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Chapter 10
Poisoning and
Substance Abuse
National EMS Education
Standard Competencies (1 of 5)
Medicine
Recognizes and manages life threats based
on assessment findings of a patient with a
medical emergency while awaiting additional
emergency response.
National EMS Education
Standard Competencies (2 of 5)
Toxicology
• Recognition and management of
– Carbon monoxide poisoning
– Nerve agent poisoning
• How and when to contact a poison control
center
National EMS Education
Standard Competencies (3 of 5)
Immunology
Recognition and management of shock and
difficulty breathing related to
• Anaphylactic reactions
Pharmacology
Uses simple knowledge of the medications
that the EMR may self-administer or
administer to a peer in an emergency.
National EMS Education
Standard Competencies (4 of 5)
Medication Administration
Within the scope of practice of the EMR,
how to
• Self-administer medication
• Peer-administer medication
National EMS Education
Standard Competencies (5 of 5)
Emergency Medications
Within the scope and practice of the EMR
• Names
• Effects
• Indications
• Routes of administration
• Dosages for the medication administered
Introduction
• A poison is a substance that causes illness
or death when eaten, drunk, inhaled,
injected, or absorbed in relatively small
quantities.
• EMRs can save patients’ lives by quickly
recognizing and promptly treating serious
poisonings.
Patient Assessment for
Poisoning (1 of 5)
• Poisoning can be classified according to the
way the poison enters the body.
– Ingestion: Poison enters through the mouth and
is absorbed by the digestive system.
– Inhalation: Poison enters through the mouth or
nose and is absorbed by the mucous
membranes lining the respiratory system.
Patient Assessment for
Poisoning (2 of 5)
• Poison classifications (cont’d)
– Injection: Poison enters through a small opening
in the skin and spreads through the circulatory
system.
– Absorption: Poison enters through intact skin
and spreads through the circulatory system.
Patient Assessment for
Poisoning (3 of 5)
Patient Assessment for
Poisoning (4 of 5)
• General assessment and treatment
– Follow the patient assessment sequence.
– Obtain a thorough history from the patient or
from bystanders.
– Be alert for visual clues that may indicate
poisoning.
– Much of the emergency care depends on the
patient’s signs and symptoms.
Patient Assessment for
Poisoning (5 of 5)
Ingested Poisons (1 of 2)
• More than 80% of all cases of poisonings
are caused by ingestion.
• Chemical burns, odors, or stains may be
found around the patient’s mouth.
• Signs and symptoms
– Nausea
– Vomiting
– Abdominal pain
Ingested Poisons (2 of 2)
• Signs and symptoms (cont’d)
– Diarrhea
– Abnormal or decreased respirations
– Loss of consciousness
– Seizures
Treatment for Ingested
Poisons (1 of 5)
• Identify the poison.
• Call the National Poison Center for
instructions, and follow these instructions.
• If you are unable to contact the poison
center, dilute the poison by giving water.
• Arrange for prompt transport to a hospital.
Treatment for Ingested
Poisons (2 of 5)
• Dilution
– Most poisons can be diluted by giving the
patient large quantities of water.
– The patient must be conscious and able to
swallow.
Treatment for Ingested
Poisons (3 of 5)
• Activated charcoal
– Finely ground powder mixed with water
– Works by binding to the poison, thereby
preventing the poison from being absorbed in
the patient’s digestive tract
– Do not give if the patient:
• Has ingested an acid or an alkali
• Has ingested a base
• Is unconscious
Treatment for Ingested
Poisons (4 of 5)
• Activated charcoal
(cont’d)
– Usual dose:
• 25 to 50 grams for
an adult patient
• 12.5 to 25 grams
for a pediatric
patient
– Serve it in a covered
cup and give the
patient a straw.
Treatment for Ingested
Poisons (5 of 5)
• Vomiting
– In the past, syrup of ipecac was used to induce
vomiting.
– Today, it is recommended in only a few
situations.
– Inducing vomiting may cause the patient to
inhale the vomit into the lungs.
– Activated charcoal is considered more effective
and safer than syrup of ipecac.
Inhaled Poisons (1 of 2)
• Occurs if a toxic substance is breathed in
and absorbed through the lungs
– Some toxic substances (carbon monoxide) are
very poisonous but not irritating.
– Other toxic gases (chlorine gas and ammonia)
are very irritating to the respiratory tract.
Inhaled Poisons (2 of 2)
• Signs and symptoms
– Respiratory distress
– Dizziness
– Cough
– Headache
– Hoarseness
– Confusion
– Chest pain
Carbon Monoxide (1 of 2)
• Common causes of carbon monoxide
poisoning include:
– Improperly vented heating appliances
– Smoke (burning buildings)
Carbon Monoxide (2 of 2)
• Signs and symptoms
– Headache
– Nausea
– Disorientation
– Unconsciousness
– Flulike symptoms
• If you find several patients together who all
report these symptoms, remove everyone
from the structure or vehicle.
Irritants (1 of 4)
• Ammonia
– Often found in agricultural settings
– Has a strong, irritating odor
– Is highly toxic
– Causes violent coughing and skin burns
– Anyone who enters an environment containing
ammonia must wear a proper encapsulating suit
with a SCBA.
Irritants (2 of 4)
Courtesy of Lynn Betts/NRCS
Courtesy of Scott Health & Safety
Irritants (3 of 4)
• Chlorine
– Found around swimming pools and water
treatment plants
– Is severely irritating to the lungs and upper
respiratory tract
– Causes violent coughing and skin burns
– Anyone who enters an environment containing
chlorine must wear a proper encapsulating suit
with a SCBA.
Irritants (4 of 4)
• The presence of hazardous materials that
are toxic and those in which there is a
danger of fire or explosion should be
indicated by the appropriate placards.
© Mark Winfrey/ShutterStock, Inc.
Treatment for Inhaled Poisons
• Remove the patient from the source of the
gas.
– If the patient is not breathing, begin mouth-tomask breathing.
– If the patient is breathing, administer large
quantities of oxygen.
• Arrange for prompt transport.
• You may have to evacuate people first.
Injected Poisons (1 of 2)
• The two major causes of poisoning by
injection are:
– Animal bites and stings
– Toxic injection
Injected Poisons (2 of 2)
• Signs and symptoms
– Obvious injury site (bite or sting marks)
– Tenderness
– Swelling
– Red streaks radiating from the injection site
– Weakness
– Dizziness
– Localized pain
– Itching
Treatment for Insect Stings
and Bites (1 of 5)
• Keep the patient quiet and still.
• A light constricting band may be used if
there is severe swelling.
• Apply ice packs to reduce swelling and
pain.
• Some people may experience an extreme
allergic reaction and go into anaphylactic
shock.
Treatment for Insect Stings
and Bites (2 of 5)
• Signs and symptoms of anaphylactic shock
– Itching
– Hives
– Swelling
– Wheezing and severe respiratory distress
– Generalized weakness
– Loss of consciousness
Treatment for Insect Stings
and Bites (3 of 5)
• Signs and symptoms of anaphylactic shock
(cont’d)
– Rapid, weak pulse
– Rapid, shallow breathing
• Treatment for anaphylactic shock
– Maintain the patient’s ABCs.
– Administer oxygen if available.
– Elevating the patient’s legs may help.
Treatment for Insect Stings
and Bites (4 of 5)
• Treatment for anaphylactic shock (cont’d)
– Remove the allergen if possible.
– Monitor the patient’s vital signs.
– If the patient’s condition progresses to the point
of respiratory or cardiac arrest, begin mouth-tomask breathing or CPR.
– Immediately arrange for rapid transport.
Treatment for Insect Stings
and Bites (5 of 5)
• Treatment for anaphylactic
shock (cont’d)
– If the patient has a prescribed
auto-injector, help the patient
use it.
• Place the tip of the autoinjector against the outer
thigh.
• Push the auto-injector
firmly against the thigh and
hold it for several seconds.
Snake Bites (1 of 3)
• Four kinds of poisonous snakes in the
United States:
– Rattlesnake
– Cottonmouth
– Copperhead
– Coral snake
• A snake injects its poison into a person’s
skin and muscles with its fangs.
Snake Bites (2 of 3)
• Signs and symptoms
– Immediate pain at the bite site
– Swelling and tenderness around the bite site
– Fainting (from the emotional shock)
– Sweating
– Nausea and vomiting
– Shock
Snake Bites (3 of 3)
• The bite of the coral snake delivers a
slightly different poison that may cause
these additional problems:
– Respiratory difficulties
– Slurred speech
– Paralysis
– Coma
– Seizures
Treatment for Snake Bites
• Keep the patient calm and quiet.
• Have the patient lie down and try to relax.
• Wash the bite area with soap and water.
• If the bite occurred on the arm or leg, splint
the affected extremity.
• Treat the patient carefully.
• Arrange for prompt transport to a hospital
with antivenin.
Absorbed Poisons (1 of 2)
• Occurs when a poisonous substance enters
the body through the skin
• Common absorbed poisons:
– Insecticides
– Toxic industrial chemicals
• Signs and symptoms
– Traces of powder or liquid on the skin
– Inflammation or redness of the skin
Absorbed Poisons (2 of 2)
• Signs and symptoms (cont’d)
– Chemical burns
– Skin rash
– Burning
– Itching
– Nausea and vomiting
– Dizziness
– Shock
Treatment for Absorbed
Poisons (1 of 2)
• Ensure that the patient is no longer in
contact with the toxic substance.
• Brush—do not wash—any dry chemical off
the patient.
– Contact with water may activate the dry
chemical and result in a burning reaction.
• Wash the patient completely for at least 20
minutes.
Treatment for Absorbed
Poisons (2 of 2)
• If additional EMS personnel are delayed,
contact the poison control center or your
medical director for additional treatment.
• If the patient is experiencing shock, have
the patient lie down and elevate the legs.
• If the patient is having difficulty breathing,
administer oxygen.
Nerve Agents (1 of 5)
• Nerve agents can be absorbed through the
skin, inhaled, or injected.
• They are among the most deadly chemicals
developed.
– Small quantities can kill large numbers of
people by causing cardiac arrest within minutes
of exposure.
Nerve Agents (2 of 5)
• Nerve agents block an essential enzyme in
the nervous system and cause these
SLUDGE-like symptoms.
Nerve Agents (3 of 5)
• Additional symptoms of organophosphate
poisoning include:
– Shortness of breath
– Slow heart rate
– Muscle weakness, twitching, or paralysis
– Slurred speech
– Seizures
– Loss of consciousness
Nerve Agents (4 of 5)
• Four of the most common nerve agents:
– Sarin (GB)
– Soman (GD)
– Tabun (GA)
– V agent (VX)
• If you are called to the scene of a nerve
agent poisoning, keep yourself, rescuers,
and bystanders from being contaminated.
Nerve Agents (5 of 5)
• A well-trained hazardous materials team in
special protective equipment is needed to
remove and decontaminate people.
• SCBA and encapsulating suits are needed
to prevent exposure to rescuers.
Treatment for Nerve Agents
(1 of 2)
• Assess and support the patient’s ABCs.
• Nerve agent antidote kits:
– DuoDote kit: contains one auto-injector syringe
that contains atropine and pralidoxime chloride
– Mark I kit: contains two auto-injector syringes—
atropine and pralidoxime chloride
Treatment for Nerve Agents
(2 of 2)
Substance Abuse
• According to the National Survey on Drug
Use, 8.9% of the US population (2.2 million
people) are substance abusers.
• Substance abuse results in an increased
incidence of injuries and illness.
– Even if the primary reason for the call is not
substance abuse, it can still be a contributing
factor.
Alcohol (1 of 3)
• Most commonly abused drug in the United
States today
– Involved in a significant number of traffic
fatalities, murders, and suicides
• Symptoms of alcohol intoxication are similar
to those of other medical illnesses or severe
injuries.
– Be extra careful with your examination.
Alcohol (2 of 3)
• Alcohol is an addictive, depressant drug.
– Persons physically dependent on alcohol can
develop severe withdrawal symptoms.
– The most severe symptoms are delirium
tremens (DTs).
• Signs and symptoms of DTs
– Shaking
– Restlessness
Alcohol (3 of 3)
• Signs and symptoms of DTs (cont’d)
– Confusion
– Hallucinations
– Gastrointestinal distress
– Chest pain
– Fever
• DTs is a serious medical emergency that
can be fatal.
Drugs (1 of 9)
• May be ingested,
inhaled, injected, or
absorbed into the
body
Courtesy of DEA
• Look for clues that
indicate the type of
drug and the way it
was administered.
• Abuse of prescription
drugs has increased in
recent years.
Drugs (2 of 9)
• Amphetamines
– Stimulate the central nervous system
– Include speed, ice, crystal, cocaine (coke)
– Signs of amphetamine use include:
• Restlessness
• Irritability
• Talkativeness
– Keep patients from harming themselves and
transport them to a facility.
Drugs (3 of 9)
• Barbiturates
– Depressants (drugs that depress the nervous
system)
– Include tranquilizers, opiates, and marijuana
– An overdose can result in respiratory
depression or arrest.
– If the patient is not breathing, begin mouth-tomask resuscitation.
– If cardiac arrest occurs, begin CPR.
Drugs (4 of 9)
• Hallucinogens
– PCP, LSD, peyote, mescaline, mushrooms
– Chemicals that cause people to see things that
are not there
– Signs and symptoms of PCP overdose
• Convulsions
• Coma
• Heart and lung failure
• Stroke
Drugs (5 of 9)
• Hallucinogens (cont’d)
– Try to reduce auditory and visual stimulation.
– Approach each scene with caution.
– Arrange for transport.
Drugs (6 of 9)
• Abused inhalants
– Intentional inhalation of volatile chemicals
– Many of these substances can be bought in
hardware stores.
– May cause drowsiness, unresponsiveness,
seizures, or sudden cardiac death
– Try to keep the patient from struggling.
Drugs (7 of 9)
• Abused inhalants (cont’d)
– Support the patient’s ABCs.
– Give high-flow oxygen.
– Carefully monitor the patient’s vital signs.
– Arrange for prompt transport.
Drugs (8 of 9)
• Toxic injection from drugs
– The patient’s reaction depends on the quantity
and type of drug injected.
– Signs and symptoms include:
• Weakness
• Dizziness
• Fever
• Chills
Drugs (9 of 9)
• Toxic injection from drugs (cont’d)
– Support the patient.
– Treat the symptoms.
– Provide transport to a medical facility.
– Check the injection site for redness, swelling,
and increased skin temperature (indications of
infection).
Treatment for a Drug Overdose
• Provide basic life support.
• Keep the patient from hurting self and
others.
• Provide reassurance and psychological
support.
• Arrange for prompt transport.
• Avoid classifying or judging the patient.
Summary (1 of 3)
• The four primary routes by which poisons
enter the body are ingestion, inhalation,
injection, and absorption.
• An ingested poison is taken by mouth.
• An inhaled poison is breathed in and
absorbed through the lungs.
Summary (2 of 3)
• The two major causes of poisoning by
injection are (1) animal bites and stings and
(2) toxic injection.
• Poisoning by absorption occurs when a
poisonous substance enters the body
through the skin.
Summary (3 of 3)
• Many nerve agents are the same types of
chemicals as insecticides. Your role in
incidents involving nerve agents is to keep
yourself and others from becoming
exposed.
• Pay special attention to scene safety and do
not enter a hazardous environment without
the proper training and equipment.
Review
1. The most common route for poisonings is:
A. injection.
B. ingestion.
C. inhalation.
D. absorption.
Review
Answer:
B. ingestion.
Review
2. Which of the following would NOT be
considered appropriate management of
anaphylactic shock?
A. Administer oxygen if it is available.
B. Remove the allergen.
C. Induce vomiting.
D. Immediately arrange for transport.
Review
Answer:
C. Induce vomiting.
Review
3. Which of the following are common causes
of carbon monoxide poisoning?
A. air conditioning units
B. cleaning supplies
C. improperly vented heating appliances
D. paints and paint thinners
Review
Answer:
C. improperly vented heating appliances
Credits
• © Mark C. Ide
• Background slide image (ambulance):
© Comstock Images/Alamy Images
• Background slide images (non-ambulance):
© Jones & Bartlett Learning. Courtesy of
MIEMSS.