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Emergency Care and Transportation of the Sick and Injured, Tenth Edition
Chapter 19: Toxicology
Chapter 19
Toxicology
Unit Summary
After students complete this chapter and the related course work, they will be familiar
with the classes of compounds involved in substance abuse and poisonings, the routes by
which poisons enter the body, and the signs, symptoms, assessment, and treatment for
various poisoning emergencies.
National EMS Education Standard Competencies
Medicine
Applies fundamental knowledge to provide basic emergency care and transportation
based on assessment findings for an acutely ill patient.
Toxicology
• Recognition and management of:
• Carbon monoxide poisoning (pp 671–673)
• Nerve agent poisoning (p 685)
• How and when to contact a poison control center (p 671)
• Anatomy, physiology, pathophysiology, assessment, and management of:
• Inhaled poisons (pp 671–673)
• Ingested poisons (pp 674–675)
• Injected poisons (pp 675–676)
• Absorbed poisons (pp 673–674)
• Alcohol intoxication and withdrawal (pp 680–681)
Knowledge Objectives
1. Define toxicology, poison, and overdose. (p 669)
2. Describe how poisons enter the body. (pp 670–676)
3. Identify the common signs and symptoms of poisoning. (pp 669–670)
4. Describe the assessment and treatment of the patient with suspected poisoning.
(pp 676–689)
5. Describe the assessment and treatment of the patient with a possible overdose. (pp
669–670, 676–689)
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6. Explain the use of activated charcoal, including indications, contraindications, and
the need to obtain approval from medical control before administering it. (pp
674–675, 678–679)
7. Identify the main types of specific poisons and their effects, including alcohol,
opioids, sedative-hypnotic drugs, inhalants, sympathomimetics, marijuana,
hallucinogens, anticholinergic agents, and cholinergic agents. (pp 679–686)
8. Describe the assessment and treatment for the patient with suspected food
poisoning. (pp 686–687)
9. Describe the assessment and treatment for the patient with suspected plant
poisoning. (pp 687–689)
10. Understand the role of airway management in the patient suffering from
poisoning or overdose. (p 677)
11. Discuss the use of activated charcoal. (pp 674–675, 678–679)
Skills Objectives
1. Demonstrate the steps in the assessment and treatment of the patient with
suspected poisoning. (pp 676–679)
2. Demonstrate the steps in the assessment and treatment of the patient with
suspected overdose. (pp 678–679)
3. Demonstrate the steps required to administer activated charcoal. (pp 674–675,
678–679)
Readings and Preparation
Review all instructional materials including Emergency Care and Transportation of the
Sick and Injured, Tenth Edition, Chapter 19, and all related presentation support
materials.
• Review local EMT treatment protocols for the emergency care of patients with
poisoning and overdose. In particular, review local protocols for activated charcoal
administration.
Support Materials
•
Lecture PowerPoint presentation
•
Case Study PowerPoint presentation
•
Examples of various forms of unit doses of activated charcoal
Enhancements
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• Direct students to visit the companion website to the Tenth Edition at
www.emt.emszone.com for online activities.
• Contact a representative from the closest regional poison control center to provide
literature and speak to the class about the services the center provides.
• Contact one or more of the following:
• A representative of a health clinic for the homeless, if there are any locally
• A narcotics officer from the local police department
• A drug and alcohol counselor
These individuals can provide very current information on local “drugs of choice” and
signs and symptoms.
• Content connections: Refer to the sections on BLS—suctioning and airway—and
reference how mastery of the skills learned in these sections will be used in the treatment
of toxicology patients. Students can apply the techniques they will learn in the next
chapter, “Psychiatric Emergencies,” for managing patients who become difficult or
combative.
• Cultural considerations: Drug and alcohol abuse among teenagers is one of the most
common problems in society today. Teens are encouraged to experiment through peer
pressure. Remind students that when talking to adolescents about substance abuse, they
should show concern for privacy and never use a judgmental tone.
Teaching Tips
• Review and present to students pertinent local protocols regarding activated charcoal
administration, direct contact of poison control centers by EMTs, and any specific
destination protocols.
• Contact the local emergency department, police department, or drug and alcohol center
to obtain information on current illicit drugs “making the rounds.”
• Although there is no specific skill drill, be sure your students are able to verbalize the
steps in the administration of activated charcoal.
Unit Activities
Writing assignments: Assign each student the name of a specific street drug to research
and write a short essay about, including the category of the drug, the common effects, etc.
Group activities: Create a “game show,” such as Jeopardy, using questions and answers
pertinent to the chapter. Divide the class into two teams for a friendly competition.
Medical terminology review: Create flash cards with pertinent terminology. Divide the
class into groups of three or four and have the students quiz each other using the flash
cards.
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Visual thinking: Create blank charts titled “opioids,” “sedative-hypnotic drugs,” etc.
Write the names of specific drugs on strips of paper turned facedown, and mix them up.
Have each student choose a strip of paper and attach it to the appropriately titled chart.
Pre-Lecture
You are the Provider
“You are the Provider” is a progressive case study that encourages critical thinking skills.
Instructor Directions
1. Direct students to read the “You are the Provider” scenario found throughout
Chapter 19.
2. You may wish to assign students to a partner or a group. Direct them to review
the discussion questions at the end of the scenario and prepare a response to each
question. Facilitate a class dialogue centered on the discussion questions and the
Patient Care Report.
3. You may also use this as an individual activity and ask students to turn in their
comments on a separate piece of paper.
Lecture
I. Introduction
A. Each day, we come into contact with things that are potentially poisonous.
1. Almost any substance may be a poison in certain circumstances.
2. Different doses can turn even a remedy into a poison.
a. Aspirin is an example.
B. Acute poisoning affects 5 million children and adults each year.
C. Chronic poisoning is much more common.
D. Deaths caused by poisoning are fairly rare.
1. Rates of death as the result of poisoning in children have decreased steadily since
the 1960s due to safety caps.
2. Deaths caused by poisoning in adults have been rising.
a. Result of drug abuse
II. Identifying the Patient and the Poison
A. Toxicology is the study of toxic or poisonous substances.
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1. A poison is any substance whose chemical action can damage body structures or
impair body function.
a. Poisons act by changing the normal metabolism of cells or by actually destroying
them.
b. Poisons may act acutely or chronically.
2. Substance abuse is the misuse of any substance to produce a desired effect.
a. A common complication of substance abuse is overdose, when a patient takes a toxic
dose of a drug.
B. Your primary responsibility to the patient who has been poisoned is to recognize
that a poisoning has occurred.
1. Very small amounts of some poisons can cause considerable damage or death.
2. If you suspect poisoning, notify medical control and begin emergency treatment at
once.
C. The signs and symptoms of poisoning vary according to the specific agent.
1. The presence of such injuries at the patient’s mouth strongly suggests the
ingestion (swallowing) of a poison.
2. If possible, ask the patient:
a.
b.
c.
d.
e.
What substance did you take?
When did you take it (or become exposed to it)?
How much did you ingest?
What actions have been taken?
How much do you weigh?
D. Try to determine the nature of the poison.
1. Look around the immediate area for an overturned bottle, a needle or syringe,
scattered pills, chemicals, even an overturned or damaged plant.
2. Place any suspicious material in a plastic bag and take it with you.
3. Containers at the scene can provide critical information, such as:
a.
b.
c.
d.
Name and concentration of the drug
Ingredients
Number of pills originally in the bottle
Prescribed dose
E. If the patient vomits, examine the contents for pill fragments.
1. Wear proper personal protective equipment.
2. Collect the vomitus in a plastic bag so that it can be analyzed at the hospital.
III. How Poisons Get Into the Body
A. The most important treatment you can generally perform for a poisoning is
diluting and/or physically removing the poisonous agent.
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1. Most often, you will not be administering a specific antidote because most
poisons do not have one.
2. How you provide treatment depends on how the poison got into the patient’s body
in the first place.
3. The four avenues to consider are:
a.
b.
c.
d.
Inhalation
Absorption (surface contact)
Ingestion
Injection
4. Injection can be the most worrisome in terms of treatment.
a. It is difficult to remove or dilute the poison.
5. All routes of poisoning can be deadly, and each should be thought of as being
equally serious.
6. Always contact medical control before you proceed with the treatment of any
poisoning victim.
B. Inhaled poisons
1. Move the patient into fresh air immediately.
2. The patient may require supplemental oxygen.
3. Always use a self-contained breathing apparatus to protect yourself from
poisonous fumes.
4. Some patients may need decontamination after removal from the toxic
environment.
a. The patient’s clothing should be removed in this process because it may contain
trapped gases that can be released, exposing you to the toxin.
5. All patients who have inhaled poison require immediate transport to an
emergency department.
a. Be prepared to use supplemental oxygen via a nonrebreathing mask and/or
ventilatory support with a bag-mask device, if necessary.
b. Make sure a suctioning unit is available in case the patient vomits.
6. Take containers, bottles, and labels with you when transporting the patient to the
hospital.
7. Patients sometimes attempt to commit suicide in a vehicle by leaving the engine
running in an enclosed garage.
a. The exhaust fumes contain high levels of carbon monoxide that will cause the patient
to lose consciousness and eventually stop breathing.
b. A recent variation involves using a tightly sealed vehicle as a type of “gas chamber.”
c. When you open the door, you may be overcome as well.
d. Contact hazardous materials responders and have them remove the victim.
C. Absorbed and surface contact poisons
1. These poisons can affect the patient in many ways.
a. Skin damage
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b. Chemical burns
c. Rashes or lesions
d. Systemic effects
2. It is important to distinguish between contact burns and contact absorption.
3. Signs and symptoms of absorbed poisoning include:
a.
b.
c.
d.
e.
f.
A history of exposure
Liquid or powder on a patient’s skin
Burns
Itching
Irritation
Typical odors of the substance
4. Emergency treatment for a typical contact poisoning includes the following steps:
a. Avoid contaminating yourself or others.
b. While protecting yourself, remove the substance from the patient as rapidly as
possible.
5. Remove all contaminated clothing.
6. Flush and wash the skin.
a. When a large amount of material has been spilled on a patient, flood the affected part
for at least 20 minutes.
b. If the patient has a chemical agent in the eyes, irrigate them quickly and thoroughly
for at least 5 to 10 minutes for acid substances and 15 to 20 minutes for alkalis.
i. Make sure the fluid runs from the bridge of the nose outward.
7. Many chemical burns occur in an industrial setting.
a. Do not try to neutralize substances on the skin with additional chemicals.
b. Wash the substance off immediately with plenty of water.
c. Obtain material safety data sheets.
i. Transport them with the patient to the hospital.
8. The only time you should not irrigate the contact area with water is when a patient
has been contaminated with a poison that reacts violently with water.
a. Brush the chemical off the patient, remove contaminated clothing, and apply a dry
dressing to the burn area.
b. Wear appropriate protective gloves and the proper protective clothing.
c. Provide prompt transport to the emergency department.
D. Ingested poisons
1. About 80% of poisoning is by mouth.
a.
b.
c.
d.
e.
Drugs
Liquids
Household cleaners
Contaminated food
Plants
2. Ingested poisoning is usually accidental in children and deliberate in adults.
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3. Signs and symptoms vary greatly with the:
a. Type of poison
b. Age of the patient
c. Time that has passed since the ingestion
4. Your goal is to rapidly remove as much poison as possible from the
gastrointestinal tract.
a. Further care will be provided at the emergency department.
5. In the past, syrup of ipecac was used to induce vomiting.
a. It is generally not used today because of the danger of inhaling vomitus.
6. Many EMS systems use activated charcoal.
a. Activated charcoal comes as a suspension that binds to the poison in the stomach and
carries it out of the system.
b. It is more effective and safer than syrup of ipecac.
7. You should always immediately assess the airway, breathing, and circulation
(ABCs) of every patient who has been poisoned.
E. Injected poisons
1. Poisoning by injection is usually the result of drug abuse, such as heroin or
cocaine.
a. The only other parties likely to have injected a patient with poison are insects and
animals.
2. Signs and symptoms can have a multitude of presentations, including:
a.
b.
c.
d.
e.
f.
Weakness
Dizziness
Fever
Chills
Unresponsiveness
Excitability
3. Injected poisons are impossible to dilute or remove because they are usually
absorbed quickly into the body or cause intense local tissue destruction.
4. Monitor the airway, provide high- flow oxygen, and be alert for nausea and
vomiting.
5. Prompt transport to the emergency department is essential.
a. Take all containers, bottles, and labels.
IV. Patient Assessment
A. Scene size-up
1. Scene safety
a. A well-trained dispatcher is of great value to determine:
i. Number of patients involved
ii. Whether additional resources are needed
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iii. Whether trauma is involved
b. If this information is not obtained before your arrival, you must assess the scene
thoroughly to ensure your own safety and to determine:
i. Nature of illness/mechanism of injury
ii. Number of patients involved
iii. Need for additional resources
iv. Whether spine stabilization is required
c. Use the appropriate personal protective equipment to avoid being contaminated.
2. Mechanism of injury/nature of illness
a. The dispatcher may give important information about a poisoning call.
b. If this information is not obtained before your arrival, look for clues and ask yourself
the following questions:
i. Are there medication bottles lying around the patient and the scene? If so, is there
medication missing that might indicate an overdose?
ii. Are there alcoholic beverage containers present?
iii. Are there syringes or other drug paraphernalia on the scene?
iv. Is there an unpleasant or odd odor in the room? If so, is the scene safe?
v. Is there a suspicious odor and/or drug paraphernalia present that may indicate the
presence of a drug laboratory?
B. Primary assessment
1. Form a general impression.
a.
b.
c.
d.
Obtain a general impression of the patient.
Assess his or her level of consciousness.
Determine any life threats.
Do not be fooled into thinking that a conscious, alert, and orientated patient is in
stable condition.
2. Airway and breathing
a.
b.
c.
d.
Quickly ensure that the patient has an open airway and adequate ventilation.
Do not hesitate to begin oxygen therapy.
Consider inserting an airway adjunct to unresponsive patients.
Consider the potential for spinal injury.
3. Circulation
a. Assess the patient’s circulatory status.
b. You will find variations depending on the substance involved.
c. Assess the pulse and skin condition.
4. Transport decision
a. A delay on the scene to further assess and treat patients is rarely indicated.
b. Consider decontamination of the patient before transport depending on the poison the
patient was exposed to.
i. Decontamination is especially important when transporting in a helicopter.
C. History taking
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1. Investigate the chief complaint.
a. Obtain the patient’s medical history.
b. If your patient is responsive, begin with an evaluation of the exposure and the
SAMPLE history.
c. If the patient is not responsive, attempt to obtain the history from other sources:
i. Friends
ii. Family members
iii. Medical identification jewelry
iv. Cards in wallets
2. SAMPLE history
a. The SAMPLE history guides you in what to focus on as you continue to assess the
patient’s complaints.
b. In addition to the SAMPLE history, you should ask the following questions:
i. What is the substance involved?
ii. When did the patient ingest or become exposed to the substance?
iii. How much did the patient ingest or what was the level of exposure?
iv. Over what period did the patient take the substance?
v. Has the patient or a bystander performed any intervention? Has the intervention
helped?
vi. How much does the patient weigh?
D. Secondary assessment
1. The secondary assessment is a more detailed, comprehensive examination of the
patient that is used to uncover issues that may have been missed during the
primary assessment.
2. Physical examinations
a. Focus on the area of the body involved with the poisoning or the route of exposure.
b. Once the ABCs have been addressed and managed in the primary assessment,
conducting a thorough physical will provide additional information on the exposure.
c. A general review of all body systems may help to identify systemic problems.
3. Vital signs
a. Many poisons produce no outward indications of the seriousness of the exposure.
b. Alterations in the level of consciousness, pulse, respirations, blood pressure, and skin
are the more sensitive indicators that something serious is wrong.
E. Reassessment
1. Continually reassess the adequacy of the patient’s ABCs.
2. Evaluate the effectiveness of interventions you have provided.
3. Repeat the assessment of vital signs:
a. Every 15 minutes for a stable patient
b. Every 5 minutes, or constantly, for a patient who has consumed a harmful or lethal
dose
4. Interventions
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Emergency Care and Transportation of the Sick and Injured, Tenth Edition
a.
b.
c.
d.
e.
Chapter 19: Toxicology
Supporting the ABCs is your most important task.
Dilute airborne exposures with oxygen.
Remove contact exposures with copious amounts of water unless contraindicated.
Consider activated charcoal for ingested poisons.
Contact medical control or a poison center to discuss treatment options.
5. Communication and documentation
a. Report as much information as you have about the poison to the hospital.
b. If the poisoning or exposure occurred in a work setting, bring, or have the company
fax, the material data sheet to the hospital.
V. Emergency Medical Care
A. Ensure scene safety.
1. Follow standard precautions.
2. Perform external decontamination.
B. Remove tablets or fragments from the patient’s mouth.
C. Wash or brush the poison from the patient’s skin.
D. Assess and maintain the patient’s ABCs.
E. Provide oxygen and perform assisted ventilations if necessary.
F. If the patient demonstrates signs and symptoms of shock:
1.
2.
3.
4.
Place patient in the appropriate position.
Keep the patient warm.
Provide the patient with supplemental oxygen.
Transport the patient promptly to the nearest appropriate hospital.
G. If approved by medical control, give activated charcoal.
1. Activated charcoal is not indicated for patients:
a. Who have ingested an acid, an alkali, or a petroleum product
b. Who have a decreased level of consciousness and cannot protect their airway
c. Who are unable to swallow
2. Activated charcoal adsorbs, or sticks, to many commonly ingested poisons,
preventing the toxin (poison) from being absorbed into the body by the stomach
or intestines.
a. You will likely carry plastic bottles of premixed suspension, each containing up to 50
g of activated charcoal.
b. Some common trade names are Insta-Char, Actidose, and Liqui-Char.
c. The usual dose for an adult or child is 1 g of activated charcoal per kilogram of body
weight.
i. 25 to 50 g for adults
ii. 12.5 to 25 g for children
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3. Before you give a patient charcoal, obtain approval from medical control.
a. Next, shake the bottle vigorously to mix the suspension.
b. You may need to persuade the patient to drink it, but never force it.
4. The major side effect of ingesting activated charcoal is black stools.
5. If the patient has ingested a poison that causes nausea, he or she may vomit after
taking activated charcoal.
VI. Specific Poisons
A. Over time, a person who routinely misuses a substance may need increasing
amounts of it to achieve the same result.
1. This is called developing a tolerance to the substance.
2. A person with an addiction has an overwhelming desire or need to continue using
the substance, at whatever cost, with a tendency to increase the dose.
3. Almost any substances can be abused.
B. The importance of safety awareness and standard precautions in caring for
victims of drug abuse cannot be stressed enough.
1. Known drug abusers have a fairly high incidence of serious and undiagnosed
infections, including HIV and hepatitis.
a. These patients may bite, spit, hit, or otherwise injure you.
b. Always wear appropriate protective equipment.
c. Expect the unexpected, and remember, the drug user, not the drug, can pose the
greatest threat.
C. Alcohol
1. Alcohol is the most commonly abused drug in the United States.
a. It kills more than 200,000 people each year.
b. Alcoholism is one of the greatest national health problems, along with heart disease,
cancer, and stroke.
2. Alcohol abuse can result in many long-term effects.
a. The most common effect is liver damage.
i. 90% of heavy drinkers will develop some level of hepatitis.
ii. 10% to 20% of alcoholics will develop cirrhosis.
b. Other long-term effects include:
i. Increased incidence of pancreatitis
ii. Development of erosive gastritis
iii. Increased risk for breast and colorectal cancer
c. Long-term abuse leads to atrophy of the cerebrum, resulting in permanently reduced
mental function.
d. Alcohol decreases the ability to respond to sexual stimulation.
i. Long-term use can lead to impotence and sterility.
3. Alcohol is a powerful CNS depressant.
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a. It is a sedative substance that decreases activity and excitement.
b. It is also a hypnotic, which means it induces sleep.
c. In general, alcohol dulls the sense of awareness, slows reflexes, and reduces reaction
time.
d. It may also cause aggressive and inappropriate behavior and lack of coordination.
e. A person who appears intoxicated may have other medical problems as well.
i. Look for signs of head trauma, toxic reactions, or uncontrolled diabetes.
ii. Severe acute alcohol ingestion may cause hypoglycemia.
f. Assume that all intoxicated patients are experiencing a drug overdose and require a
thorough examination by a physician.
4. Alcohol potentiates many other drugs and is commonly not the only drug taken.
5. If a patient exhibits signs of serious CNS depression, you must provide
respiratory support.
a. Depression of the respiratory system can also cause emesis, or vomiting.
b. The vomiting may be very forceful or even bloody (hematemesis) because large
amounts of alcohol irritate the stomach.
c. Internal bleeding should also be considered if the patient appears to be in shock.
6. Patients in alcohol withdrawal may experience frightening hallucinations, or
delirium tremens (DTs).
a. The syndrome is characterized by:
i. Agitation and restlessness
ii. Fever
iii. Sweating
iv. Tremors
v. Confusion and/or disorientation
vi. Delusions and/or hallucinations
vii. Seizures
b. These conditions may develop if patients no longer have their daily source of alcohol.
c. Provide prompt transport.
d. Reassure the patient and provide emotional support.
D. Opioids
1. Opioids are named for the opium in poppy seeds, the origin of heroin, codeine,
and morphine.
2. Synthetic opioids include meperidine (Demerol), hydromorphone (Dilaudid), and
oxycodone hydrochloride (OxyContin).
a. Many addicts may have started using many of the opioids with an appropriate
medical prescription.
3. These agents are CNS depressants and can cause severe respiratory depression.
a. Tolerance develops quickly, so some users may require massive doses to experience
the same high.
b. These drugs often cause nausea and vomiting and may lead to the development of
hypotension.
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c. Although seizures are uncommon, they can occur.
d. Patients typically appear sedated or unconscious and cyanotic with pinpoint pupils.
i. Pinpoint pupils are the most commonly accepted sign of opiate abuse.
4. Treatment includes supporting the airway and breathing.
a. Always open the airway, give supplemental oxygen, and be prepared for vomiting.
b. Do not attempt any home remedies (eg, applying ice to the groin, forcing milk into
the mouth).
c. Be aware that someone else may have attempted inappropriate methods of
resuscitation.
d. The only effective antidote is certain narcotic antagonists such as naloxone (Narcan).
i. Patients will respond within 2 minutes when given intravenously.
ii. Naloxone is usually administered by paramedics or by physicians.
E. Sedative-hypnotic drugs
1. Barbiturates and benzodiazepines are easy to obtain and relatively cheap.
a. These drugs are CNS depressants and alter the level of consciousness, with effects
similar to those of alcohol.
i. The patient may appear drowsy, peaceful, or intoxicated.
2. In general, these agents are taken by mouth.
a. Occasionally, the capsules are suspended or dissolved in water and injected.
b. Sedative-hypnotic drugs quickly induce tolerance, so the person requires increasingly
larger doses.
3. These drugs may also be given to unsuspecting people as a “knock-out” drink, or
“Mickey Finn.”
4. Generally, your treatment is to provide airway clearance, ventilatory assistance,
and prompt transport.
5. A benzodiazepine antidote may be administered in the hospital.
a. It is called flumazenil and is given intravenously.
F. Abused inhalants
1. These agents are inhaled instead of ingested or injected.
a. Some of the more common agents include acetone, toluene, xylene, and hexane.
b. Found in glues, cleaning compound, paint thinners, and lacquers
2. Gasoline and various halogenated hydrocarbons, such as Freon, used as
propellants in aerosol sprays, are also abused as inhalants.
a. These are commonly abused by teenagers.
b. The effective dose and the lethal dose are very close, making these extremely
dangerous drugs.
3. Always use special care in dealing with a patient who may have used inhalants.
a. Halogenated hydrocarbon solvents can make the heart hypersensitive to the patient’s
own adrenaline.
b. Even the action of walking may cause a fatal ventricular arrhythmia.
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4. Use a stretcher to move the patient, give oxygen, and transport the patient to the
hospital.
G. Sympathomimetics
1. Sympathomimetics are CNS stimulants that mimic the effects of the sympathetic
(fight-or-flight) nervous system.
a. These stimulants frequently cause hypertension, tachycardia, and dilated pupils.
b. A stimulant is an agent that produces an excited state.
2. Common examples include amphetamines, methamphetamines, crack cocaine,
ecstasy, fen-phen, MDA, and speed.
a. Designer drugs, such as ecstasy and Eve, are also frequently abused in certain areas
of the United States.
3. Cocaine may be taken in a number of different ways.
a. It can be absorbed through all mucous membranes and even across the skin.
b. The immediate effects of a given dose last less than an hour.
c. Smoked crack produces the most rapid means of absorption and, therefore, the most
potent effect.
4. Cocaine is one of the most addicting substances known.
a. Its immediate effects include excitement and euphoria.
b. Acute overdose is a genuine emergency.
5. Be aware that severe agitation can lead to tachycardia and hypertension.
a. Patients may be paranoid, placing you at risk.
b. Law enforcement officers should restrain the patient if necessary.
c. Do not leave the patient unattended during transport.
6. All of these patients need prompt transport because of the risk of seizures, cardiac
arrhythmias, and stroke.
H. Marijuana
1. Marijuana is abused throughout the world.
a.
b.
c.
d.
As many as 20 million people use marijuana daily in the United Sates.
Inhaling marijuana produces euphoria, relaxation, and drowsiness.
It impairs short-term memory and the capacity to do complex thinking and work.
The euphoria could progress to depression and confusion.
2. Marijuana use rarely necessitates transport to the hospital.
a. The exception is for a patient who is hallucinating, very anxious, or paranoid.
b. Reassure the patient and transport with a minimum amount of excitement.
3. Marijuana is often used as a vehicle to get other drugs into the body.
I. Hallucinogens
1. Hallucinogens alter a person’s sensory perceptions.
a. The classic hallucinogen is lysergic acid diethylamide (LSD).
b. Abuse of PCP is relatively uncommon among young adults.
c. Phencyclidine is a dissociative anesthetic that is easily synthesized and highly potent.
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2. These agents:
a. Cause visual hallucinations
b. Intensify vision and hearing
c. Generally separate the user from reality
3. Patients experiencing a “bad trip” will be:
a.
b.
c.
d.
Hypertensive
Tachycardic
Anxious
Paranoid
4. Your care is the same as that for a patient who has taken a sympathomimetic.
a.
b.
c.
d.
e.
Use a calm, professional manner.
Provide emotional support.
Do not use restraints unless you or the patient is in danger of injury.
Watch the patient carefully throughout transport.
Provide reassurance and request ALS assistance.
J. Anticholinergic agents
1. The classic picture of a person who has taken too much of an anticholinergic
medication is “hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad
as a hatter.”
2. These are medications that have properties that block the parasympathetic nerve.
3. Common drugs include atropine, Benadryl, and Jimson weed.
a. With the exception of Jimson weed, these medications usually are not abused drugs.
4. Some tricyclic antidepressants have significant anticholinergic effects.
a. Death from these agents can be rapid—the patient can go from appearing “normal” to
seizure and death within 30 minutes.
b. Transport immediately.
c. The seizures and arrhythmias are best treated in the hospital.
K. Cholinergic agents
1. These include “nerve gases” designed for chemical warfare, insecticides, and
some types of wild mushrooms.
a. These agents overstimulate normal body functions that are controlled by the
parasympathetic nerves, resulting in:
i. Salivation
ii. Mucus secretion
iii. Urination
iv. Crying
v. An abnormal heart rate
2. The signs and symptoms of cholinergic drug poisoning are easy to remember with
the mnemonic DUMBELS:
a. Defecation
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b.
c.
d.
e.
f.
g.
Chapter 19: Toxicology
Urination
Miosis (constriction of the pupils)
Bronchorrhea (discharge of mucus from the lungs)
Emesis
Lacrimation (tearing)
Salivation
3. Alternatively, you can use the mnemonic SLUDGE:
a.
b.
c.
d.
e.
f.
Salivation
Lacrimation
Urination
Defecation
GI (gastrointestinal) irritation
Eye constriction/emesis
4. The most important consideration is to avoid exposure yourself.
a. Decontamination may take priority over immediate transport.
b. Your priorities after decontamination are to:
i. Decrease the secretions in the mouth and trachea.
ii. Provide airway support.
5. Antidote kits may be available.
a. The most common of these antidotes are the Mark I kit and the DuoDote kit.
b. Indications include a known exposure to nerve agents or organophosphates with
manifestation of signs and symptoms.
c. The kit consists of an auto-injector of atropine and one of 2-PAM chloride.
L. Miscellaneous drugs
1. Accidental or intentional overdose with cardiac medications has become common.
a.
b.
c.
d.
Children may ingest them thinking they are candy.
Signs and symptoms depend on the medication ingested.
Contacting the poison center as soon as possible is important.
It is likely you will be given an order to administer activated charcoal.
2. Aspirin poisoning remains a potentially lethal condition.
a. Ingesting too many may result in:
i. Nausea
ii. Vomiting
iii. Hyperventilation
iv. Ringing in the ears
b. Patients with this problem are frequently:
i. Anxious
ii. Confused
iii. Tachypneic
iv. Hyperthermic
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v. In danger of having seizures
3. Overdosing with acetaminophen is also very common.
a. Generally not very toxic
b. However, symptoms of an overdose generally do not appear until it is too late.
c. Gathering information at the scene is very important.
4. Be extremely careful in dealing with a child who has ingested a poisonous
substance.
5. Some alcohols, including methyl alcohol and ethylene glycol, are even more toxic
than ethyl alcohol (drinking alcohol).
a. Both will cause severe tachypnea, blindness, renal failure, and eventually death.
b. Immediate transport to the emergency department is essential.
VII. Food Poisoning
A. Food poisoning is almost always caused by eating food contaminated by
bacteria.
B. There are two main types of food poisoning.
1. The organism itself may cause disease.
2. The organism may produce toxins that cause disease.
a. A toxin is a poison or harmful substance produced by bacteria, animals, or plants.
C. One organism that produces direct effects of food poisoning is the Salmonella
bacterium.
1. Salmonellosis is characterized by severe gastrointestinal symptoms within 72
hours of ingestion, including nausea, vomiting, abdominal pain, and diarrhea.
2. Proper cooking kills bacteria, and proper cleanliness in the kitchen prevents the
contamination of uncooked foods.
D. The more common cause of food poisoning is the ingestion of powerful toxins
produced by bacteria, often in leftovers.
1.
2.
3.
4.
The bacterium Staphylococcus is quick to grow and produce toxins in food.
Foods prepared with mayonnaise, when left unrefrigerated, are a common vehicle.
Results in sudden GI symptoms, including nausea, vomiting, and diarrhea
Symptoms usually start within 2 to 3 hours after ingestion or as long as 8 to 12
hours after ingestion.
E. The most severe form of toxin ingestion is botulism.
1. Botulism can result from eating improperly canned food.
a. The spores of Clostridium bacteria grow and produce a toxin.
2. The symptoms are neurologic.
a. Blurring of vision
b. Weakness
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c. Difficulty in speaking and breathing
3. Often fatal, symptoms may develop within the first 24 hours after ingestion or as
long as 4 days later.
F. In general, you should not try to determine the specific cause of acute
gastrointestinal problems.
1. Gather as much history as possible from the patient.
2. Transport him or her promptly to the hospital.
3. When two or more persons in one group have the same illness, you should take
along some of the suspected food.
VIII. Plant Poisoning
A. There are several thousand cases of plant poisoning annually.
1. Many household plants are poisonous if ingested.
2. Some cause skin irritation.
3. Some can affect the circulatory system, the gastrointestinal tract, or the central
nervous system.
B. It is impossible to memorize every plant and poison, let alone their effects.
1. You can and should do the following:
a.
b.
c.
d.
Assess the patient’s airway and vital signs.
Notify the regional poison center for assistance in identifying the plant.
Take the plant to the emergency department.
Provide prompt transport.
C. Irritation of the skin and/or mucous membranes is a problem with the common
houseplant called dieffenbachia.
1. Emergency medical treatment includes:
a. Maintaining an open airway
b. Giving oxygen
c. Transporting the patient promptly to the hospital for respiratory support
IX. Summary
A. Poison acts acutely or chronically to destroy or impair body cells.
B. If you believe a patient may have taken a poisonous substance, you should
support the ABCs and notify medical control.
C. Management also entails collecting any evidence of the type of poison that was
used and taking it to the hospital; diluting and physically removing the
poisonous agent; providing respiratory support; and transporting the patient
promptly to the hospital.
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D. Emergency treatment may include administration of an antidote, usually at the
hospital, if an antidote exists.
E. A poison can be introduced into the body by inhalation, absorption, ingestion, or
injection.
F. It is difficult to remove or dilute injected poisons, a fact that makes these cases
especially urgent.
G. Always consult medical control before you proceed with the treatment of any
poisoning victim.
H. Move patients who have inhaled poison into the fresh air; be prepared to use
supplemental oxygen via a nonrebreathing mask and/or ventilatory support via
a bag-mask device.
I. With absorbed or surface contact poisons, be sure to avoid contaminating
yourself. You should remove all contaminated substances and clothing from the
patient, and flood the affected part.
J. Approximately 80% of all poisonings are by ingestion, including plants,
contaminated food, and most drugs. In general, activated charcoal should be
used in these patients.
K. People who abuse a substance can develop a tolerance to it or can develop an
addiction.
L. The most commonly abused drug in the United States is alcohol. It can depress
the central nervous system and can cause respiratory depression. You must
support the airway in such cases and be prepared for the patient to vomit.
M. Opioids, sedative-hypnotic drugs, and abused inhalants can also depress the
central nervous system and can cause respiratory depression.
N. Take special care with patients who have used inhalants because the drugs may
cause seizures or sudden death.
O. Sympathomimetics, including cocaine, stimulate the central nervous system,
causing hypertension, tachycardia, seizures, and dilated pupils. Patients who
have taken these drugs may be paranoid, as may patients who have taken
hallucinogens.
P. Anticholinergic medications, often taken in suicide attempts, can cause a person
to become hot, dry, blind, red-faced, and mentally unbalanced. An overdose of
tricyclic antidepressants can lead to cardiac arrhythmias.
Q. The symptoms of cholinergic medications can be remembered by using the
mnemonic DUMBELS, for excessive Defecation, Urination, Miosis,
Bronchorrhea, Emesis, Lacrimation, and Salivation; or SLUDGE, for Salivation,
Lacrimation, Urination, Defecation, Gastrointestinal irritation, and Eye
constriction/emesis.
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R. Two main types of food poisoning cause gastrointestinal symptoms. In one,
bacteria in the food directly cause disease, such as salmonellosis. In the other,
bacteria such as Staphylococcus produce powerful toxins.
S. The most severe form of toxin ingestion is botulism. The first neurologic
symptoms may appear as late as 4 days after ingestion.
T. Plant poisoning can affect the circulatory system, the gastrointestinal system,
and the central nervous system. Some plants irritate the skin or mucous
membranes and may cause obstruction of the airway.
Post-Lecture
This section contains various student-centered end-of-chapter activities designed as
enhancements to the instructor’s presentation. As time permits, these activities may be
presented in class. They are also designed to be used as homework activities.
Assessment in Action
This activity is designed to assist the student in gaining a further understanding of issues
surrounding the provision of prehospital care. The activity incorporates both critical
thinking and application of basic EMT knowledge.
Instructor Directions
1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit
at the end of Chapter 19.
2. Direct students to read and individually answer the quiz questions at the end of the
scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a
class review and dialogue of the answers, allowing students to correct responses
as may be needed. Use the quiz question answers noted below to assist in building
this review. Allow approximately 10 minutes for this part of the activity.
3. You may wish to ask students to complete the activity on their own and turn in
their answers on a separate piece of paper.
Answers to Assessment in Action Questions
1. Answer: B
Open the patient’s airway.
2. Answer: D
Alcohol
3. Answer: B
Liver damage
4. Answer: C
Oxycodone hydrochloride (OxyContin)
5. Answer: C
Pinpoint pupils
6. Answer: A
a decreased blood glucose level.
7. Answer: D
All of the above
8. Answer: A
5
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Chapter 19: Toxicology
9. Answer: It is always important to be aware of your surroundings for safety, but
you should also look around the scene for objects, substances, or situations that
could be considered clues to help you determine what is possibly wrong with the
patient and the appropriate treatment that should follow. For example, are there
any medication bottles lying around? If so, do they belong to the patient? Are all
of the pills there? Do you see any alcohol containers? Is there any drug
paraphernalia close to the patient or in the room? Are there any suspicious odors
in the room? These clues may not only prove beneficial for your patient but for
you as well in regards to safety.
10. Answer: Asking additional information regarding what type of substance(s) was
taken, how long ago it was taken, how much of the substance was taken, over
what time frame it was taken, and how much the patient weighs can help you
determine the severity of the ingestion and what actions need to be taken. Don’t
forget to ask if anything was done to help the patient because the best of
intentions may not always be best for the patient. Also, besides helping you, this
information needs to be reported to the emergency department to further guide the
patient’s care.
Assignments
A. Review all materials from this lesson and be prepared for a lesson quiz to be
administered (date to be determined by instructor).
B. Read Chapter 20, “Psychiatric Emergencies,” for the next class session.
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Unit Assessment Keyed for Instructors
1. If an alkaline is in the eye, how long should the eye be irrigated?
Answer: 15 to 20 minutes
p 673
2. How do the majority of poisons enter the body?
Answer: Ingestion
p 674
3. What are the contraindications to the administration of activated charcoal?
Answer: Ingestion of an acid, alkali, or petroleum product; decreased level of
consciousness; inability to swallow
p 679
4. What is the usual dose of activated charcoal for an adult or child?
Answer: The usual dosage for an adult or child is 1 g of activated charcoal per
kilogram of body weight (adult 25 to 50 g; pediatric 12.5 to 25 g).
pp 679
5. What does the term tolerance mean?
Answer: The need for increasing amounts of a substance over time to reach the same
desired effect
p 679
6. How does alcohol affect the system?
Answer: Depresses the central nervous system
p 680
7. What is the medical problem related to opioids that is a concern for responders?
Answer: Respiratory depression
p 681
8. Give an example of a sympathomimetic.
Answer: Any of the following: MDMA, amphetamines, crack cocaine, heroin,
methcathinone, methamphetamine, phentermine, PCP
p 683
9. List the terms for the mnemonic DUMBELS.
Answer: Defecation, Urination, Miosis, Bronchorrhea, Emesis, Lacrimation,
Salivation
p 685
10. What organ does acetaminophen overdose damage?
Answer: Liver
p 686
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Chapter 19: Toxicology
Unit Assessment
1. If an alkaline is in the eye, how long should the eye be irrigated?
2. How do the majority of poisons enter the body?
3. What are the contraindications to the administration of activated charcoal?
4. What is the usual dose of activated charcoal for an adult or child?
5. What does the term tolerance mean?
6. How does alcohol affect the system?
7. What is the medical problem related to opioids that is a concern for responders?
8. Give an example of a sympathomimetic.
9. List the terms for the mnemonic DUMBELS.
10. What organ does acetaminophen overdose damage?
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