonitis
 Headache, dizziness, slurred speech, ataxia, ALOC, cardiac
dysrhythmias
 Foot and wrist drop with numbness and tingling


Management

Standard emergency procedures
Ingested toxins
 Alcohol
 Physiologic Effects
CNS depressant
 Alcoholism
 Susceptible to methanol or ethylene glycol ingestion
 Peripheral vasodilation, diuresis


General Alcoholic Profile
Drinks early in the day, alone, or secretly
 Binges, blackouts, GI problems, “green tongue syndrome,” chronic
flushing of face and palms
 Cigarette burns, tremulousness, and odor of alcohol

Ingested
 Alcohol cont
 Chronic Alcohol Ingestion
Poor nutrition
 Alcohol hepatitis
 Liver cirrhosis, pancreatitis
 Sensory loss in hands/feet
 Loss of balance and coordination
 Upper GI hemorrhage
 Hypoglycemia
 Falls (fractures and subdural hematoma)

Ingested
 Withdrawal
 Delirium Tremens (DTs)- “Shaking Frenzy”
 Signs and Symptoms
Tremor of hands, tongue, eyelids
 N&V, general weakness, anxiety
 Tachycardia, sweating, hypertension, hallucinations, irritability or
depressed mood, poor sleep
 Increased sympathetic tone, orthostatic hypotension


TX
ABC/O2,IV,EKG.
 Determine if other drugs are involved.
 Consider medications.
 25g D50W if hypoglycemic
 100mg thiamine IV or IM
 Benzos for DT’s

Ingested
 Medications
 Commonly due to dosage errors
 Example-Beta Blocker overdose
Signs and Symptoms
 Nausea, vomiting, headache, dizziness, confusion
 Profound hypotension, cardiac dysrhythmias
 Bronchospasm, pulmonary edema
 Management
 Standard procedure
 BB/TCA-Sodium , Calcium, Glucagon

Surface absorbed poisons
 Caustic Substances


Typically occurs by ingestion or surface absorption.
Acids
Cause significant damage at sites of exposure.
 Are rapidly absorbed into the bloodstream.


Alkalis


Slower onset of symptoms allows for longer contact and more
extensive tissue damage
Signs and Symptoms
Facial burns
 Pain in the lips, tongue, throat, or gums
 Drooling, trouble swallowing
 Hoarseness, stridor, or shortness of breath
 Shock


Manage-Airway
Surface
 Example
 Hydrofluoric Acid


Toxic; used to clean and etch glass.
Signs and Symptoms
Burning at site of contact.
 Confusion, palpitations, muscle cramps.


Management
standard toxicologic emergency procedures.
 Irrigate and immerse the affected area.

Specific Drugs
AND DRUG ABUSE
Definitions
 Drug abuse-nontherapeutic
 Overdose-in excess
 Addiction-overwhelming need
 Tolerance-larger doses
 Withdrawal-psychological/physical effects
Why?
 Pleasurable
 Social Anxiety
 Performance enhancing
 Curiosity
Specific Drugs
 Hallucinogens
 Mind altering/CNS
 Common agents-LSD, PCP, Mescaline
 Example-Jimson Weed
Anticholinergic effects
 Atropine
 Effects 24-48 hours
 Assessment-Hallucinations, Hyperthermia, Photophobia
 Tx-ABC, Rapid transport, beware of Seizures and Violent Behavior

Specific
 Sympathomimetic
 Examples-Cocaine, Bath Salts, Khat, AlphaPVP and Gravel

IPOD cleaner

Effects-extreme sympathetic arousal

Assessment-Cocaine=Chest pain/Bath Salts=Delusions,
Paranoia/Khat=Anxious-----Excited Delirium?

Treatment-Safety, Sedation?, Calm
Bath Salts Video
 http://www.youtube.com/watch?v=bKbTbRqXVFg
Specific
 Amphetamines
 Example-Crystal Meth,

Contains- Ephedrine/Pseudoephedrine

Assessment-rapid speech, violence and paranoia, Meth mouth

Treatment-ABC, treat signs and Symptoms-----Excited
Delirium
Methamphetamine
Specific
 Cannabis compounds
 Example- K2 and SPICE

“Ear Wax”

More potent hard to control dosages

Assessment-Loss of Control, Decreased pain response,
delusions

Treatment-Safety, Supportive
Brands
“Ear Wax”
Specific
 Club/Rave Drugs
 Examples-Ecstasy, Roofies (rohypnol)
 Effects-Ecstasy=Reduces inhibitions and eliminates
anxiety/Roofies=Relaxation and drowsiness, Dangerous when
consumed with alcohol (Date Rape Drug)
 Assessment-Ecstasy=Constant motion, Excessive
talking/Roofies=If mixed with alcohol coma Decreased HR
and RR
 Treatment-Ecstasy-monitor temperature/hydration.
Roofies=SANE capable hosp.
Specific
 Prescription and OTC medications
 Examples-Robotussin, Corcidin, Krocodill, Skittles Parties

Effects-Dextromethorphan long acting anesthetic and
depressant/Krocodil=tissue necrosis/Skittles Parties=Clean
out the medicine cabinets.

Assessment-Loss of motor control(like they are intoxicated)
Seizures

Treatment-ABC- Supportive-treat signs and symptoms, PCC
Krocodil tissue damage
Prescription Antidepressants
 TCA
 Include amitriptyline, amoxapine, doxepin, nortriptyline,
imipramine, clomipramine.
 TCAs have a narrow therapeutic index.
 Assessment


Dry mouth, blurred vision, urinary retention, constipation,
Confusion, hallucinations, hyperthermia, Respiratory depression,
SZR, hypotension, cardiac dysrhythmias.
Tx
Monitor and treat cardiac dysrhythmias.
 Avoid use of flumazenil, which may precipitate seizures.

Prescription
 MAO
 Inhibit the activity of Monoamine Oxidase which breaks down
neurotransmitters like epinieprhine, seritonin, and dopamine.
 Infrequently Prescribed Antidepressant



Only if TCA or SSRI don’t work
High mortality with overdose because of drug’s action
Signs and Symptoms
Headache, Nausea, agitation, restlessness, tremor, hyperthermia
 Palpitations, severe hypertension and tachycardia
 Progresses to bradycardia, hypotension, coma, and death


Tx

Standard
Prescription
 Trazodone, Bupropion, and SSRIs
 Signs and Symptoms
 Drowsiness, tremor, nausea, vomiting, tachycardia
 Serotonin syndrome
 Triggered by increasing the dose or by adding selected drugs
 Marked by agitation, anxiety, confusion, insomnia, headache,
coma, salivation, diarrhea, abdominal cramps, “goose bumps”,
flushed skin, hyperthermia, rigidity, shivering, incoordination,
and myoclonic jerks
 Tx
 Standard
OTC
 ASA
 Common Overdose Drug
 Includes aspirin, oil of wintergreen
 Signs and Symptoms


Tachypnea, hyperthermia, confusion, lethargy, coma, cardiac
failure, and dysrhythmias, Abdominal pain, vomiting, pulmonary
edema, ARDS
Tx

Activated charcoal indicated
 Tylenol, Acetometophin
 Common OTC Antipyretic and Analgesic
ASA/Tylenol
 Tylenol cont’d
OTC
 NSAIDS
 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
 Include ibuprofen, keterolac, naproxen sodium
 Signs and Symptoms

Headache, tinnitus, nausea, vomiting, abdominal pain,
drowsiness, Dyspnea, wheezing, pulmonary edema, swelling of
extremities, rash, itching
Specific
 Plants
 Decorative Plants
Common source of accidental poisoning in children
 Signs and Symptoms
 Excessive salivation, lacrimation, diaphoresis, abdominal
cramps, nausea, vomiting, diarrhea, and altered mental status


Examples- Intentional-Salvia Divinorium aka Magic Mint,
Sally-D

Effect-Hallucinogenic, users report it is just intense as
Mescaline. Not controlled by DEA.

Assessment-Hallucinations, Delusion
Sally-D
Opiates
 Heroin
 Names-smack, skag, horse, brown, black, tar
 Origin-Heroin is an opiate drug that is synthesized from
morphine, a naturally occurring substance extracted from the
seed pod of the Asian opium poppy plant
 Action-Works on opiate receptor in the brain specifically mu,
kappa, and delta receptors in the central nervous system
 Onset-Intravenous heroin peaks in the serum in less than 1
minute while intranasal and intramuscular heroin peaks in 3
to 5 minutes
 Routes-injected, snorted/sniffed, or smoked
 Problems
Heroin's lipid solubility
 7 times more toxic than morphine when IV
 Concurrent Rx use
Heroin Effect
Poppies
Herbals
 Complimentry medicine
 Herbal-used to treat illness or disease, considered




safe
Supplements-Product used to supplement the diet,
may also contain herbs
Often used for conditions such as Arthritis,
Asthma,Diabetes
Common herbals-Ginseng, Garlic
Common supplements-Fish oil, Glucosaimine
Herbals
 What to expect
 Patient is often taking many of these Herb/Supp
 Side effect of these medication-Cardiac, Fluid loss
 Locate and take with you to Hospital
 Example-Cascara Sagrada
Used for Constipation, Indigestion
 Adverse effects-Vomiting, Dysrhythmias
 Treat for Fluid loss monitor EKG


Chondroitin
Use-joint damage
 Adverse effect-Nausea and Diarrhea can enhance the effect of
blood thinners

General Management
 Scene Size-Up
 What is the call
 Be alert to the potential for violence.


Restraints
Look for signs of hazardous material/Drugs/suspicious
material
Pill bottles
 Meth equipment


Resources

Suicidal Patients and Protective Custody
Involve law enforcement/medical direction.
Know local laws and procedures
General Management
 Primary Assessment
 ABC
 Transport decision
 Secondary
 Obtain Hx


Rapid head to toe assessment


Identify the toxin and length of exposure
Monitor vital signs closely
Hx from Family members/Poison control
General Management

Drug removal
Reduce intake/Remove the individual from the toxic environment.
 Reduce absorption of toxins in the body.
 NG tube and activated charcoal.
 Enhance elimination of the toxin
 Antidotes

Drugs for treatment





Names-naloxone, Narcan
Action-Narcotic Antagonist, competes for opiate receptors in
the brain. It also displaces narcotic molecules from receptors
IV Narcan has an onset of 1-2 minutes and a duration of 45-90
minutes.
Indications-For reversal of depression cause by the following
(MSO4, Demerol, Heroin, Dilaudid, codeine, Percodan,
Fentanyl, Methadone. Tx of coma of unknown origin
Dose and Route- 1 to 2 mg SIVP, IM, and SQ. 2mg IN
Contraindications/Precautions/Side-effect-Hypersensitivity,
Narcan should be admin cautiously to patient who are known
to be physically dependent on narcotics
Drugs
 Names- Sodium Bicarbonate, Bicarb
 Action-Alkanlinizing agent, salt that provides
bicarbonate to buffer metabolic acidosis
 Indication-TCA overdose
 Dosage and Route-1meq/kg initial followed by .5
meq/kg q 10 min IV for persistent or prolonged QRS
 Contraindications/Precaution-None in TCA
overdose, do not admin with calcium chloride.
Weight important when calculating doses
Drug
 Calcuim Chloride
 Name Action-Reverse symptoms of Calcium Channel blockers
 Indications-Calcuim Channel od, Hydrofluroic acid exposure
with cardiac arrest or Tetany(Overactive neurological reflexes,
cramping.)
 Dosage and Route-1,000mg IV, hydrofluoric 400mg iv
 Contraindications- renal-cardiac disease no arrest,
hypercalcemia,
 Precatuions/Side-effects-hypotension, watch for inflitration,
sodium bicarbonate and calcium precipitate
Drugs
 Names-GlucaGen
 Action-Glucagon has direct myocardial action and
has been investigated as an inotrope in both
ischemic and non-ischemic heart failure
 Indications-Calcium Channel Blocker and Beta
Blocker OD
 Dosage and Route-1mg IV or IM
 Contraindications-Allergies to Protein
Drugs
 Names-Romazicon
 Action-Benzo. Antagonist, inhibits action on
GABA/Benzo. Complex. Reverses sedation
 Indication-Complete and partial reversal of CNS and
respiratory depression. From the following agents
Valium , Versed, Ativan, Restoril, Ambien,
Klonopin, Xanax
 Dosage and Route-.2mg up 1.0mg
 Contraindication-TCA overdoses or people with a hx
of szr. Precaution-Causes szr.
Drugs
 Benadryl
 Names-diphenhydramine
 Actions –blocks histamine receptors
 Indications-Extrapyramidal reactions
 Dosage and route-50mg iv or IM
 Contraindications-MAO, Nursing mothers, Newborns
 Precautions/Side effects-drowiness,hypotension,palpations
use with caution in patients with Asthma
Nerve Agents
 Affect nerve impulse conduction
 Examples
 GB (sarin)
 VX
 GD (soman)
 GA (tabun)
 Organophosphates
General Characteristics
 Military

Tabun (GA), Sarin (GB), Soman (GD), VX
 Commercial

Parathion, Sevin
 Therapeutic Drugs



Antilirium®
Prostigmine ®
Mestinon ®
Normal Nerve Function
ACh
Nerve Agent Action
AChE
ACh
GB
Nerve Agents
 Absorption or inhalation
 Assessment: SLUDGE MM
 Management
 Atropine
 Pralidoxime chloride
Agent Release
 Possible cloud, puddle strange or unusual odor
 Dead or damaged plants and/or animals
 Potential targets
 Key: manifestation of common signs and symptoms
occurring rapidly among a large group of individuals
Protect yourself
 Approach from uphill.
 Maintain distance.
 Evacuate.
 Decontaminate.
 Provide appropriate medical treatment
Drugs
 Atropine
 Name
 Action-Anticholinergic
 Indication-symptomatic bradycardia or Organophosphate
poisoning/nerve agent
 Dosage and Route-.5mg up to 3 for brady iv. For poisoning
2mg q IV,IO, or IM until lungs are clear.
 Contraindications- obstructive disease of the GI tract,
neuropathy, glaucoma
 Precaution/Side effects-paradoxical bradycardia when pushed
to slowly.
Drugs
 2-pam
 Names-Pralidoxime
 Action-reactivates cholinesterase after poisoning with
anticholinesterase agents, reverse muscle paralysis
 Indications-to be used after atropine in nerve agent posioning
 Dosage and Route-600mg IM auto-injector
 Contraindications Precautions/side effects-use in caution with pregnant female
or those nursing
THE END