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1
Toxicology,
Alcohol & Drug Abuse
2008
Types of Toxicological
Emergencies

Unintentional
•
•
•
•
•
•
Dosage errors
Idiosyncratic reactions
Childhood poisoning
Environmental exposure
Occupational exposure
Neglect and exposure
2

Intentional poisoning/overdose
• Chemical warfare
• Assault/homicide
• Suicide attempts
3



Use of poison control centers
Oregon Poison Control
1-800-452-7165
Evaluation of the poisoned patient
4
Scene Size-up




Where are you?
Who’s around you?
Is there any potential danger?
Any evidence of pill bottles, used
needles, etc.
5
History
• Provides a working diagnosis;
notoriously unreliable
• What - samples
• How much
• How
• When
• Why
• What else
6
Physical exam

Vitals
• Airway
• Stridor
• Snoring
• Vomitus
• Gag reflex
• Risk of aspiration
7
• Breathing evaluation
• Baseline RR
• Quality of respirations
–Shallow; need early ventilatory
support
–Deep; underlying hypoxemia or
metabolic acidosis
• Early - noncardiogenic pulmonary
edema
• Later - ARDS
8
• Circulation
• Baseline pulse rate and BP
–Hypotension common
–Hypertension occasionally; serious ie
CVA
• ECG monitoring
–Tachyarrhythmias common; not
usually serious perfusion problem
–Bradyarrhythmias uncommon; more
serious underlying metabolic problem
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
Temperature
• Baseline temp.
• Hypothermia and hyperthermia
frequently accompany poisons
10

Neuro complications
• Altered level of consciousness
(AMS) frequent
• Seizures one of most common
• Mild drowsiness
• Agitation
• Hallucinations
• Confused, combative
• Coma
• Medullary depression
• Cardiopulmonary depression
• Death
11

Underlying disease states
• Asthma, COPD etc. increased risk for resp.
compromise
• Underlying cardiac disease increased risk
for severe arrhythmias.
12

Supportive care
• Prevent or limit respiratory,
cardiac, neurologic complications
• Oxygen,
• IV
• ECG
13

Respiratory complications
•
•
•
•
Airway protection
ET or NT intubation
Bronchodilator therapy prn
Positive pressure ventilation prn
14

Cardiovascular complications
• Appropriate antiarrhythmics
• Atropine
• Pacing
• Fluid challenge for hypotension
• Vasodilators for hypertension
15

Neurologic complications
• Anticonvulsants; diazepam/versed prn
• Chemical restraints only compounds
intoxication and may precipitate
catastrophic cardiopulmonary
complications
16

Routes of absorption
• Ingestion
• Inhalation
• Injection
• Absorption
17
Ingestion

Most common route
• Assessment findings
• What?
• When?
• Quantity?
• Alcohol?
• Self-treatment?
• Psychiatric care?
• Weight?
18
Physical examination
• Skin
• Eyes
• Mouth
• Chest
• Circulation
• Abdomen
19
General management
considerations
• Prevent Aspiration
• Intubation/RSI?
• Fluids & Drugs
• GI decontamination
• Syrup of Ipecac
–Reduces absorption by @ 30%
–Interferes with activated charcoal
• Gastric lavage
–36-40 Fr. orogastric tube
–After 1-2 hrs post ingestion
questionable
20
• Activated charcoal
• Agent of choice
• Adsorbs molecules of chemicals on
its surface
• Reduces absorption by @ 50%
• Dose 1 g/kg
21

Cathartics
• Sorbitol, mag sulfate, mag citrate
• Speed up motility
• Studies show they don’t positively
affect patient outcome
• Liquid stools
• Dehydration, electrolyte imbalances
occur
• Administration of activated charcoal
20-30 min. prior to gastric lavage
doubles effectiveness
22
How do people poison
themselves?
23
They Inhale it
• Paint, other hydrocarbons
• Carbon monoxide
• Ammonia
• Chlorine
• Freon
• Toxic vapors, fumes, aerosols
• Mace, mustard gas
24
What do they look like?

Primarily respiratory
• Tachypnea, cough, hoarseness, stridor,
dyspnea, retractions, wheezing, chest pain
or tightness, rales, rhonchi

Cardiac:
• Dysrhythmias

CNS
• Dizziness, H/A, confusion, seizures,
hallucinations, coma
25
Carbon Monoxide

Inadvertant
• Faulty furnace
• Indoor heating source

Purposeful
• Suicide
Poisonous Gases



Oxygen robbing
Chlorine
Warfare
• Chlorine
• Mustard gas
• Bromine
28
Now what?





Be safe!
Remove patient from environment
Exam
Provide supportive care
Contact Poison Control and follow
directions
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They inject
it
• IV drug abuse – more later
• Venomous bites and stings
• Bees, hornets, yellow jackets, wasps,
ants (only females)
• Spiders, ticks, other arachnids;
scorpions
• Snakes
• Marine animals; jelly fish, stingrays,
anemones, coral, fish
30
Ticks/Lyme Disease
Frequently requires Antibiotics
(Amoxicillin, Zithromax)
Tick generally must be attached
for 24-48 hours
31

Results in immediate & delayed
reactions
• Immediate reaction
• Rash
• Fever
• Malaise
• Fatigue
• H/A
• Muscle & joint aches
• Sore throat
• Sinus infection
32

Delayed reaction
•
•
•
•
•
•
•
•
•
•
•
•
Chronic malaise/fatigue
Muscle pain/joint pain with/without arthritis
Neuropathy
Tremor
Bell’s palsy
Meningitis
Vision problems (double vision, photophobia)
Vestibular problems
Seizures
Cardiac symptoms
N/V
Immune suppression
33
Hymenoptera (Bee stings,
Wasp stings, Ants)
• Bumblebees, Sweat bees, Honeybees;
Hornets, Yellow jackets; Fire ants,
Harvester ants
• Type of reaction
• Local;
• Toxic; 10 or more stings
– N/V/D, light-headedness, syncope, H/A,
fever, drowsiness, muscle spasms, edema,
seizures
– Sx subside w/in 48 hrs
34
Bees and Bugs

Systemic/anaphylactic:
• The shorter the onset, more severe the
reaction
• Initial sx: itching eyes, facial flushing,
generalized urticaria, dry cough
• Sx intensify; chest or throat constriction,
wheezing, dyspnea, cyanosis,
abdominal cramps, N/V/D, vertigo, chills,
fever, shock, loss of consciousness
• Reaction can be fatal in 30 min.
35
Bees and Bugs

Delayed reaction
• Serum-sickness-like sx; fever, malaise, H/A,
urticaria, lymphadenopathy appears 10-14
days later.

Dx: difficult
• Honeybees; leaves it’s stinger with venom sac
attached
• Yellow Jackets: nest in ground
• Wasps: under eaves or windowsills
• Southern US Fire Ants; groupings of 3-4 stings
and pustules
36
Bees and Bugs

Tx:
• Scrape honeybees stinger out; don’t
squeeze; remove quickly
• Wash sting sites with soap and water
• Ice packs
• Benadryl, Prednisone
• Epinephrine 1:1000 0.3 - 0.5 mg sq IF
SYSTEMIC
37
Brown Recluse Spiders
(Fiddleback spider)

Southern, midwestern states
• Tennessee, Arkansas, Oklahoma, Texas,
Hawaii, California
• 15mm long. 6 eyes in a circle
• Lives in dark, dry locations
• Violin-shaped markings on back
38
Does it
hurt?



Usually painless
Bites occur at night
Local reaction
• Initially, small erythematous macule surrounded
by a white ring
• Over next 8 hours, localized pain, redness,
swelling
• Tissue necrosis over days > weeks

Chills, fever, N/V, joint pain, DIC
 Tx: Diphenhydramine; supportive
39
40
Black Widow spiders



Live in all parts of continental US
Found in woodpiles or brush
Female spider bites
• Orange hourglass on black abdomen
41
Does it hurt?




Immediate localized pain, redness, swelling.
Progressive muscle spasms of all large muscle
groups can occur
N/V, sweating, seizures, paralysis, decreased
level of consciousness.
Management: Supportive care;
• Consider Diazepam
• 2 – 10 mg IVP
• or Calcium gluconate
• 0.1 – 0.2 mg/kg of 10% solution.
• Monitor B/P
• Antivenin is available
42
Scorpion stings


All species can sting, =
localized pain
Only bark scorpion has
caused fatalities
• Mostly in Arizona,
California, Nevada, New
Mexico, Texas.
• Move mostly at night
• Venom stored in bulb at
end of tail
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Does it hurt?

Venom acts on nervous system
• Burning, tingling effect
• Gradually progresses to numbness.

Systemic effects
•
•
•
•

Slurred speech, restlessness
Hyperactivity in 80% of children
Muscle twitching, seizures
Salivation, abdominal cramping, N/V
Management: Supportive
• Apply constricting band above wound site –
watch band – occludes lymphatic flow only
• Avoid analgesics; may increase toxicity
44
Snakebite
• 8000 bites/yr - mortality is
@ 50/yr
• N. Carolina has highest %
• Peak months July, August
6am - 9 pm
45
Pit Vipers

Cottonmouth, rattlesnake, copperhead
• Indentation 1/2-way between eye and
nostril
• Hollow, retractable fangs
• Vertical pupils
• Triangular head
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Pit Vipers (cont.)


Venom contains enzymes that may
destroy proteins, other tissue
components; destroys RBCs, affects
blood clotting
Death from shock possible in 30
minutes
• Most occur 6-30 hours
47
Pit Vipers (cont.)

S/S: Fang marks, swelling and pain
•
•
•
•
•

Weakness, dizziness, faintness
Sweating/chills
Thirst, N/V, Diarrhea,
Tachycardia, hypotension
Bloody urine
Tx: Keep pt. Supine
• Immobilize limb
• Maintain extremity in neutral position
• DO NOT apply constricting bands, Ice, etc.
48
Coral snakes

Distinct pattern of red
and black bands wider
than interspaced yellow
rings
 “Red on yellow, kill a
fellow”/coral snake
 “Red on black, venom •Venom
•Affects coagulation
lack”/harmless snake
•Affects endothelium of
vessels
•Paralyzes activity of white
blood cells
•Neurotoxins A & B affect
nervous system; esp.
cardiorespiratory centers49
Coral Snakes (cont.)

May be NO effects for 12-24 hours
• Localized numbness, weakness, drowsiness
• Ataxia, slurred speech, excessive salivation
• Paralysis of tongue, larynx
• Drooping eyelids, double vision, dilated pupils
• Abdominal pain, N/V
• Hypotension, Respiratory failure
• Seizures
50
Coral Snakes (cont.)


Size of victim important; condition of
victim will seriously affect outcome
Location very important; bites on head
and trunk 2-3x more dangerous; bites
on upper extremities more serious than
lower.
51
Coral Snakes (cont.)

Tx:
• Wash wound with copious amounts of
water
• Apply compression bandage, keep
extremity at level of heart
• Immmobilize limb
• Transport for antivenin
• Do NOT apply ice, cold pack, freon sprays,
or incise wound
52
Marine Animal
Injection

Jellyfish, Coral, Sea urchins, Sting rays
 Secondary infections
 S/S: intense local pain, swelling
• Weakness, N/V
• Dyspnea, tachycardia
• Hypotension, shock

Tx: Supportive care
• Consider a constricting band between heart, &
wound; occlude lymphatic flow only
• Heat or hot water
• Meat tenderizer
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Poisoning By Absorption

Surface absorption
• Poisonous plants; ivy, sumac, oak
• Organophosphates
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Now What?

Management considerations
•
•
•
•
•
•
•
Remove patient from environment
Wear protective clothing
Remove pt. clothing
Initiate supportive measures
Contact poison control
Soap and water
Decontaminate eyes with 15-30 min. Water
flush
• Supportive care
55
Cholinergics


Pesticides (organophosphates,
carbamates)
Nerve agents (sarin, Soman)
56
Cholinergics (cont.)

Findings
• SLUDGE
• Headache, Dizziness, Weakness, Nausea
• Bradycardia, wheezing, bronchoconstriction,
myosis, coma, convulsions, diaphoresis

Management
• Decontamination
• Airway and ventilation
• Aggressive airway management
• Circulation
57
Cholinergics (cont.)
• Pharmacological
• Atropine 2 – 5 mg IV q 15-30 min. until vitals
improve
• Pralidoxime chloride (2-PAM)
• Diazepam 2 – 10 mg IV for seizure control
• Activated charcoal – if ingested & gag reflex
intact
• Transport considerations
• Protect self
• Notify receiving hospital
• May require decontamination outside ED
58
Caustic substances

Acids, alkalis
• 12,000 exposures/yr
• 150 major complications/deaths
• Plumbing liquids
• Cause tissue coagulation, necrosis
• S/S - Acids: pH <2
• Eschar at burn site
• Local burns to mouth, throat
• Esophagus usually not damaged
• Stomach lining injured
• Immediate, severe pain
• Acidemia
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
Alkali's: pH > 12.5
• Induce liquefaction necrosis
• Pain often delayed
• Cause perforation, bleeding,
inflammation of central chest structures
• W/in 2-3 days, complete loss of
protective mucosal tissue
• S/S:
• Facial burns, pain in lips, tongue, throat,
gums
• Drooling, trouble swallowing
• Hoarseness, stridor, SOB
• shock
60

Tx:
•
•
•
•
•
•
Aggressive, rapid
Prevent injury to rescuers
Airway management critical
Cricothyrotomy
Don’t use activated charcoal
Rapid transport
61
Hydrofluoric Acid

Used to etch glass
 Extremely toxic
 Penetrates deeply into tissues; inactivated
only by contact with calcium; settles in tissues
as salt
• Causes total disruption of cell functioning, bone
destruction

S/S: burning at site of contact, SOB,
confusion, palpitations, muscle cramps
 Tx: Supportive: Immerse affected limb in ice
water with Mag. Sulfate or calcium salts
62
Hydrocarbons

Organic compounds;
• Kerosene, turpentine, mineral oil, chloroform, etc.
• Lighter fluid, paint, glue, lubricants, solvents,
aerosol propellants.

S/S:
• Burns, wheezing, dyspnea, slurred speech, ataxia,
obtundation
• Foot and wrist drop with numbness, tingling
• Cardiac dysrhythmias

Tx: Rarely serious – call poison control
63
Tricyclic antidepressants

Narrow therapeutic index
• Amitrriptyline, Elavil, amoxapine,
clomipramine, doxepin, imipramine,
nortriptyline

S/S: dry mouth, blurred vision, urinary
retention, constipation, confusion,
hallucinations, hyperthermia, respiratory
depression, seizures, tachycardia,
hypotension, heart block, wide QRS,
Torsades de pointes

Tx: Sodium Bicarbonate, 1 mEq/kg
64
MAO Inhibitors

Atapryl, Eldepryl
 Relatively unpopular
• Narrow therapeutic index
• Serious interactions with red wine, cheese

Symptoms may not appear for up to 6 hours
• Headache, agitation, restlessness, tremor
• Nausea, palpitations, tachycardia, hypertension,
hyperthermia, bradycardia, hypotension, coma,
death

No antidote available; tx life-threatening sx.
65
Hallucinogens

LSD, PCP, peyote, mushrooms, jimson
weed, mescaline
• “Psychedelic” - visual or tactile

PCP
• Ketamine still used
• Powdered or solution; added to tobacco or
marijuana
• Onset in 2-5 min.; Peak effect in 15 min.
• Elimination half-life about 7 h - 3 days.
66

LSD
• Blotter acid, sugar cubes, gelatin
• Sx in 1/2 - 1 hr; peak in 2 hrs (paranoia
may occur), acute psychosis may persist
for days
67
• Morning Glory
• Mescaline/Peyote
cactus
• 6-12 buttons
required to produce
hallucinogenic
effects
• N/V, blurred vision,
hypertension,
tachycardia
• Effects peak at 2 hrs,
last for 6-12 hrs
• Religious
ceremonies
• Tx with rest and
reassurance
68

Mushrooms; psilocybin or ibotenic acidmagic mushrooms
• Common in US; pacific NW, texas, florida,
hawaii
• Religious ceremonies since aztec
• Eaten raw, brewed in soup or tea, or dried
• GI discomfort in 15-30 min. N/V
• Effects last from 4-12 hrs
69

Nutmeg; common in
foods and herbal
remedies
• Myristicin is major
component
• 10-50 g of fresh nutmeg
(2-9 whole nutmegs)
• Sx in 3-6 hrs; N/V,
abdominal pain
• Cold extremities with
weak pulses shallow
respirations; sx resolve
in 24 hr with supportive
care
70

Designer amphetamines
• Adam, Eve, Ecstasy
• Effects are drug and dose
dependent
• Severe psychomotor agitation
• Disorders of thought process
• Hypertension, seizures, DIC,
ARDS, death
• Management supportive
71

Marijuana
• Cannabis sativa; marijuana and
hashish
• Medicinal qualities in china > 4000
years ago
• Today; glaucoma and chronic pain
• Most commonly used illicit substance
after alcohol and tobacco
• THC levels peak about 8 min after
inhalation, and 45 min. after ingestion.
Effects last 2-6 hrs.
72
73
Narcotics

Heroin, methadone,
morphine, codeine,
meperidine,
hydromorphone (Dilaudid),
hydrocodone (Percodan)
• Street heroin cut with
quinine, lactose, sucrose,
mannitol, talc, procaine,
baking soda.
• Effects include drowsiness,
euphoria, miosis, decreased
respiration, N/V, respiratory
arrest
74
75

Withdrawal
• Piloerection, lacrimation, yawning,
rhinorrhea, sweating, nasal stuffiness,
myalgia, vomiting, abdominal
cramping, diarrhea, irritable,
hyperactive, confused
76

Narcotic overdose
• Cardinal findings; pinpoint pupils,
hypoventilation


Tx: Airway, ventilation, circulation
Naloxone, 0.4-2.0 mg/0.01 mg/kg in
child, SQ, IM, IV, ET; effective in 1-2
min.
• Naloxone acts as antagonist at opiate
receptor sites
• Overdose often mixed
• Serum half-life of Narcan is 1 hr with
action duration of 2-3 hr. (methadone
half-life 72 hr).
77

Complications of narcotic abuse
• Skin ulcers or lesions
• nonpitting edema of extremities
• Infection
• Abscesses, Cellulitis, Thrombophlebitis
• Endocarditis
• Malaria (1929)
• Tetanus (1876) esp. female, subcu
injectors
78
• Hepatic complications; most common
• GI complications
• Ilius
• Fecal impaction
• CNS complications
• Meningitis
• Spinal abscess
79
Cocaine

Most common cause of drug related
deaths
• Plant alkaloid found in coca plant. Leaves
are crushed with a hydrocarbon solvent
followed by extraction of alkaloid with
sulfuric acid
• Smoked, snorted, or injected
• Crack is almost pure cocaine vaporizes at
high temp.
• Absorbed from all sites; mucous
membranes, GI tract, respiratory tree.
80
Cocaine






Smoked, injected, snorted, swallowed
Intensity & duration depends on route
1997 – 1.5 million Americans use
Drug most frequently involved in ED visits
Often used with Valium, Ativan, Heroin as
upper/downer combo
Adolescents combine Cocaine, Marijuana,
Alcohol
81
Short-term effects







Pleasure
Increased alertness
Paranoia
Vasoconstriction
Myocardial damage
Dysrhythmias
Death
82
Long term effects

Severe
depression
 Loss of energy
 Damage to
•
•
•
•
Heart
Lung
Brain
Kidneys
83
84
85
Cocaine (cont.)
• Intranasal admin peak effect in 1/2 hr
• GI peak effect in 90 min.
• IV and inhalation peak at 30 seconds to 2
min.
• Tachycardia, hypertension, hyperthermia,
agitation, seizures are common.
86
Cocaine (cont.)

AMI common; onset immediate > 24 hr.
• Coronary artery spasm, thrombosis, atrial and
ventricular arrhythmias, aortic rupture, CHF, QRS
widening

Spontaneous pneumothorax and
pneumomediastinum possible 2ndary to deep
breath holding
 CVA
 OB risks
 Renal failure
87
Cocaine (cont.)

Topical cocaine

Management
• Sedation, control of hyperthermia and
seizures, fluids.
88
Amphetamines &
Amphetaminie-like Drugs
•
•
•
•
•
•
•
Benzedrine
Dexedrine
Ritalin
Midol
Vicks inhaler
Bronkaid tabs
Alka-Seltzer plus, Allerest, Contac, Dexatrim,
Dimetapp, Novahistine tabs, Extra-strength
Sinutab, Triaminic
• Actifed, Drixoral, Novahistine, Sudafed
89
Amphetamines (cont.)
• First synthesized in 1887, but not
commercially available until 1932
• Similar to epinephrine, norepinephrine

Effects:
• Restlessness, hyperactivity, repetitive
behavior, anorexia, sleep reduction
• Rapidly absorbed from GI tract; peak
levels within 1 hr.
90
Amphetamines (cont.)

Toxicity:
• Diaphoresis, extreme restlessness,
repetitive and bizarre behavior, coma,
intracranial hemorrhage, flushing,
tachycardia, hypertension, arrhythmias, MI,
N/V/D
• Abrupt withdrawal rarely life-threatening.
Depression, increased appetite, cramps,
N/D, HA.
• Care supportive
91
Methamphetamines
92

80% children in foster care are Meth related
Barbiturates
• First introduced as sedative in 1903.
Currently used to treat seizures, induction
of anesthesia, treatment of ICP
•
•
•
•
Methohexital
Phenobarbital
Secobarbital
Primadone
100
Barbiturates (cont.)


Barb. intoxication mimics alcohol
intoxication. Rule of thumb; 10x
hypnotic dose can produce severe
toxicity.
Treatment: ET, gastric lavage, IV,
diuresis, Hemodialysis
101
Benzodiazepines

Commonly used for anxiety,
insomnia, seizures, Alcohol
withdrawal, conscious sedation,
general anesthesia.
•
•
•
•
•
•
•
•
•
Xanax
Librium
Klonopin
Tranxene
Valium
Dalmane
Ativan
Versed
Halcion
102
Benzodiazepines (cont.)

Predominantly CNS effects, well
absorbed from GI tract. IM injection is
unpredictable
103
Benzodiazepines (cont.)

Most serious toxicity occurs in ingestion of
other agents or parenteral administration.
 CNS effects;
• Drowsiness, dizziness, slurred speech, confusion,
ataxia, intellectual impairment.

Managment:
•
•
•
•
•
Dextrose, thiamine, naloxone
Do not induce vomiting
Give activated charcoal
Gastric lavage
Monitor closely
104
Cyanide

Potent cellular toxin; as little as 50 mg may
cause death.
• Extract of bitter almonds/cherry laurel leaves,
extracts of apricot, cherry, peach pits
• Silver polish
• Prolonged exposure to IV nitroprusside
• Burning of synthetics and wool, silk, vinyl,
polyurethane

Several hours exposure (<50 ppm) can
cause sx
 Recovery is rapid after removal.
105

Exposure to 100 ppm may be fatal in 30
min.
 Sx:
•
•
•
•
•
•
•
Severe dyspnea,
Loss of consc., Seizures,
Arrhythmias,
HA,
Drowsiness,
Paralysis,
Pulmonary edema,

Bright red retinal vessels, smell of bitter
almonds important clues.
 Tx: amyl nitrite for inhalation, 10 ml of 3%
solution of sodium nitrite for IV infusion.;
Give 300 mg, followed by 12.5 g of
sodium thiosulfate.
106
Drug abuse
• Epidemiology
• Incidence
• Morbidity/mortality
• Risk factors
• Prevention
• Psychological issues
• Psycho-social issues
107
Drug abuse (cont.)

Pathophysiology of long term drug
abuse
• End-organ damage
• Brain, liver, heart
• Malnutrition
• Habituation/dependence/addiction
• Tolerance
• Withdrawal syndromes
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Alcoholism - Ethanol
• Incidence
• Morbidity/mortality
– 42% traffic fatalities, 69% drownings, 23%
suicides
– 100,000+ deaths/yr
• Risk factors
• Prevention
• Psychological issues
• Psycho-social issues
109
Alcoholism (cont.)

End-organ damage
• Brain
• Liver
• Heart
• Bone
• Pancreas
110
Alcoholism –
Clinical Manifestations









Altered Immunity
Anorexia
Dysrhythmias
Coma
Irritability and disorientation
Muscle cramps
Poor wound healing
Seizures
Tremor and ataxia
111
Alcoholism (cont.)



Malnutrition
Withdrawal syndrome
Wernicke’s encephalopathy (disorder
of the brain)
112
Alcoholism –
Body System Disturbances

Fluid and electrolyte from diuresis

GI disorders (bleeds, esophageal varices)

Liver (cirrhosis)

Pancreatitis

Cardiac and skeletal muscle myopathy

Immune suppression

Trauma (suppressed clotting factors)
113
Prehospital concerns

Delirium Tremens (DT’s)
• Treat symptomatically
• Valium/Versed
• Rehydration
114
Wernicke-Korsakoff’s
syndrome
• Personality; psychosis, polyneuritis,
disorientation, muttering delirium,
insomnia, illusions, hallucinations
• Classic triad; ataxia, ophthalmoplegia
(nystagmus and 6th nerve palsy), and
altered mental status; also, hypothermia,
coma, hypotension
115
Methanol
• Antifreeze, paint solvent, Sterno, gasoline
additives
• Life-threat even with small amount; 30 ml
of 100% methanol lethal;
• Converted in liver to formaldehyde to
formate = cellular hypoxia.
• S/S: visual sx-photophobia, blurred vision,
dilated pupils; CNS depression; abd. Pn;
N/V; metabolic acidosis. Onset 1 hr - 72
hrs
116
Ethylene Glycol
• Colorless, oderless, sweet-tasting,
nonvolatile liquid
• Detergents, paints, pharmaceuticals,
polishes, antifreeze, lysol spray, coolants
• Toxicity due primarily to accumulation of
toxic metabolites.
• CNS sx 1-12 hr later: Ataxia, nystagmus,
seizures, hallucination, coma
117
Ethylene Glycol (cont.)



Cardiopulmonary sx 12-72 hrs later:
Tachycardia, tachypnea, mild HTN,
pneumonia, pulmonary edema, cardiac
failure
Renal failure w/in 24-72 hrs
Tx: Gastric lavage, Alcohol, calcium
chloride
118
Salicylates - aspirin
(acetylsalicylic acid)
• Oil of Wintergreen (methyl salicylate)
• Darvon, Percodan, Fiorinal

Directly stimulates respiratory centers
in brainstem, = respiratory alkalosis.

Causes mobilization of glycogen
stores and inhibits gluconeogenesis,
= hyperglycemia, normoglycemia,
hypoglycemia
119
Salicylates - ASA

S/S:
• GI irritation, Upper GI bleeding, persistant
vomiting
• Mixed respiratory and metabolic acidosis
• Confusion, lethargy, convulsions,
respiratory arrest, coma, brain death,
cardiac toxicity, significant hyperthermia,
pulmonary edema
120
Salicylates - ASA

Toxic doses
• Peak serum levels in 18-24 hrs, although
toxic levels within 6 hours.
• Therapeutic levels, salicylate mainly
cleared by hepatic metabolism
• Toxic levels, renal excretion is major
route of elimination
• 150-300 mg/kg = mild-moderate toxicity;
hyperpnea, vomiting, diaphoresis,
tinnitus, acid/base disturbances
121
Salicylates - ASA

Tx:
• Activated charcoal
• IV fluids
• D50
• Hemodialysis
122
Acetaminophen poisoning
(APAP)
• Tylenol, Datril
• Poisoning may result in fatal hepatic necrosis
• Therapeutic dose 15 mg/kg q 4-6h (children)
max daily dose 80 mg/kg
• 325-1000 mg q 4 h (adults) max daily dose 4 g
• Eliminated primarily by hepatic metabolism
• Mechanism of toxicity unclear; a highly reactive
metabolite is thought to cause hepatic necrosis
by binding to protein macromolecules
123
Acetaminophen poisoning
(APAP)

Toxic doses
• 140 mg/kg in children
• 7/5 g in adults

Toxicity:
• Stage I: 1/2 - 24 h
• N/V, Anorexia, malaise, pallor, diaphoresis
• Stage II: 24-48 h
• Transient clinical improvement
• RUQ pain with liver enlargement,
tenderness
• Pancreatitis
• Oliguria
124
Acetaminophen poisoning
(APAP)

Toxicity:
• Stage III: 72-96 h
• GI sx reappear, persist, or worsen
• Jaundice
• SGOT, SG
• Stage IV: 4 d - 2 weeks
• Resolution or progressive hepatic failure
125
Overdose guidelines

Alcohol – thiamine, D50W

Cocaine – Benzodiazepines
• Beta blockers absolutely contraindicated

Narcotics/opiates – naloxone

Amphetamines – benzodiazepines, haldol

Hallucinogens – benzodiazepines, haldol

Benzodiazepines – flumazenil

Barbiturates – forced diuresis,
alkalinization of urine
126
127
128
Bye-Bye now~
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