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Paramedic Care:
Principles & Practice
Volume 3
Medical Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 8
Toxicology and Substance
Abuse
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Epidemiology
Poison Control
Centers
Routes of Toxic
Exposure
General Principles
of Toxicologic
Assessment and
Management
Ingested Toxins
Inhaled Toxins
Surface-Absorbed
Toxins
Specific Toxins
Injected Toxins
Substance Abuse
and Overdose
Alcohol Abuse
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Epidemiology
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Epidemiology
Over 4 million poisonings occur annually
10% of ED visits and EMS responses
involve toxic exposures
70% of accidental poisonings occur in
children under 6 years old
80% of attempted suicides involve a drug
overdose
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Poison Control Centers
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Poison Control Centers
Poison Control
– National network of specially trained providers
– Typically regional or statewide
– Accessed by telephone
Contact Poison Control Early
– Assist in determining potential toxicity
– Advise on prehospital treatment
– Advise the receiving facility and medical
direction
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Routes of Toxic Exposure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Routes of Toxic Exposure
Ingestion
– Common agents:
Household products
Petroleum-based
agents
Cleaning agents
Cosmetics
Drugs, plants, or
foods
– Absorption occurs in
the stomach and
small intestine
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Routes of Toxic Exposure
Inhalation
– Rapid absorption of the toxic agent through the
alveolar-capillary membrane
– Irritates pulmonary passages, causing extensive
edema and destroying tissue
– Causative agents can appear as gases, vapors,
fumes, or aerosols
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Common Inhaled Poisons
Toxic gases
Carbon monoxide
Ammonia
Chlorine
Freon
Toxic vapors,
fumes, or aerosols
Carbon
tetrachloride
Methyl chloride
Tear gas
Mustard gas
Nitrous oxide
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Routes of Toxic Exposure
Surface Absorption
– Entry of a toxic
substance through
the skin or mucous
membranes
– Causes
Plants
Chemical
Organophosphates
©The Stock Connection
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Routes of Toxic Exposure
Injection
– Results in both immediate and delayed effects
Immediate
Local effects
Anaphylaxis
Delayed
As toxin is absorbed
– Most poisonings by injection result from the
bites and stings of insects and animals
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Principles of
Toxicologic Assessment
and Management
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Principles of Toxicologic
Assessment and Management
Standard Toxicologic Emergency
Procedures
– Recognize a poisoning promptly
– Assess the patient thoroughly to identify the
toxin and measures required to control it
– Initiate standard treatment procedures
Protect rescuer safety
Remove the patient from the toxic environment
Support ABCs
Decontaminate the patient
Administer antidote if one exists
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Assessment
Scene Size-up
– Be alert to the potential for violence.
– Look for signs of hazardous material
involvement.
Enter a hazardous materials scene only if properly
trained and equipped to do so.
Initial Assessment
– Airway and respiratory compromise are common
in toxicologic emergencies.
– Manage life-threatening conditions.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Assessment
History, Physical Exam, and Ongoing
Assessment
– Identify the toxin and length of exposure
– Contact poison control and medical direction
according to local policy
– Complete appropriate physical exams
– Monitor vital signs closely
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Treatment
Initiate supportive treatment
Decontamination
– Reduce intake of the toxin
Remove the individual from the toxic environment
– Reduce absorption of toxins in the body
Use of Ipecac is no longer indicated except in extreme
circumstances
Use gastric lavage and activated charcoal
– Enhance elimination of the toxin
Use cathartics
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Use of Ipecac:
All of the Following Must Apply
There is no contraindication to the use of
ipecac syrup; and
There is a significant risk of serious toxicity in
the victim; and
There is no alternative therapy available
effective to decrease gastrointestinal
absorption (e.g., activated charcoal); and
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Use of Ipecac:
All of the Following Must Apply
There will be a delay greater that 1 hour
before the patient will arrive at the
emergency department; and
Ipecac syrup can be administered within
30–90 minutes of the ingestion; and
Ipecac syrup administration will not
adversely affect more definitive treatment
that might be provided at a hospital.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Treatment
Antidotes
– Useful only if the substance is known
– Rarely 100% effective
– Must be used in conjunction with other therapies
to ensure effectiveness
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Treatment
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Treatment
Suicidal Patients and Protective Custody
– Involve law enforcement
– Involve medical direction
– Know local procedures and laws
Laws for protective custody vary widely
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ingested Toxins
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ingested Toxins
Assessment
– History
What was ingested?
When was it ingested?
How much was ingested?
Did you drink any alcohol?
Have you attempted to treat yourself?
Have you been under psychiatric care? Why?
What is your weight?
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ingested Toxins
Physical Exam
–
–
–
–
–
–
Skin
Eyes
Mouth
Chest
Circulation
Abdomen
Exposure to Multiple Toxins
– Suicide attempt
– Experimentation
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ingested Toxins
Management
– Contact poison control/medical direction
– Prevent aspiration
– Administer fluids and drugs
IV access
Use of D50W, naloxone, and thiamine
Decontamination
– Do NOT induce vomiting
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Inhaled Toxins
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Inhaled Toxins
Assessment
– History and Physical Exam
Evaluate the scene
Central nervous system effects
Dizziness, headache, confusion, seizure, hallucinations,
coma
Respiratory effects
Cough, hoarseness, stridor, dyspnea, retractions,
wheezing, chest pain or tightness, crackles, rhonchi
Cardiac effects
Dysrhythmias
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Inhaled Toxins
Management
– Ensure your personal safety.
Do not enter a hazardous scene unless properly
trained and equipped to do so.
– Remove the patient from the environment.
Remove the patient’s contaminated clothing.
– Perform the initial assessment, history, and
physical exam.
– Initiate supportive measures.
– Contact poison control and medical direction
according to local protocol.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Surface-Absorbed Toxins
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Surface-Absorbed Toxins
Assessment and Management
– Ensure your personal safety.
Do not enter a hazardous scene unless properly
trained and equipped to do so.
– Remove the patient from the environment.
Remove the patient’s contaminated clothing.
– Perform the initial assessment, history, and
physical exam.
– Initiate supportive measures.
– Contact poison control and medical direction
according to local protocol.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Specific Toxins
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Specific Toxins
Toxidromes
– Similar toxins typically have similar signs and
symptoms
– In some cases it may be difficult to identify a
specific toxin
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Carbon Monoxide
Number one cause of poisoning in
industrialized countries
Inhaled colorless, odorless gas
– Poorly ventilated heating systems
– Confined spaces
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Carbon Monoxide
Sources
– Endogenous
Normal breakdown
of hemoglobin
May increase with
disease states
– Exogenous
Product of
combustion
– Methylene chloride
© 2007 fortworthfire.com
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Carbon Monoxide
Pathophysiology
– CO competes with oxygen for the oxygenbinding sites on hemoglobin
Affinity is approximately 200–250 times that of oxygen
– The amount of hemoglobin that is saturated with
oxygen is steadily diminished
– Can be removed only via degradation of
carboxyhemoglobin
Administration of oxygen
Hyperbaric therapy
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Carbon Monoxide
Effects of CO Exposure
– Central Nervous System
Headache, dizziness, confusion, seizures, and
ultimately coma
Long-term cognitive and psychiatric disorders
– Cardiovascular
Chest pain, hypotension with tachycardia, cardiac
dysrhythmias, myocardial ischemia and ultimately
ventricular fibrillation
– Respiratory
Pulmonary edema
– Other body systems and functions
Metabolic derangements
Multiple Organ Dysfuntion Syndrome
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Carbon Monoxide
Summary of effects of CO exposure
–
–
–
–
–
–
–
Limits oxygen transport
Inhibits oxygen transfer
Causes tissue inflammation
Causes reduced cardiac function
Increases activation of nitric oxide
Causes vasodilation
Induces free-radical formation
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Carbon Monoxide
At-risk populations
–
–
–
–
Extremes of age
Patients with heart disease
Pregnant women
Patients with a decreased oxygen-carrying
capacity
– Patients with chronic respiratory conditions
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Carbon Monoxide
Signs and Symptoms
– Often vague and nonspecific
Mimics viral illness, coronary syndrome, or migraine
– Symptoms may be acute or chronic
– Symptoms worsen with significant exposure
Cherry-red skin color is unreliable and usually a late
indicator of CO poisoning
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Carbon Monoxide
CO Detection
– Home use
– Hand-held
detectors
– CO oximetry
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Carbon Monoxide
Management
– Ensure rescuer safety
– Remove the patient
from the contaminated
area
– Initiate supportive
measures
High-flow, highconcentration oxygen
Monitor CO levels
– Hyperbaric therapy
Courtesy of NASA
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Carbon Monoxide
Poisoning Treatment Algorithm
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cyanide
Colorless gas that has a faint, bitter-almond
odor
Cyanide-containing products are routinely
used in certain manufacturing processes
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cyanide
Sources
– Product of combustion
Plastics, wool, silk, synthetic rubber, polyurethane, and
asphalt
Found in routine firefighting operations
– Ingested, inhaled, or absorbed
– Long-term sodium nitroprusside therapy
Pathophysiology
– Effectively stops energy production by the cell
– Cell shifts from aerobic to anaerobic metabolism
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cyanide
CO and Cyanide Poisoning
– The effects of CO and cyanide are cumulative
Signs and Symptoms
– Burning sensation in the mouth and throat
– Headache, confusion, combative behavior
– Hypertension and tachycardia followed by
hypotension and further dysrhythmias
– Seizures and coma
– Pulmonary edema
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cyanide
Management
– Ensure rescuer
safety
– Initiate
supportive care
– Administer
antidote:
© Jeff Forster
Lilly Antidote
Kit
Pasadena
Antidote Kit
Cyanokit®
Courtesy © Dey, L.P.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiac Medications
Exposure
– Commonly due to dosage errors
Signs and Symptoms
– Nausea, vomiting, headache, dizziness,
confusion
– Profound hypotension, cardiac dysrhythmias
– Bronchospasm, pulmonary edema
Management
– Standard toxicologic emergency procedures
– Antidotes
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Calcium Channel Blocker
Overdose Algorithm
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Beta Blocker
Overdose Algorithm
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Caustic Substances
Caustic substances are either acids or
alkalis
– Acids
pH < 2
Cause significant damage at sites of exposure
Are rapidly absorbed into the bloodstream
– Alkalis
pH > 12
Slower onset of symptoms allows for longer contact
and more extensive tissue damage
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Caustic Substances
Signs and Symptoms
–
–
–
–
–
Facial burns
Pain in the lips, tongue, throat, or gums
Drooling, trouble swallowing
Hoarseness, stridor, or shortness of breath
Shock from bleeding, vomiting
Management
– Perform standard toxicologic emergency
procedures
– Maintain an adequate airway
May require cricothyrotomy
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hydrofluoric Acid
Extremely toxic
– Can be lethal
despite the
appearance of only
moderate burns
Inactivated only
when it comes in
contact with cations
deep in body
tissues
© Fundamental Photographs, NYC
© David Effron, MD
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hydrofluoric Acid
Signs and Symptoms
– Burning at site of contact
– Trouble breathing
– Confusion, palpitations, muscle cramps
Management
– Perform standard toxicologic emergency
procedures
– Irrigate and immerse the affected area in cool
water with magnesium sulfate, calcium salts, or
benzethonium chloride
– Transport immediately for definitive care
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
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,
obtundation, cardiac dysrhythmias
– Foot and wrist drop with numbness and tingling
Management
– Standard toxicologic emergency procedures
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Tricyclic Antidepressant
Include amitriptyline, amoxapine, doxepin,
nortriptyline, imipramine, clomipramine
– TCAs have a narrow therapeutic index
– Safer agents available
Signs and Symptoms of Toxicity
– Dry mouth, blurred vision, urinary retention,
constipation
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Tricyclic Antidepressants
Signs and Symptoms of Severe Toxicity
– Confusion, hallucinations, hyperthermia
– Respiratory depression, seizures
– Tachycardia, hypotension, cardiac dysrhythmias
Management
– Perform standard toxicologic emergency
procedures
– Monitor and treat cardiac dysrhythmias
– Avoid use of flumazenil, which may precipitate
seizures
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Tricyclic Antidepressant
Overdose Algorithm
Click here to view the Tricyclic Antidepressant Overdose Algorithm.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
MAO Inhibitors
Infrequently Prescribed Antidepressant
– High mortality with overdose because of drug’s
action
– Interacts with many other medications
Signs and Symptoms
– Headache, agitation, restlessness, tremor
– Nausea, severe hypertension, hyperthermia
– Palpitations and tachycardia
Progresses to bradycardia, hypotension, coma, and
death
Management
– Standard toxicologic emergency procedures
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Newer Antidepressants
Trazodone, Bupropion, and SSRIs
Signs and Symptoms
– Drowsiness, tremor, nausea, vomiting,
tachycardia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Newer Antidepressants
Serotonin syndrome
– Cognitive Effects: mental confuson, hypomania,
hallucinations, agitation, headache, coma
– Autonomic Effects: shivering, sweating, fever,
hypertension, tachycardia, nausea, diarrhea
– Somatic Effects: myoclonus/clonus, hyperreflexia,
tremor
Management
– Standard toxicologic emergency procedures
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Re-Uptake Inhibitors
Click here to view an animation on re-uptake inhibitors.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
SSRI
Overdose Algorithm
Click here to view the SSRI Overdose Algorithm.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Lithium
Prescribed to treat bipolar disorder
– Narrow therapeutic index
Signs and Symptoms
– Thirst, dry mouth, tremors, muscle twitching,
and increased reflexes
– Confusion, stupor, seizures, coma, nausea,
vomiting, diarrhea, bradycardia, and
dysrhythmias
Treatment
– Standard toxicologic emergency procedures
Activated charcoal not effective with lithium
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Salicylates
Common Overdose Drug
– Includes aspirin, oil of wintergreen
Signs and Symptoms
– Tachypnea, hyperthermia, confusion, lethargy,
coma, cardiac failure, and dysrhythmias,
metabolic acidosis
– Abdominal pain, vomiting, pulmonary edema,
ARDS
Treatment
– Standard toxicologic emergency procedures
Activated charcoal indicated
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Salicylate
Overdose Algorithm
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Acetaminophen
Common OTC Antipyretics and Analgesics
Signs and Symptoms
Stage 1
1/2 hour –
24 hours
Nausea, vomiting, weakness, and fatigue
Stage 2
24–48 hours
Abdominal pain, decreased urine, elevated liver
enzymes
Stage 3
72–96 hours
Liver function disruption
Stage 4
4–14 days
Gradual recovery or progressive liver failure
Treatment
– Standard toxicologic emergency procedures
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Acetominophen
Overdose Algorithm
Click here to view the Acetominophen Overdose Algorithm.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Other Nonprescription
Pain Medications
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
Treatment
– Standard toxicologic emergency procedures
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Theophylline
Bronchodilator Prescribed for Chronic
Respiratory Problems
Signs and Symptoms
– Agitation, tremors, seizures, cardiac
dysrhythmias, nausea, and vomiting
Management
– Standard toxicologic emergency procedures
Repeated doses of activated charcoal are indicated
Treat cardiac dysrhythmias
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Metals
Iron
– Overdose of dietary supplement
– Signs and Symptoms
Vomiting (with hematemesis), diarrhea, abdominal
pain, shock, liver failure, bowel scarring and
obstruction, metabolic acidosis with tachypnea
– Treatment
Standard toxicologic emergency procedures
Activated charcoal not indicated
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Metals
Lead and Mercury
– Overdose often results from chronic
environmental exposure
Paints, glazes, industrial use, thermometers
– Signs and Symptoms
Headache, irritability, confusion, coma, memory
disturbances, tremors, weakness, agitation, abdominal
pain
– Treatment
Standard toxicologic emergency procedures
Activated charcoal not indicated
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Contaminated Food
Bacteria, Viruses, and Toxic Chemicals
– Bacterial toxins
Exotoxins and enterotoxins
– Seafood poisonings
Signs and Symptoms
– Nausea, vomiting, diarrhea, and abdominal pain
– Facial flushing and respiratory distress
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Contaminated Food
Treatment
– Perform assessment
– Collect samples of the suspect food source
– Maintain the airway and support breathing
Intubate and assist ventilations if indicated
Administer high-flow, high-concentration oxygen
– Establish IV access
– Consider medications
Antihistamines, antiemetics
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Poisonous Plants
and Mushrooms
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
© Leonard Lee Rue III/
Photo Researchers, Inc.
Treatment
– Follow treatment guidelines for
contaminated food
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Injected Toxins
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Injected Toxins
General Principles of Management
–
–
–
–
–
–
–
–
–
Protect rescuers
Remove the patient from danger
Identify the organism that caused the injury
Perform an initial assessment and rapid physical
exam
Prevent or delay absorption of the poison
Initiate supportive measures as indicated
Watch for anaphylactic reactions
Transport the patient rapidly
Contact poison control and medical direction
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Insect Bites and Stings
Hymenoptera most common
– Includes bees, wasps, hornets, and ants
Signs and Symptoms
– Localized pain, redness, swelling, skin wheal
Idiosyncratic reactions
– Observe for signs of an allergic reaction
Localized pain, redness, swelling, skin wheal
Generalized flushing of the skin or itching
Tachycardia, hypotension, bronchospasm, laryngeal
edema, facial edema, uvular swelling
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Insect Bites and Stings
Insect Stings
– Treatment
Wash the area
Remove stingers, if present
Use care not to disturb the venom sac
Apply cool compresses to the injection site
Observe for and treat allergic reactions and/or
anaphylaxis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Insect Bites and Stings
Africanized Honey
Bees
– “Killer Bees”
– Much more
aggressive than
their European
counterparts
– Attack in groups
– Triggers
© Nature Picture Library
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Africanized Honey Bees
Management
– Personnel should
don appropriate
protective
equipment
– Approached with a
hose line using
water and a fog
pattern
Ideally use foam
– Proprietary systems
BeeAlert
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Insect Bites and Stings
Brown Recluse
Spider Bite
– Found primarily in
the South and
Midwest
– Lives in dark, dry
locations
– Violin-shaped
marking on the
back
“Fiddleback”
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Insect Bites and Stings
Brown Recluse
Spider Bite
– Signs and Symptoms
Localized, white-ringed
macule
Progresses to
localized pain,
redness, and swelling
over next 8 hours
Chills, fever, nausea,
vomiting, and joint pain
may also develop
© Scott and White Hospital and Clinic
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Insect Bites and Stings
Brown Recluse
Spider Bite
– Signs and
Symptoms
Tissue necrosis
develops over
subsequent days and
weeks
– Treatment
Follow general
treatment guidelines
Provide supportive
care
© Scott and White Hospital and Clinic
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Insect Bites and Stings
Black Widow Spider
Bite
– Signs and Symptoms
Immediate pain, redness,
and swelling
Progressive muscle
spasms of all large
muscle groups
Nausea, vomiting,
sweating, seizures,
paralysis, and altered
level of consciousness
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Insect Bites and Stings
Black Widow Spider Bite
– Treatment
Follow general treatment guidelines
Provide supportive care
Consider using muscle relaxants to relieve severe
muscle spasms
Diazepam 2.5–10 mg IV or 0.1–0.2 mg/kg of a 10%
calcium gluconate solution IV
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Insect Bites and Stings
Scorpion Stings
– Signs and
Symptoms
Localized burning
and tingling
sensation
Slurred speech,
restlessness, muscle
twitching, salivation,
nausea, vomiting,
and seizures
– Treatment
Follow general
treatment guidelines
Apply constricting
band
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Snakebites
Two families of venomous snakes
– Crotalidae
Pit Viper Bites
Cottonmouth, rattlesnakes, and copperhead
– Elapidae
Coral Snake Bites
Characteristic yellow-banded red and black rings
“Red touch yellow, kill a fellow; red touch black, venom
lack”
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pit Vipers
Rattlesnake - © National Geographic Image Collection
Cottonmouth snake - © Nature Picture Library
Copperhead - Animals Animals/Earth Scenes
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Coral Snake
© Nature Picture Library
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pit Viper Bites
Contains enzymes
that are capable of
destroying proteins
and most other
tissue
– Will produce
infarction and
tissue necrosis
Most deaths from
pit viper bites occur
from 6 to 30 hours
after the bite
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pit Viper Bites
Treatment
– Keep the patient supine
– Immobilize the injured limb and maintain it in a
neutral position
– Apply high-flow, high-concentration oxygen
– Establish IV access
– Transport
– DO NOT apply constricting bands, ice, cold
packs, tourniquets, or electrical stimulation to
the wound
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Coral Snake Bites
Contains some of the enzymes found in pit
viper venom
Neurotoxin
– Coral snake venom primarily affects nervous
tissue
May result in respiratory and skeletal muscle
paralysis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Coral Snake Bites
Signs and Symptoms
– Localized numbness, weakness, drowsiness,
ataxia, slurred speech, excessive salivation,
paralysis of the tongue and larynx
– Drooping of the eyelids, double vision, dilated
pupils, abdominal pain, nausea, vomiting, loss of
consciousness, seizures, respiratory failure,
hypotension
Treatment
– Treat similarly to a pit viper bite
Wash the wound with large amounts of water and
maintain the immobilized extremity at the level of the
heart
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Coral Snake Bites
Management
– Wash the wound with copious amounts of water
– Apply a compression bandage and keep the
extremity at the level of the heart
– Immobilize the limb with a splint
– Start an IV using crystalloid fluid
– Transport the patient to the emergency
department for administration of antivenin
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Coral Snake Bites
DO NOT
– Apply ice, cold pack, or Freon sprays to the
wound
– Incise the wound
– Apply electrical stimulation from any device in
an attempt to retard or reverse venom spread
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Marine Animal Injection
Injection of toxins
from marine life can
result from:
– Stings of jellyfish,
corals, and the
bony spines of
animals such as
sea urchins and
stingrays
Stingray
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Marine Animal Injection
Signs and Symptoms
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Intense local pain and swelling
Nausea and vomiting
Dyspnea
Tachycardia
Hypotension or shock in severe cases
Treatment
–
–
–
–
Establish and maintain the airway
Apply a constricting band above the site
Apply heat or hot water
Inactivate or remove any stingers
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Marine Animal Injection
Management
– Establish and maintain the airway
– Apply a constricting band between the wound
and the heart no tighter than a watchband to
occlude lymphatic flow only
– Apply heat or hot water (110°–113°F)
– Inactivate or remove any stingers
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ciguatera Poisoning
Illness caused by
eating fish that contain
toxins produced by a
marine microalgae
Poisoning primarily
occurs from predator
reef fish
– Barracuda, moray eel,
grouper, amberjack,
and parrotfish
Heavybeak parrotfish
(Photo Researchers, Inc.)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ciguatera Poisoning
Signs and Symptoms
– Gastrointestinal
Nausea, vomiting, diarrhea, and abdominal pain
– Neurologic
Profound weakness, paresthesias, severe pruritus,
tooth pain or the feeling that teeth are loose, pain on
urination, and blurred vision
– Cardiovascular
Hypotension, bradycardia (slowed heartbeat), or
dysrhythmia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ciguatera Poisoning
Management
– Symptoms usually go away in days or weeks but
can last for years
– Treat patient for presenting symptoms
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Substance Abuse
and Overdose
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Substance Abuse
and Overdose
Addiction
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–
–
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Habituation
Physiological dependence
Psychological dependence
Tolerance
Withdrawal
Drug Overdose
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Common Drugs of Abuse
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Common Drugs of Abuse
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Common Drugs of Abuse
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Common Drugs of Abuse
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Common Drugs of Abuse
Drugs Used for Sexual Purposes
– Ecstasy (MDMA)
Signs and symptoms include anxiety, nausea,
tachycardia, and hypertension, followed by relaxation
and euphoria
Provide supportive care
– Rohypnol (“Date Rape Drug”)
Potent benzodiazepine, illegal in the U.S.
Treat as a benzodiazepine overdose and sexual
assault victim
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Alcohol Abuse
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Alcohol Abuse
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
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Alcohol Abuse
Consequences of Chronic
Alcohol Ingestion
–
–
–
–
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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)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cirrhosis
Click here to view an animation on cirrhosis.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Alcohol Abuse
Withdrawal Syndrome
– Delirium Tremens (DTs)
– Signs and Symptoms
Coarse tremor of hands, tongue, eyelids
Nausea, vomiting, general weakness, anxiety
Tachycardia, sweating, hypertension, hallucinations,
irritability or depressed mood, poor sleep
Increased sympathetic tone, orthostatic hypotension
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Alcohol Abuse
Withdrawal Syndrome
– Treatment
Establish and maintain the airway
Determine if other drugs are involved
Establish IV access
Lactated Ringer’s or normal saline
Consider medications
25g D50W if hypoglycemic
100mg thiamine IV or IM
Transport, maintaining a sympathetic attitude, and
reassure the patient
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Epidemiology
Poison Control
Centers
Routes of Toxic
Exposure
General Principles of
Toxicologic
Assessment and
Management
Ingested Toxins
Inhaled Toxins
Surface-Absorbed
Toxins
Specific Toxins
Injected Toxins
Substance Abuse and
Overdose
Alcohol Abuse
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ