The document provides information on poisonings and toxicology in the emergency department setting. It discusses that approximately 48% of poison exposure calls involve young children under 5 years old, with poisonings in this age group usually being unintentional. It then outlines key questions to ask patients regarding toxic exposures and summarizes the pathophysiology of different types of toxins, including their effects on the sympathetic, parasympathetic, and central nervous systems. The document concludes by describing primary and secondary patient assessments, various medical interventions for different toxin classes, and considerations for specific toxins like acetaminophen, salicylates, antidepressants, ethanol, and drugs of abuse.

1. The only difference between
medicine and poison is the dose.

2. Poisoning basic facts
 Approximately 47.8 percent of the poison exposure calls handled by the IPC in
2012 involved children ages 5 and under.
 Poisonings are usually unintentional in children less than 5 years old.
 Intentional poisonings usually seek treatment at a higher rate in comparison to
people who have been unintentionally poisoned.
 Adults/adolescents most often present with ingestion of psychopharmacologic
drugs; in comparison younger children tend to present with ingestion of
household products, plants, cleaning agents, medication, or vitamins.

3. Toxicology and the ED
 What drug?
 What route?
 What dose?
 What age of the patient?
 What time was the event?
 What symptoms?

4. Pathophysiology…
 Primarily look at effects of the nervous system
 Sympathetic nervous system (fight or flight response)
 Symptoms can include tachycardia, pupil dilation,
increased cardiac output, peripheral vasoconstriction,
bronchodilation
 Toxins include adrenergics and stimulants such as meth,
cocaine, caffeine (ex. Nodoz pills), epinephrine (ex. Epi-
pen)

5. Pathophysiology… cont.
 Sympathetic blockers
 Primarily going to be your beta blockers (-olol drugs)
 Symptoms going to be decreased blood pressure,
decreased heart rate, look for signs of decreased
perfusion and shock.

6. Pathophysiology… the other half
 Parasympathetic nervous system (rest and digest)
 Functions in opposition to the sympathetic nervous system.
 Symptoms based on the type of receptor involved, either muscarine
or nicotine.
 Muscarine receptors result in miosis (pupil constriction),
vasodilation, bradycardia, decreased cardiac output,
bronchorrhea (sputum), increased gut motility, micturition
(urination), and sweating. (Think S.L.U.D.G.E.)
 Nicotine receptors result in fasciculations (mini twitches),
weakness, paralysis, tachycardia, and hypertension.

7. Pathophysiology… the final chapter
 Anticholinergics! (aka I wish I was a stimulant but I can’t quite
cut it)
 Examples include Atropine, belladonna alkaloids, shrooms (some), tricyclic
antidepressants, and OTC sleep meds
 Presentation includes Hot(hyperthermia), Crazy (hallucinations), Blind
(dilated pupils), Dry (dry mucous membranes), Red (flushed skin),
basically you get a red, febrile, hallucinating person who can’t see and really
wants a drink
 The difference between anticholinergics and stimulants is peristalsis
remains decreased and the skin remains dry in this situation.

8. Primary Assessment
 Assessment always begins with the initial impression,
if you get the sinking feeling in your gut there is
probably a reason…
 ABC’s with immediate intervention
 Airway, is it open, can the patient protect it on their own?
 Breathing, are they breathing on their own, do you have to assist?
 Circulation, do they have a radial pulse? Are they diaphoretic,
tachy?
 Disability (Neuro) Fast GCS, remember AVPU
 Expose, signs of trauma, route of administration, is there toxin on
clothes/skin. Don’t forget to flip and look at the back if needed.

9. Secondary Assessment
 Full set of vitals
 Give comfort (meds, blankets, breathing for them…)
 History, medical and events. This can include chief complaint in the
chart, don’t forget EMS can be a great source of information.
 RETURN TO PRIMARY ASSESSMENT IF NEEDED!
 E.g. If they stop breathing don’t continue with the
history taking, it can wait.
 Nursing is a constant state of motion, once you finish your
primary/secondary start over and look for changes.

10. Interventions
**Decontamination for exposure; before anything or you will end
up in the same boat as the patient (with any luck this was done in the
field)
 Airway: repositioning, oral/nasal airway, ET tube, SPO2 sensor
 Breathing: Oxygen (nasal cannula or mask), Ambu bag, vent (CXR for
aspiration during the course of the stay)
 Circulation: IV(s), lab work (CBC, CMP, Tylenol, ASA, ETOH, UDS),
fluids, med administration (including reversal agents if applicable),
cardiac monitor, BP reading.
 Maintain Control (of self and others)
 Provide support to patient and family as applicable.
 Suicide risk assessment and safety screening

11. Interventions: Primary
Activated Charcoal
 Generally indicated for ingestion with known time in
the previous hour. Some cases may have this given after
that time window.
Reversal agents
 Romazicon for benzodiazepines, Narcan for opiates
 Last drug given is first drug reversed
 Romazicon can cause seizure in people who take large or
increasing dosed of benzodiazepines
 Reversal can simply be airway maintenance and time

12. Interventions: Primary cont.
 Dermal Decontamination
 strip off contaminated clothes, rinse with large amounts
of water
 Ocular Decontamination (Morgan Lens)
 usually connected to 0.9% NS and irrigating to gravity.
Consider use of numbing agent prior to insertion of
Morgan Lens

13. Interventions: Secondary
 These are the less often used interventions
 Gastric Lavage
 Forced Diuresis 3-6 ml/kg/hour NS
 Alkalinization (antifreeze ingestion)
 Hemodialysis (non-reversable toxic level situations)

14. Specific agent situations

15. Caustics/Corrosives
 Examples include Cleaning Agents, Bleach, Pool
chemicals
 Symptoms – Oral or facial burns, Drooling, Dyspnea or
Stridor
 Any indication of airway involvement should be
addressed immediately
 Intervention – Dilution, Irrigation
 Avoid Emesis (if it burns going down it will burn coming
back up)
 Activated charcoal not indicated in this case

16. Hydrocarbons
 Solvents & Fuels
 Symptoms – Odor!
 Intervention – Dilution or Decontamination
 Avoid Emesis, can cause aspiration however absorption
of ingested substance can lead to toxic levels.
 Charcoal is ineffective.
 Inhaled affects the neural system
 Ingested affects the pulmonary system, resulting in
pulmonary edema and pneumothorax
 High risk for aspiration pneumonitis which can be fatal

17. Acetaminophen
 Primary affect is Hepatic Damage (long term)
 2-4 Hour Half-life
 Severe Toxicity >10 grams
 Mucomist (Acetylcysteine) used for hepatic protection
 Serum level available from Lab

18. Salicylates
 Mixed respiratory alkalosis, metabolic acidosis
 Body attempts to correct metabolic acidosis with a respiratory
alkalosis resulting in mixed state
 Toxicity >250mg/kg
 Interventions - Bicarb/K+/Charcoal/Cooling
 Dialysis if Severe

19. Tricyclic Antidepressants
 Common are amitriptyline & Doxepin
 Anticholinergic
 Long Half-life, patient can present decently and deteriorate
during course of treatment
 Presentation: Altered Mentation, tachy dysrhythmias,
potential for seizure
 Interventions-IVF, airway maintenance, continuous
monitoring
 Treatment focused on individual symptoms
 Atropine not viable for brady arrhythmias due to
anticholinergic properties

20. SSRIs
 Common ones include: citalopram (celexa),
escitalopram (lexapro), fluoxetine (prozac), paroxetine
(paxil), sertraline (zoloft)
 Serotonin Syndrome: Muscle rigidity, myoclonus
(uncontrolled twitching), hyperthermia, AMS,
incoordination, hyper-reflexia, coma
 Treatment: Activated charcoal,
symptomatic/supportive treatment
 May result in liver failure due to hepatic metabolization

21. Iron
 Typically from vitamins, pre-natal have sepecially high
amounts of iron
 Presentation – based on stages
 Stage I: (30 min to 6 hrs post ingestion) Nausea, vomiting,
abd pain, hematemesis
 Stage II: (6-12 hrs) May see temporary improvement, does not
always occur
 Stage III: (12+ hrs) Metabolic acidosis, circulatory failure, CNS
depression/coma, hepatic failure
 Stage IV; (1-2 months) gastric scarring and stricture
 Tx – Whole Bowel Irrigation/Deferoxamine

22. Ethanol… (this is where we say “never drink like that again”)
 Protect Airway (they vomit and aspirate), include
Cardiac Monitor and SPO2
 Typically also present with orientation issues, may get
out of bed and fall furthering injury
 Sensation of pain altered, unable to report well
 CNS and Respiratory Depressant
 Hypoglycemia
 Alcoholics Need Thiamine

23. Methanol & Ethylene Glycol
(antifreeze)
 Presentation – altered mental status, may appear like
alcohol intoxication. Potential for dysrhythmias,
seizure.
 Un-metabolized form nephrotoxic, metabolized form
results in metabolic acidosis
 Metabolic acidosis and concurrent cerebral edema
 Treatment – Ethanol/Fomepizole as competition for
metabolism, Bicarb to assist in reversal of acidosis
 Hemodialysis in severe cases

24. Sedative Hypnotics
 Benzodiazepines/Barbiturates
 Presentation - Altered mental status,
hypotension/shock
 Intervention – Airway management
 Consider Romazecon, be aware of seizure
potential. Unable to medicate seizure if
romazecon administered

25. Opiates & Narcotics
 Presentation – Constricted Pupils, altered mental
status, bradycardia, hypotension, bradypnea/apnea
 CNS & Respiratory Depression
 Airway management, potential for emesis and aspiration
 Reversal agent = Narcan

26. Psychostimulants
 Cocaine, Meth, pseudoephedrine, amphetamine salts
(e.g. ADD meds)
 Presentation: CNS Stimulant (tachy pnea,
tachycardia), Manic or Paranoid, hypertension,
seizure, Dysrythmias (can result in MI or CVA in
younger population)
 Interventions – Cardiac Monitor, Charcoal, Haldol,
Cooling, Seizure Precautions

27. Questions?

28. References
http://illinoispoisoncenter.org/Illinois_Poison_Center_Fact_Sheet
ENA Orientation to Emergency Nursing Toxicology chapter, 2000.