MOD F TECH 46 Poisoning and Substance misuse Flashcards
Definition of a Poison
•A poison (toxin) is any substance which, when taken into the body in sufficient quantity, may cause temporary or permanent damage either endangering life or seriously impairing body functions.
•
•Once in the body poisons attack vital organs, such as the brain, heart, lungs, liver and kidneys. Different poisons attack different organs and produce varying signs and symptoms – they may develop quickly or over a number of days.
•
•Although a patient may well recover, permanent damage may occur to internal organs.
Types of Poisons
Poisons are Classified as:
Corrosive / Irritants
Non - Corrosive
Overdose and poisoning is a common complaint we are called to in the Ambulance Service and accounts for 140,000 hospital admissions per year.
•
Poisons are usually taken in one of following ways:
Accidentally or Intentionally (self-harm), mal-intent
or non-accidentally.
A number of factors will affect severity and
outcome including age, toxicity of the agent,
quantity and route of exposure
How Poisons enter the Body
Inhalation – fumes, gases, solvents, vapours
Ingestion – liquids, or solids by mouth
Injection – needles, animal and insect bites
Absorption – pesticides or herbicides through the skin and eyes
JRCALC Principles of treatment
•Identify poisons / agent – household product, pharmaceutical / recreational substance, plant / fungi, alcohol, chemicals (CBRNe) or even cosmetics?
•
•Specific treatment for the type of poison
•
•Rapid access to hospital
Duty of Care
- It is not uncommon to find a patient who has or claims to have taken an overdose and subsequently refuses treatment or admission to hospital.
- If this happens then ensure that their mental health, capacity and suicide risk have all been assessed.
- If despite reasonable persuasion the patient still refuses treatment then it is not acceptable to leave them in a potentially dangerous situation without any access to care – do the police need to attend and / or a local mental health team?
History
- The event e.g.: when did it happen
- Drug /substance ingested
- Quantity of the drug/substance ingested
- Collect all suspected drugs/substances
- Mode of poisoning e.g. ingestion, inhalation
- Additional contributory factors – alcohol
- Has any treatment occurred yet?
Corrosive / Irritant Substances
Clinical Signs:
üLips mouth show signs of corrosion
üBurning / staining
üSevere pain / swelling mouth and throat
üWretching / vomiting
üAbdominal cramps / diarrhoea
üDifficult speech due to swelling of the mucosa
üOdours on breath
Management of Corrosive / Irritant Substances
üEnsure open airway
üO2 therapy (Paraquat with caution – only in hypoxic pt’s with SpO2 <88% aiming for target saturation
of 88-92%)
üPulse
üNever induce vomiting
üAscertain poison taken / time / quantity
Nil by mouth unless directed to by container
/ petroleum dilute = MILK
Retain samples for = Identification
Transport to hospital = Urgently
Retain vomit for = Analysis
Taking a relative to hospital with the patient if possible
unconscious Patient:
Ensure open airway
Administer oxygen
Assist ventilation if necessary
CPR = Bag / Mask Mechanical resuscitator
Avoiding Contamination
B.M.
Transport in Recovery position
Non – Corrosive Substances
Neurotoxic poisons
Generally affects the nervous system by depressing vital functions; more common ones are:
q
qMorphine
q Heroin
Barbiturates
Clinical Signs
qPinpoint pupils (with opiates
q Slow and shallow breathing
(depressed respiration)
q Lethargy and reduction in activity
q Vomiting and diarrhoea
q Loss of consciousness
Management of Neurotoxic Poisons
qEnsuring open airway
q Oxygen therapy in high concentrations
q Assist ventilation if necessary
q CPR if required
q Do not induce vomiting
q Copious amounts of water / milk to dilute and delay absorption
qPlace in recovery position
and do not induce vomiting, if the
patients unconscious
q Keep patient still and quiet
to reduce pulse rate
q Do not allow the patient to walk
Poisonous Gases
•Because of the variety of poisons which can be inhaled and their differing effects on the body, there are few clear cut signs and symptoms
Management of
Poisonous Gases
Approach the scene with care
Remove the patient from the poison source
Ensure open airway
Administer high concentrations of oxygen
CPR if required
Loosen and remove contaminated clothing
Identify what type of gas was inhaled
Inform the receiving hospital if possible (pre-alert)
Transport to hospital
Paraquat Poisoning Cases
Management of
Paraquat Poisoning
•In addition to the usual clinical signs, there may be evidence of burning around the mouth.
Open airway
O2 therapy only when hypoxaemic to maintain SAO2 @88-92%
Artificial ventilation only by bag valve mask.
Do not encourage the patient to vomit
Pesticide and
Herbicide Poisoning
- In addition to the usual clinical signs there may be evidence of burning staining around the mouth, tongue and lips
- Remove the patient from the source
- Ensure open airway
- Assisted ventilation Bag Mask / Ventilator providing O2
- Remove contaminated clothing taking care not to contaminate yourself
qWash contaminated skin thoroughly
q If eyes contaminated irrigate with copious amounts of clean water, covering both with soft pad
q Take to hospital for examination (eye causality)
q Take with you, container / sample of the substance / vomit for analysis
National Poisons Information Service
•NPIS is a service commissioned by the Health Protection Agency that provides expert advice on all aspects of acute and chronic poisoning
•
•It promotes, supports and develops best practice for the management of cases of poisoning in NHS facilities
•
•However it does not answer queries from the public but supports NHS Direct (0845 4647) and NHS24 (08454 24 24 24)
Alcohol Poisoning
•Alcohol intoxication is a common emergency & can pose a major problem when combined with drugs in overdose
•
•When combined with opiate drugs or sedatives, it will further decrease LOC & increase the risk of aspiration of vomit
•
•Pay particular to airway management & use the recovery position where appropriate
•
•Always remember to check BM as hypoglycaemia can mimic the signs of alcohol intoxication
Drug Overdoses
- Could be accidental or intentional
- Management:
- Safety
- A,B,C,D,E – correcting as go along
- Hx – what drug, how much, when taken, how taken, mixed with anything else, collect all suspected drugs to take to A&E, any treatment occurred yet
- Administer high flow O2 if working alone or as double ECA crew; administer according to clinician’s guidance
Some common drugs used in poisoning / overdoses
- Paracetamol
- Aspirin
- Tricyclic antidepressants – amitriptyline, dothiepin
- Heroin and other opiates – morphine, pethidine
- Barbiturates / ‘downers’ – amytal, seconal
- Amphetamines – speed / ecstasy
- Alcohol
- Organo-phosphates – pesticides, insecticides, nerve agents
- Benzodiazepines – Diazepam, Midazolam
- Recreational drugs – Cocaine, Cannabis
- Beta-blockers – Atenolol, Propanolol
- Legal Highs!! New Psychoactive Substances (NPS)
Legal Highs or New Psychoactive substances (NPS)
Home office produced pack as part of Drug Misuse and dependency policy, which includes:
- facts and information about NPS
- case studies on working with young people who use NPS
- resources to help start conversations about NPS with young people
- references for further help and information
https://www.gov.uk/government/publications/new-psychoactive-substances-nps-resource-pack
Psychological considerations
- May behave irrationally or unpredictably. Remember safety is paramount. Behave sensitively and tactfully with sympathy or gentle firmness where necessary
- Some drugs heighten awareness – limit pt’s exposure to excessive light & sound?
- Remain objective and professional at all times
- Remain neutral – avoid criticism or judgement – it will not help and may aggravate the situation
Important Points
Removing contaminated clothing and any contamination of the skin takes priority over everything except immediate life support treatment
Avoid contamination yourself, particularly hands; always wear protective gloves at this type of incident
Clear contaminated equipment before use again
Several of these products produce severe excitable states. Manage patients gently, quietly and with minimum fuss
q
Remember patient requires rapid medical intervention at nearest A&E Dept or specialist Poisons Unit
General Management Checklist
Safety first – perform dynamic risk assessment
Avoid contaminating yourself
Act quickly, speed is essential
Ensure open airway
Assist ventilation if required (never mouth to mouth)
If unconscious do not induce vomiting
Conscious (if caustic or petroleum products have been swallowed) give milk, water
Do not give salt drinks this will induce vomiting
Save a sample of vomit
Monitor patient for deterioration
Keep patient quiet and don’t allow them to walk
Reassurance
Collect sample of poisons and bottles
Drug abuse
•Use of any substance that causes –
•
- Physical
- Psychological
- Economic
- Legal
- Social……………..harm
Physical dependence
- Physical adaptation to the drug
- Tolerance
- Withdrawal symptoms when removed
- Emotion state
- Craving
- Withdrawal effects feeling of well being
Tolerance
•Physiological adaptation such that
•
…………Larger and larger doses required
Withdrawal syndrome
- A predictable series of signs & symptoms
- Largely due to disruption of CNS activity
- Following abrupt discontinuation
Addiction
A chronic disorder characterised by
- Compulsive use of a substance
- Continued used despite the harm caused
Main categories
- Narcotics/ Opiates - (Coca plant - derivatives) Opium, heroin, morphine, codeine etc
- CNS Depressants - Alcohol, sedatives, tranquilisers, antihistamines, nitrous oxide
- CNS Stimulants - Cocaine*, ecstasy, amphetamines
- Hallucinogens - LSD, phencyclidine (PCP)**, ‘Toads’, ‘magic mushrooms’
- Inhalants - Butane, glue, petrol, nicotine
- Steroids - Dianabol, nandrolone
- Cannabis
* Cocaine is dual classified as a narcotic
** PCP is dual classified as a stimulant
Narcotics
Ingested, Injected, Inhaled (smoked)
General effects
•
- Relaxation
- Euphoria
- Drowsiness
- Nausea
- Sniffles
- Watery eyes
Nodding
Overdose
•
- Pale/ Cyanosed
- Cool
- Clammy
- Respiratory depression/ arrest
- Tachycardia
- Constricted pupils
- Convulsions
- Coma
Death
CNS Depressants
Ingested
General effects
- Relieve anxiety
- Relieve irritability
- Sensory alteration
- Muscle relaxant
- Impaired judgement
- Impaired coordination
Loss of appetite
Overdose
•
- Pale
- Cool
- Clammy
- Shallow respirations
- Tachycardia
- Dilated pupils
- Coma
Death
Hallucinogens
Ingested, Inhaled, Absorbed
General effects
Altered perception of
- Time
- Smell
- Touch
- Taste
Sight
Overdose
- Convulsions
- CVA
- Secondary injury
- Flashbacks
Inhalants
Inhaled (smoked, sniffed)
General effects
- Light headedness
- Inhalants on clothes, hands, in bag, gas canisters etc
- Rashes around nose and mouth
Overdose
- Pale
- Cool
- Clammy
- Loss of muscle control
- Slurred speech
- Reduced LOC
- CVA
- Coma
Death
Steroids
Ingested, Injected
General effects
•
- Increased strength
- Increased musculature
- Severe acne
- Rashes
- Stunted growth
- Masculine traits
- Aggressiveness
- Tumours
- Cancer
Cataracts
Overdose
•
- Hallucinations
- Aggression
•
Cannabis
Ingested, Inhaled
General effects
- Impaired short term memory
- Shorten attention span
- Delayed reflexes
- Euphoria
- Relaxed inhibitions
- Lung damage
- Birth defects
- Cancer
Overdose
•
- Pale
- Cool
- Clammy
- Tachycardia
- Nausea & vomiting
- Dehydration
Secondary injury
Volatile Substances
- Adhesives or glues
- Nail polish/ polish remover
- Rubber solutions
- Petrol
- Dyes
- Lighter fuel
- Aerosols
- Cleaning agents
Fire Extinguishers
Effects
- Light headedness
- Euphoria
- Decrease in anxiety
- Lessening of inhibition
- Drowsiness
- Impaired muscular co-ordination
•
- Impaired judgement
- Nausea
- Hallucinations
- Increased or irregular heart rate
- Headache
- Pulmonary oedema
Risks
- Sudden death
- Cardio arrhythmia (Irregular heart beat)
- Choking – vomit or substance
- Asphyxiation through contraction of the wind pipe (aerosols)
- Burns - Exposure to flame or chemicals
- Cancer
- Poor judgement skills and recklessness
Management
Management
If the patient is unconscious
- Ensure ABC’s,
- High levels of oxygen,
- Recovery position,
- Observe vital signs.
