Ch.22 Toxicology Flashcards
Is the study of toxic or poisonous substances
Toxicology
A substance whose chemical action could damage structures or impir function when introduced into the body
Poison
Is a poisonous substance produced by bacteria, animals, or plants that acts by changing the normal metabolism of cells or by destroying them. __ can have acute effects (for example, an injection of heroin may cause respiratory arrest) and chronic effects (for example, years of substance abuse may lead to a weakened immune system).
Toxin
Is the misuse of any substance to produce a desired effect ( for example, heroin—intoxication).
Substance abuse
A common complication of substance abuse is ___, when a patient takes a toxic or lethal dose of a substance
Overdose
An excessive quantity of a drug that, when taken or administered, can have toxic or lethal consequences
Overdose
Swallowing; taking a substance by mouth
Ingestion
Typical signs and symptoms of specific overdoses
Opiates ( morphine, codeine )
Opioids (heroin, fentanyl, methadone, oxycodone)
Hypoventilation or respiratory arrest
Pinpoint pupils
Sedation or coma
Hypotension
Typical signs and symptoms of specific overdoses
Sympathomimetics ( mephedrone, cocaine, methamphetamine)
Hypertension
Tachycardia
Dilated pupils
Agitation or seizures
Hyperthermia
Typical signs and symptoms of specific overdoses
Sedative-hypnotics ( diazepam, secobarbital, temazepam, midazolam)
Slurred speech
Sedation or coma
Hypoventilation
Hypotension
Typical signs and symptoms of specific overdoses
Anticholinergics ( atropine, diphenhydramine, chlorpheniramine, doxylamine, datura stramonium[jimsonweed])
Tachycardia
Hyperthermia
Hypertension
Dilated pupils
Dry skin and mucous membranes
Sedation, agitation, seizures, coma, or delirium
Decreased bowel sounds
Typical signs and symptoms of specific overdoses
Cholinergics (organophosphates, pilocarpine, nerve gas)
Airway compromise
SLUDGEM :
S salivation, sweating
L lacrimation(excessive tearing of the eyes)
U urination
D defecation, drooling, diarrhea
G gastric upset and cramps
E emesis (vomiting)
M muscle twitching / miosis (pinpoint pupils)
A substance that is used to neutralize or counteract a poison
Antidote
Respirator with independent air supply used by firefighters to enter toxic and otherwise dangerous atmospheres
Self-contained breathing apparatus
Some patients may need to be decontaminated by the hazmat team after they are___ from the toxic environment. The patient’s clothing should be removed in this process because it may contain trapped gases that can be released, exposing you to the substance. You cannot administer emergency care until this step has been completed and there is no danger of the poison contaminating you.
removed
During the scene size-up, if you suspect the presence of a toxic gas, call for specialized resources such as the___. Never approach a contaminated patient unless you have specialized hazmat training and are using the appropriate PPE (not all patients exposed to toxic gases will have contaminants on them). It will be necessary to use a self-contained breathing apparatus for protection from poisonous fumes if they are present.
hazardous materials (hazmat) team
Some inhaled poisons, such as__, are colorless and odorless and produce severe hypoxia without damaging or even irritating the lungs.
carbon monoxide
Most___ toxins can be treated by removing the patient from the exposure and applying oxygen. However, some___ agents cause progressive lung damage, even after the patient has been removed from direct exposure; this damage may not be evident for several hours. Meanwhile, it may take 2 or 3 days or more of intensive care to restore normal lung function. Therefore, all patients who have___ poison require prompt transport to an ED. Be prepared to use supplemental oxygen via a nonrebreathing mask and/or ventilatory support with a bag-mask device, if necessary. Remember that pulse oximetry readings may be inaccurate with some___ poisons. Make sure a suction unit is available in case the patient vomits.
inhaled
An odorless, colorless, tasteless, and highly poisonous gas that results from incomplete oxidation of carbon in combustion
Carbon monoxide
The first chemical agent ever used in warfare. It has a distinct odor of bleach and creates a green haze when released as a gas. Initially it produces upper airway irritation and a choking sensation
Chlorine
___that come in contact with the surface of the body can affect the patient in many ways. Many corrosive substances will damage the skin, mucous membranes, or eyes, causing chemical burns, rashes, or lesions. Acids, alkalis, and some petroleum (hydrocarbon) products are very destructive. Other substances are absorbed into the bloodstream through the skin and have systemic effects, just like medications or drugs taken via the oral or injectable routes. Other substances, such as poison ivy or poison oak, may cause an itchy rash without being dangerous to the patient’s health. It is important, therefore, to distinguish between contact burns and contact absorption.
Poisons
The process by which medications travel through body tissues until they reach the blood stream
Absorption
___of toxic substances through the skin is a common problem in the agriculture and manufacturing industries. Most solvents, insecticides, herbicides, and pesticides are toxic and can be readily absorbed through the skin.
Absorption
Signs and symptoms of___ poisons include a history of exposure, liquid or powder on a patient’s skin, burns,
itching, irritation, redness of the skin in light-skinned people, or typical odors of the substance.
Emergency treatment for a typical contact poisoning includes the following two steps:
1. Avoid contaminating yourself or others.
2. While protecting yourself from exposure, remove the irritating or corrosive substance from the patient as rapidly as possible.
Remove all clothing that has been contaminated with poisons or irritating substances. If a dry powder has been spilled thoroughly brush off the chemical (avoid creating a dust cloud), flush the skin with clean water for 15 to 20 minutes, and then wash the skin with soap and water. If liquid material has been spilled on a patient, flood the affected part for 15 to 20 minutes. If the patient has a chemical agent in the eyes, irrigate them quickly and thoroughly. To avoid contaminating the other eye as you irrigate the affected eye, make sure the fluid runs from the bridge of the nose outward (FIGURE 22-4). Initiate this action on the scene and continue it during transport. Keep in mind that you may have to help the patient keep his or her eyes open.
absorbed
Many chemical burns occur in industrial settings, where safety showers and specific protocols for handling surface burns are available. If you are called to such a scene, a hazmat team should be available to assist you. Always ensure you, your team members, and the exposed patient are thoroughly decontaminated prior to transport. Failure to do so will result in the risk of contaminating the entire ED and staff. After effective decontamination has occurred, promptly transport to the ED for definitive care. Obtain a__(or safety data sheet [SDS]) from industrial sites and transport it with the patient. If it is not immediately available, ask the company to send it to the receiving hospital while you are en route.
This will help to identify and quickly make available specific interventions and potential antidotes. Chapter 40, Incident Management, discusses hazardous materials and decontamination in detail.
material safety data sheet (MSDS)
A form, provided by manufacturers and compounders (blenders) of chemicals, containing information about chemical composition, physical and chemical properties, health and safety hazards, emergency response, and waste disposal of a specific material; also known as a safety data sheet (SDS)
Material safety data sheet
According to the AAPCC, over 80% of all poisonings are by mouth (____).____ poisons include liquids, household cleaners, contaminated food, plants, and, in most cases, drugs.____ poisoning is usually accidental in children and except for contaminated food, deliberate in adults. Plant poisonings are common among children, who like to explore and often bite the leaves of various bushes or shrubs
The signs and symptoms of___ poisons vary greatly with the type of poison, the age of the patient, and the time that has passed since the ingestion. Small children may respond by crying if the poison is an acid or alkaline, and these types of poisons often cause burns around the mouth. Gastrointestinal pain may be present in some cases, and patients may vomit before or after your arrival. If the patient has an altered mental status, it is critical that you protect the patient from aspirating if he or she vomits. Other signs and symptoms depend on the substance involved; for example, some poisons may cause cardiac dyshythmias, whereas others may cause seizures. It is important to treat these signs and symptoms and notify the poison center and medical control of the patient’s condition. Consider whether there is unabsorbed poison remaining in the gastrointestinal tract and whether you can safely and effectively prevent its absorption.
Ingested
Although every poison will result in a specific set of symptoms and signs, always immediately assess the___ of every patient who has been poisoned. Many patients have died as a result of conditions related to the___ that might have been managed easily. Be prepared to provide aggressive ventilatory support and CPR, if necessary, to a patient who has ingested an opioid, a sedative, or a barbiturate, each of which can depress the central nervous system (CNS) and slow breathing.
XABCs
A synthetically produced narcotic medication, drug, or agent similar to the opiate morphine, but not derived from opium; used to relieve pain
Opioid
A substance that decreases activity and excitement
Sedative
Exposure by injection includes intravenous (IV) drug abuse and envenomation by insects, arachnids, and reptiles. (These injuries are covered in Chapter 21, Endocrine and Hematologic Emergencies, and Chapter 33, Environmental Emergencies, respectively.)___ poisons cannot be diluted or removed from the body in the field because they are usually absorbed quickly into the body or cause intense local tissue destruction. When people become ill from an___ poison, their condition can be life threatening and you must act quickly
Injected
A situation in which a person has had contact with blood, body fluids, tissues, or airborne particles in a manner that suggests disease transmission may occur
Exposure
Signs and symptoms of poisoning by injection depend on the___ that was injected. They include weakness, dizziness,
fever, chills, slow breathing, and unresponsiveness, or the patient may be easily excited
If you suspect that rapid absorption has occurred, monitor the patient’s airway, provide high-flow oxygen for any patient with respiratory distress or signs of hypoxia (ie, oxygen saturation level of less than 94%, cyanosis, and be alert for nausea and vomiting. Remove rings, watches, and bracelets from areas around the injection site if swelling occurs. Prompt transport to the ED is essential. Take all containers, bottles, and labels with the patient to the hospital.
toxin
Because of the risk of possible cross-contamination by poisons that can be inhaled, absorbed, ingested, and injected, you must take appropriate__. As you approach the scene, think like a detective and look for clues that might indicate the substance involved. Ask yourself the following questions:
• Is there an unpleasant or odd odor in the room? If so, is the scene safe? (This could indicate an inhaled poison.)
• Are there medication bottles near the patient or at the scene? If so, is there medication missing that might indicate an overdose?
• Are there alcoholic beverage containers present?
• Are there syringes or other drug paraphernalia on the scene?
• Is there a suspicious odor and/or drug paraphernalia present that may indicate the presence of an illegal drug laboratory?
Drug laboratories can be volatile, so ensure scene safety
standard precautions
Occurs when a person is contaminated by an agent as a result of coming in contact with another contaminated person
Cross-contamination
The process of removing or neutralizing and properly disposing of hazardous materials from equipment, patients, and responders
Decontamination
Do not rule out the possibility of an overdose or an exposure when assessing a patient who has sustained trauma. Medications that promote___ or bleeding can speed up the development of shock due to hypovolemia. Also, identifying an overdose or exposure can help the medical team prepare for unforeseen complications.
vasodilation
In certain cases, some EMS systems allow EMTs to give ___by mouth.____ binds to specific toxins-for example, pills that have been ingested and prevents their absorption by the body. The toxins are then carried out of the body in the stool.
____is not indicated, nor will it be effective, for patients who have ingested alkali poisons, cyanide, ethanol, iron, lithium, methanol, mineral acids, or organic solvents. If the patient has a decreased level of consciousness and cannot protect his or her airway, do not give ____ If local protocol permits, your ambulance will likely carry plastic bottles of premixed suspension, each containing up to 50 g of__(FIGURE 22-7). Some common trade names for the suspension form are InstaChar, Actidose, and LiquiChar. The usual dose for an adult or child is 1 g of activated charcoal per kilogram of body weight (more if food is present). The usual adult dose is 30 to 100 g, and the usual pediatric dose is 15 to 30 g for children younger than age 13 years.
activated charcoal
Before you give a patient__, obtain approval from medical control. Consider the amount and type of the toxin and the patient’s condition. In most cases, the ___should be used within 1 hour of ingestion. Next, shake the bottle vigorously to mix the suspension. The medication looks like mud, so it is best to cover the outside of the container so that the fluid is not visible and ask the patient to drink it with a straw. Some patients may not tolerate the medication due to its gritty texture. You might need to convince the patient why this intervention is important, particularly if the patient is a child, but never force the patient. If the patient takes a long time to drink the mixture, you will have to shake the container frequently to keep the medication mixed. Once the patient has finished, discard the container from which the charcoal was administered. Be sure to record the time when you administered the activated charcoal. If the patient refuses the__, document the refusal and your attempts to counsel the patient, and transport the patient for further evaluation.
activated charcoal
The adverse effects of ingesting___ include constipation and black stools. If the patient has ingested a poison that causes nausea, he or she may vomit after taking ___l, and the dose will have to be repeated. As you reassess the patient, be prepared for vomiting, nausea, and possible airway conditions.
activated charcoal
A mixture of ground particles that are distributed evenly throughout a liquid but do not dissolve
Suspension
Over time, a person who routinely misuses a substance may need increasing amounts of it to achieve the same result. This is called developing a___ to the substance.
tolerance
A person with an___ has an overwhelming desire or need to continue using the substance, at whatever cost, with a tendency to increase the dose. This does not happen only with the classic drugs of abuse, such as cocaine or heroin. Almost any substance can be abused, including laxatives, nasal decongestants, vitamins, and food. You should be familiar with the concepts of tolerance,__, and abuse and the differences between the terms.
addiction
The need for increasing amounts of a drug to obtain the same effect
Tolerance
A state of overwhelming obsession or physical need to continue the use of a substance
Addiction
Alcohol is a powerful___ depressant. It is a sedative, a substance that decreases activity and excitement, and a hypnotic, meaning that it induces sleep. In general, alcohol dulls the sense of awareness, slows reflexes, and increases reaction time (FIGURE 22-8). It may also cause aggressive and inappropriate behavior and lack of coordination. However, a person who appears intoxicated may have other medical conditions as well. Look for signs of head trauma, mental illness, toxic reactions, or uncontrolled diabetes. Severe acute alcohol ingestion may cause hypoglycemia, which may contribute to the symptoms. You should assume that all intoxicated patients are experiencing a drug overdose and require a thorough examination by a physician. In most states, patients who are impaired in any way—whether by mental illness, medical condition, or intoxication-cannot legally refuse transport. Always consult with your supervisor, law enforcement, or medical control in these situations. Chapter 23, Behavioral Health Emergencies, covers this topic in more detail.
CNS
A sleep-inducing effect or agent
Hypnotic
___increases the effects of many drugs and is commonly taken with other substances. OTC drugs, including
antihistamines and diet medications, can cause serious complications when combined with__.
If a patient exhibits signs of serious CNS depression, provide respiratory suppört. This may be difficult, however, because depression of the respiratory system can also cause emesis, or vomiting. The vomiting may be forceful or even bloody (hematemesis) because large amounts of alcohol irritate the stomach. Internal bleeding should also be considered if the patient appears to be in shock (hypopefusion) because blood might not clot effectively in a patient who has a prolonged history of___ abuse.
Alcohol
A patient in alcohol withdrawal may experience frightening hallucinations, or__. Approximately 1 to 7 days after a person stops drinking or when alcohol consumption levels are decreased suddenly,___ may develop. Alcoholic hallucinations come and go. A patient with an otherwise clear mental state may see fantastic shapes or figures or hear odd voices. Such auditory and visual hallucinations often precede__, which are a more severe complication.
Patients may experience one or more of the following signs and symptoms:
• Agitation and restlessness
• Fever
• Sweating
• Tremors
• Confusion and/or disorientation
• Delusions and/or hallucinations
• Seizures
delirium tremens (DTs)
Provide prompt transport after you have completed your assessment and given necessary care. A person who is experiencing hallucinations or___ is extremely ill. Should seizures develop, treat them as you would any other seizure. Do not restrain the patient, although you must protect him or her from self-injury. If the patient has difficulty breathing, provide supplemental oxygen and watch carefully for vomiting; have suction ready. Hypovolemia may develop because of sweating, fluid loss, insufficient fluid intake, or vomiting associated with__. If you see signs of hypovolemic shock, clear the airway and turn the patient’s head to one side to minimize the chance of aspiration during transport. These patients may not respond appropriately to suggestions or conversation; they are often confused and frightened. Therefore, use a calm and relaxed approach. Reassure the patient, and provide emotional support.
Delirium tremens (DTs)
A severe withdrawal syndrome seen in alcoholics who are deprived of ethyl alcohol; characterized by restlessness, fever, sweating, disorientation, agitation, and seizures; can be fatal if untreated
Delirium tremens
A narcotic is a drug that produces sleep or altered mental consciousness. An___ is a type of narcotic medication used to relieve pain. An opiate is a subset of the opioid family, and refers to natural, nonsynthetic opioids.___ are named for the opium in poppy seeds, from which the opiates codeine and morphine are derived. According to the National Institute on Drug Abuse (NIDA), prescription__ drugs are among the most commonly abused drugs in the United States. Some people become physically dependent on opioids after taking an appropriate medical prescription. These drugs include several synthetic (laboratory-manufactured) opioids, such as hydromorphone, oxycodone, hydrocodone, and methadone (TABLE 22-
2). According to NIDA, there were over 46,000 deaths in 2018 from opioid overdoses.
opioid
A drug that produces sleep or altered mental consciousness
Narcotic
A synthetically produced narcotic medication, drug, or agent similar to the opiate morphine, but not derived from opium; used to relieve pain
Opioid
A subset of the opioid family, referring to natural, nonsynthetic opioids
Opiate
Common Opioids and Opiates
• Butorphanol (Stadol)
• Codeine
• Fentanyl (Sublimaze)
• Heroin
• Hydrocodone (Vicodin)
• Hydromorphone (Dilaudid)
• Morphine
• Methadone (Dolophine)
• Oxycodone hydrochloride (OxyContin)
• Oxymorphone (Opana)
These agents are CNS depressants and can cause severe respiratory depression. However, with___ administration, they
produce a characteristic “high” or “kick.” Tolerance develops rapidly, so some users may require massive doses to experience the same high. In general, emergency medical conditions related to opioids are caused by respiratory depression, including a decreased volume of inspired air and decreased respirations. This can lead to respiratory and then cardiac arrest if not treated promptly. These drugs often cause nausea and vomiting and may lead to hypotension. Although seizures are uncommon, they can occur and an overdose can result in the patient entering a comatose condition. Patients typically appear sedated or unconscious and exhibit cyanosis with pinpoint pupils. Whereas all of these signs and symptoms may be present with other drugs, the pinpoint pupils is a classic sign of opiate intoxication.
IV administration
Some patients who abuse opioids via __are at high risk for hepatitis C and human immunodeficiency virus(HIV). Be aware of your surroundings and practice bloodborne precautions. Be alert for improperly disposed needles.
IV injection
A substance that is used to neutralize or counteract a poison
Antidote
____is an antidote that reverses the effects of opiate or opioid overdose. This medication can be given intravenously, intramuscularly, or intranasally. Ideally,___ is administered intravenously. In many instances, however, IV access is difficult to obtain in the chronic user of illicit IV drugs such as heroin. These patients have venous scarring, called track marks, from repeated use of needles on peripheral veins. Therefore, the intranasal route is becoming a preferred alternative route for the administration of__. It is safer than giving an IM injection because a needle is not required to administer the medication.
Naloxone (Narcan)
EMTs are permitted to administer prefilled____ by the intramuscular route or by the intranasal route, in which the antidote is atomized through the nares onto the nasal mucosa. Be aware that this drug can cause harm. This medication should only be used when the patient has agonal respirations or apnea. Place an oropharyngeal (oral) or nasopharyngeal (nasal) airway and ventilate the patient using a bag-mask device prior to administering naloxone. Adequate ventilation while you prepare to administer___ decreases the risk of permanent brain damage related to hypoxia. Watch the patient closely; as the level of consciousness rises, the patient will no longer tolerate the oropharyngeal airway and you will have to remove it to prevent aspiration.
In some areas, lay people are permitted to administer__. Be aware that it may have been administered prior to
your arrival. Find out from bystanders what has occurred and who was given ____.
When a patient goes into cardiac arrest, follow the algorithm shown in FIGURE 22-9, including administration of____ if it is available. However, providing bag-mask ventilations is a critical treatment for these patients as well. Whether or not____ is available, provide ventilations and rapid transport.
naloxone
Barbiturates and benzodiazepines have been a part of legitimate medicine for a long time. They are easy to obtain and relatively cheap. People sometimes solicit prescriptions from several physicians for the same hypnotics or a variety of___ (TABLE 22-3). These drugs are CNS depressants and alter the level of consciousness, with effects similar to those of alcohol so that the patient may appear drowsy, peaceful, or intoxicated. By themselves, these drugs do not relieve pain, nor do they produce a specific high, although users often take alcohol or an opioid at the same time to boost their effects.
sedative-hypnotic drugs
In general, these agents are taken by mouth. Occasionally, however, contents of capsules are suspended or dissolved in water and injected to produce a sudden state of ease and contentment. Use of IV___ drugs quickly induces tolerance, so the person requires increasingly larger doses. You are less likely to be called to treat an acute overdose in someone who chronically abuses these drugs; however, you may be called to a scene of an attempted suicide in which the patient has taken large quantities of these drugs. In these situations, patients will often have marked respiratory depression and may be in a coma.
_____drugs such as chloral hydrate may also be given to people as a “knock-out” drink, or “Mickey Finn,” to
incapacitate them without their knowledge. Date rape or club drugs such as flunitrazepam (Rohypnol or roofies) and ketamine (Ketalar or Special K) are often colorless, tasteless, and odorless. They cause an unwary person to become sedated and even unconscious, which may facilitate sexual assault or rape. The person later awakens, confused and unable to remember what happened. Chapter 24, Gynecologic Emergencies, discusses this topic in more detail
sedative-hypnotic
Many abused ____ produce several of the same CNS effects as do other sedative-hypnotics, but these agents are inhaled instead of ingested or injected. This method of abuse is known as huffing. Some of the more common agents include acetone, toluene, xylene, and hexane, which are found in glues, cleaning compounds, paint thinners, and lacquers. Similarly, gasoline and various halogenated hydrocarbons, such as Freon or difluorethane (used as propellants in aerosol sprays such as compressed air to dust off electronics), are also abused as___. None of these____ are medications; rather, these substances briefly displace oxygen in the brain and cause a rush of euphoria. Because these are inexpensive products that can be bought in hardware stores, they are commonly abused by teenagers and curious adults seeking an alcohol-like high. The effective dose and the lethal dose are very close, making these extremely dangerous drugs. Long-term abuse can lead to permanent brain damage.
Take special care in dealing with a patient who may have used inhalants. Effects of inhalants range from mild drowsiness to coma, but unlike most other sedative-hypnotics, these agents often cause seizures. The lack of oxygen to the brain may cause a loss of brain function. Also, halogenated hydrocarbon solvents can make the heart hypersensitive to the patient’s own adrenaline, putting the patient at high risk for sudden cardiac death because of ventricular fibrillation; even the action of walking may release enough adrenaline to cause a fatal ventricular dysrhythmia. You must try to keep such patients from struggling with you or exerting themselves. Give supplemental oxygen for patients with respiratory distress or signs of hypoxia, and use a stretcher to move the patient. Prompt transport to the hospital is essential; monitor vital signs en route.
Inhalants
_____is a highly toxic, colorless, and flammable gas with a distinctive rotten-egg odor. Poisoning by hydrogen sulfide usually occurs by inhalation.____ affects all organs, but it has the most impact on the lungs and CNS.
____occurs naturally in sewers, swamps, volcanoes, and crude petroleum.____ poisoning is also a method used to commit suicide, referred to as chemical or detergent suicide. According to the Chemical Hazards Emergency Medical Management database, this method of self-inflicted exposure to toxic gas originated in Japan and reached the United States via the Internet. The patient may obtain a warning sign to place near the area of the suicide, such as an enclosed vehicle, to warn responders of the deadly gas. If you approach an enclosed vehicle with an unconscious patient inside, be alert for warning signs, as well as containers, buckets, or pots. Remember, do not enter a scene where a toxic gas may be present. Be aware of your surroundings as you approach, and if you suspect the presence of a toxic gas, wait for a hazmat team to tell you the scene is safe.
Workers in industrial settings may experience low-level exposure to____ over a long period of time, leading to eye, nose, and throat irritation, as well as headaches and bronchitis. Chronic exposure to this gas may cause an inability to smell the gas. When patients are exposed to high concentrations of the gas, they will experience nausea and vomiting, confusion, dyspnea, and a loss of consciousness. Seizures, shock, coma, and cardiopulmonary arrest may also result.
There is no antidote for hydrogen sulfide poisoning. Therefore, a hazmat team must quickly remove the patient from the contaminated area. Once the patient has been decontaminated, management is largely supportive. Monitor and assist the patient’s respiratory and cardiovascular functions and provide rapid transport.
Hydrogen sulfide
____are CNS stimulants that mimic the effects of the sympathetic (fight-or-flight) nervous system. These stimulants frequently cause hypertension, tachycardia, and dilated pupils. A stimulant is an agent that produces an excited state. Examples include amphetamine and methamphetamine (also called meth or ice), which are commonly taken by mouth or smoked. They are also injected by drug abusers in many cases.____ drugs are typically taken to make the user “feel good,” improve task performance, suppress appetite, or prevent sleepiness. They may also produce irritability, anxiety, fear, lack of concentration, or seizures. Paranoia and delusions are common symptoms of___ abuse.
Other examples include phentermine hydrochloride, an appetite suppressant, and amphetamine sulfate (Benzedrine), taken for weight control (short term), narcolepsy, and chronic fatigue syndrome. Caffeine and pheny|propanolamine (a nasal decongestant) are mild__. So-called designer drugs such as 3,4-methylenedioxymethamphetamine (MDMA, known as ecstasy or Molly) are also frequently abused in the United States.
____drugs are known by various street names that change often (TABLE 22-4).
Sympathomimetics
An agent that produces an excited state
Stimulant
Street name for 3, 4 methylenedioxymethampheramine (MDMA)
Adam. (book also said known as ecstasy or Molly)
Street name for phencyclidine (PCP)
Angel dust
Street name for amphetamines
Bennies
Street name for cocaine
Coke
Street name for crack cocaine, heroin, amphetamine, methampheramine, methcathinone
Crank
Street name for 4-methyl-2, 5-dimethoxyampetamine
DOM
Street names for MDMA
ecstasy, eve, molly,
Street name for 4-methylthioamphetamine
Golden eagle
Street name for cocaine, crack cocaine, smokable methamphetamine, methamphetamine, mdma,pcp
Ice
Street name for methampetine
Meth
Street name for methaqualone
MDA
Street name for crack cocaine, amphetamine, methamphetamine
Speed
Street name for amphetmines (besides bennies)
Uppers
____, also called crystal, snow, freebase, rock, gold dust, blow, and lady, is one of the most addictive substances known. It may be taken several different ways. Classically, it is inhaled into the nose and absorbed through the nasal mucosa, damaging tissue, causing nosebleeds, and ultimately destroying the nasal septum. It can also be injected intravenously or subcutaneously (skin popping).___ can be absorbed through all mucous membranes and even across the skin. In any form, the immediate effects of a given dose, including excitement and euphoria, last less than 1 hour.
Cocaine
Another method of abusing____ is by smoking it. Crack is pure__. It melts at 93°F (33.9°C) and vaporizes at a slightly higher temperature. Therefore, crack is easily smoked. In this form, it reaches the capillary network of the lungs and can be absorbed into the body in seconds. The immediate outflow of blood from the heart speeds the drug to the brain, so its effect is felt at once. Smoked crack produces the most rapid means of absorption and, therefore, the most potent effect.
Acute cocaine overdose is a genuine emergency because patients are at high risk for seizures, cardiac dysrhythmias, and stroke. You may see blood pressure measurements as high as 250/150 mm Hg. Chronic___ abuse may cause hallucinations; patients with “____bugs” think that bugs are crawling out of their skin.
Be aware that patients who have been poisoned by a sympathomimetic may be paranoid, putting you and other health care providers in danger. Law enforcement officers should be at the scene to restrain the patient, if necessary. Do not leave the patient unattended and unmonitored during transport.
cocaine
___, or___, are an emerging class of drugs similar to MDMA. The drug commonly includes the chemical methylenedioxyprovalerone (MDPV). ____should not be confused with products such as Epsom salt (magnesium sulfate), although selling it under this umbrella label has allowed its manufacturers and users to escape the legal restrictions imposed on illicit drugs. Brand names include Ivory Wave and Cloud Nine. Many states are working to make it illegal to manufacture or possess this drug.
____produce euphoria, increased mental clarity, and sexual arousal. Most users of this drug snort or insufflate the powder nasally. The effects reportedly last as long as 48 hours. Adverse effects include teeth grinding, appetite loss, muscle twitching, lip-smacking, confusion, gastrointestinal conditions, paranoia, headache, elevated heart rate, and hallucinations.
Keep the patient calm and transport. Consider ALS assistance; some of these patients may require chemical restraint to
facilitate safe transport.
Synthetic cathinones (bath salts)
The flowering hemp plant, Cannabis sativa, called__, is abused throughout the world. According to the Pew Research Center, almost one-half (49%) of Americans say they have tried__. Tetrahydrocannabinol, or THC, is the chemical in the____ plant that produces its high. Inhaling___ smoke from a cigarette or pipe produces euphoria, relaxation, and drowsiness. It also impairs short-term memory and the capacity to do complex thinking and work. In some people, the euphoria progresses to depression and confusion. An altered perception of time is common, and anxiety and panic can occur. With very high doses, some patients may experience hallucinations or become very anxious or paranoid. In these cases, keep the patient calm and provide transport. However, be aware that____ may be used as a vehicle to get other drugs into the body. For example, it may be laced with crack, fentanyl, or PCP.
marijuana
Several states have legalized the recreational use of__, and many others allow for the medical use of____ and products that contain THC. As the move toward legalization continues and as people become more aware of the health risks associated with smoking, delivery methods have evolved. Many medical users opt against smoking___ and instead obtain THC in the form of edibles or baked goods, candies, and other food additives that have been infused with___. These edibles are attractive to children and have led to an increase in emergency visits related to THC ingestion in children. The ingestion of____ can also lead to cannabinoid hyperemesis syndrome, characterized by chronic____ use and extreme nausea and vomiting that is relieved only by a hot shower or bath. Bathing can become compulsive in these patients. The definitive treatment for this condition is to stop using___; however, these users often believe that more____ will help the nausea and continue to consume it.
marijuana
____or “spice” refers to a variety of herbal incense or smoking blends that resemble THC and produce a similar high.____ is often marketed as a “safe” alternative to that drug under brand names such as K2 and Skunk. However, according to NIDA, the chemicals commonly found in spice products have no medical benefit and have a high potential for abuse. Powerful and unpredictable effects may result, ranging from simple euphoria to complete loss of consciousness.
Synthetic marijuana
A____ alters a person’s sensory perceptions (TABLE 22-5). The classic____ is lysergic acid diethylamide
(LSD). Abuse of another___, phencyclidine (PCP, or angel dust), is relatively uncommon among young adults. PCP is a dissociative anesthetic that is easily synthesized and highly potent. Its effectiveness by oral, nasal, pulmonary, and IV routes makes it easy to add to other street drugs. It is dangerous because it causes severe behavioral changes in which people often inflict injury on themselves.
hallucinogens
An agent that produces false perceptions in any one of the five senses
Hallucinogen
Commonly abused hallucinogens
• Bufotenine (toad skin)
• Datura stramonium (jimsonweed)
• Dextromethorphan (DXM)
• Dimethyltryptamine (DMT)
• Ketamine
• LSD
• Mescaline (peyote)
• Morning glory
• Nutmeg
• PCP
• Psilocybin (mushrooms)
• Salvia
All these agents cause visual hallucinations, intensify vision and hearing, and generally separate the user from reality.
The user, of course, expects that the altered sensory state will be pleasurable. Often, however, it can be terrifying. At some point, you are bound to encounter patients who are having a “bad trip.” They will usually have hypertension, tachycardia, anxiety, and paranoia.
Many___ have sympathomimetic properties. Your care for a patient who is having a bad reaction to a hallucinogenic agent is the same as that for a patient who has taken a sympathomimetic. Use a calm, professional manner, and provide emotional support. Do not use restraints unless you or the patient is in danger of injury. Follow the guidelines specified by local authorities. These patients may suddenly experience hallucinations or odd perceptions, so watch them carefully throughout transport. Never leave a patient who has taken a___ unattended and unmonitored. Request ALS assistance when appropriate.
hallucinogens
____are medications that block the parasympathetic nerves. The classic picture of a person who has taken too much of an____ medication is “hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as a hatter.” In other words, the patient will exhibit hyperthermia, dilated pupils, dry skin and mucous membranes, reddened skin, and agitation or delirium. Common drugs with a significant____ effect include atropine, antihistamines such as diphenhydramine (Benadryl), Datura stramonium (jimsonweed), and certain tricyclic antidepressants such as amitriptyline (Elavil). With the exception of jimsonweed, these medications usually are not abused drugs but may be taken as an intentional overdose. It is often difficult to distinguish between an___ overdose and a sympathomimetic overdose.
Both groups of patients may be agitated and have tachycardia and dilated pupils.
In addition to its____ effects, a tricyclic antidepressant overdose may cause more serious and life-threatening
effects because the medication may block the electrical conduction system in the heart, leading to lethal cardiac dysrhythmias. Patients with acute tricyclic antidepressant overdose must be transported immediately to the ED; they may appear “normal,” but seizure and death can occur within 30 minutes. The seizures and cardiac dyshythmias caused by a severe tricyclic antidepressant overdose are best treated in the hospital. If you work in a tiered system, consider calling for ALS backup when you are en route to the scene.
Anticholinergic agents
_____are medications that overstimulate the normal body functions controlled by the parasympathetic nervous system. These agents have been used for chemical warfare, such as during the sarin gas attack on the Tokyo subway system in 1995. These agents also occur in organophosphate insecticides, which are commonly used for lawn and garden care. A patient who has been poisoned by a___ will exhibit excessive salivation or drooling; mucous membrane oversecretion, resulting in a runny nose (rhinorrhea); excessive urination; excessive tearing of the eyes; uncontrolled diarrhea; and an abnormal heart rate.
Cholinergic agents
The signs and symptoms of cholinergic drug poisoning are easy to remember using the mnemonic DUMBELS:
D Diarrheal
U Urination
M Miosis (constriction of the pupils), muscle weakness
B Bradycardia, bronchospasm, bronchorrhea (discharge of mucus from the lungs)
E Emesis (vomiting)
L Lacrimation (excessive tearing)
S Seizures, salivation, sweating
You can also use the SLUDGEM mnemonic for chlorogenic agents
S Salivation, sweating
L Lacrimation (excessive tearing)
U Urination
D Defecation, drooling, diarrhea
G Gastric upset and cramps
E Emesis (vomiting)
M Muscle twitching/miosis (pinpoint pupils)
Patients who have been poisoned will have excessive body secretions. In addition, patients may have bradycardia.
The most important consideration in caring for a patient who has been exposed to a____ is to avoid exposure yourself. Because these agents may cling to a patient’s clothing and skin, decontamination will take priority over prompt transport to the ED. In many jurisdictions, the hazmat team will provide decontamination and contain the exposure chemical.
To care for the exposed patient, hospital staff or paramedics can use the anticholinergic drug atropine to dry up the patient’s secretions, followed by the use of pralidoxime to reverse the nerve agent’s effect on the patient’s nervous system.
In the meantime, your priorities after decontamination are to decrease the secretions in the mouth and trachea that threaten to suffocate the patient and provide airway support.
cholinergic agent
The military has developed antidotes to nerve gas agents that responders can self-administer if the agents are available.
In some areas across the country, these kits are issued to emergency medical providers depending on local protocols. The most common kit is the___. The Antidote Treatment Nerve Agent Auto-Injector (ATNAA) is the military form of the___
The____ is a single auto-injector containing 2 mg of atropine and 600 mg of pralidoxime. If a known exposure to nerve agents or organophosphates with manifestation of signs and symptoms has occurred, use the antidote kit only on yourself. If your service carries these antidote kits, you should receive training on their proper use prior to administering them.
DuoDote Auto-Injector
Some alcohols, including ____and ethylene glycol, are even more toxic than ethyl alcohol (drinking alcohol).
___is found in dry gas products and stove kits (Sterno); ethylene glycol is found in some antifreeze products.
Both cause a feeling of intoxication. Left untreated, both will also cause severe tachypnea, blindness (________), renal failure (ethylene glycol), and eventually death. Even ethyl alcohol can stop a patient’s breathing if taken in too high a dose or too fast, particularly in children. Although____ or ethylene glycol may be used as a substitute by a chronic abuser of alcohol who is unable to obtain ethyl alcohol, they are more often taken by someone attempting suicide. In either case, prompt transport to the ED is essential. TABLE 22-6 lists the most common fatally ingested poisons.
methyl alcohol
The term ptomaine poisoning was coined in 1870 to indicate poisoning by a class of chemicals found in rotting food. It is still used currently in many news accounts of food poisoning. ___ is almost always caused by eating food that is contaminated by bacteria. The food may appear normal, with little or no decay or odor to suggest danger.
There are two main types of__. In one, the organism itself causes disease; in the other, the organism
produces toxins that cause disease
food poisoning
Common Causes of Food Poisoning
• Campylobacter
• Clostridium botulinum toxin
• Clostridium perfringens
• Cryptosporidium
• Cyclospora
• Escherichia coli
• Giardia lamblia
• Listeria monocytogenes
• Norovirus
• Rotavirus
• Salmonella
• Shigella
• Staphylococcus toxin
• Vibrio parahaemolyticus
• Yersinia enterocolitica
One organism that produces direct effects of food poisoning is the____ bacterium. Salmonellosis is a condition characterized by severe gastrointestinal symptoms within 72 hours of ingestion, including nausea, vomiting, abdominal pain, and diarrhea. In addition, patients with salmonellosis may be systemically ill with fever and generalized weakness. Some people are carriers of certain bacteria; although they may not become ill themselves, they may transmit diseases, particularly if they work in the food services industry. Usually, proper cooking kills bacteria, and proper cleanliness in the kitchen prevents the contamination of uncooked foods.
Salmonella
The more common cause of food poisoning is the ingestion of powerful toxins produced by bacteria, often in leftovers.
The bacterium____, a common culprit, is quick to grow and produce toxins in foods that have been prepared in advance and kept too long, even in the refrigerator. Foods left unrefrigerated are a common vehicle for the development of staphylococcal toxins. Usually,____ food poisoning results in sudden gastrointestinal symptoms, including nausea, vomiting, and diarrhea. Although time frames may vary from person to person, these symptoms usually start within 2 to 3 hours after ingestion or as long as 8 to 12 hours after ingestion.
Staphylococcus
The most severe form of toxin ingestion is____. This often-fatal disease usually results from eating improperly canned food, in which the spores of Clostridium bacteria have grown and produced a toxin. The symptoms of____ are neurologic: blurring of vision, weakness, and difficulty in speaking and breathing.____ can also cause muscle paralysis and is typically fatal when it reaches the muscles of respiration. Symptoms of___ may develop as long as 4 days after ingestion or as early as the first 24 hours.
botulism
_____are susceptible to toxicity for several reasons. Consider the case of an accidental overdose or poisoning. The older patient may have forgotten that the medication had been taken and take repeated doses. Alcohol abuse can make a patient more likely to make medication mistakes. Many older patients take multiple prescriptions that may negatively interfere with each other, resulting in increased effects or unwanted drug interactions. The aging process may also impair the older patient’s ability to metabolize or excrete the poison. The drug could quickly accumulate to toxic levels and become fatal in lesser doses than in a younger person. Chapter 36, Geriatric Emergencies, discusses these risk factors in more detail.
If an older person inhales a poison, even in tiny quantities, lung damage can be severe. Consider the decreased lung capacity and ability to exchange oxygen and carbon dioxide in an older patient’s lungs. Pulmonary function could be worsened to potentially fatal levels with the inhalation of minute amounts of poison. For poisons that are absorbed by or injected into the skin, reduced circulation to the skin can decrease or delay absorption into the body. Watch for an increased reaction or irritation at the skin site.
A ____may also intentionally overdose in an attempt to commit suicide. Be alert for any indication of an intentional
overdose or poisoning, even though the patient might deny an attempted suicide.
Geriatric patients
According to the National Poison Data System, tens of thousands of cases of poisoning from plants occur each year, some severe. Many household plants are poisonous if ingested; children have been known to nibble on the leaves (TABLE 22-8).
Some poisonous plants cause local irritation of the skin; others can affect the circulatory system, the gastrointestinal tract, or the CNS. It is impossible for you to memorize every plant and poison, let alone their effects (FIGURE 22-10). You can and should do the following: 1. Assess the patient’s airway and vital signs.
2. Notify the regional poison center for assistance in identifying the plant.
3. Take the plant to the ED.
4. Provide prompt transport.
Plant poisoning
Irritation of the skin and/or mucous membranes is a problem with the common houseplant called___, which resembles elephant ears. When chewed, a single leaf may irritate the lining of the upper airway enough to cause difficulty swallowing, breathing, and speaking. For this reason,____ has been called “dumb cane.” In rare circumstances, the airway may be completely obstructed. Emergency medical treatment of____ poisoning includes maintaining an open airway, giving oxygen when necessary, and transporting the patient promptly to the hospital for respiratory support.
Assess the patient for airway difficulties throughout transport. If necessary, provide positive pressure ventilation.
dieffenbachia
____ is a Powerful CNS depressant
• Sedative
• Hypnotic
• Dulls the sense of awareness
• Slows reflexes
• Reduces reaction time
• Causes aggressive and inappropriate behavior and lack of coordination
Alcohol
About 1 to 7 days after a person stops chronic drinking or when alcohol consumption levels are decreased suddenly, ___ may develop
Delirium tremens (DTs)
Poisoning by hydrogen sulfide usually occurs by inhalation. Hydrogen sulfide affects all organs, but has the most impact on the __ and __
Lungs and CNS
