Ch. 21: Poising & Overdose Emergencies

Question 1

Poison

Answer 1

any substance that can harm the body, sometimes seriously enough to create a medical emergency

Question 2

toxins

Answer 2

a substance that is poisonous to humans

Question 3

four types of poison

Answer 3

ingested, inhaled, absorbed injected

Question 4

Patient Assessment: Ingested Poison

Answer 4

Questions: What substance was involved? When did the exposure? How much was ingested? Over how long did the ingestions occur? Any interventions? Patient’s weight? Symptoms?
Decision Point: Is the patient at risk of vomiting or other airway complications?

Question 5

Food Poising

Answer 5

• caused by bacteria growth when exposed to the right conditions
• S&S: Vary but frequently include nausea, vomiting, abdominal cramps, diarrhea, and fever.

Question 6

Activated Charcoal

Answer 6

a substance that adsorbs many poisons and prevents them from being absorbed by the body
Contradictions: can’t swallow, altered mental status, ingested acids or alkalis (can damage mouth, throat, and esophagus); accidentally swallowed gasoline
Not indicated for food poising

Question 7

Syrup of ipecac

Answer 7

orally administered drug causes vomiting in most people with just one dose; relatively ineffective, and has the potential to make a patient aspirate vomitus, it is rarely used today.

Question 8

dilution

Answer 8

thinning down or weakening by mixing with something else. Ingested poisons are sometimes diluted by drinking water or milk. (often advised for patients who do not require transport)

Question 9

Patient Care: Ingested Poison

Answer 9

® Emergency care of a patient who has ingested poison includes the following steps:
1. Detect and treat immediately life-threatening problems in the primary assessment. Evaluate the need for prompt transport for critical patients.
2. Perform a secondary assessment. Use gloved hands to carefully remove any pills, tablets, or fragments from the patient’s mouth; package the material and transport it with the patient.
3. Assess baseline vital signs.
4. Consult medical direction. As directed, administer activated charcoal to adsorb the poison, or water or milk to dilute it. This can usually be done en route.
5. Transport the patient with all containers, bottles, and labels from the substance.
6. Perform reassessment en route.
® Note: may require assisted ventilations
Use a pocket face mask with a one-way valve, a bag-valve-mask unit with supplemental oxygen, or positive pressure ventilation when providing ventilations to a patient who is suspected of ingesting a poison.

Question 10

Antidotes

Answer 10

a substance that will neutralize the poison or its effects

Question 11

Naloxone

Answer 11

antidotes; directly reverses narcotics’ depressant effects on level of consciousness and respiratory drive; no effect if no narcotics in the system; no needles

Question 12

examples of inhaled poisons

Answer 12

□ Carbon monoxide poisoning is a common problem
□ chlorine gas (often from swimming pool chemicals)
□ ammonia (often released from household cleaners)
□ sprayed agricultural chemicals and pesticides
□ carbon dioxide (from industrial sources)

Question 13

Patient Assessment: Inhaled Poison

Answer 13

What substance? 
When did the exposure occur?
Period of exposure? 
Interventions? 
Signs and Symptoms?

Question 14

Patient Care: Inhaled Poison

Answer 14

□ Emergency care steps include the following:
1) If the patient is in an unsafe environment, have trained rescuers remove the patient to a safe area. Detect and treat immediately life-threatening problems in the primary assessment. Evaluate the need to promptly transport critical patients.
2) Perform a secondary assessment; obtain vital signs.
3) Administer high-concentration oxygen. This is the single most important treatment for
inhaled poisoning after the patient’s airway is opened.
4) Transport the patient with all containers, bottles, and labels from the substance.
Perform reassessment en route.

Question 15

Carbon Monoxide

Answer 15

□ Malfunctioning oil-, gas-, and coal-burning furnaces and stoves can also be sources of carbon monoxide. The indoor use of gasoline- powered small engines such as electrical generators or pumps is another common cause of CO poisoning.
usually associated with motor-vehicle exhaust and fire suppression
Signs and Symptoms
• Headache, especially “a band around the head”
• Dizziness
• Breathing difficulty
• Nausea
• Cyanosis
• Altered mental status; in severe cases, unconsciousness may result
• a patient with vague, flulike symptoms who has been in an enclosed area. This is especially true when a group of people in the same area have similar symptoms
• may begin to feel better shortly after being removed from the dangerous environment. However, it is still very important to continue to administer 100 percent oxygen and to transport these patients to a hospital
• Oxygen is antidote but it takes time to clean out of patient’s bloodstream
Cherry red lips is not commonly seen

Question 16

Smoke Inhalation

Answer 16

associated with fire scenes
□ substances found in smoke to burn the skin, irritate the eyes, injure the airway, cause respiratory arrest, and in some cases cause cardiac arrest.
□ irritated (reddened, watering) eyes and, of far greater concern, injury to the airway associated with smoke.
□ signs indicate an airway injured by smoke inhalation
• Difficulty breathing
• Coughing
• Breath that has a “smoky” smell or the odor of chemicals involved at the scene
• Black (carbon) residue in the patient’s mouth and nose
• Black residue in any sputum coughed up by the patient
• Nose hairs singed from superheated air

Question 17

Detergent Suicides

Answer 17

mixing two easily obtained chemicals, a person can cause the release of toxic hydrogen sulfide gas (i.e. toilet cleaner and bath salts) (source of acid and sulfur)
□ Hydrogen sulfide
• Rotten egg odor
• even at moderate concentrations, it can be quite dangerous
• takes the place of oxygen but also bonds with iron in cells, preventing oxygen from binding to those cells and getting to where it is needed
• Mild Exposure: coughing, eye irritation, and sore throat
• More Severe Exposure: dizziness, nausea, shortness of breath, headache, and vomiting
• Severe Cases: fluid will collect in the lungs (pulmonary edema), resulting in death
Small enclosed spaces possibly sealed with tape

Question 18

Absorbed Poison

Answer 18

□ Often will irritate or damage skin (not always)

Danger that they could be absorbed by EMT

Question 19

Patient Care: Absorbed Poison

Answer 19

Emergency care of a patient with absorbed poisons includes the following steps:
1. Detect and treat immediately life-threatening problems in the primary assessment. Evaluate the need for prompt transport of critical patients.
2. Perform a secondary assessment; obtain vital signs. This includes removing contaminated clothing while protecting oneself from contamination.
3. Remove the poison by doing one of the following:
• Powders. Brush powder off the patient; then continue as for other absorbed poisons. • Liquids. Irrigate with clean water for at least 20 minutes and continue en route if
possible.
• eyes. Irrigate with clean water for at least 20 minutes and continue en route if possible.
4. Transport the patient with all containers, bottles, SDSs, and labels from the substance.
5. Perform reassessment en route.
□ Get the poison off the skin or out of the eye
® Best to irrigate the skin (with garden or fire hose)
◊ Not high pressure; don’t injure skin
◊ Do not attempt to ‘neutralize’ acids

Question 20

Injected Poison

Answer 20

most common injected poisons are illicit drugs injected with a needle, venom of snakes and inspects

Question 21

Poison Control Center

Answer 21

□ 1-800-222-1222 connects you with the poison center covering the area the call is coming from.
® the poison control center staff does not have the authority to provide on-line medical direction
® Telephone is preferred
Gather all information you need before you call

Question 22

Chronic drinkers (alcoholics) often have derangements

Answer 22

in blood sugar levels, poor nutrition, the potential for considerable gastrointestinal bleeding, and other problems

Question 23

Alcohol Abuse

Answer 23

§ a drug that can have a potent effect on a person’s central nervous system
§ Emergencies May be due to alcohol just consumed or cumulative effect
§ do not hesitate to ask for police assistance with any patient who appears intoxicated or irrational or exhibits potentially dangerous behavior.

Question 24

Alcohol combines with other depressants (antihistamines and tranquilizers)

Answer 24

the effects of alcohol can be more pronounced and, in some cases, lethal

Question 25

Patient Assessment: Alcohol Abuse

Answer 25

the effects of alcohol can be more pronounced and, in some cases, lethal
S&S:
□ Odor of alcohol on the patient’s breath or clothing. By itself, however, this is not enough to conclude alcohol abuse. Be certain that the odor is not “acetone breath,” as with some diabetic emergencies.
□ Swaying and unsteadiness of movement
□ Slurred speech, rambling thought patterns, incoherent words or phrases
□ A flushed appearance to the face, often with the patient sweating and complaining of being warm
□ Nausea or vomiting
□ Poor coordination
□ Slowed reaction time
□ Blurred vision
□ Confusion
□ Hallucinations, visual or auditory (“seeing things” or “hearing things”)
□ Lack of memory (blackout)
Altered mental status

Question 26

Signs of alcohol withdraw

Answer 26

□ The alcohol-withdrawal patient may experience seizures or delirium tremens (DTs), a condition characterized by sweating, trembling, anxiety, and hallucinations. In some cases alcohol withdrawal can be fatal.
□ Confusion and restlessness
□ Unusual behavior, to the point of demonstrating “insane” behavior
□ Hallucinations
□ Gross tremor (obvious shaking) of the hands
□ Profuse sweating
□ Seizures (common and often very serious)
□ Hypertension
Tachycardia

Question 27

Patient Care: Alcohol Abuse

Answer 27

§ often vomit, take Standard Precautions, including gloves, mask, and protective eyewear as necessary
1. Stay alert for airway and respiratory problems. Be prepared to perform airway maintenance, suctioning, and positioning of the patient should the patient lose consciousness, seize, or vomit. Help the patient so vomitus will not be aspirated. Have a rigid-tip suction device ready. Provide oxygen and assist respirations as needed.
2. Assess for trauma the patient may be unaware of because of his intoxication.
3. Be alert for changes in mental status as alcohol is absorbed into the bloodstream. Talk to the patient in an effort to keep him as alert as possible.
4. Monitor vital signs.
5. Treat for shock.
6. Protect the patient from self-injury. Use restraint as authorized by your EMS system.
Request assistance from law enforcement if needed. Protect yourself and your crew.
7. Stay alert for seizures.
8. Transport the patient to a medical facility.
Remember that the patient’s condition may worsen as the alcohol continues to be absorbed by his system.

Question 28

Type of consent: alcohol abuse

Answer 28

can’t make informed consent

implied consent

Question 29

substance abuse

Answer 29

a term that indicates a chemical substance is being taken for other than therapeutic (medical) reasons

Question 30

uppers

Answer 30

® stimulants that affect the nervous system and excite the user
® attempt to relieve fatigue or to create feelings of well-being
® i.e. caffeine, amphetamines and methamphetamines, and cocaine. Cocaine may be “snorted,” smoked, or injected. Other stimulants are frequently taken in pill form. Also included in this category are so-called “bath salts.” These are synthetic drugs that have very potent stimulant effects and sometimes hallucinogenic effects as well, Nicotine
® Big scene safety issue with cocaine
® Signs & symptoms: abuse these drugs display excitement, increased pulse and breathing rates, rapid speech, dry mouth, dilated pupils, sweating, and the complaint of having gone without sleep for long periods. Repeated high doses can produce a “speed run.” The patient will be restless, hyperactive, and usually very apprehensive and uncooperative.

Question 31

downers (sedatives-hyponic)

Answer 31

® depressant effect on the central nervous system
® relaxing agent, sleeping pill, or tranquilizer
® i.e barbiturates (pill or capsule form), Rohypnol (flunitrazepam), also known as “roofies”,xanax
® Similar effects to alcohol
® i.e. GHB (gamma hydroxybutyrate), also known as Georgia Home Boy or goo
◊ has caused respiratory depression so severe that patients have required assisted ventilations even though some of them were still breathing.
Signs & symptoms: sluggish, sleepy patients lacking typical coordination of body and speech. Pulse and breathing rates are low, often to the point of a true emergency. Bradycardia and low BP

Question 32

Narcotics

Answer 32

® drugs capable of producing stupor or sleep.
® Relieve pain
® i.e codeine, OxyContin (oxycodone), heroin, pill
® three signs: coma (or depressed level of consciousness), pinpoint pupils, and respiratory depression (slow, shallow respirations) (opiate triad)
Signs & symptoms: reduced rate of pulse and rate and depth of breathing, which is often seen with a lowering of skin temperature. The pupils are constricted, often pinpoint in size. The muscles are relaxed, and sweating is profuse. The patient is very sleepy and does not wish to do anything. In overdoses, coma is common. Respiratory arrest or cardiac arrest may rapidly develop.

Question 33

Hallucinogens

Answer 33

® mind-affecting drugs that act on the nervous system to produce an intense state of excitement or a distortion of the user’s perceptions
® eaten or dissolved in the mouth and absorbed through the mucous membranes
® i.e. LSD, PCP, mushrooms, ecstasy, also known as XTC, X, or MDMA (because it is methylene- dioxymethamphetamine), ketamine (opioid/hallucinogens)
® Use have to be calm
Signs & symptoms: a fast pulse rate, dilated pupils, and a flushed face. The patient often “sees” or “hears” things, has little concept of real time, and may not be aware of the true environment. Often what he says makes no sense to the listener. The user may become aggressive or be very timid.

Question 34

Volatile Chemicals

Answer 34

® produce vapors that can be inhaled
® give an initial “rush” then act as a depressant on the central nervous system
® i.e. cleaning fluids, glue, model cement, and correction fluids used to correct ink-based errors
Signs & symptoms: abuse these drugs appear dazed or show temporary loss of contact with reality. The patient may develop a coma. The linings of the nose and mouth may show swollen membranes. The patient may complain of a “funny numb feeling” or “tingling” inside the head. Changes in heart rhythm can occur. This can lead to death.

Question 35

Patient Assessment: Substance Abuse

Answer 35

□ be able to detect possible drug abuse at the overdose level and to relate certain signs to certain types of drugs and drug withdrawal
□ signs and symptoms of substance abuse, dependency, and overdose can vary from patient to patient, even for the same drug or chemical
® problem is made more complex by the fact that many substance abusers take more than one drug or chemical at a time
When questioning the patient and bystanders, you will get better results if you begin by asking if the patient has been taking any medications. Then, if necessary, ask if the patient has been taking drugs.

Question 36

Drug withdraw symptoms

Answer 36

® Shaking 
					® Anxiety 
					® Nausea 
					® Confusion and irritability 
					® Hallucinations, visual or auditory (“seeing things” or “hearing things”) 
					® Profuse sweating 
Increased pulse and breathing rates

Question 37

Patient Care: Substance Abuse

Answer 37

1. Perform a primary assessment. Provide basic life support measures if required.
2. Be alert for airway problems and inadequate respirations or respiratory arrest. Provide
   oxygen and assist ventilations if needed.
3. If the patient’s mental status is depressed enough to threaten his airway and he is in
   respiratory failure and your local protocols allow, administer naloxone intranasally.
4. Treat for shock. (Treatment for shock will be discussed in the chapter titled “Bleeding
   and Shock.”)
5. Talk to the patient to gain his confidence and to help maintain his level of responsiveness.
   Use his name often, maintain eye contact, and speak directly to him.
6. Perform a physical exam to assess for signs of injury to all parts of the body. Assess carefully
   for signs of head injury.
7. Look for gross soft-tissue damage on the extremities resulting from the injection of
   drugs (“tracks”). Tracks usually appear as darkened or red areas of scar tissue or scabs
   over veins (Figure 21-5).
8. Protect the patient from self-injury and his attempts to hurt others. Use restraint as
   authorized by your EMS system. Request assistance from law enforcement if needed.
9. Transport the patient as soon as possible.
10. Contact medical direction according to local protocols.
11. Perform reassessment with monitoring of vital signs. Stay alert for seizures, and be on
    guard for vomiting that could obstruct the airway.
    Continue to reassure the patient throughout all phases of care.