20)Poisoning And Overdose

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20)Poisoning And Overdose

  1. 1. Poisoning and Overdose
  2. 2. Poisoning and Overdose <ul><li>Poison/Toxin </li></ul><ul><ul><li>Any substance that usually kills, inures, or impairs an organism through its chemical actions. </li></ul></ul><ul><li>Toxicology </li></ul><ul><ul><li>Study of poisons </li></ul></ul><ul><li>Toxic </li></ul><ul><ul><li>Poisonous </li></ul></ul><ul><li>Overdose </li></ul><ul><ul><li>Self administration of a drug in excess OR in combination with other agents to the point where poisoning occurs. </li></ul></ul><ul><li>DTs </li></ul><ul><ul><li>“ Delirium Tremens” </li></ul></ul><ul><ul><li>A severe form of alcohol withdrawal that involves sudden and severe mental or neurological changes </li></ul></ul>
  3. 3. Introduction <ul><li>Regional Poison Center </li></ul><ul><ul><li>1-800-222-1222 </li></ul></ul><ul><li>Second leading COD 2004 </li></ul><ul><ul><li>Exposure every 14 seconds </li></ul></ul><ul><ul><li>2,482,041 exposures in 2007 </li></ul></ul><ul><ul><li>51.2% in childrem < 6 yo </li></ul></ul><ul><ul><li>73.3% fatalities bt 20-59 yo </li></ul></ul><ul><ul><li>32,691 poisoning deaths in 2005 </li></ul></ul>
  4. 6. Types of Exposure <ul><li>Ingestion </li></ul><ul><ul><li>Swallowing </li></ul></ul><ul><ul><ul><li>Suicidal pt with pills, Alcoholic with methanol, toddler/animal with antifreeze </li></ul></ul></ul><ul><li>Injection </li></ul><ul><ul><li>Opioids – Insulin – Envenomation </li></ul></ul><ul><li>Inhalation </li></ul><ul><ul><li>CO is most common </li></ul></ul><ul><ul><li>Glue sniffing </li></ul></ul><ul><ul><li>Freebasing cocaine </li></ul></ul><ul><li>Absorption </li></ul><ul><ul><li>Organophosphate poisoning </li></ul></ul><ul><ul><li>Corrosives (acids/alkali) </li></ul></ul>
  5. 8. Poisoning and Overdose S/S per Route <ul><li>Ingested </li></ul><ul><ul><li>Hx of ingestions </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>AMS </li></ul></ul><ul><ul><li>Abd pain </li></ul></ul><ul><ul><li>Chemical burns around the mouth </li></ul></ul><ul><ul><li>Different breath odors </li></ul></ul><ul><li>Emergent care </li></ul><ul><ul><li>Remove pills, tablets, fragments from pt mouth with gloved hands as needed, without injuring yourself </li></ul></ul><ul><ul><li>Consult medical direction – Activated Charcoal </li></ul></ul><ul><ul><li>Bring ALL containers, bottles, labels, etc of poison agent to hospital </li></ul></ul>
  6. 9. S/S per Route: Inhalation <ul><li>S/S </li></ul><ul><ul><li>Hx of inhalation of toxic substance </li></ul></ul><ul><ul><li>SOB </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Cough </li></ul></ul><ul><ul><li>Hoarseness </li></ul></ul><ul><ul><li>Dizziness </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Confusion </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>AMS </li></ul></ul><ul><ul><li>Singed nasal hairs </li></ul></ul><ul><li>Emergent care </li></ul><ul><ul><li>Have trained rescuers remove pt from scene </li></ul></ul><ul><ul><li>Supplemental O2 </li></ul></ul><ul><ul><li>Bring ALL containers, bottles, labels, etc of poison agent to hospital </li></ul></ul>Smoke inhalation
  7. 10. S/S per Route: Absorbed <ul><li>S/S </li></ul><ul><ul><li>Hx of exposure </li></ul></ul><ul><ul><li>Liquid or powder on pt skin </li></ul></ul><ul><ul><li>Burns </li></ul></ul><ul><ul><li>Itching </li></ul></ul><ul><ul><li>Irritation </li></ul></ul><ul><ul><li>Redness </li></ul></ul><ul><li>Emergent Care </li></ul><ul><ul><li>Remove contaminated clothing while protecting yourself </li></ul></ul><ul><ul><li>Brush powders off pt </li></ul></ul><ul><ul><li>Irrigate for at least 20 minutes of liquid exposure </li></ul></ul><ul><ul><li>If in eyes, irrigate for at least 20 minutes and while en route away from unaffected eye </li></ul></ul>
  8. 11. S/S per Route: Injection <ul><li>S/S </li></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Dizziness </li></ul></ul><ul><ul><li>Chills </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Tack marks </li></ul></ul><ul><li>Emergent Care </li></ul><ul><ul><li>Airway patency and ventilation </li></ul></ul><ul><ul><li>Be alert for vomiting </li></ul></ul><ul><ul><li>Bring ALL containers, bottles, labels, etc of poison agent to hospital </li></ul></ul>
  9. 12. Sedatives, Hypnotics, Anti-Anxieties <ul><li>Sedatives/Hypnotics/Anti anxiety </li></ul><ul><ul><li>Sedatives </li></ul></ul><ul><ul><ul><li>Calming, decrease activity </li></ul></ul></ul><ul><ul><li>Hypnotics </li></ul></ul><ul><ul><ul><li>Induce Sleep </li></ul></ul></ul><ul><ul><li>Examples: </li></ul></ul><ul><ul><ul><li>Barbiturates </li></ul></ul></ul><ul><ul><ul><li>Benzodiazepines </li></ul></ul></ul><ul><ul><ul><ul><li>Ativan, Valium, Xanax, Sleeping Pills </li></ul></ul></ul></ul><ul><ul><ul><li>GHB </li></ul></ul></ul><ul><ul><ul><li>Rohypnol </li></ul></ul></ul><ul><li>S/S </li></ul><ul><ul><li>Resp depression </li></ul></ul><ul><ul><li>Depressed LOC </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><ul><li>Death </li></ul></ul>
  10. 13. Opiods <ul><li>Opioids </li></ul><ul><ul><li>Narcotics </li></ul></ul><ul><ul><li>CNS depressants </li></ul></ul><ul><ul><li>Made from the Opium Poppy ( Papaver somniferum) </li></ul></ul><ul><li>Examples </li></ul><ul><ul><li>-Morphine – Codeine – Heroin – Oxycodone (Oxycontin)– Methadone – Meperidine (Demerol) – Fentanyl - Opium </li></ul></ul><ul><li>S/S </li></ul><ul><ul><li>CNS depression </li></ul></ul><ul><ul><li>Depressed LOC </li></ul></ul><ul><ul><li>Depressed Resp </li></ul></ul><ul><ul><li>PINPOPINT PUPILS </li></ul></ul>
  11. 14. Meperidine (Demerol) Methadone Morphine Morphine Opium Heroin
  12. 15. Stimulants <ul><li>Stimulants </li></ul><ul><ul><li>Stimulates CNS </li></ul></ul><ul><ul><li>Increase alertness and physical activity </li></ul></ul><ul><li>Examples </li></ul><ul><ul><li>Amphetamines/Speed, Methamphetamine, Ritalin, Ecstasy, Cocaine, PCP, Nicotine </li></ul></ul><ul><li>S/S </li></ul><ul><ul><li>Excitability </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Increased heart rate </li></ul></ul><ul><ul><li>Increased BP </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Dysrhythmia </li></ul></ul><ul><ul><li>Death </li></ul></ul><ul><ul><li>Ischemia </li></ul></ul><ul><ul><li>CVA </li></ul></ul><ul><ul><li>MI </li></ul></ul><ul><ul><li>Hyperthermia </li></ul></ul>
  13. 16. Amphetamines- Adderall Cocaine Methamphetamine- Crystal Meth. Ritalin Ecstasy Nicotine
  14. 17. Ecstacy
  15. 19. Alcohol <ul><li>Alcohol </li></ul><ul><ul><li>Intoxicating agent in </li></ul></ul><ul><ul><li>fermented and distilled </li></ul></ul><ul><ul><li>liquors </li></ul></ul><ul><li>S/S </li></ul><ul><ul><li>AMS </li></ul></ul><ul><ul><li>Motor deficit </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><ul><li>Resp failure </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Aspiration </li></ul></ul><ul><ul><li>Death </li></ul></ul>
  16. 20. Analgesics <ul><li>Analgesic </li></ul><ul><ul><li>Pain killers </li></ul></ul><ul><li>Examples </li></ul><ul><ul><li>Aspirin </li></ul></ul><ul><ul><li>Acetaminophen </li></ul></ul><ul><ul><li>Motrin </li></ul></ul><ul><ul><li>Advil </li></ul></ul><ul><li>S/S </li></ul><ul><ul><li>Few early on </li></ul></ul><ul><ul><li>Liver damage within 48 hrs </li></ul></ul>
  17. 21. Organophosphates <ul><li>Organophosphates </li></ul><ul><ul><li>Inhibit acetylcholinesterase activity </li></ul></ul><ul><ul><li>Initial overstimulation followed by disruption of nerve transmission </li></ul></ul><ul><li>Examples </li></ul><ul><ul><li>Insecticides </li></ul></ul><ul><ul><li>Fertilizer </li></ul></ul><ul><ul><li>Nerve gases </li></ul></ul><ul><li>S/S </li></ul><ul><ul><li>Over stimulation of secretions </li></ul></ul><ul><ul><li>Bronchocontrsiction </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>SLUDGE </li></ul></ul>
  18. 23. Food <ul><li>Food </li></ul><ul><ul><li>Botulism </li></ul></ul><ul><li>Suspect </li></ul><ul><ul><li>When 2 of more people are ill after eating same food </li></ul></ul><ul><li>S/S </li></ul><ul><ul><li>Flu like S/S </li></ul></ul><ul><ul><li>Double vision </li></ul></ul><ul><ul><li>Trouble moving eyes/swallowing </li></ul></ul><ul><ul><li>Head-to-toe weakness </li></ul></ul><ul><ul><li>Paralysis </li></ul></ul><ul><ul><li>Resp arrest </li></ul></ul>Clostridium botulinum
  19. 24. Assessment <ul><li>HIGH level of suspicion </li></ul><ul><li>Not always obvious </li></ul><ul><li>Suspect when large number of people become ill at once </li></ul><ul><ul><li>i.e. Multiple people in a building with c/o headache, nausea, ALOC = CO poisoning </li></ul></ul><ul><li>Bring containers and labels with you </li></ul><ul><li>Report noticeable odors </li></ul><ul><li>Consider trauma </li></ul><ul><li>ABC’s </li></ul>
  20. 25. General Approach <ul><li>Pt Hx </li></ul><ul><ul><li>ESSENTIAL </li></ul></ul><ul><ul><li>High suspicion </li></ul></ul><ul><ul><ul><li>Date of prescription vs medication left </li></ul></ul></ul><ul><ul><li>ID/Quantity/Time of exposure/How/ Where exposed/Any treatments tried </li></ul></ul><ul><ul><li>Transport pills/bottles </li></ul></ul><ul><li>Approach </li></ul><ul><ul><li>Vitals, Oxygen, Monitor, IV, Transport (VOMIT) </li></ul></ul><ul><ul><li>Supportive care </li></ul></ul><ul><ul><ul><li>Aspiration? </li></ul></ul></ul><ul><ul><li>Consider AEIOU-TIPS </li></ul></ul><ul><ul><li>Traditional approach </li></ul></ul><ul><ul><ul><li>Syrup of Ipecac (Airway compromise) </li></ul></ul></ul><ul><ul><ul><li>Gastic lavage (Manpower, esophageal rupture) </li></ul></ul></ul><ul><ul><ul><li>Activated charcoal (Relatively safe option) </li></ul></ul></ul>
  21. 26. Scene Size Up/Initial Assessment <ul><li>Scene Size-Up </li></ul><ul><ul><li>Scene safety/BSI </li></ul></ul><ul><ul><li>Decontaminate pt </li></ul></ul><ul><ul><ul><li>Remove contaminated clothing </li></ul></ul></ul><ul><ul><ul><li>Irrigate 20 minutes </li></ul></ul></ul><ul><ul><ul><li>Brush off powders </li></ul></ul></ul><ul><li>Initial Assessment </li></ul><ul><ul><li>General impression </li></ul></ul><ul><ul><li>ABC’s </li></ul></ul><ul><ul><li>LOC/AVPU </li></ul></ul><ul><ul><li>Trauma? </li></ul></ul><ul><ul><li>Most deaths are due to Respiratory Compromise </li></ul></ul><ul><ul><ul><li>Aggressively manage airway </li></ul></ul></ul>
  22. 27. Focused Hx/Px <ul><li>Hx </li></ul><ul><ul><li>What substance? </li></ul></ul><ul><ul><li>When did pt ingest/become exposed? </li></ul></ul><ul><ul><li>How much did the pt ingest? </li></ul></ul><ul><ul><li>Over what time period? </li></ul></ul><ul><ul><li>Interventions? </li></ul></ul><ul><ul><li>How much does the pt weigh? </li></ul></ul><ul><li>Px </li></ul><ul><ul><li>Baseline Vitals </li></ul></ul><ul><ul><li>Track marks? </li></ul></ul><ul><ul><li>Some poisons present with a classical patter </li></ul></ul><ul><ul><ul><li>Opiods – PINPOINT pupil, AMS, Decreased/Shallow Resps </li></ul></ul></ul><ul><ul><ul><li>Organophosphates – SLUDGE </li></ul></ul></ul><ul><ul><ul><ul><li>- Salivation – Lacrimation – Urination – Defecation – GI complaints – Emesis </li></ul></ul></ul></ul>
  23. 28. Toxidromes <ul><li>Set of clinical S/S that are diagnostic of certain toxins/class of toxins </li></ul><ul><li>Narcotics </li></ul><ul><ul><li>Decreased LOC, Res Depression, Constricted pupils </li></ul></ul><ul><ul><ul><li>Morphine, Codeine, Demerol (no pupil change), etc </li></ul></ul></ul><ul><li>Anticholinergics </li></ul><ul><ul><li>“ Hot as Hades, blind as a bat, dry as a bone, red as a beet, mad as a hatter” </li></ul></ul><ul><li>Cholinergics </li></ul><ul><ul><li>Organophosphate poisoning </li></ul></ul><ul><ul><li>SLUDGE </li></ul></ul><ul><ul><ul><li>Salivation, Lacrimation, Urination, Defecation, GI complaints, Emesis </li></ul></ul></ul>
  24. 29. Opioid Overdose
  25. 30. Salivation Lacrimation Urination Defecation GI Complaints Emesis Organophosphate Poisoning
  26. 31. Management <ul><li>Ensure Open Airway </li></ul><ul><li>Ensure proper ventilation </li></ul><ul><li>Prevent further absorption </li></ul><ul><ul><li>Activated Charcoal </li></ul></ul><ul><li>Treat S/S </li></ul><ul><ul><li>O2 </li></ul></ul><ul><ul><li>Supportive Care </li></ul></ul><ul><ul><li>ALS </li></ul></ul><ul><ul><ul><li>Naloxone </li></ul></ul></ul><ul><ul><ul><ul><li>Opioids </li></ul></ul></ul></ul><ul><ul><ul><li>Atropine </li></ul></ul></ul><ul><ul><ul><ul><li>Organophosphate </li></ul></ul></ul></ul>
  27. 32. Re Assessment <ul><li>Re assessment </li></ul><ul><ul><li>Be alert for vomiting </li></ul></ul><ul><ul><li>Be alert for further deterioration due to poisoning </li></ul></ul><ul><ul><li>ABC’s </li></ul></ul><ul><ul><li>Vitals </li></ul></ul><ul><ul><li>LOC </li></ul></ul>
  28. 33. Activated Charcoal Pharmacology <ul><li>Generic </li></ul><ul><ul><li>Activated Charcoal </li></ul></ul><ul><li>Trade </li></ul><ul><ul><li>SuperChar – InstaChar – Actidose – LiquiChar </li></ul></ul><ul><li>Indications </li></ul><ul><ul><li>Poisoning by toxic ingestion </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>AMS </li></ul></ul><ul><ul><li>Inability to swallow </li></ul></ul><ul><ul><li>Ingestions of alkali/acids </li></ul></ul><ul><li>Form </li></ul><ul><ul><li>Pre mixed in water with various amounts of charcoal. (12.5 g normal) </li></ul></ul><ul><li>Dose </li></ul><ul><ul><li>Adults/Children = 1g/kg of body weight </li></ul></ul><ul><ul><li>Usual Adult dose = 25-50 g </li></ul></ul><ul><ul><li>Usual child/infant dose= 12.5-25 g </li></ul></ul><ul><li>Route </li></ul><ul><ul><li>PO </li></ul></ul><ul><li>Actions </li></ul><ul><ul><li>Binds to certain poisons and blocks absorption </li></ul></ul><ul><li>Side Effects </li></ul><ul><ul><li>Black Stools </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>If pt vomits, repeat dose once </li></ul></ul>
  29. 34. Activated Charcoal Administration <ul><li>Obtain order from medical control </li></ul><ul><li>Shake container thoroughly </li></ul><ul><li>Pt may need to be persuaded to drink medication since it looks like mud </li></ul><ul><li>Cover container and supply a straw to aid in administration </li></ul><ul><li>If pt takes a long time to drink the charcoal shake again as it will settle out of solution </li></ul><ul><li>DOCUMENT activity and time </li></ul><ul><li>Transport </li></ul><ul><li>Re assess pt </li></ul>
  30. 35. Refusals <ul><li>Encourage pt to go to hospital </li></ul><ul><li>Call police if needed </li></ul><ul><li>Pt cannot be assumed to be acting in best intent if OD/Suicidal/AMS. </li></ul>

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