Alexander ch32 lecture

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Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 32
Toxicologic
Emergencies

• The Advanced EMT applies fundamental
knowledge to provide basic and selected
advanced emergency care and transportation
based on assessment findings for an acutely
ill patient.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Describe the importance of understanding the
pathophysiology and assessment-based management
of patients with toxicologic emergencies.
3. Give examples of common substances involved in
intentional and unintentional toxicologic emergencies
in adults and children.
4. Describe each of the four routes by which a poison can
enter the body.
5. Perform a scene size-up to identify indications that a
patient may be suffering from a toxicologic emergency.
Objectives (1 of 4)

6. Given a scenario involving a patient with a toxicologic
emergency, anticipate special considerations in
protecting your safety and that of other personnel, the
patient, and bystanders.
7. Given a series of scenarios, demonstrate the
assessment-based management of patients suffering
a variety of toxicologic emergencies.
8. Anticipate the effects of various classifications of toxins
and commonly abused substances on the respiratory,
nervous, cardiovascular, and gastrointestinal systems.
9. Explain the limited role of specific antidotes in toxicologic
emergencies.
Objectives (2 of 4)

10.Explain the key historical information that should
be determined for patients who have been exposed to
a toxin.
11.Anticipate pitfalls in obtaining an accurate and complete
history from patients with toxicologic emergencies.
12.Describe the indications, contraindications, mechanism
of action, side effects, dosage, and administration of
activated charcoal.
13.Describe special considerations in assessing and
managing patients with exposure to specific toxins,
including care of patients suffering from withdrawal
syndromes.
Objectives (3 of 4)

14.Explain the importance of contacting the poison control
center with as complete a patient history as possible.
15.Explain the importance of conscientious assessment and
management of patients who have ingested a toxin.
16.Explain the reassessment considerations for patients with
a toxicologic emergency.
Objectives (4 of 4)

• Exposure to toxins, accidental and intentional, is
a common reason for emergency medical care.
• Majority of toxin exposures unintentional;
intentional poisoning majority of suicide attempts
and poisoning deaths.
• Intentional exposure: abuse or misuse of
substances; mechanism of intentionally harming
another person.
Introduction (1 of 3)

• Unintentional exposures: accidental exposures,
therapeutic errors, occupational and
environmental exposures
• Ingestion of toxins is the most common route for
both fatal and nonfatal exposures.
– Common substances: analgesics, personal and
household substances, sedative–hypnotics, pesticides,
antidepressants

• Fatal exposures
– Sedative–hypnotics, opioids, cardiovascular drugs,
acetaminophen, antidepressants, anticonvulsants,
alcohol, stimulants, street drugs
• Pediatric population
– Analgesics, batteries, hydrocarbons, plants, cough and
cold preparations

Think About It
• What immediate patient care actions must Alice
and Cosette take?
• What information do Alice and Cosette need about
the medications the police officer handed them?
• What information do they need about the patient’s
history?
• What type of physical examination should they
perform?

Toxicology
• Toxicology
– Study of prescription and illegal drugs, and plant,
animal, other toxins
• Toxidromes
– Categories of toxic substances

Toxicology (2 of 5)
• Routes of toxins
– Ingestion
– Inhalation
– Surface absorption
– Injection

Toxicology (3 of 5)
• Ingested substances enter body by being
swallowed.
– Plants, medications, alcohols, household substances
– Substances absorbed from gastrointestinal tract when
they reach stomach and small intestine
• Inhaled toxins (fumes, gases) cause tissue
damage on contact with respiratory mucosa or
cross respiratory membrane to exert effects.
– Anhydrous ammonia, cyanide, and carbon monoxide

Toxicology (4 of 5)
• Surface absorption causes damage directly to skin
and mucous membranes; absorbed through them
to enter bloodstream; causes systemic effects.
– Organophosphates, cocaine
• Injection—Toxins are injected into subcutaneous
or muscular tissues, or directly into venous
system.
– Bites, stings, IV drugs

Toxicology (5 of 5)
• Toxins can have a number of effects, depending
on their nature.
– Some primarily local, causing irritation of exposed
tissues.
– Others have profound effects on a particular system.
– Others affect the function of all systems.

Poison Control Centers
• 55 poison control centers throughout the United
States
• Staffed 24 hours a day by specialists in medical
toxicology
• Poison control hotline: national toll-free phone
number 1-800-222-1222
• Determine severity of exposure; suggest how best
to manage exposures to specific toxins.

Figure 32-1
Only trained rescuers with appropriate PPE should rescue patients from toxic
environments. (© Kevin Link /Science Source)

Assessment and Management
• Nature of toxicologic emergency can be clear or
unknown.
• Recognize patterns of behavior and signs and
symptoms.
• Scene size-up
– Early identification of hazard
– Activation of appropriate resources
– Utilization of PPE

Assessment and Management—
Scene Size-Up (1 of 7)
• Resources
– Law enforcement
– Fire department
– Hazmat
– Search and rescue
– Additional transport units

• Intentional poisoning, overdoses, and substance
abuse often go hand in hand and increase risk for
violent behavior.
• Increased suspicion
– Involvement of more than one patient
– Unusual odors
– Presence of vapors or spills of unknown substances
– Unresponsive patients
– Behavioral emergencies
– Altered mental status

• Obtain
– Name of substance or substances
– Quantity involved
– Time of exposure
– Patient’s weight
– What has been attempted in treatment of patient prior
to your arrival

• Obtain (continued)
– Duration of exposure, if relevant
– Label information. Transport container with the patient
if possible.
– Use DOT Emergency Response Guide or Material
Safety Data Sheet (MSDS) to obtain information.
– Identify potential for polysubstance overdoses.

• Airway complications
– CNS depressants, vomiting, soft-tissue damage
• Breathing complications
– Pulmonary edema, inflammation
• Circulatory complications
– Vasodilation, poor cardiac output, reduced perfusion

• Unresponsive—check carotid pulse
– If necessary, begin cardiopulmonary resuscitation
(CPR) and apply AED.
• If pulse is present, use manual airway maneuvers,
suction, airway adjuncts, and advanced airway
devices to open and maintain a patent airway.
– Use Fowler’s position in conscious patients who are
vomiting.
– Administer oxygen for patients with increased
metabolic rate.

• Assess for shock.
– Check for cool, pale skin; diaphoresis; and pulse rate,
strength, regularity.
• Syrup of ipecac no longer recommended because
it produces repeated episodes of forceful vomiting.
• Poisoning and overdose patients can deteriorate
quickly.

History and Secondary Assessment
• Obtain SAMPLE history.
• Obtain vital signs.
– Results of monitoring devices
– Blood glucose level in patient with diabetes or who has
altered mental status
• Perform focused or head-to-toe exam.
• What information should you obtain about the
exposure?

Clinical Reasoning
• Without careful questioning and high index of
suspicion for toxicologic emergency, poisoning
can go undetected until patient suddenly
deteriorates.
• Look for clues around the scene.
– Many patients who attempt suicide do so with mixed
methods.
– With some types of poisoning, presence of more than
one affected patient provides a strong clue.

Figure 32-2
Remove toxic inhalation patients to fresh air and administer oxygen.

Treatment (1 of 2)
• Supportive: manage airway, breathing, ventilation,
oxygenation, circulation
• Obtain IV access.
• Minimize amount of toxin patient exposed to.
• Most toxins do not have specific antidotes.
• Narcotic overdoses with respiratory depression,
give naloxone.

Treatment (2 of 2)
• Activated charcoal is adsorbent; administer within
1 to 2 hours after ingestion.
– Premixed in slurry containing sorbitol, sugar alcohol
that adds flavor and acts as cathartic
• Poison control center contacted depends on your
protocols, substance, patient’s condition, and
history.

Scan 32-1
Activated Charcoal

Reassessment
• Level of toxin in patient’s system may be
increasing as you assess.
• Anticipate deterioration; monitor closely.
• Mental status; airway, breathing, circulation; be
alert to any changes; monitor vital signs and
SpO2.

Carbon Monoxide (1 of 4)
• Colorless and odorless gas
– Created during incomplete combustion of fuels
(petroleum products, wood, carbon fuels)
– Dangerous in enclosed spaces
• Quickly absorbed across respiratory membrane,
where it binds readily with hemoglobin

• Initial signs and symptoms
– Poor oxygen-carrying capacity, cellular hypoxia
– Headache, dizziness, confsion, sleepiness
– Vomiting
– Shortness of breath
– General malaise
– Tachycardia, tachypnea
– Hyperthermia, agitation
– Memory problems, impaired judgment

• Signs and symptoms of severe poisoning:
– Chest pain, confusion, ataxia, seizures,
unconsciousness, rhabdomyolysis; and renal failure
can occur with prolonged exposure
• Identify hazard.
• Activate appropriate resources.
• Remove patients from source.
• Open and maintain airway; assist with ventilation.
• Anticipate vomiting.

• All patients exposed to carbon monoxide require
administration of oxygen by nonrebreather mask.
• High-flow oxygen can reduce half-life.
• Hyperbaric oxygen therapy reduces half-life
dramatically.
• Start IV, fluid administration for hypotension.

Cyanide
• Found in several products/items; prevalent route
is home fires; often occurs with carbon monoxide
poisoning.
• Cellular asphyxiant: stops energy production at
cellular level; keeps mitochondria from processing
oxygen; results in anaerobic metabolism.
• Death occurs in seconds to minutes after
inhalation or ingestion.

Cyanide (2 of 4)
• Suspect additional patients in home fires.
• Weakness, malaise
• Headache, dizziness
• Confusion, seizures
• Shortness of breath
• Pulmonary edema, coma
• Odor of bitter almonds may be detected.
• Pulse oximetry may be high.

Cyanide (3 of 4)
• Signs and symptoms reflect hypoxia and acidosis.
• Manage airway, breathing, circulation.
• Provide high-flow oxygen.
• Severe dyspnea and pulmonary edema
• Activated charcoal indicated for ingested cyanide.

Cyanide (4 of 4)
• Consult with medical direction.
• Antidotes for cyanide: hydroxocobalamin (vitamin
B12); three-part cyanide antidote kit containing
amyl nitrite, sodium nitrite, sodium thiosulfate

Caustic Substances (1 of 4)
• Acids and alkalis cause chemical burns when in
contact with body.
• Exposure to substances may result in dermal,
ocular, inhalation, ingestion injuries.
• Household chemicals containing acids or alkalis
are often ingested in attempted suicide.

• Strong acids on skin; coagulation necrosis
• Significant ingestions of acids: metabolic acidosis
• Strong alkalis: liquefaction necrosis
• If ingested, acids and alkalis can result in erosion
of esophagus and stomach, hemorrhage, and
severe pain.
• Never induce vomiting in patients with caustic
ingestion.

• Signs and symptoms
– Skin irritation
– Burns of mouth and tongue, with drooling and difficulty
swallowing
– Hematemesis
– Stridor
– Hoarseness
– Difficulty breathing

• Scene safety guidelines; do not expose other
providers
• Airway management can be complicated because
of extensive tissue damage.
– Nonvisualized airways contraindicated.
• Remove contaminated clothing and jewelry.
• Flush dermal and ocular exposures with copious
amounts of water; use water only.

Figure 32-3
Huffing is the deliberate concentration and inhalation of vapors or fumes to achieve
intoxication. Users may saturate a cloth with volatile liquid substances and place it over the
mouth and nose or concentrate aerosols in a bag for inhalation.

Hydrocarbons (1 of 4)
• Gasoline, butane, kerosene, lamp oils, mineral oil,
toluene
• Found in: lighter fluids, laundry stain removers,
spray lubricants, glues, paints, aerosol propellants
(fluorocarbons)
• Exposure can occur through any route.

• Nervous system: dizziness, confusion, ataxia,
altered mental status, unresponsiveness, apnea
• Cardiovascular: hypotension, sudden cardiac
arrest
• Gastrointestinal: stomach and intestines

• Nausea, vomiting, diarrhea, burning of oropharynx
• Exposure to skin: erythema, dermatitis, burns
• Liquid forms of hydrocarbons: high risk of
aspiration, leading to pneumonitis, dyspnea,
hypoxia

• Huffing is deliberate inhalation of hydrocarbons for
purpose of intoxication.
– Symptoms focused in respiratory system: wheezing,
tachypneic, shortness of breath, hypotension
– Erythema and dried paint may be present around
mouth and nose area.
– Sudden sniffing death syndrome

Organophosphates (1 of 3)
• Found in pesticides; can be weapon of terrorism
• Exposure inhalation, absorption, ingestion
• Potent cholinergics
– Produce prolonged, unopposed stimulation of
parasympathetic nervous system, inhibiting
acetylcholinesterase
• What does the acronym SLUDGE stand for?

• Muscle twitching, paralysis, seizures, altered
mental status, bradycardia, hypotension,
bronchospasm, pulmonary edema
• Scene safety: avoid exposure of EMS personnel
or bystanders; decontaminate patient.
• Irrigate with copious amounts of water, using soap
if available.

• Airway management complicated by copious
bronchial and oral secretions; use suction.
• Antidote kits carried by Advanced EMTs.
• Atropine and praladoxime: consult with medical
direction about administering these medications.

Ethanol and Toxic Alcohols (1 of 10)
• Ethanol (beverage alcohol) culturally accepted
intoxicating substance; it is a CNS depressant.
• Slurred speech, ataxic gait, poor coordination,
nystagmus, altered mental status, behavioral
changes
• Severe alcohol intoxication: respiratory
depression, emesis potentially with aspiration,
unconsciousness

• Do not assume only problem is acute alcohol
intoxication.
• Increased risk of injury because of decreased
sensation of pain or lack of concern for injury.
• Check blood glucose level in any patient who has
changes in cognition or behavior.

• Detrimental effects to body of long-term abuse
– Wernicke-Korsakoff’s syndrome: alcohol-related
psychosis; combination of thiamine deficiency and
permanent neurologic damage
– Amnesia and confabulation

• Detrimental effects to body of long-term abuse
(continued)
– Cardiomyopathy, hypertension, high cholesterol
– Pancreatitis, cirrhosis, stomach cancer, decreased
blood-clotting factors
– Males: testicular atrophy, feminizing characteristics

• Delirium tremens (DTs): two to three days
following cessation of alcohol with history of
dependence; mortality rate: 5 to 15%
– Tachycardia; hypertension; sweating; delusions; and
visual, auditory, tactile hallucinations
– Sudden alcohol withdrawal may precipitate seizures
6 to 48 hours from time of last drink.

• Treat patient in DTs cautiously; behavior can be
erratic and violent; state of metabolic hyperactivity.
• Alcoholics are preoccupied with obtaining and
using drug.
• Toxic alcohols can cause severe illness; are fatal
in small doses.

• Methanol (wood alcohol): used in commercial
products, illegally produced alcoholic drinks
• Patients exposed to methanol
– Blindness or blurred or cloudy vision (methanol
poisoning)
– Abdominal pain
– Altered mental status, including coma
– Rapid respiratory rate (tachypnea)

• Manage airway, breathing, circulation.
• Provide oxygen; start IV.
• Maintain renal perfusion; prevent renal failure.

• Isopropanol (isopropyl alcohol or rubbing alcohol):
disinfectant
– Wide distribution, exposure high
– Altered mental status, ataxia, slurred speech, abnormal
behavior; “twice as drunk, twice as sick, twice as long.”
– Abdominal pain, upper gastrointestinal bleeding
– Manage airway, anticipate vomiting
– Respiratory depression, hypotension, dysrhythmia

• Ethylene glycol: ingredient in vehicle radiator
antifreeze
– Lethal in small amounts; sweet tasting
– Neurologic changes (unconsciousness, ataxia, slurred
speech, seizures); tachypnea, tachycardia, nausea,
vomiting; risk of renal failure
– Manage airway; anticipate vomiting.
– Monitor respiratory depression; anticipate hypotension
and dysrhythmia.

Food and Plant Toxins (1 of 7)
• Food toxins
– Botulism: toxins produced by infectious agents
– Some seafoods contain dangerous toxins.
– Toxin: ciguatera (ciguatoxin); seldom fatal; abdominal
pain, nausea, vomiting, diarrhea
– Neurologic symptoms
 Paresthesias, reversal of sensations of hot and cold, itching,
joint and muscle pain, tooth pain, weakness, lack of
coordination, dizziness

• Food toxins (continued)
– Histamine fish poisoning (scombroid)
– Signs and symptoms: mimics allergic reaction; flushing
of skin; severe, throbbing headache; nausea; vomiting;
diarrhea; abdominal cramping; palpitations; itching and
hives; dizziness; dry mouth
– Hypotension, bronchospasm, angioedema
– Affected fish can have “off” flavor.

• Food toxins (continued)
– Histamine fish poisoning: assess and manage
breathing, circulation.
– Administer IV fluids for hypotension; administer
nebulized beta2 agonist for wheezing.
– Preferred treatment is antihistamines.
– Treat for anaphylaxis per your protocol.

• Plant toxins
– Many poisonous plants found in the home, the garden,
roadside, fields, and the wild.
– Jimsonweed (smoked or drunk as tea) potent
anticholinergic effects
– Altered mental status, flushed and dry skin, dilated
pupils, hyperventilation

Table 32-2
Poisonous Plants*
Toxin Plant Signs and Symptoms
Cyanide Stone fruit pits (peaches, apricots,
plums) and fruit seeds (pears,
apples)
Weakness, nausea, vomiting, seizures, coma
Colchicine Autumn crocus, meadow saffron Cramps, nausea, hematuria, shock, coma
Calcium oxylate/oxalic acid Dieffenbachia (dumb cane),
philodendron, rhubarb leaves
Severe gastroenteritis, burning and swelling of
oral mucosa, anuria
Amygdalin Parts of wild and cultivated cherry
trees, including seeds
Stupor, vocal cord paralysis, seizures, coma
Belladonna alkaloids Jimsonweed (Datura), nightshade Anticholinergic effects; fever; tachycardia;
dilated pupils; red, hot, dry skin
Glycosides Purple foxglove, lily of the valley Cardiac dysrhythmia, nausea, shock,
gastroenteritis
Solanine Tomato plant leaves; green parts of
potato, horse nettle
Severe gastroenteritis, headache, apnea,
shock
*Other poisonous plants: hyacinth, narcissus, and daffodil (cholinergics); mistletoe; oleander; poinsettia; iris; azaleas
and rhododendrons; wisteria; castor bean (source of ricin); buttercups; hemlock.

• Plant toxins (continued)
– Anticholinergic toxidrome
 Mad as a hatter
 Dry as a bone
 Red as a beet
 Blind as a bat
 Hot as hell

Figure 32-4
Amanita and Galerina mushrooms. (© Jacana / Science Source)

– Purple foxglove, oleander, wallflower, dogbane contain
cardiac glycosides (active ingredient of antidysrhythmic
medication, digitalis)
– Overdose of cardiac glycosides: arrhythmias, changes
in visual perception (color changes and loss of visual
acuity)
– Most poisonous mushroom deaths are the result of
Amanita, which causes liver failure.

– Galerina: particularly toxic mushroom
– Poison ivy: delayed hypersensitivity reaction
– Exposure to smoke from burning plants can produce
anaphylaxis.
– Ensure adequate airway, ventilation, and oxygenation.
– Anticipate vomiting; establish IV.
– Identification of plant is critical.

Venom (1 of 9)
• Many venomous insects and animal bites cause
local discomfort and swelling without producing
systemic effects.
• EMS providers encounter bee and wasp stings,
and spider and marine animal bites.
• In most cases, patient will be able to relate
clear history of bite or will have identified localized
effects.
• Infection risk with insect and animal bites.

Figure 32-5
A brown recluse spider. (Photo: © Centers for Disease Control)

Figure 32-6
(A) A brown recluse spider bite 24 hours after envenomation. (Both photos: Courtesy of
Baylor Scott and White Healthcare)

Figure 32-6 (continued)
(B) A brown recluse spider bite four days after envenomation. (Both photos: Courtesy of
Baylor Scott and White Healthcare)

Venom (2 of 9)
• Spiders and scorpions—brown recluse
– Small, with violin-shaped band on back
– Bite is painless; venom results in massive localized
tissue destruction.
– Within 8 hours of bite, increasing pain, swelling, and
redness occur.
– Tissue destruction can continue for days to weeks;
nausea and vomiting, chills and fever, joint pain.
 Can lead to substantial necrosis

Figure 32-7
A black widow spider. (© Joseph T. Collins / Science Source)

Venom (3 of 9)
• Spiders and scorpions—black widow
– Shiny black spider with red or orange hourglass-
shaped mark on back.
– Potent neurotoxin: painful spasms in large muscles,
nausea, vomiting, diaphoresis, seizures, paralysis,
altered mental status

Venom (4 of 9)
• Spiders and scorpions—scorpions
– Common in southwestern states
– Bark scorpion only one to cause fatalities; rare
– Mostly seen at night, found beneath objects during day
– Venom neurotoxin
 Altered mental status, muscle twitching, cramping, seizures
– If your protocol, apply loose constricting band above
site to slow distribution of toxin.

Figure 32-8
Typical features of nonpoisonous snakes, pit vipers, and coral snakes.

Venom (5 of 9)
• Snakes—pit vipers
– Rattlesnakes, water moccasins, copperheads.
– Envenomated bite has both localized and systemic
effects; not all bites are envenomated.
– Pain, discoloration, swelling at site; tissue necrosis
– Weakness, chills, diaphoresis, nausea, vomiting,
diarrhea, shock, respiratory failure

Venom (6 of 9)
• Snakes—pit vipers (continued)
– Neither ice nor constricting bands applied
– Do not elevate extremity; keep in neutral position.
– Manage airway and breathing; apply oxygen for
moderate to severe signs and symptoms.
– Establish IV access.
– Transport to facility that has or can rapidly obtain
anti-venom.

Venom (7 of 9)
• Snakes—coral
– Resemble many harmless snakes in appearance; red
and black bands separated by thinner yellow stripes
– Bites rare; venom very potent neurotoxin
– Signs and symptoms: delayed many hours;
paresthesias, altered mental status, impairment of
cranial nerve function, weakness, muscle twitching,
respiratory failure, hypotension, tachycardia
– Apply compression bandage; after wrapping extremity,
splint and keep level with body.
– Do not apply ice.

Venom (8 of 9)
• Marine animals
– Freshwater and saltwater animals can be venomous.
– Painful but do not cause serious illness
– Stings or punctures very painful: localized itching,
raised wheal, welt
– Severe cases: nausea, vomiting, diarrhea, abdominal
pain, paresthesia, lymphadenopathy, difficulty
breathing or swallowing, chest pain, muscle cramps

Venom (9 of 9)
• Marine animals (continued)
– For saltwater bites and stings, flush area with saline,
70% isopropyl alcohol, vinegar.
– Remove stingers or nematocysts from skin by
scraping.
– Application of heat inactivates venom and relieves pain
in local reactions.

Over-the-Counter Medications (1 of 2)
• Readily available; figure prominently in suicide
attempts
• Acetaminophen (Tylenol), aspirin
• Sign and symptoms
– Abdominal pain, nausea, vomiting, tinnitus, headache,
dyspnea, wheezing, and pulmonary edema

Over-the-Counter Medications (2 of 2)
• Antihistamines have anticholinergic properties.
• Dry mouth and thirst, blurred vision, tachycardia,
hyperthermia and flushed skin, confusion or
excitement, hypertension
• Iron toxicity can cause severe gastrointestinal
disturbance: nausea, vomiting, pain,
hematemesis, hypovolemia
• Systemically, iron interferes with cellular energy
production; metabolic acidosis, liver, heart,
kidneys, lungs severely damaged

Prescription Medications (1 of 8)
• Toxicity and overdose
– Benzodiazepines, other sedative–hypnotics, narcotics
– Antidepressant and psychotropic medications
– Cardiac medications

• Benzodiazepines
– Rarely result in death in overdose on their own
– Can result in altered mental status, slurred speech,
sedation, respiratory depression, and hypotension
– Flumazenil used in hospital for overdose

• Narcotics
– Controlled substances are used to relieve pain, treat
coughs, and slow gastrointestinal activity.
– Overdose causes CNS depression, respiratory
depression, constricted pupils, bradycardia,
hypotension. Can lead to death.
– Manage ABCs. Administer naloxone if respiratory
depression

• Other drugs that depress CNS function: alcohol
and barbiturates
– Slurred speech, altered mental status, respiratory
depression, hypotension
– Death can occur from both substances.
– Treatment is supportive.

• Antidepressants: population at risk for suicide
• Tricyclic antidepressants, monoamine oxidase
inhibitors (MAOIs), selective serotonin reuptake
inhibitors (SSRIs)

• Neuroleptics are used as antipsychotics,
sedatives, and antiemetics.
• Neuroleptic malignant syndrome: altered mental
status, muscular rigidity, fluctuating blood
pressure, tachycardia, hyperpyrexia, diaphoresis,
rhabdomyolysis

• Lithium is used in bipolar disorder as mood
stabilizer; toxicity can occur easily.
• Signs and symptoms: gastrointestinal complaints,
dry mouth, tremors, lethargy, confusion, seizures,
coma, muscle tremors, bradycardia

• Cardiac medication toxicity: suspect poisoning
and overdose in patients who have altered mental
status, bradycardia, tachycardia
• Beta blockers: bradycardia, hypotension, asystole
in cases of overdose
• Calcium channel blockers: treat hypertension,
tachycardias, angina through smooth muscle
relaxation

Prescription and
Over-the-Counter Medications
• Digitalis (digoxin, Lanoxin): controls heart rate and
strengthens cardiac contraction; toxicity can occur
easily
• Signs and symptoms: loss of appetite, nausea,
vomiting, headache, diarrhea, weakness, blurred
vision, yellow-green vision, mood changes,
confusion, bradycardia, cardiac dysrhythmia

Street Drugs (1 of 9)
• Stimulants—cocaine
– Can be inhaled in powder form or injected as liquid;
crack cocaine is smoked
– Effects are immediate; relatively short acting.
– Increase in dopamine at synapses, causing users to
feel euphoric, energetic, alert.
– Both appetite and need for sleep are decreased.

• Stimulants—cocaine (continued)
– Vasoconstrictor: increases heart rate, body
temperature, blood pressure
– Agitation, irritability, paranoia, psychosis, violent
behavior
– Can cause stoke, myocardial infarction, cardiac
dysrhythmia, or seizures.
– Result in tolerance, psychological dependence,
physical addiction withdrawal

• Stimulants—amphetamines
– Used as diet pills, to increase mental alertness, to treat
attention deficit disorder (ADD) and attention deficit
hyperactivity disorder (ADHD).
– Increase levels of both dopamine and norepinephrine;
effects similar to those of cocaine
– Methamphetamine, Dexedrine, Ritalin, Adderall

• Stimulants—amphetamines (continued)
– Ingested, injected, inhaled as powder, smoked
– Can cause tolerance, psychological and physiologic
dependence.
– Behavioral changes, potential for violence, seizures,
hypertension, hyperthermia, dysrhythmia, cardiac
arrest
– Deaths are due to excited delirium.

• Hallucinogens—PCP
– Phencyclidine (PCP): dissociative anesthetic
– Smoked, injected, ingested in tablet or liquid form,
snorted
– Hallucinogenic effects: belligerent, agitated, violent,
psychotic, diminished response to pain
– PCP overdose: nystagmus, ataxia, slurred speech,
hypertension, tachycardia, behavioral changes

• Hallucinogens—PCP (continued)
– At risk of excited delirium, rhabdomyolysis,
hypertensive crisis, respiratory depression,
unresponsiveness, seizures
– Activate law enforcement early.
– Physical and/or chemical restraints may become
necessary to prevent harm to providers or patients
themselves.
– Cool hyperthermic patient with washcloths soaked in
water.

• Hallucinogens—LSD
– Derived from ergot fungus
– LSD (acid): psychological effects highly variable,
depending on user, external stimuli, dose
– It is ingested; fatal overdose is extremely rare.
– Psychological effects can be frightening: anxiety, panic,
paranoia.

• Hallucinogens
– Mescaline: from peyote cactus
– Illusions (sensory misperceptions), hallucinations,
sensation of expanded consciousness
– Psilocybin: hallucinogen derived from mushrooms
– Psilocybin effects: nausea, vomiting, muscle weakness,
ataxia

Figure 32-9
Intravenous drug abuse.

• Narcotics
– Opiates: derived from opium poppy plant
– Legally used as prescription pain relievers; illegally
used as drugs of abuse.
– Opiates ingested or injected
– Natural (morphine, codeine, heroin)
– Synthetic (oxycodone, fentanyl)
– Constricted pupils, respiratory depression, sedation,
track marks

Other Drugs of Abuse (1 of 3)
• GHB (gamma hydroxybutyric acid): anesthetic
agent; implicated as date rape drug
• Sedative–hypnotic; creating disinhibition of
behavior and enhanced sensuality
• Street terms: Georgia Home Boy, liquid ecstasy,
liquid X, liquid G

• Ketamine (Special K, Vitamin K, K): dissociative
anesthetic; sense of dissociation or
depersonalization/unreality
• GHB can cause dramatic respiratory depression
requiring immediate airway management; equally
dramatic improvement minutes to hours later.

• Dextromethorphan: OTC cough and cold
medications; used as dissociative; “robo-tripping”
• Marijuana overdose is rare.
• Paranoia, anxiety, panic, dry mouth, altered
sensation (illusions), dilated pupils

Chapter Summary (1 of 4)
• Poisoning and overdose are common reasons for
seeking emergency care.
• Wide variety of toxic substances you must be
aware of.
• These substances classified into toxidromes to
make remembering effects and treatments easier.
• Toxins can enter body through four routes:
ingestion, injection, inhalation, absorption.

• Thorough scene size-up is essential in both
establishing safety of scene and gaining
information about possibility of toxicologic
emergency.
• Goals of treating toxicologic emergencies:
decontamination, establishing and maintaining
airway, ensuring adequate ventilation and
oxygenation.

• IV access important in toxicologic emergencies;
fluids often benefit patients with hypotension.
• Consider need for ALS in patients in whom airway
management complicated and when cardiac
dysrhythmia anticipated.
• Decontamination: reduce amount of toxin by
limiting exposure, reducing absorption and
distribution, and enhancing elimination.

• Two medications that Advanced EMTs can give in
toxicologic emergencies are activated charcoal
and naloxone, a narcotic antagonist.
• Always consider possibility of polysubstance
overdoses, and presence of trauma and medical
conditions that may occur in context of toxicologic
emergencies.
• Poison control center and medical direction
valuable resources in determining level of concern
and recommended treatment.

Alexander ch32 lecture

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