Environment and Toxicology Emergencies Flashcards
1. Explain the concepts related to care of an emergency department patient experiencing an environment and toxicology emergency. 2. Describe the various patient presentations related to environment and toxicology emergencies. 3. List interventions necessary for a patient presenting with an environment and toxicology emergency.
types of burns
chemical
electrical
radiation
thermal
pathophysiology of first 24 hours of burns
coagulation necrosis of soft tissue leading to release of vasoactive substances
capillary wall compromised, increase in permeability
vasodilation
edema peaks at 24 hours, next 18-24 hours cap permeability normalizes and third spacing resolves
fluid loss
altered tissue perfusion, airway swelling, hypovolemia leading to hypovolemic shock, decreased CO, cellular chock
assessing burns
ABCDE - trauma patients
modified for properties of causative agent and resulting injury
safety in burn treatment
decontamination
isolation
PPE
airway in burn tx
cervical spinal motion restriction
modified jaw-thrust maneuver to open airway and stabilize c-spine in neutral alignent
indictions for early intubation in burn patients
agitation, decreased LOC hoarseness, stridor, vocal change progressive edema oral, nasal erythema can't handle secretions extensive facial burns carbonaceous sputum
NOT singed nasal hair alone
airway risks d/t burns
risk for obstructed airway
inhalation injury
cric or trach may be needed
breathing in burn tx
supplemental O2
CO or cyanide poisoning
circumferential burns
tx for circumferential burns
chest wall escharotomy
electrocautery
fasciotomy
circulation sx in burns
profound hypovolemia
hypovolemic shock
decreased CO
cellular shock
treatment of cellular shock in burns
IVs, careful fluids with LR
monitor I/O, cardiac output
BP cuffs and art lines may be unreliable
complications of cellular shock in burns
fluid shifting
mostly first 4-6 hours for 24+ hours
hypovolemic shock likely if >20% burned
disability assessment in burns
generally alert
if not, assess for other injurie
exposure assessment in burns
stop burning process
keep patient warm
cover with clean, dry sheet
no ice or cold fluids
chemical burns overview
powders, gases, liquids
inhalation, ingestion, skin contact
safety in treating chemical burns
PPE, isolation
treatment for chemical burns
remove clothing
brush of dry powders
irrigate with copious water for 15 min until pt reports burning has stopped
use material data safety sheets, poison control, toxicologist
special substance considerations with chemical burns
metallic lithium
sodium
K+
magnesium
react poorly with water and may potentiate injuries
acid burns
coagulation of tissue causing necrosis
generally more damaging to stomach
common acidic chemicals that cause burns
battery acid
inegar
sulfuric acid
alkaline burns
penetrate deeply into tissue and liquefy tissue
more damaging to esophagus
common alkaline chemicals causing burns
lye/drain cleaner
alkaline batteries
baking soda
ammonia
sx chemical ingestion burns (acidic or alkaline)
oral burns red, white, yellow maybe bleeding drooling, vomiting stridor, hoarse voice SQ emphysema abd pain, distention
intervene for chemical ingestion
strict NPO
do not induce vomiting
toxicologist
characteristics of hydrofluoric acid
fluoride ion seeks Ca
systemic toxicity
clear, colorless liquid
corrosive, toxic
used during oil refinement and precursor to many chemicals
sx hydrofluoric acid exposure
depends on concentration usually affect digits pain worsens as it penetrates tetany Chvostek sign Trousseau sign dysrhythmias
Chvostek sign
spasm or twitch of facial muscle elicited by tapping facial nerve in region of parotid gland
Trousseau sign
sign of latent tetany in which carpal spasm can be elicited by compressing the upper arm with tourniquet or blood pressure causing ischemia to distal nerves
assessing hydrofluoric acid exposure
EKG
serum Ca, sx hypocalcemia
intervene for hydrofluoric acid exposure
analgesics
2.5% calcium gluconate
how to use calcium gluconate for hydrofluoric acid exposure
combine 1 ampule Ca gluconate with 100 g water-soluble lubricating jelly
cover with plastic dressing
hold in place
mechanisms of thermal burns
scald flame flash contact tar steam
intervene for thermal burns
stop burning process
< 10%: moist, cool dressings
>10%: dry, sterile dressings or clean sheet maintain body temp protect wounds avoid breaking blisters no topical agents
tar/asphalt burns
adheres to skin
creates tough barrier, difficult to remove
tar may continue to burn skin
intervene for tar/asphalt burns
stop burning fat emollient to loosen tar abx ointment citrus-based products peel off cool tar treat underlying burns as thermal
Rule of 9s to estimate burn size
surface area of each section of body is a multiple of 9
perineum = 1%
head = 18% in children, 9% in adults
palm method to estimate burn size
better for scattered burns
patients hand = 1% TBSA
depths of burns
superficial partial thickness (1st degree)
deep partial thickness (2nd)
full thickness (3rd and 4th)
tissue affected by depth of burn
1st: epidermis (superficial)
2nd: epidermis, partial dermis
3rd: entire epidermis, dermis destroyed
4th: underlying fat, fascia, muscle and/or bone affected
sx of burns based on depth
1st: redness, hypersensitivity, pain
2nd: red, blistered, wet, weepy, whiter, edematous
3rd: whitish or charred, coagulated vessels may appear
4th: often similar to 3rd
healing of burns based on depth
1st: heals on its own in days without scarring
2nd: may heal spontaneously over 2-3 weeks, minimal scarring
3rd: scar formation, skin grafting
4th: scar contracture formation, skin grafting, surgical intervention
fluid resuscitation in burns overview
only deep partial and full thickness burns in calculations, do not include 1st degree
LR
time fluid resuscitation for first 24 hours after injury
Parkland formula for burn fluid resuscitation
4mL LR x BSA % x kg
half of volume in first 8 hours
other half in next 16 hours
ABLS: advanced burn life support guidelines
adults (thermal, chemical)
2ml LR x kg x %BSA
adults (high voltage)
4mL LR x kg x %BSA
accounts for renal damage
peds
3mL LR x kg X %BSA
pediatric considerations in fluid resuscitation for burns
greater BSA/kg impaired thermoregulation limited glycogen stores thinner skin, deeper burns small airway, less edema for obstruction lower to ground, inhalation scald burns most common consider abuse, neglect
characteristics of carbon monoxide
may be associated with burn injuries or might be separate
colorless, odorless, tasteless
byproduct of organic material combustion
hemoglobin binding affinity 200+ x greater than O2
sx CO poisoning: 10-20%
HA n/v loss of coordination flushed skin dyspnea
sx CO poisoning: 20-40%
confusion
lethargy
visual changes
angina
sx CO poisoning: 40-60%
arrhythmias
sz
coma
sx CO poisoning: over 60%
cherry-red skin
death
Cheyne-Stokes respirations
carboxyhemoglobin levels in CO poisoning
amount of CO bound to Hg is associated with pt presentation
smoker can have baseline increased level
assessing CO poisoning
SpO2 unreliable
need carboxyhemoglobin level
intervene for CO poisoning
high-flow oxygen for at least 4 hours via nonrebreather to reduce CO half-life
severe exposures require burn center transfer and/or hyperbarics
define electrical burns
surface wounds usually small but there are severe internal injuries
caused by current flow, arc flash, or clothing ignition
sx low voltage electrical burns
delayed pain onset
fatal dysrhythmias
sx high voltage electrical burns
tissue heated immediately with tissue necrosis
arrhythmias
compartment syndrome
rhabdo
hypovolemia
intervene for electrical burns
EKG LR 1-2 L/hr I/O -adults 75-100 ml/hr -peds: 1ml/kg/hr
black widow spider characteristics
red hourglass on abdomen
dark, secluded, damp spaces
almost always one bite
sx black widow spider bite
pain at time of bite halo ring large muscle cramps HTN, tachycardia N/V paresthesia, weakness
intervene for black widow spider bite
ice, elevate tetanus muscle relaxants antihistamines (sustemic edema) antivenin with caution
characteristics of brown recluse spider
dark, violin-like spot
dark, undisturbed places
nocturnal
southern US
sx brown recluse spider bite
painless at time of bite bluish, irregular ring pruritus, blisters, redness edema F/C, N/V malaise, myalgia necrotic ulcerating wound eschar
intervene for brown recluse spider bite
ice, elevate
tetanus
wound care
snake pupils
venomous: elliptical (minus coral snakes)
nonvenomous: round
snake bites
venomous: two fangs, produce punctures
nonvenomous: several rows of small teeth, produce scratches
snake head shapes
venomous: triangular d/t venom glands
nonvenomous: rounded
presence of pit between eye and nostril in snakes
venomous: yes, in pit vipers
nonvenomous: no
tail in snakes
venomous: single row of subcaudal plates
nonvenomous: double row
snakes that produce hemotoxic venom
pit vipers
rattlesnakes
copperheads
cotton mouths
snakes that produce neurotoxic venom
coral snakes
local rxn to hemotoxic snake venom
rapid pain redness, swelling ecchymosis loss of limb fxn severe tissue necrosis
systemic rxn to hemotoxic snake venom
tachycardia, tachypnea, dyspnea constricted pupils ptsos, diplopia muscle twitch, paresthesias difficulty speaking confusion bleeding disorders
sx neurotoxic snake venom
bite less red and swollen
effects can delay up to 12 hrs
general: local paresthesais, diplopia, ptosis, difficulty swallowing
resp: resp distress, pharyngeal spasm, hypersalivation, cyanosis, trismus
interventions for dry snake bites
no venom
abx and tetanus
interventions for envenomation snake bites
\+ venom IV prior to tourniquet removal immobilize, raise limb monitor for compartment syndrome consider antivenin
antivenin
ideally w/in 4 hours
effective up to 24 hrs
availability: Crotalid, poison center
monitor for anaphylaxis
tick removal
forceps close to skin and mouth of tic
remove, pulling straight back to counter direction entered
remove like splinter if parts remain
do not squeeze or crush
save for species identifiation
early sx Lyme disease
erythema migrans rash (in70-85%)
circular (bullseye) rash w/ flu-like sx
late sx Lyme disease
monoarticular arthritis multiple skin lesions Bells palsy memory loss meningitis heart block myocarditis painful arthritis
intervene for lyme disease
abx: oral doxy bid x 2 weeks
salicylate for pain
pacemaker for heart block
sx Rocky Mountain spotted fever
fever, chills
HA
rash
incubates 2-14 days
rash in Rocky Mountain spotted fever
maculopapular, nonpruritic spots on soles, ankles, palms, wrists, forearms
becomes nonblanching and petechial
spreads in centripetal fashion
complications of Rocky Mountain spotted fever
renal failure
thrombocytopenia
hyponatremia
impaired liver fxn
intervene for Rocky Mountain spotted fever
doxycycline
characteristics of rabies
viral disease
transmitted via bite of rabid animal via saliva
bats, raccoons, skunks, foxes
sx of initial stage of rabies
parethesia, pain, itching
sx of prodromal stage of rabies
HA, fever runny nose, sore throat myalgia GI sx acute, progressive encephalitis hydrophobia, aerophobia
intervene for rabies
early, aggressive wound management with soap and water
use sunlight to dry and sterilize contaminated materials
characteristics of stingrays
1+ venom-coated barbed stingers on tail for self-defense
can cause painful injuries, esp to lower extremities if entering their territory
sx stingray sting
severe pain, swelling, bleeding at site
possible systemic effects that could be life threatening
intervene for stingray sting
hot water immersion for 2 hrs pain management tetanus barb removal wound irrigation wound cultures, abx
characteristics of jellyfish
nematocysts are stinging darts that fire when tentacles make contact
sx jellyfish stings
local
moderate to severe pain
reddened welts
intervene for jellyfish stings
irrigate remove tentacles with ppe pain management acetic acid aka vinegar baking soda paste
cold or heat not determined, depends on species
define contact dermatitis
allergic rxn after exposure to urushiol oils from poison ivy, oak, and sumac
intervene for contact dermatitis
OTC topical agents or benadryl
sx may be worse with inhalation or existing allergy
avoid contact
standard wound care, allergy tx based on severity
characteristics of giardia
protozoan parasite that causes giardiasis
lives in intestines
transmission of giardia
spread by water contaminated with fecal matter
sx giardia
diarrhea, steatorrhea abd cramping bloating weight loss malabsoprtion
intervene for giardia
rehydrate
metronidazole, tinidazole, nitazoxanide
characteristics of tapeworms
taeniasis caused by Taenia
2-25 meters
transmission of tapeworms
raw/undercooked beef or pork
sx tapeworm
GI discomfort nausea flatulence diarrhea hunger pains may pass proglottids (tapeworm parts)
intervene for tapeworm
praziquantel
characteristics of pinworms
small, thin, white roundworm
lives in colon/rectum
females may leave through anus whle person sleeps to lay eggs
transmission of pinworms
oral-fecal
sx pinworm
mild sx or none
anal itching
diagnosing pinworm
tape test
intervene for pinworm
mebendazole, pyrantel pamoate, albendazole
types of lice
pediculus humanus capitis (head)
pediculus humanus corporis (body)
pthirus pubis (pubic)
transmission of lice
person to person
sx lice
itching, sores from scratching
sleeplessness
intervene for lice
topical meds, shamppoo
combine
wash clothes, linens, combs in hot water
vacuum floor, furniture
define scabies
itch mite that buries in upper layer of skin
transmission of scabies
direct, prolonged skin to skin contact
sx scabies
intense pruritus, esp at night
papular itchy rash
vesicles, scales
key areas: hands and other moist areas (axilla, groin)
intervene for scabies
premethrin cream head to toe and again one week later
crotamiton lotion/cream, not for children
wash clothes, linens in hot water
thoroughly clean, vacuum rooms
transmission of ringworm/tineas
spread to people and animals via fomites
sx ringworm/tineas
circular, red, scaly, itchy rash
central clearing
intervene for ringworm/tineas
tineas pedis, corporis, cruris (feet, body, groin): otc/topical antifungal
tineas capitis (scalp): systemic antifungal (griseofulvin, terbinafine)
define arterial gas embolism
high-pressure air forced into arterial circulation
complications of arterial gas embolism
trapped air in lung expands, leading to rupture of lung tissue, releasing gas bubbles into arterial circulation
causes of arterial gas embolism
divers ascending too quickly, panicky, or while holding breath
also normal ascents with COPD
sx arterial gas embolism
chest tightness, dyspnea pink, frothy sputum pneumothorax sx limb paresthesia vertigo altered LOC visual disturbances SZs sensory loss
intervene for arterial gas embolism
O2
needle decompression
hyperbarics
avoid Trendelenburg
define decompression sickness
bubbles growing in tissues causing local damage aka “the bends”
due to inadequate decompression after exposure to increased pressure
pathophysiology of decompression sickness
during diving, nitrogen absorbed by body tissues but during ascent if pressure is reduced too quickly, the nitrogen forms bubbles and enters bloodstream
sx decompression sickness
sob, crepitus, cough numbness, tingling HA visual loss, diplopia fatigue, dizziness, unconsciousness, SZs paresthesias, paralysis joint discomfort, progressive pain
intervene for decompression sickness
O2, fluids, analgesia
urgent hyperbarics
consider antiplatelet, antithrombin meds and heliox (helium-oxygen)
define heat cramps
sweat-induced electrolyte depletion r/t intense physical activity and hot environment
sx heat cramps
muscle cramps weakness thirst nausea tachycardia pale, cool, moist skin
intervene for heat cramps
electrolyte replacement
cool environment
rest
define heat exhaustion
prolonged period of fluid loss r/t exposure to warm environment without fluid and electrolyte replacement
left untreated, may progress to heatstroke
sx heat exhaustion
rapid onset of heat cramps anorexia, vmoiting general malaise muscle incoordination HA, syncope temp normal to elevated (98.6-104)
intervene for heat exhaustion
IV fluid, electrolytes
cool environment
rest
define heat stroke
temp at or above 105.8F or 40C
CNS, cardiac, cellular fxns affected
causes of heat stroke
strenuous physical activity in hot environment and unable to dissipate body heat
non-exercise induced
non-exercised induced causes of heat stroke
young and elderly more vulnerable
environmental
med related:
- thyroid
- sympathomimetics
- haldol
- antihistamines
- anticholinergics
- propanolol
sx heat stroke
rapid onset N/V/D hot, dry skin tachycardia, tachypnea decreased LOC posturing, SZs, dilated/fixed pupils hypotension, decreased urinary output coagulopathies
intervene for heat stroke
cool rapidly room temp IV fluids monitor electrolytes, clotting I/Os control shivering (benzos)
define frostbite
type of burn injury d/t formation of ice crystals in tissue, leading to cellular damage, vasospasms, arterial thrombosis
frostbite overview
damage to cells irreversible
days to weeks to determine extent of underlying damage
may be associated with hypothermia
sx frostbite
burning, numbness, tingling
white, waxy skin color
stinging, hot feeling after thawing
blisters
intervene for frostbite
assess for hypothermia analgesia circulating water immersion debride nonhemorrhagic blisters gently handle tissue loose, bulky clothing tetanus
tissue handling in frostbite
do not rewarm or thaw if there is a possibility of re-freezing
frozen tissue should never be rubbed because further tissue damage will occur
characteristics of mild frostbite
brief exposure, early rewarming bright red or normal skin color warm digits sensation clear blisters blisters to digit tips
characteristics of deep frostbite injury
prolonged exposure, delayed rewarming
mottled/purple skin cool digits no sensation hemorrhagic blisters proximal blisters only
primary cause of hypothermia
ambient environment
secondary cause of hypothermia
medical condition that decreases body temperature
mild hypothermia
90-95F vasoconstriction shivering cold sensation coagulopathy
moderate hypothermia
82.4-90F bradycardia confusion, agitation metabolic acidosis cold-induced diruesis
severe hypothermia
68-82.3F
coma
resp depression
profound hypovolemia
profound hypothermia
68F
apnea
asystolic arrest
intervene for hypothermia
passive rewarming
active external rewarming
active internal rewarming
passive rewarming for hypothermia
dry skin, remove wet clothing
warm environment
active external rewarming for hypothermia
forced-air warming system
warm water immersion
active internal rewarming for hypothermia
warm IV fluids heated, humidified oxygen peritoneal lavage w/ heated dialysate rapid fluid infuser cardiac bypass, HD
complications of hypothermia
refractory v.fib until rewarmed
other dysrhythmias
cardiac dysrhythmias in hypothermia
a.fib
osborn or J waves
bradycardia
v.fib
intervene for cardiac dysrhythmias in hypothermia
volume replacement
rewarm body core before periphery to prevent rewarming shock (leads to fibrillation)
caution with IV meds
induced emesis s/p ingestion
not routinely used
serious side effects
marginally effective
contraindications for activated charcoal s/p ingestion
corrosive agent, hydrocarbons
decreased/absent bowel sounds
toxins not bound by charcoal
toxins that are not bound by activated charcoal
iron lead lithium toxic alcohols caustics
dosing activated charcoal
multidosed for:
- extended release meds
- carbamazepine
- dapsone
- quinine
- theophylline
- enteric coated tablets
q4-6 hr for 12-24 hrs
indications for gastric lavage s/p ingestion
life-threatening poisons
symptomatic pts w/in 1 hr ingestion or who ingested agent that slows GI motility
ingestion of sustained-release meds or massive or life-threatening amounts of a substance
cathartics s/p ingestion
magnesium sulfate, magnesium citrate, sorbitol
added to activated charcoal to enhance GI elimination
contraindicated if bowel sounds are absnet
whole bowel irrigation s/p ingestion
electrolyte solution
most common for ingested agents not well absorbed by charcoal
contraindicated in GI pathology
indications for HD s/p ingestion
severe poisonings with sx:
- metabolic acidosis
- electrolyte abnormalities
- renal failure
contraindications for HD s/p ingestion
substance highly protein-bound rarely fatal agents agents with antidotes HD unstable pts bleeding disorders poor vascular access
define toxidrome
set of toxic sx caused by particular class of medication
define sympathomimetic toxidrome
mimic neurotransmitters of SNS
epi, dopamine, norepi, catecholamines
drugs that are sympathomimetic
cocaine amphetamines methamphetamine ephedra alkaloids MDMA, ecstasy albuterol dopamine tricyclic antidepressants MAOIs
sx sympathomimetic toxidrome
HTN, tachycardia, tachypnea hyperthermia CNS excitation tremors, SZs hyperreflexia mydriasis diaphoresis
intervene for sympathomimetic toxidrome
sedation
nonpharm cooling
BP, pulse control
pharm management
pharm management of sympathomimetic toxidrome
benzos
nitroprusside
haldol
neurmuscular blocks
complications of cocaine overdose
ventricular arrhythmias MI, aortic dissection rhabdo, lactic acidosis hyperglycemia SZs, strokes placental abruption, premature delivery nasal septum perforation
intervene for cocaine OD
same as sympathomimetic toxidrome but consider condition-specific complications
sedative-hypnotic toxidrome
barbiturates depress CNS and may be classified as sedatives
non-barbituates may be considered hypnotics
types of barbituates
phenobarbital
thiopental
types of nonbarbituates
benzos
antihistamines
sx sedative-hypnotic toxidrome
hypotension, bradycardia
bradypnea
hypothermia
arrhythmias
intervene for sedative-hypnotic toxidrome
aspiration precautions early intubation beta-adrenergic agonists flumazenil for benzos antiarrhythmics
cholinergic toxidrome
cholinergic drugs mimic or enhance action of acetylcholine of PNS and have muscarinic and nicotinic effects
examples of cholinergic substances
pesticides/insecticides organophosphates (sarin) pilocarpine bethanechol choline some mushrooms
sx cholinergic toxidrome
SLUDGE: salivation lacrimation urination defecation GI upset emesis
intervene for cholinergic toxidrome
control hypoxemia 2nary resp distress
atropine
2PAM (Pralidoxime)
benzos for SZs
pralidoxime (2PAM)
for cholinergic toxidrome
restores action of acetylcholinesterase to break down acetylcholine
administered with atropine to dry secretions
anticholinergic toxidrome
blocks acetylcholine and inhibits parasympathetic nervous system
types of anticholinergic medications
antihistamiens tricyclic antidrepressants cyclobenzaprine antispasmodics mydriatics ipratropium bromide atropine antiparkinson meds
also nightshade (Bella Donna) and Jimson weed (Devil’s snare)
mnemonic to remember anticholinergic toxidrome
blind as a bat mad as a hatter red as a beet hot as Hades dry as a bone bowel and bladder lose their tone heart runs alone
sx anticholinergic toxidrome
HTN, tachycardia tachypnea, hyperthermia mydriasis decreased bowel sounds dry mucous membranes, flushing urinary retention agitation, delirium, hallucinations
intervene for anticholinergic toxidrome
sedate with benzos cooling haldol physostigmine slow IV pushes continuous EKG/tele
physostigimine
for cholinergic toxidrome
PNS alkaloid that inhibits cholinesterase
rapid administration can result in resp failure and heart paralysis
opioid toxidrome
opiates and narcotics that depress CNS
sx opioid toxidrome
respiratory, CNS depression
miosis
hypotension, bradycardia
bradypnea, hypothermia
intervene for opioid toxidrome
intubate, ventilate
narcan
-duration 30-60 min
-repeat dose may be needed
opiate withdrawal
sudden cessation of opiates after physical dependence
types of opiates
heroin morphine hydrocodone oxycodone codein
sx opiate withdrawal
rhinorrhea, sneezing, yawning lacrimation abd, leg cramps N/V/D dilated pupils
assessing opiate withdrawal
last dose
route of use
tox screen
intervene for opiate withdrawal
supportive care
benzos for cramps, anxiety, insomnia
clonidine for lacrimation, diarrhea, tachycardia
opioid substitute (methadone)
types of hallucinogenic
LSD
PCP
GHB (date rape drug)
sx LSD toxidrome
sympathomimetic effects
euphoria
fear, anxiety, panic
hallucinations, paranoia, psychosis
intervene for LSD toxidrome
reduce stimulation
restraints for safety
benzos for agitation
haldol for psychosis
sx PCP toxidrome
violent, combative behavior increased strength lack of pain sensation nystagmus miosis
intervene for PCP toxidrome
reduce stimulation benzos for agitation haldol for psychosis antihypertensives restraints
sx GHB toxidrome
depressed LOC to coma with significant resp depression
hypertension, bradycardia
SZ
intervene for GHB toxidrome
intubate, ventilate
benzos for agitation
sexual assault kit
toxic inhalants
toxic ingestion via lungs
methods of using toxic inhalants
sniffing - inhaling from container
huffing - soaking cloth in solvent and inhaling
bagging - fumes from a bag
types of toxic inhalants
aerosols gases solvents cleaning products food products
sx toxic inhalation
sudden sniffing death CNS stimulation or depression arrhythmias, cardiac arrest eye, resp, GI irritation wheezing ataxia with wide gait epistaxis burns long term use = organ damage
intervene for toxic inhalation
well-ventilated space
decontaminate
intubate, ventilate
benzos
interventions for alcohol ingestion in general
intubate, ventilate
HD
monitor for Wernicke-Korsakoff syndrome
tx for ethylene glycol or methanol ingestion
ethanol or fomepizole to block metabolism of ethylene glycol and methanol
fomepizole preferred, don’t need to monitor for low BG and can be given with HD
sodium bicarb for acidosis
tx for ethanol specific ingestion
IV fluids
monitor BG
nutritional support (B1, thiamine)
Wernicke-Korsakoff syndrome
in alcohol ingestion lack of vitamin B1 mental confusion taxia ophthalmoplegia
sx alcohol withdrawal/DT
AMS, confusion, disorientation hallucinations, agitation tremors tachycardia, tachypnea, HTN hyperthermia
delirium tremens
tremors
hallucinations
anxiety
disorientation
intervene for alcohol withdrawal/DT
benzos
antispychotics
types of alcohol
ethanol
isopropanol
ethylene glycol
methanol
characteristics of ethanol
alcohol beverages
least toxic
leads to intoxication
characteristics of isopropanol
rubbing alcohol
less toxic than others
metabolite is acetone
sx isopropanol ingestion
fruit breath odor 2/2 acetone
hyperglycemia
urine ketones
CNS depression
characteristics of ethylene glycol
antifreeze, deicing agents
odorless, syrupy liquid with sweet taste
sx ethylene glycol ingestion
intoxication tachycardia, HTN hyperventilation metabolic acidosis renal failure
large doses: nystagmus, ataxia, SZs, coma
characteristics of methanol
windshield wiper fluid, canned fuels, solvents
light, volatile, flammable
sweeter than ethanol
sx methanol ingestion
similar to ethanol but 10-30 hrs later
metabolites cause profound metabolic acidosis, destroy optic nerve
N/V
abd pain
iron ingestion
usually via nutritional supplements
assessing iron ingestion
multiple types of iron - specify type and amount
40-60mg/kg of elemental iron causes severe sx
intervene for iron ingestion
gastric lavage NO activated charcoal whole bowel irrigation serum iron level hypovolemic shock tx chelation with deferoxamine
deferoxamine
tx for iron ingestion via chelation
turns urine pink - continue tx until urine color normal
initial stage of heavy metal toxicity
0-2 hours
N/V, abd pain
hematemesis, bloody stools
hypotension
second stage of heavy metal toxicity
2-48 hrs
GI disturbances resolves
dehydration
third stage of heavy metal toxicity
48-96 hrs
metabolic acidosis, coagulopathy
hemorrhage, shock
hepatic, renal failure
define cyanide
cellular asphyxiant
sources of cyanide
industrial processes
terrorism
foods
byproduct of long-term nitroprusside
sources of industrial cyanide
insecticides
industrial fumigants
metal plating
plastic burning
sources of cyanide in food
apricot pits
orange seeds
cassava
types of cyanide exposure
inhalation
dermal
ingestion
parenteral
common byproduct of fires
sx cyanide poisoning
hypoxia, resp distress HA, dizziness, SZs metabolic acidosis arrhythmias, hypotension burning sensation in mouth bitter almond breath
intervene for cyanide poisoning
15 LMP nonrebreather amyl nitrate intubate, ventilate sodium nitrite sodium thiosulfate decon vasopressors benzos
why is it easy to OD on acetaminophen?
found in many OTC and Rx meds in which it is not obvious that the med contains acetaminophen
pathophysiology of acetaminophen toxicity
toxic to liver in small doses
metabolites destroy liver cells which leads to necrosis and damage
toxicity at levels > 140 mg/kg
alcohol abuse or liver disease at increased risk
intervene for acetaminophen toxicity
gastric lavage if recent or above 7.5 grams
activated charcoal
level 4 hours after ingestion
contact poison center for chronic ingestion or past 24 hours
N-acetylcysteine if toxic level
administration of N-acetylcysteine for acetaminophen ingestion
within 8 hours of ingestion for best results
can be started up to 24 hours after poisoning
sx of acetaminophen ingestion at 0-24 hours
malaise
nausea
diaphoresis
sx of acetaminophen ingestion at 24-48 hours
RUQ pain
elevated LFTs
decreased urine
sx of acetaminophen ingestion at 72-96 hours
malaise hypoglycemia jaundice, enlarged liver coagulopathies coma
sx of acetaminophen ingestion at 7-8 days
recovery with potential liver damage
type of salicylate
aspirin
salicylate toxicity
CNS hematologic cardiovascular gastrointestinal acid-base electrolyte status
sx salicylate toxicity
tachypnea, tachycardia N/V/abd pain diaphoresis, fever, dehydration tinnitus hypoglycemia electrolyte imbalance AMS, SZs hemorrhagic gastritis coagulation abnormalities
intervene for salicylate toxicity
fluids, I/O, electrolyte monitoring HD activated charcoal sodium bicarb tx hypoglycemia repeat labs q 6-12 hrs
indications for HD in salicylate toxicity
severe poisonings renal failure serum levels > 75 mg/dL decreased renal fxn significant acidosis severe fluid/electrolyte disturbances
NSAIDs overview
analgesics, antipyretics, antiinflammatories
ibuprofen, naproxen
safer than acetaminophen, less likely to be toxic
NSAID toxicity
acute ingestion under 100 mg/kg is not toxic
over 300 mg/kg is severe
sx NSAID toxicity
drowsiness, lethargy, SZs GI irritation renal failure, hepatotoxicity apnea metabolic acidosis
intervene for NSAID toxicity
monitor
gastric lavage
actvated charcoal
SZ precautions, benzos
characteristics of tricyclic antidepressants
peripheral anticholinergic and CNS effects
pathophysiology of tricyclic antidepressant toxicity
false low Na levels d/t being highly protein bound and lipid soluble
Na channel blockade
cannot be removed via HD
long elimination half-life
sx of tricyclic antidepressant toxicity
cardiotoxicity
adrenergic compromise
anticholinergic activity
cardiotoxicity in tricyclic antidepressant toxicity
tachydysrthymias prolonged PRI, QT wide QRS hypotension AV bocks
adrenergic compromise in tricyclic antidepressant toxicity
decrease LOC
syncope
SZs
coma
anticholinergic activity in tricyclic antidepressant toxicity
tachycardia dry mouth urinary retention hyperthermia mydriasis
intervene for tricyclic antidepressant toxicity
intubate gastric lavage activated charcoal cathartic agents sodium bicarb for pH isotonic fluids vasopressors, benzos prn
overview of beta blocker and calcium channel blocker toxicity
negative chrono-, dromo-, and inotropic effects
severe pediatric toxicity with one tablet
sx may have rapid progression and be resistant to conventional therapy
onset may be late
sx beta blocker/calcium channel blocker toxicity
bradycardia, hypotension cardiac conduction abnormalities confusion, AMS, syncope SZs, coma N/V hyperglycemia (CCB), hypoglycemia (BB)
intervene for beta blocker/calcium channel blocker toxicity
gastric lavage activated charcoal pacing for refractory brady glucagon calcium chloride atropine vasopressors correct glucose abnormalities
use of glucagon in beta blocker/calcium channel blocker toxicity
positive ino- and chronotropic effects
antidote for meds that reduce intracellular Ca
use of calcium chloride in beta blocker/calcium channel blocker toxicity
calcium gluconate contraindicated due to decreased bioavailability of calcium
digoxin overview
negative chronotropic
positive inotropic
meds and plants
risk of digoxin toxicity
concurrent use of other cardiac meds or diuretics
presence of hypokalemia
acute sx digoxin toxicity
peak 30 min to 12 hrs
arrhythmias, hypotension
hyperkalemia
lethargy, coma
chronic sx digoxin toxicity
anorexia
N/V
yellow/green halos
intervene for digoxine toxicity
serum levels
activated charcoal
treat electrolyte, glucose, volume abnormalities
atropine or TCP for brady
monitor K+, arrhythmias, CHF
digoxine-immune fab antidote
indications to use digoxin-immune fab antidote in digoxin toxicity
large ingestion in previously health adults (10 mg)
bradycardia refractory to atropine
ventricular arrhythmias
levels above 10 ng/mL
hyperkalemia over 5.5
