Slide 1 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Poisoning and Poisoning and Overdoses Overdoses Chapter 21 Chapter 21
Slide 1Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Poisoning and OverdosesPoisoning and Overdoses
Chapter 21Chapter 21
Slide 2Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Case HistoryCase History
You are dispatched to a poisoning and find a You are dispatched to a poisoning and find a 5-year-old girl who is suspected of having 5-year-old girl who is suspected of having ingested a large quantity of acetaminophen ingested a large quantity of acetaminophen (Tylenol) tablets. The mother shows you an (Tylenol) tablets. The mother shows you an empty bottle, but the child appears perfectly empty bottle, but the child appears perfectly normal and has normal vital signs. The child normal and has normal vital signs. The child is alert and oriented.is alert and oriented.
Slide 3Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
IntroductionIntroduction
Poison Poison A substance that usually A substance that usually
kills, injures, or impairs an kills, injures, or impairs an organism through its organism through its chemical actionchemical action
OverdoseOverdose Drugs, taken in excess or in Drugs, taken in excess or in
combination with other combination with other agents, to the point where agents, to the point where poisoning occurs poisoning occurs
Slide 4Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
IncidenceIncidence
More than 5 million poisonings More than 5 million poisonings occur each year in U.S.occur each year in U.S. Most occur in children <5 years of age.Most occur in children <5 years of age.
Poisonings cause more than 10,000 Poisonings cause more than 10,000 deaths.deaths.
Other causesOther causes Drug abuseDrug abuse SuicideSuicide Animal or insect bitesAnimal or insect bites
Slide 5Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Poison Control CentersPoison Control Centers
Provide access to experts in Provide access to experts in toxicology.toxicology.
Staffed 24 hours a day.Staffed 24 hours a day.
Coordinate emergency responseCoordinate emergency response Provide advice to patients at homeProvide advice to patients at home Refer people to area hospitals with Refer people to area hospitals with
poisoning care capabilitiespoisoning care capabilities Advise EMTs, physicians, and Advise EMTs, physicians, and
nursesnurses
Slide 6Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Types of PoisoningsTypes of Poisonings
IngestedIngested
InjectedInjected
InhaledInhaled
AbsorbedAbsorbed
Slide 7Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Cardinal RulesCardinal Rules
Treat the patient, not Treat the patient, not poison.poison.
Protect self and Protect self and bystanders.bystanders.
Look for clues of trauma.Look for clues of trauma.
Maintain a high level of Maintain a high level of suspicion.suspicion.
Slide 8Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Scene Size-upScene Size-up
Survey the scene to protect Survey the scene to protect yourself and bystanders.yourself and bystanders.
DangersDangers Toxic gasesToxic gases Absorbed toxinsAbsorbed toxins
Do not enter without adequate Do not enter without adequate protection.protection. Only trained hazmat rescuers Only trained hazmat rescuers
should enter.should enter.
Slide 9Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Initial AssessmentInitial Assessment
What is your general What is your general impression?impression?
Findings indicate any trauma?Findings indicate any trauma?
Is the patient awake and Is the patient awake and responsive?responsive?
AAirway, irway, BBreathing, reathing, CCirculationirculation
Slide 10Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Focused HistoryFocused History
What is the poison?What is the poison?
How was it taken?How was it taken? Was it ingested, inhaled, absorbed, or injected?Was it ingested, inhaled, absorbed, or injected?
When was it taken?When was it taken?
How much was taken?How much was taken?
Over what period of time?Over what period of time?
Slide 11Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Focused HistoryFocused History
Is there any other evidence at the scene (e.g., Is there any other evidence at the scene (e.g., commercial products, pills)?commercial products, pills)?
Were any other interventions attempted?Were any other interventions attempted? VomitingVomiting DilutionDilution Activated charcoalActivated charcoal Syrup of ipecacSyrup of ipecac AntidoteAntidote
How much does the patient weigh?How much does the patient weigh?
Slide 12Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Perform a Perform a Focused Physical ExaminationFocused Physical Examination
SkinSkin PupilsPupils Breath soundsBreath sounds
AbdomenAbdomen Mental statusMental status Vital signsVital signs
Slide 13Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Emergency Medical CareEmergency Medical Care
Remove patient from poisonous environment.Remove patient from poisonous environment.
Ensure patent airway and administer oxygen.Ensure patent airway and administer oxygen.
Be alert for vomiting.Be alert for vomiting.
Bring all poison agents to hospital.Bring all poison agents to hospital. ContainersContainers BottlesBottles LabelsLabels
Slide 14Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Ingested Poisons – Ingested Poisons – Signs and SymptomsSigns and Symptoms
History of ingestionHistory of ingestion NauseaNausea VomitingVomiting DiarrheaDiarrhea
Slide 15Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Ingested Poisons – Ingested Poisons – Signs and SymptomsSigns and Symptoms
Altered mental statusAltered mental status
Abdominal painAbdominal pain
Chemical burns around Chemical burns around the mouththe mouth
Different breath odorsDifferent breath odors
Slide 16Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
OdorsOdorsSmell Possible Poison
Acetone (sweet, fruity) Ethanol, isopropyl alcohol, diabetic
Alcohol Alcohol, isopropylalcohol
Disinfectants Creosol and phenol
Rotten eggs Hydrogen sulfide
Garlic Insecticides
Stale tobacco Nicotine
Wintergreen Methyl salicylate
Slide 17Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Emergency Medical CareEmergency Medical Care
Remove poison from patient’s Remove poison from patient’s mouth using gloves.mouth using gloves.
Consult medical direction.Consult medical direction. Activated charcoalActivated charcoal
Bring all containers (bottles, Bring all containers (bottles, labels, etc.,) to hospital.labels, etc.,) to hospital.
Slide 18Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Types of IngestionsTypes of Ingestions
Sedative-hypnoticsSedative-hypnotics
Antianxiety agentsAntianxiety agents
OpioidsOpioids
Psychiatric medicationsPsychiatric medications
StimulantsStimulants
Slide 19Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Types of Ingestions – Types of Ingestions – Sedative-HypnoticsSedative-Hypnotics
BarbituratesBarbiturates Secobarbital (Seconal)Secobarbital (Seconal) Pentobarbital (Nembutal)Pentobarbital (Nembutal)
BenzodiazepinesBenzodiazepines Diazepam (Valium)Diazepam (Valium) Chlordiazepoxide (Librium)Chlordiazepoxide (Librium) Chlorazepate (Tranxene)Chlorazepate (Tranxene)
Slide 20Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Types of Ingestions –Types of Ingestions –Sedative-HypnoticsSedative-Hypnotics
OthersOthers Methaqualone (Quaalude)Methaqualone (Quaalude) Ethchlorvynol (Placidyl)Ethchlorvynol (Placidyl) Chloral hydrate (Noctec)Chloral hydrate (Noctec) Mebrobamate (Miltown)Mebrobamate (Miltown)
Slide 21Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Toxic Effects –Toxic Effects –Sedative-HypnoticsSedative-Hypnotics
Altered mental statusAltered mental status
Respiratory depression Respiratory depression and arrestand arrest
Most toxic when Most toxic when combined with alcoholcombined with alcohol
Support of ABCs is Support of ABCs is critical.critical.
Slide 22Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Types of IngestionsTypes of Ingestions Opioids (Narcotics) Opioids (Narcotics)
Central nervous system depressantCentral nervous system depressant ExamplesExamples
• HeroinHeroin
• MorphineMorphine
• PercocetPercocet
• PercodanPercodan
Slide 23Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Toxic Effects/Management – Toxic Effects/Management – Opioids (Narcotics) Opioids (Narcotics)
Toxic effects and signs and Toxic effects and signs and symptomssymptoms Altered (depressed) mental statusAltered (depressed) mental status Respiratory depressionRespiratory depression Pinpoint pupilsPinpoint pupils Track marksTrack marks
ManagementManagement Support ABCsSupport ABCs Administration of naloxoneAdministration of naloxone (Narcan) by (Narcan) by
ALS providers or hospitalALS providers or hospital
Slide 24Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Ingested SubstancesIngested Substances
StimulantsStimulants Cause increased Cause increased
excitability (e.g., excitability (e.g., amphetamines)amphetamines)
AlcoholAlcohol
Heart and lung drugsHeart and lung drugs
AnalgesicsAnalgesics
Slide 25Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Inhaled Poisons – Inhaled Poisons – Signs and SymptomsSigns and Symptoms
History of inhalation of History of inhalation of toxic substancetoxic substance
Difficulty breathingDifficulty breathing
Chest painChest pain
CoughCough
HoarsenessHoarseness
DizzinessDizziness
HeadacheHeadache
ConfusionConfusion
SeizuresSeizures
Altered mental statusAltered mental status
Slide 26Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Poisonous GasesPoisonous Gases
Simple asphyxiantsSimple asphyxiants
Carbon dioxideCarbon dioxide
Small hydrocarbon moleculesSmall hydrocarbon molecules
Chemical asphyxiantsChemical asphyxiants
Irritant gasesIrritant gases
OrganophosphatesOrganophosphates
Slide 27Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Toxic Injection – Toxic Injection – Signs and SymptomsSigns and Symptoms
WeaknessWeakness
DizzinessDizziness
ChillsChills
FeverFever
NauseaNausea
VomitingVomiting
Slide 28Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Absorbed Poisons – Absorbed Poisons – Signs and SymptomsSigns and Symptoms
History of exposureHistory of exposure
Liquid or powder on patient’s skinLiquid or powder on patient’s skin
BurnsBurns
ItchingItching
IrritationIrritation
RednessRedness
Slide 29Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Emergency Medical CareEmergency Medical Care
SkinSkin Remove contaminated clothing.Remove contaminated clothing. Protect self from contamination.Protect self from contamination.
PowderPowder Brush powder off patient.Brush powder off patient. Irrigate for at least 20 minutes.Irrigate for at least 20 minutes. Continue en route to facility, if possible .Continue en route to facility, if possible .
Liquid Liquid Irrigate for at least 20 minutes.Irrigate for at least 20 minutes. Continue en route to facility, if possible.Continue en route to facility, if possible.
Slide 30Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Medication NameMedication Name
GenericGeneric Activated charcoalActivated charcoal
TradeTrade SuperChar™SuperChar™ InstaChar™InstaChar™ Actidose™Actidose™ LiquiChar™LiquiChar™
Slide 31Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Activated CharcoalActivated Charcoal
IndicationsIndications Poisoning by mouthPoisoning by mouth
Contraindications Contraindications Altered mental statusAltered mental status Ingestion of acids or alkalisIngestion of acids or alkalis Inability to swallowInability to swallow
Slide 32Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Medication FormMedication Form
Medication is pre-mixed in water.Medication is pre-mixed in water. Plastic bottle containing 125 grams activated Plastic bottle containing 125 grams activated
charcoalcharcoal
Powder should be avoided in field.Powder should be avoided in field.
Slide 33Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
DosageDosage
Adults and childrenAdults and children 1 gram activated charcoal/kg of body weight1 gram activated charcoal/kg of body weight
Usual adult doseUsual adult dose 25 - 50 grams25 - 50 grams
Usual infant/child doseUsual infant/child dose 12.5 - 25 grams12.5 - 25 grams
Slide 34Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
ActionsActions
Charcoal binds to certain poisons.Charcoal binds to certain poisons.
Binding action prevents absorption.Binding action prevents absorption.
Not all brands are the same.Not all brands are the same. Some bind much more poisonSome bind much more poison Consult medical direction about the brand to use.Consult medical direction about the brand to use.
Slide 35Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Side Effects Side Effects
Black stoolBlack stool
Some patients may vomit.Some patients may vomit. If the patient vomits, repeat dose one time.If the patient vomits, repeat dose one time.
Reassessment strategiesReassessment strategies Prepare for vomiting and deterioration of patient’s Prepare for vomiting and deterioration of patient’s
condition.condition.