Chapter 27
Toxicology
National EMS Education
Standard Competencies
Medicine
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression and implement a
comprehensive treatment/disposition plan for
a patient with a medical complaint.
National EMS Education
Standard Competencies
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
Anatomy, physiology, pathophysiology,
assessment, and management of
− Inhaled poisons
− Ingested poisons
−
−
−
−
Injected poisons
Absorbed poisons
Alcohol intoxication and withdrawal
Opiate toxidrome
National EMS Education
Standard Competencies
Anatomy, physiology epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management of
the following toxidromes and poisonings
−
−
−
−
−
Cholinergics
Anticholinergics
Sympathomimetics
Sedative/hypnotics
Opiates
National EMS Education
Standard Competencies
Anatomy, physiology epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management of
the following toxidromes and poisonings
(cont’d)
− Alcohol intoxication and withdrawal
− Over-the-counter and prescription medications
− Carbon monoxide
− Illegal drugs
− Herbal preparations
Introduction
• Paramedics are often called to treat patients
who are abusing licit or illicit drugs.
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Introduction
• Poison
− Substance that is
toxic by nature, no
matter how it gets
into the body or
how much is taken
• Drug
− Substance that
has a therapeutic
effect when given
in the appropriate:
• Circumstances
• Dose
Introduction
• Bioavailability: extent to which a drug is
present in sufficient amounts to produce
desired result
• Half-life: point when the bioavailability of a
given drug has decreased to 50%
• Excretion: How a drug is removed from the
body
Types of Toxicologic
Emergencies
• Unintentional
− Can occur in many
ways, including:
• Children who
mistakenly put
poison in their
mouths
• Intentional
− “Overdose” or
“intimate crime”
Poison Centers
• Poison Centers (1-800-222-1222) can
provide a rundown on a poison’s:
− Ingestion
− Toxic potential
− Steps to negate effects
• Never hesitate to call!
Routes of Absorption
• Poisoning by ingestion
− Immediate damage or delayed effects
• What is ingested?
• Why was it ingested?
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− Generally provides time for
identification/treatment
− Management: remove or
neutralize the poison
Routes of Absorption
• Poisoning by inhalation
− Toxic agent may be present in the environment.
• Patient will inhale the toxin as long as he/she
remains in the environment.
• Likely to find more than one patient
− May be accidental or intentional
Routes of Absorption
• Poisoning by inhalation (cont’d)
− Window for identification/treatment is limited.
− Consider scene safety.
− Look for information to help identify toxin.
− Utilize the Poison Center and medical control.
− Correct hypoxia.
Routes of Absorption
• Poisoning by injection
− Usually gain access as the result of:
• Stings or bites from insects and animals
• Abuse of intravenously administered drugs
− Possibilities vary by geographic location.
Routes of Absorption
• Poisoning by injection (cont’d)
− Some poisons are neurotoxic; others produce
localized or systemic reactions.
− Physical findings will provide clues.
− The patient may be able to identify the culprit.
Routes of Absorption
• Poisoning by absorption
− Poisonings by pesticides are often the most
serious.
Understanding and Using
Toxidromes
• Toxidrome: the syndrome-like symptoms of
a class or group of similar poisonous agents
Overview of Substance Abuse
• Drug abuse: use of drugs that causes harm
to the user or to others affected by the user
• Habituation: psychological dependence on
a drug or drugs
Overview of Substance Abuse
• Physical dependence: a physiologic state of
adaptation to a drug
• Psychological dependence: emotional state
of craving a drug to maintain well-being
• Tolerance: physiologic adaptation to drug
effects
Overview of Substance Abuse
• Withdrawal syndrome: occurs after the
abrupt cessation or decrease of a drug
• Drug addiction: chronic disorder
characterized by the compulsive use of a
substance
• Antagonist: drug with affinity for a cell
receptor
Overview of Substance Abuse
• Potentiation: enhancement of the effect of
one drug by taking it with another drug.
• Synergism: action of two substances in
which the effects are greater than
independent effects
Patient Assessment
• Toxicologic emergencies are generally
considered medical emergencies.
• General assessment approach is the same
for all patients.
Scene Size-Up
• Patients who have taken an overdose may
be dangerous.
− Call for law enforcement or a crisis unit if
necessary.
Primary Assessment
• Form a general impression.
• Identify concerns or life threats.
• Identify MOI or NOI.
• Identify need for additional resources.
• Set the priority.
History Taking
• Use OPQRST and SAMPLE history.
• Obtain the following:
− What is the agent?
− When was it ingested, injected, absorbed, or
inhaled?
History Taking
• Obtain the following (cont’d):
− How much was taken, injected, absorbed, or
inhaled?
− What else was taken?
− Has the patient vomited or aspirated?
− Why was the substance taken?
Secondary Assessment
• For trauma, classify as significant or
nonsignificant MOI.
• Prioritize injuries.
• Manage injuries.
• Document findings.
Reassessment
• Monitor patient’s condition.
• Reprioritize the status if necessary.
• Check interventions.
Emergency Medical Care
• Ensure scene safety.
• Maintain the airway.
• Ensure that breathing is adequate.
• Ensure that circulation is not compromised.
• Administer high-concentration oxygen.
Emergency Medical Care
• Establish vascular
access.
• Be prepared to
manage shock,
coma, seizures,
and dysrhythmias.
• Transport the
patient as soon as
possible.
Alcohol
• Most widely abused drug in the United
States
• Red flags may include:
− Drinking alone or in “secret”
− Loss of memory or “blackouts”
− “Green tongue syndrome”
Alcohol
• Pathophysiology
− Evolves through
two distinct
phases:
• Problem drinking
• Physical
dependence
− More prone to
serious illnesses
and injuries
Alcohol
• Acute alcohol intoxication
− Establish and maintain the airway.
− Give high concentration oxygen.
− Assist ventilations as necessary.
− Establish vascular access.
Alcohol
• Acute alcohol intoxication (cont’d)
− Monitor ECG rhythm.
− Assess blood glucose level.
− Administer thiamine if directed by medical
control.
− Transport to an appropriate facility.
Alcohol
• Withdrawal seizures
− Occur within 12 to 48 hours of last drink
− Use the same care as for alcohol intoxication.
− Consider administering benzodiazepines.
Alcohol
• Delirium tremens
− Usually starts 48 to 82 hours after the last drink
− Signs and symptoms may include:
• Tremors
• Diaphoresis
• Hallucinations
• Hypotension
Alcohol
• Delirium tremens (cont’d)
− Try to keep the patient calm.
− Administer supplemental oxygen by nasal
cannula.
− Establish vascular access.
− Check breath sounds.
− Maintain an ongoing dialogue.
Stimulants
• Users may become addicted within days.
− Success of overcoming addiction is low.
− May be taken orally, smoked, or injected
− Clinical presentation may include:
• Excitement
• Delirium
• Dilated pupils
Cocaine
• Alkaloid extracted from Erythroxylon coca
• Pathophysiology
− A local anesthetic and a CNS stimulant
− Quickly absorbed across mucosal membranes
− Crack cocaine: cocaine mixed with baking soda
and water that is cooked or baked
Cocaine
• Pathophysiology (cont’d)
− Effects are felt between 8 seconds to 1 minute.
− When the effects wear off, the user experiences
a “crash.”
− Speedballing: use of heroin and cocaine
Cocaine
• Assessment
− Can cause serious complications, including:
• Lethal ECG dysrhythmias
• Acute myocardial infarction
• Pneumomediastinum
− Quinidine-like effect on cardiac conduction
Amphetamine, Methamphetamine, and
Amphetamine-like Drugs
• Amphetamines
include:
− Methamphetamine
− Methylenedioxyam
phetamine
− Methylenedioxymethamphetamine
• Have a number of
clinical applications
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Amphetamine, Methamphetamine, and
Amphetamine-like Drugs
• Methamphetamine
− Low-cost, long-acting (up to 12 hours)
− Ingredients are available locally
− Patient management is the same as for
cocaine.
Bath Salts
• Active ingredient is methcathinone
• Users typically snort, smoke, or ingest.
− More serious side effects include:
• Agitation
• Hallucinations
• Paranoia
Management of Stimulant
Abuse
• Establish and maintain the airway.
• Give high-concentration oxygen.
• Establish vascular access.
• Apply the ECG monitor, pulse oximeter, and
capnometer.
Management of Stimulant
Abuse
• Administer benzodiazepines per protocol.
• Manage hypotension with serial fluid
infusions.
• Consider nitroprusside for hypertension.
Management of Stimulant
Abuse
• Consider haloperidol for violent behavior.
• Transport to the appropriate facility.
• Follow protocols regarding beta blockers.
• Apply ice packs to reduce hyperthermia.
Management of Stimulant
Abuse
• Maintain urine output.
• Administer benzodiazepines for seizure.
• Neuromuscular blockade may be needed.
Marijuana and Cannabis
Compounds
• Derived from
Cannabis sativa
• Clinical uses:
− Treatment of
glaucoma
− Relief of nausea
and appetite loss
from chemotherapy
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Marijuana and Cannabis
Compounds
• Pathophysiology
− Psychoactive ingredient:
delta 9-tetrahydrocannabinol
− Usually smoked, but can be ingested
− Signs and symptoms may include:
• Euphoria
• Decreased short-term memory
• Bloodshot eyes
Marijuana and Cannabis
Compounds
• Assessment and management
− Focus on supportive care.
• Spice
− A blend of synthetic cannibinoids
− Can make people delirious
Hallucinogens
• Causes some distortion of sense perception
− Experience is affected by:
• User’s previous drug experience
• Dose taken
• User’s expectations
• Social setting
• Classified as synthetic or naturally occurring
LSD
• Pathophysiology
− Primarily affects the senses
− Physiologic effects may include:
• Mild tachycardia
• Mild hypertension
• Dilated pupils
LSD
• Assessment and management
− Treatment is primarily supportive.
− Limit sensory stimulation as much as possible.
Phencyclidine (PCP)
• Pathophysiology
− Typically smoked or snorted (can be injected)
− Small doses can produce symptoms of
intoxication.
− Hallmarks:
• Mind-body separation
• Hallucinations
• Violent outbreaks
Phencyclidine (PCP)
• Assessment and management
− Try to calm the patient, and address wounds.
− Administer high-flow oxygen.
− Monitor vital signs.
− Provide safe transport.
Ketamine
• Pathophysiology
− Typical oral dosing is 75–300 mg.
− At higher doses, user may have:
• Pronounced nausea
• Difficulty moving
• Complaint of “entering another reality”
Ketamine
• Assessment and management
− Secure the patient well.
− Assess and manage ABCs.
− Provide oxygen therapy.
− Establish vascular access.
− Provide safe transport.
Peyote and Mescaline
• Pathophysiology
− Profound vomiting
often occurs.
− Symptoms include:
• Dilated pupils
• Increased pulse
rate
• Mild hypertension
• Increased body
temperature
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Peyote and Mescaline
• Assessment and management
− Pay attention to the ABCs.
− Administer supplemental oxygen.
− Monitor vital signs.
− Provide psychological support.
− Arrange safe transport.
Psilocybin Mushrooms
• Typical dose: 2–4
mushrooms
• Pathophysiology
− Onset: 30 minutes
− Effects last 4–6 hours.
− Symptoms may include:
• Vomiting
• Mydriasis
• Mild tachycardia
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Psilocybin Mushrooms
• Assessment and management
− Pay attention to ABCs.
− Monitor vital signs.
− Safely transport.
− Establish vascular access.
Sedative and Hypnotics
• Sedative: reduce anxiety and calm agitation
• Hypnotic: used as sleeping aids
• Function as CNS depressants
Barbiturates
• Pathophysiology
− Four basic configurations:
• Long-acting
• Intermediate-acting
• Short-acting
• Ultra-short-acting
Barbiturates
• Assessment
− Mild to moderate barbiturate intoxication
presents much like alcohol intoxication.
− As dose increases:
• Increasingly lethargic
• Increasingly lower level of responsiveness
Barbiturates
• Management
− Airway control is the first priority.
− Administer high-concentration oxygen.
− Monitor ECG rhythm.
− Establish venous access.
− Use pulse oximetry and capnography.
Barbiturates
• Management (cont’d)
− If shock develops, crystalloids may be needed.
− For long-acting barbiturates, administer sodium
bicarbonate to alkalinize the urine.
− Gastric emptying is not recommended.
Barbiturates
• Management (cont’d)
− Withdrawal syndrome will occur in 24 hours.
• Potentially life-threatening signs and symptoms
− Prevent seizures and cardiovascular collapse.
− Rapid transport is indicated.
Benzodiazepines
• Pathophysiology
− Stimulate the gamma-aminobutyric acid
pathways, resulting in:
• Sedation
• Reduced anxiety
• Relaxation of striated muscle
Benzodiazepines
• Assessment
− Single-entity overdose has low morbidity rate
− Common clinical effects may include:
• Altered mentation
• Drowsiness
• Slurred speech
• General incoordination
Benzodiazepines
• Management
− Assess and manage the airway.
− Administer high-concentration oxygen.
− Establish vascular access.
Benzodiazepines
• Management (cont’d)
− Apply ECG monitor, pulse oximeter, and
capnometer.
− Consider administering flumazenil.
− Transport to appropriate facility.
Narcotics, Opiates, and
Opioids
• Narcotic: drug that produces sleep or
altered mental status
• Opiate: natural drugs derived from opium
• Opioid: non-opium-derived synthetics
Narcotics, Opiates, and
Opioids
• Pathophysiology
− Bind with receptor sites in the brain and tissues
− Effects are lessened when taken orally.
− A dose of naloxone may not permanently
reverse the effects of heroin.
Narcotics, Opiates, and
Opioids
• Assessment
− Classic presentation features:
• Euphoria
• Hypotension
• Respiratory depression
• Pinpoint pupils
− Produce a dreamlike state
Narcotics, Opiates, and
Opioids
• Management
− Establish a patent airway and vascular access.
• Administer naloxone.
− If the patient does not respond to naloxone:
• They may have taken a potent synthetic drug.
• They may have taken multiple drugs.
Cardiac Medications
• Pathophysiology
− Alter the function or rhythm of the heart
− Major classes include:
• Antidysrhythmics
• Beta blockers
• Calcium channel blockers
• Cardiac glycosides
• Antigiotensin-converting enzyme inhibitors
Cardiac Medications
• Type I antidysrhythmic medications
− Includes procainamide and lidocaine
− Affect depolarization and impulse conduction
− Treatment of overdose is usually supportive.
• In certain instances, IV sodium bicarbonate may be
used.
Cardiac Medications
• Type II antidysrhythmic medications
− Used to control pulse rate and blood pressure
− High doses of IV glucagon is the antidote.
− Atropine, epinephrine infusion, and cardiac
pacing may be required in severe cases.
Cardiac Medications
• Type III antidysrhythmic medications
− Cause a prolongation of the cardiac action
potential and increase the refractory period
− Treatment is primarily supportive.
• IV magnesium sulfate may be used.
Cardiac Medications
• Type IV antidysrhythmic medications
− Control pulse rate and blood pressure
− Slow calcium influx into cells.
− Treated with IV calcium chloride or calcium
gluconate
Cardiac Medications
• Assessment and management
− Signs and symptoms vary but may include:
• Hypotension
• Weakness
• Rhythm disturbances
• Difficulty breathing
Cardiac Medications
• Assessment and management (cont’d)
− Ensure a patent airway and adequate
ventilation.
− Administer high-flow supplemental oxygen.
− Establish vascular access.
− Maintain contact with medical control.
Organophosphates
• A major component in many insecticides
− Include:
• Acephate
• Diazinon
• Malathion
• Carbamates
• Warfarins
• Pyrethrums
Organophosphates
• Pathophysiology
− Exert their effects at junctions of the nerve cells
of the autonomic nervous system
− Symptoms may include:
• Anxiety and restlessness
• Dizziness
• Tremors
Organophosphates
• Pathophysiology (cont’d)
− Signs and symptoms will usually present within
the first 8 hours.
− SLUDGE is helpful in diagnosis.
Organophosphates
• Assessment and management
− Decontaminate before initiating care.
− Establish and maintain the airway.
− Establish vascular access.
• Administer atropine IV push.
• Administer pralidoxime infused with normal saline.
Organophosphates
• Assessment and management (cont’d)
− Apply the ECG monitor, pulse oximeter, and
capnometer.
− Immediately transport.
Carbon Monoxide
• Pathophysiology
− Colorless, odorless, tasteless gas
− Displaces oxygen, preventing oxygen to tissues
• Suffocation at the cellular level
Carbon Monoxide
• Assessment
− Signs and symptoms are variable and vague.
− Physical examination may reveal:
• Bounding pulses
• Dilated pupils
• Pallor or cyanosis
• Cherry red color of the skin
Carbon Monoxide
• Management
− Provide the highest concentration of oxygen.
− Remove the patient from the environment.
− Establish and maintain the airway.
− Give high-flow supplemental oxygen.
Carbon Monoxide
• Management (cont’d)
− Keep the patient quiet and at rest.
− Monitor the ECG rhythm and LOC.
− Transport to the appropriate facility.
Chlorine Gas
• Chlorine compounds are commonly used in
the home and in occupational settings.
Chlorine Gas
• Pathophysiology
− Minor exposure may
include:
• Burning sensation in
eyes, nose, and throat
• Slight cough
− Severe exposure
may include:
• Cyanosis
• Shock
• Seizures
Chlorine Gas
• Assessment and management
− Remove all patients from the area and triage.
− Deliver high-concentration humidified oxygen.
− Irrigate burning or itching eyes and skin.
Cyanide
• Pathophysiology
− Rapid-acting and deadly poison
− Combines with cytochrome oxidase, which
blocks utilization of oxygen at the cellular level
• Death within minutes to an hour if ingested
Cyanide
• Assessment
− Patient may have an altered mental status.
− Signs and symptoms may include:
• Palpitations
• Odor of almonds on the breath
• Rapid respirations and pulses
• Bright red venous blood and body
Cyanide
• Management
− Should be treated as fast as possible
− If cyanide was inhaled:
• Remove the patient from the source.
• Establish an airway.
• Administer 100% supplemental oxygen.
• Assist ventilations as needed.
Cyanide
• Management (cont’d)
− Use the cyanide antidote kit.
− If unavailable, break amyl nitrite into gauze pad.
• Hold over the patient’s nose for about 20 seconds
• Allow the patient to breathe a high concentration of
oxygen for about 40 seconds.
Cyanide
• Hydroxocobalamin
− A safe alternative or adjunct to traditional
treatment
− Included in the “Cyanokit”
− Allergy/anaphylaxis is the primary concern.
Cyanide
• Methylene blue
− An antidote used to treat methemoglobinemia
− Methemoglobinemia: alteration of hemoglobin
• Induced by amyl nitrite and sodium nitrite
− Administered under the guidance of an expert
Caustics
• Strong acids and
strong alkalis
− Mostly involves
accidental dermal
or ocular exposure
Caustics
• Severe pain
• Burns
• Difficulty talking
© Jones & Bartlett Learning.
Photographed by Kimberly Potvin.
− Cause chemical
injury to tissues
− Signs and
symptoms include:
Courtesy of Lynn Betts/NRCS
• Pathophysiology
Caustics
• Assessment and management
− For caustic ingestion:
• Give milk.
• Establish vascular access.
• Immediate transport is indicated.
− For dermal exposure:
• Dilute and flush away substance.
Caustics
• Assessment and management (cont’d)
− For eye exposure:
• Place the prong section of a nasal cannula on the
bridge of the patient’s nose.
• Plug in a macro IV administration set, and provide
continuous irrigation.
Caustics
• Assessment and management (cont’d)
− DO NOT:
• Give any “neutralizing substances.”
• Induce vomiting.
• Perform gastric lavage.
• Give activated charcoal.
Common Household Items
• May include:
− House plants
− Pesticides and herbicides
− Hydrocarbon products
− Glue
− Cleaning agents
Drugs That Increase Sexual
Gratification
• Sildenafil (Viagra)
− For hypotension, administer normal saline.
− For cardiac arrest, follow local protocols.
• Marijuana
− Supportive care is indicated.
Drugs That Increase Sexual
Gratification
• Cocaine and other stimulant drugs
− Administer serial boluses of normal saline.
• Amyl nitrite
− Hypotension may result.
• Ecstasy
Drugs That Increase Sexual
Gratification
• Dextromethorphan
− Large doses can lead to:
• Hallucinations
• Loss of motor control
• Dreamlike euphoria
Drugs Used to Facilitate
Sexual Assault
• GHB (Gamma-hydroxybutyrate)
− Odorless and colorless liquid, with a salty taste
− Exerts its effects within 30 to 60 minutes
− Can produce a hypnotic effect
Drugs Used to Facilitate
Sexual Assault
• GHB (cont’d)
− Establish and maintain the airway.
− Monitor LOC.
− Assist breathing and administer oxygen.
− Establish vascular access.
− Provide rapid transport.
Drugs Used to Facilitate
Sexual Assault
• Rohypnol (roofies)
− Potent benzodiazepine
− Illegal to make or distribute
Methyl Alcohol
• Pathophysiology
− Formaldehyde and formic acid are responsible
for methanol poisoning.
− Peak blood levels attained within 30 to 90
minutes.
© Jones & Bartlett Learning. Photographed by Kimberly Potvin.
© Jones & Bartlett Learning. Photographed by Kimberly Potvin.
Methyl Alcohol
• Assessment
− Symptoms appear 12–18 hours after ingestion:
• Nausea and vomiting
• Headache or vertigo
• Abdominal pain
• Blurred vision or blindness
Methyl Alcohol
• Assessment (cont’d)
− Physical exam findings may include:
• Altered mental status
• Dilated pupils with sluggish or no reaction
• Tachypnea
• Hypotension
Methyl Alcohol
• Management
− Establish the airway and vascular access.
− Assess blood glucose level.
− Consider sodium bicarbonate.
− Provide immediate transport.
− Activated charcoal is contraindicated.
Ethylene Glycol
• A colorless, odorless liquid
− Lethal dose: 2 mL/kg, or as little as 150 mL
• Pathophysiology
− Water-soluble
− Liver and kidneys metabolize into toxic
metabolites
Ethylene Glycol
• Assessment
− Stage 1:
• CNS depression
• Intoxicated
appearance
• Nausea, vomiting
• Seizures
• Coma
− Stage 2:
•
•
•
•
•
Tachypnea
Tachycardia
Hypertension
Rales
CHF
− Stage 3:
• Renal damage
Ethylene Glycol
• Management
− Care is the same as for methanol poisoning.
• May be ordered to administer calcium gluconate
Hydrocarbons
• Hydrocarbon inhalation
− “Bagging” or “huffing” everyday products
• “Huffing”: breathing fumes off a soaked rag or towel
• “Bagging”: placing a soaked rag or towel into a bag
and breathing in the fumes
Hydrocarbons
• Hydrocarbon inhalation (cont’d)
− Remove from the noxious environment.
− Administer high-concentration oxygen.
− Promptly transport to the appropriate facility.
Hydrocarbons
Hydrocarbons
• Hydrocarbon ingestion
− Pathophysiology
• Lower the viscosity, higher the risk of aspiration
• Low viscosity facilitates the uptake of a hydrocarbon
by tissues of the CNS.
• Many products cause gastric irritation.
Hydrocarbons
• Hydrocarbon ingestion (cont’d)
− Assessment and management
• All symptomatic patients should be transported.
• Decontaminate the patient.
• Establish and maintain airway and ventilation.
• Establish vascular access.
Hydrocarbons
• Hydrocarbon ingestion (cont’d)
− Assessment and management (cont’d)
• Continuously monitor the ECG rhythm.
• Administer sequential infusions of normal saline.
• Transport the patient to the most appropriate facility.
Hydrofluoric Acid/
Hydrogen Fluoride
• Pathophysiology
− Toxicity from an extremely small amount
− Leaches calcium and magnesium from body:
• Profound hypocalcemia and hypomagnesemia
• A massive release of sequestered potassium
Hydrofluoric Acid/
Hydrogen Fluoride
• Pathophysiology (cont’d)
− Inhalation causes:
•
•
•
•
Bronchospasm
Local airway injury
Wheezes, rhonchi
Pneumonitis or
pulmonary edema
− Ingestion causes:
•
•
•
•
Vomiting
Abdominal pain
Gastritis
Profound systemic
toxicity
Hydrofluoric Acid/
Hydrogen Fluoride
• Assessment and management
− Manage the ABCs.
− For ingestion, provide stomach evacuation.
− Administer a calcium- or magnesium-containing
substance.
Hydrogen Sulfide
• Pathophysiology
− Highly toxic, colorless gas, with rotten-egg odor
− Poisoning usually occurs by inhalation.
− Affects all organs, but has the most impact on
the lungs and CNS.
Hydrogen Sulfide
• Pathophysiology (cont’d)
− Low-level exposure
can cause:
• Eye, nose, and throat
irritation
• Headache
• Bronchitis
− Very high exposure
can cause:
•
•
•
•
Seizures
Shock
Coma
Cardiopulmonary
arrest
Hydrogen Sulfide
• Assessment and management
− No proven antidote.
− Remove patient from the contaminated area.
− Management is largely supportive.
Oxides of Nitrogen
• Includes nitric oxide and nitrogen dioxide
• Pathophysiology
− Exposure can result in:
• Irritation of the throat and upper respiratory tract
• Buildup of fluid in the lungs
• Difficulty breathing
Oxides of Nitrogen
• Assessment and management
− Prehospital treatment includes:
• Remove patient from environment.
• Provide supportive care.
• Gain IV access.
• Be prepared to intubate.
Tricyclic Antidepressants
• Pathophysiology
− Requires close attention to dosing compliance
− Small therapeutic window
− Involved in more deaths than any other class of
medication
Tricyclic Antidepressants
• Assessment
− Signs and symptoms may include:
• Altered mental status
• Dysrhythmias
• Dilated pupils
• Urinary retention
• QT prolongation on ECG
Adapted from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.
Tricyclic Antidepressants
• Management
− Maintain the airway.
− Administer high-flow supplemental oxygen.
− Establish vascular access.
− Provide continuous ECG monitoring.
Tricyclic Antidepressants
• Management (cont’d)
− Consider activated charcoal and sodium
bicarbonate.
− Manage hypotension with normal saline.
− Assess blood glucose levels.
Tricyclic Antidepressants
• Management (cont’d)
− Seizures: consider benzodiazepines and
intubation.
− Provide rapid transport.
Monoamine Oxidase Inhibitors
• Pathophysiology
− Increase norepinephrine and serotonin levels
− Major potential for drug interactions
− Tight therapeutic window
− Can precipitate a hypertensive crisis if taken
with tyramine-containing foods
Monoamine Oxidase Inhibitors
• Assessment
− Symptoms are often delayed 6–12 hours or
more following ingestion.
− Prepare to manage a life-threatening event.
Monoamine Oxidase Inhibitors
• Assessment (cont’d)
− Early signs and
symptoms include:
•
•
•
•
Hyperactivity
Dysrhythmias
Hyperventilation
Nystagmus
− With a severe
overdose, expect:
•
•
•
•
•
Bradycardia
Hypotension
Seizures
Pulmonary edema
Cardiac arrest
Monoamine Oxidase Inhibitors
• Management
− No antidote available for overdose
− Establish and maintain the airway.
− Administer high-flow supplemental oxygen.
− Establish large-bore vascular access.
− Monitor the ECG rhythm.
Monoamine Oxidase Inhibitors
• Management (cont’d)
− Consider activated charcoal.
− Treat hypotension with normal saline.
− If seizures occur, treat with benzodiazepines.
− If hypertensive, consider phentolamine
Selective Serotonin Reuptake
Inhibitors
• Pathophysiology
− Have a larger therapeutic window than MAOIs
− Fewer anticholinergic and cardiac effects than
TCAs
Selective Serotonin Reuptake
Inhibitors
• Assessment
− 50% of patients may be asymptomatic.
− Most common symptoms are:
• Nausea, vomiting
• Dysrhythmias
• Sedation
• Tremors
Selective Serotonin Reuptake
Inhibitors
• Management
− Establish and maintain the airway.
− Administer high-flow supplemental oxygen.
− Establish vascular access.
− Provide continuous ECG monitoring.
Selective Serotonin Reuptake
Inhibitors
• Management (cont’d)
− Consider activated charcoal and
benzodiazepines.
− If widening of the QRS, consider sodium
bicarbonate administration.
− Transport to appropriate facility.
Selective Serotonin Reuptake
Inhibitors
• Serotonin syndrome
− Can occur with drugs that increase central
serotonin neurotransmission
− Difficult to diagnosis
• Lower muscle rigidity is one of the few classic signs.
− Primary treatment is to discontinue therapy.
Lithium
• Pathophysiology
− Almost completely absorbed in the GI tract
roughly 8 hours after ingestion
− High risk of toxic levels and overdose
Lithium
• Assessment
− Early signs and
symptoms:
•
•
•
•
•
Nausea
Vomiting
Hand tremors
Excessive thirst
Slurred speech
− Increased toxicity:
•
•
•
•
•
•
Ataxia
Muscle weakness
Incoordination
Blurred vision
Hyperreflexia
Seizures and coma
Lithium
• Management
− Establish and maintain the airway.
− Establish vascular access and treat
hypotension.
− Maintain continuous ECG monitoring.
− Transport to appropriate facility.
Nonprescription Pain
Medications
• Pathophysiology
− NSAIDS are rapidly absorbed from the GI tract
before being eliminated.
− Half-lives vary widely.
− Most problems involve long-term use.
Nonprescription Pain
Medications
• Assessment
− Signs and symptoms may include:
• Altered mentation
• Seizures
• Hypotension
• Nausea, vomiting
− Many patients remain asymptomatic.
Nonprescription Pain
Medications
• Management
− Establish the airway and vascular access.
− Treat hypotension with normal saline.
− Treat seizures with benzodiazepines.
− Transport to appropriate facility.
Salicylates
• Pathophysiology
− Clinical presentation can change based on:
• Patient’s age
• Dose ingested
• Duration of exposure
− Overdose in children is usually accidental.
− Overdose in adults is usually intentional.
Salicylates
• Assessment and management
− Establish the airway and vascular access.
− Administer normal saline for hypotension.
− Monitor carbon dioxide levels.
− Administer activated charcoal if instructed.
− Transport to an appropriate facility.
Acetaminophen
• Well-tolerated with
few side effects
• Pathophysiology
− Rapidly absorbed
from the GI tract.
− Signs and
symptoms occur in
four distinct stages.
Acetaminophen
• Assessment and management
− Try to accurately estimate the time of ingestion.
− Antidote is acetylcysteine.
− Establish the airway and vascular access.
Acetaminophen
• Assessment and management (cont’d)
− For recent ingestions, administer activated
charcoal.
− Transport to an appropriate facility.
Theophylline
• Pathophysiology
− Even in therapeutic doses, can cause:
• Sinus or atrial tachycardia
• Frequent premature atrial contractions
• Atrial fibrillation
• Atrial flutter
• Premature ventricular contractions
• Ventricular dysrhythmias
Theophylline
• Pathophysiology (cont’d)
− Small therapeutic window
− Peak levels are reached within 90–120 minutes.
Theophylline
• Assessment and management
− Common complaints include:
• Restlessness, insomnia
• Tremors
• Agitation
• Cardiac dysrhythmias
Theophylline
• Assessment and management
− Establish the airway and vascular access.
− Continuously monitor ECG rhythm.
− Administer activated charcoal, and treat
hypotension.
− Give adenosine for symptomatic reentry
supraventricular tachycardia.
Lead
• Pathophysiology
− Inorganic lead
• Absorption usually occurs via respiratory or GI tract.
• Excretion from the body is slow.
− Organic lead (tetraethyl lead)
• Once in the body, metabolizes to inorganic lead and
triethyl lead
Lead
• Assessment and
management
− Identify source.
− Establish the
airway and
vascular access.
− Transport to an
appropriate facility.
Iron
• Pathophysiology
− Toxic effects reflect the amount ingested.
• Mild to moderate toxicity: 20 to 60 mg/kg
• Severe and potentially lethal toxicity: 60 mg/kg
Iron
• Assessment and management
− Two broad categories of iron poisoning:
• GI toxicity symptoms
• Systemic toxicity symptoms
− Provide basic attention to the ABCs.
− Transport to an appropriate facility.
Mercury
• Pathophysiology
− Accumulates in:
• Liver
• CNS
• Kidneys
• Assessment
− Depends on:
• Type of mercury
• Route of entry
− Involves:
• CNS
• GI/renal systems
Mercury
• Management
− Remove the patient from the source.
− Pay basic attention to the ABCs.
− Transport to the appropriate facility.
Arsenic
• Pathophysiology
− Can enter the body through:
• Ingestion
• Inhalation
• Absorption
• Dermally
− Eliminated through the kidneys
Arsenic
• Assessment
− Clinical presentation depends on:
• Type
• Amount
• Concentration
• Rate of absorption and elimination
Arsenic
• Assessment
− Symptoms appear within 30 minutes to several
hours, and may include:
• Severe abdominal pain
• Metal taste in the mouth
• General malaise
• Hypotension
• Rhabdomyolysis
Arsenic
• Management
− Establish the airway and vascular access.
− Administer normal saline for hypotension.
− Continuously monitor the ECG.
Arsenic
• Management (cont’d)
− Consider magnesium sulfate for torsades de
pointes.
− Provide rapid transport to an appropriate facility.
Poisonous Plants
• Only a few plants are poisonous.
Poisonous Plants
Poisonous Plants
• Pathophysiology
− Dieffenbachia
• All parts contain sharp caladium oxalate crystals.
− Caladium
• Contains caladium oxalate crystals
© Hatem Eldoronki/ShutterStock, Inc.
© Andriy Doriy/ShutterStock, Inc
Poisonous Plants
• Pathophysiology (cont’d)
− Lantana
• Berries contain lantadene A.
− Castor bean
• Ricin causes a variety of toxic effects.
Courtesy of Brian Prechtel/USDA
© MaxFX/ShutterStock, Inc.
Poisonous Plants
• Pathophysiology (cont’d)
− Foxglove
• Contains cardiac glycosides
© Jean Ann Fitzhugh/ShutterStock, Inc.
Poisonous Plants
• Assessment
− Get all the information you can and then contact
the Poison Center.
• When was the plant ingested?
• What, exactly, did the child eat?
• What signs of symptoms does the child have?
Poisonous Plants
• Management
− Most exposures require no treatment.
− Contact Poison Center and medical control.
− A child who is symptomatic should be evaluated
in the ED.
Poisonous Mushrooms
• Pathophysiology
• Age of the
mushroom
• Season gathered
© paul prescott/ShutterStock, Inc.
• Amount ingested
• Preparation
method
© Ivor Toms/Alamy Images
− Factors that
determine toxic
results:
Poisonous Mushrooms
• Assessment
− Time of symptom onset can serve as a predictor
of potential severity.
• Within 2 hours: typically non-life-threatening
• 6 hours or later: potentially fatal
Poisonous Mushrooms
• Management
− Establish the airway and vascular access.
− Administer normal saline for hypotension.
− Contact the Poison Center and medical control.
− Transport to an appropriate facility.
Food Poisoning
• When you encounter two or more people
sick at the same time and at the same
scene, think food poisoning or CO
poisoning.
Food Poisoning
• Pathophysiology
− Toxins that produce food-related deaths:
• Salmonella
• Listeria
• Toxoplasma
Food Poisoning
• Assessment
− Onset of signs and symptoms can range from
several hours to days or weeks.
− Gastrointestinal complaints are the most
common.
− Respiratory distress or arrest can occur.
Food Poisoning
• Management
− Establish the airway and vascular access.
− Administer normal saline for hypotension.
− Consider diphenhydramine for facial flushing.
− Transport to an appropriate facility.
Summary
• Toxicologic emergencies usually fall under
one of two general headings: intentional
and unintentional.
• Poison Centers may be an indispensable
aid.
• The four primary methods whereby a toxin
commonly enters the body are ingestion,
inhalation, injection, and absorption.
Summary
• Many drugs of similar design, on entering
the body, produce similar signs and
symptoms as the original parent drug.
• The area of medicine dealing with drugs of
abuse is challenging because of uncertainty
about the prevalence of the problem and
the continual evolution of the substances
themselves.
Summary
• Alcohol is the most widely abused drug in
the United States.
• Generally, patients with toxicologic
emergencies are considered medical
patients.
Summary
• ALS care for toxicologic emergencies builds
on the basics:
− Ensure the scene is safe for access and egress.
− Maintain the airway; secure it as needed.
− Ensure that breathing is adequate.
− Ensure that circulation is not compromised.
− Maintain adequate blood/oxygen saturations
(95%).
− Establish vascular access.
− Transport the patient as soon as possible.
Credits
• Chapter opener: © Mark C. Ide
• Backgrounds: Gold—Jones & Bartlett Learning.
Courtesy of MIEMSS; Green—Jones & Bartlett
Learning; Purple—Jones & Bartlett Learning.
Courtesy of MIEMSS; Blue—Courtesy of Rhonda
Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.