Chapter 10

Poisoning and Substance Abuse

National EMS Education Standard Competencies

(1 of 5)

Medicine

Recognizes and manages life threats based on assessment findings of a patient with a medical emergency while awaiting additional emergency response.

National EMS Education Standard Competencies

(2 of 5) • •

Toxicology

Recognition and management of – – Carbon monoxide poisoning Nerve agent poisoning How and when to contact a poison control center

National EMS Education Standard Competencies

(3 of 5)

Immunology

• Recognition and management of shock and difficulty breathing related to Anaphylactic reactions

Pharmacology

Uses simple knowledge of the medications that the EMR may self-administer or administer to a peer in an emergency.

National EMS Education Standard Competencies

(4 of 5)

Medication Administration

• • Within the scope of practice of the EMR, how to Self-administer medication Peer-administer medication

National EMS Education Standard Competencies

(5 of 5)

Emergency Medications

• • • • • Within the scope and practice of the EMR Names Effects Indications Routes of administration Dosages for the medication administered

Introduction

• • A poison is a substance that causes illness or death when eaten, drunk, inhaled, injected, or absorbed in relatively small quantities.

EMRs can save patients’ lives by quickly recognizing and promptly treating serious poisonings.

Patient Assessment for Poisoning

(1 of 5) • Poisoning can be classified according to the way the poison enters the body.

– Ingestion: Poison enters through the mouth and is absorbed by the digestive system.

– Inhalation: Poison enters through the mouth or nose and is absorbed by the mucous membranes lining the respiratory system.

Patient Assessment for Poisoning

(2 of 5) • Poison classifications (cont’d) – Injection: Poison enters through a small opening in the skin and spreads through the circulatory system.

– Absorption: Poison enters through intact skin and spreads through the circulatory system.

Patient Assessment for Poisoning

(3 of 5)

Patient Assessment for Poisoning

(4 of 5) • General assessment and treatment – – Follow the patient assessment sequence.

Obtain a thorough history from the patient or from bystanders.

– Be alert for visual clues that may indicate poisoning.

– Much of the emergency care depends on the patient’s signs and symptoms.

Patient Assessment for Poisoning

(5 of 5)

Ingested Poisons

(1 of 2) • • More than 80% of all cases of poisonings are caused by ingestion.

• Chemical burns, odors, or stains may be found around the patient’s mouth.

Signs and symptoms – – – Nausea Vomiting Abdominal pain

Ingested Poisons

(2 of 2) • Signs and symptoms (cont’d) – – – Diarrhea Abnormal or decreased respirations Loss of consciousness – Seizures

Treatment for Ingested Poisons

(1 of 5) • • Identify the poison.

Call the National Poison Center for instructions, and follow these instructions.

• If you are unable to contact the poison center, dilute the poison by giving water.

• Arrange for prompt transport to a hospital.

Treatment for Ingested Poisons

(2 of 5) • Dilution – Most poisons can be diluted by giving the patient large quantities of water.

– The patient must be conscious and able to swallow.

Treatment for Ingested Poisons

(3 of 5) • Activated charcoal – – Finely ground powder mixed with water Works by binding to the poison, thereby preventing the poison from being absorbed in the patient’s digestive tract – Do not give if the patient: • Has ingested an acid or an alkali • Has ingested a base • Is unconscious

Treatment for Ingested Poisons

(4 of 5) • Activated charcoal (cont’d) – Usual dose: • 25 to 50 grams for an adult patient • 12.5 to 25 grams for a pediatric patient – Serve it in a covered cup and give the patient a straw.

Treatment for Ingested Poisons

(5 of 5) • Vomiting – In the past, syrup of ipecac was used to induce vomiting.

– Today, it is recommended in only a few situations.

– Inducing vomiting may cause the patient to inhale the vomit into the lungs.

– Activated charcoal is considered more effective and safer than syrup of ipecac.

Inhaled Poisons

(1 of 2) • Occurs if a toxic substance is breathed in and absorbed through the lungs – Some toxic substances (carbon monoxide) are very poisonous but not irritating.

– Other toxic gases (chlorine gas and ammonia) are very irritating to the respiratory tract.

Inhaled Poisons

(2 of 2) • Signs and symptoms – – – – – – – Respiratory distress Dizziness Cough Headache Hoarseness Confusion Chest pain

Carbon Monoxide

(1 of 2) • Common causes of carbon monoxide poisoning include: – – Improperly vented heating appliances Smoke (burning buildings)

Carbon Monoxide

(2 of 2) • Signs and symptoms – – – – – Headache Nausea Disorientation Unconsciousness Flulike symptoms • If you find several patients together who all report these symptoms, remove everyone from the structure or vehicle.

Irritants

(1 of 4) • Ammonia – – – – – Often found in agricultural settings Has a strong, irritating odor Is highly toxic Causes violent coughing and skin burns Anyone who enters an environment containing ammonia must wear a proper encapsulating suit with a SCBA.

Irritants

(2 of 4) Courtesy of Lynn Betts/NRCS Courtesy of Scott Health & Safety

Irritants

(3 of 4) • Chlorine – Found around swimming pools and water treatment plants – Is severely irritating to the lungs and upper respiratory tract – – Causes violent coughing and skin burns Anyone who enters an environment containing chlorine must wear a proper encapsulating suit with a SCBA.

Irritants

(4 of 4) • The presence of hazardous materials that are toxic and those in which there is a danger of fire or explosion should be indicated by the appropriate placards.

© Mark Winfrey/ShutterStock, Inc.

Treatment for Inhaled Poisons

• • • Remove the patient from the source of the gas.

– If the patient is not breathing, begin mouth-to mask breathing.

– If the patient is breathing, administer large quantities of oxygen.

Arrange for prompt transport.

You may have to evacuate people first.

Injected Poisons

(1 of 2) • The two major causes of poisoning by injection are: – – Animal bites and stings Toxic injection

Injected Poisons

(2 of 2) • Signs and symptoms – – – – – – – – Obvious injury site (bite or sting marks) Tenderness Swelling Red streaks radiating from the injection site Weakness Dizziness Localized pain Itching

Treatment for Insect Stings and Bites

(1 of 5) • • Keep the patient quiet and still.

• A light constricting band may be used if there is severe swelling.

• Apply ice packs to reduce swelling and pain.

Some people may experience an extreme allergic reaction and go into anaphylactic shock.

Treatment for Insect Stings and Bites

(2 of 5) • Signs and symptoms of anaphylactic shock – – – – – – Itching Hives Swelling Wheezing and severe respiratory distress Generalized weakness Loss of consciousness

Treatment for Insect Stings and Bites

(3 of 5) • • Signs and symptoms of anaphylactic shock (cont’d) – – Rapid, weak pulse Rapid, shallow breathing Treatment for anaphylactic shock – – Maintain the patient’s ABCs.

Administer oxygen if available.

– Elevating the patient’s legs may help.

Treatment for Insect Stings and Bites

(4 of 5) • Treatment for anaphylactic shock (cont’d) – – – Remove the allergen if possible.

Monitor the patient’s vital signs.

If the patient’s condition progresses to the point of respiratory or cardiac arrest, begin mouth-to mask breathing or CPR.

– Immediately arrange for rapid transport.

Treatment for Insect Stings and Bites

(5 of 5) • Treatment for anaphylactic shock (cont’d) – If the patient has a prescribed auto-injector, help the patient use it.

• Place the tip of the auto injector against the outer thigh.

• Push the auto-injector firmly against the thigh and hold it for several seconds.

Snake Bites

(1 of 3) • • Four kinds of poisonous snakes in the United States: – – Rattlesnake Cottonmouth – – Copperhead Coral snake A snake injects its poison into a person’s skin and muscles with its fangs.

Snake Bites

(2 of 3) • Signs and symptoms – – – – – – Immediate pain at the bite site Swelling and tenderness around the bite site Fainting (from the emotional shock) Sweating Nausea and vomiting Shock

Snake Bites

(3 of 3) • The bite of the coral snake delivers a slightly different poison that may cause these additional problems: – – – – – Respiratory difficulties Slurred speech Paralysis Coma Seizures

Treatment for Snake Bites

• • • • Keep the patient calm and quiet.

Have the patient lie down and try to relax.

Wash the bite area with soap and water.

If the bite occurred on the arm or leg, splint the affected extremity.

• • Treat the patient carefully.

Arrange for prompt transport to a hospital with antivenin.

Absorbed Poisons

(1 of 2) • • • Occurs when a poisonous substance enters the body through the skin Common absorbed poisons: – – Insecticides Toxic industrial chemicals Signs and symptoms – – Traces of powder or liquid on the skin Inflammation or redness of the skin

Absorbed Poisons

(2 of 2) • – – – – Signs and symptoms (cont’d) – – – Chemical burns Skin rash Burning Itching Nausea and vomiting Dizziness Shock

Treatment for Absorbed Poisons

(1 of 2) • • Ensure that the patient is no longer in contact with the toxic substance.

Brush —do not wash—any dry chemical off the patient.

– Contact with water may activate the dry chemical and result in a burning reaction.

• Wash the patient completely for at least 20 minutes.

Treatment for Absorbed Poisons

(2 of 2) • If additional EMS personnel are delayed, contact the poison control center or your medical director for additional treatment.

• If the patient is experiencing shock, have the patient lie down and elevate the legs.

• If the patient is having difficulty breathing, administer oxygen.

Nerve Agents

(1 of 5) • • Nerve agents can be absorbed through the skin, inhaled, or injected.

They are among the most deadly chemicals developed.

– Small quantities can kill large numbers of people by causing cardiac arrest within minutes of exposure.

Nerve Agents

(2 of 5) • Nerve agents block an essential enzyme in the nervous system and cause these SLUDGE-like symptoms.

Nerve Agents

(3 of 5) • – – – – Additional symptoms of organophosphate poisoning include: – – Shortness of breath Slow heart rate Muscle weakness, twitching, or paralysis Slurred speech Seizures Loss of consciousness

Nerve Agents

(4 of 5) • Four of the most common nerve agents: – – – – Sarin (GB) Soman (GD) Tabun (GA) V agent (VX) • If you are called to the scene of a nerve agent poisoning, keep yourself, rescuers, and bystanders from being contaminated.

Nerve Agents

(5 of 5) • A well-trained hazardous materials team in special protective equipment is needed to remove and decontaminate people.

• SCBA and encapsulating suits are needed to prevent exposure to rescuers.

Treatment for Nerve Agents

(1 of 2) • • Assess and support the patient’s ABCs.

Nerve agent antidote kits: – – DuoDote kit: contains one auto-injector syringe that contains atropine and pralidoxime chloride Mark I kit: contains two auto-injector syringes — atropine and pralidoxime chloride

Treatment for Nerve Agents

(2 of 2)

Substance Abuse

• • According to the National Survey on Drug Use, 8.9% of the US population (2.2 million people) are substance abusers.

Substance abuse results in an increased incidence of injuries and illness.

– Even if the primary reason for the call is not substance abuse, it can still be a contributing factor.

Alcohol

(1 of 3) • • Most commonly abused drug in the United States today – Involved in a significant number of traffic fatalities, murders, and suicides Symptoms of alcohol intoxication are similar to those of other medical illnesses or severe injuries.

– Be extra careful with your examination.

Alcohol

(2 of 3) • Alcohol is an addictive, depressant drug.

– Persons physically dependent on alcohol can develop severe withdrawal symptoms.

– The most severe symptoms are delirium tremens (DTs).

• Signs and symptoms of DTs – – Shaking Restlessness

Alcohol

(3 of 3) • Signs and symptoms of DTs (cont’d) – – – Confusion Hallucinations Gastrointestinal distress – – Chest pain Fever • DTs is a serious medical emergency that can be fatal.

Drugs

(1 of 9) Courtesy of DEA • • • May be ingested, inhaled, injected, or absorbed into the body Look for clues that indicate the type of drug and the way it was administered.

Abuse of prescription drugs has increased in recent years.

Drugs

(2 of 9) • Amphetamines – – – Stimulate the central nervous system Include speed, ice, crystal, cocaine (coke) Signs of amphetamine use include: • Restlessness • Irritability • Talkativeness – Keep patients from harming themselves and transport them to a facility.

Drugs

(3 of 9) • Barbiturates – Depressants (drugs that depress the nervous system) – – Include tranquilizers, opiates, and marijuana An overdose can result in respiratory depression or arrest.

– If the patient is not breathing, begin mouth-to mask resuscitation.

– If cardiac arrest occurs, begin CPR.

Drugs

(4 of 9) • Hallucinogens – – PCP, LSD, peyote, mescaline, mushrooms Chemicals that cause people to see things that are not there – Signs and symptoms of PCP overdose • Convulsions • Coma • Heart and lung failure • Stroke

Drugs

(5 of 9) • Hallucinogens (cont’d) – – – Try to reduce auditory and visual stimulation.

Approach each scene with caution.

Arrange for transport.

Drugs

(6 of 9) • Abused inhalants – – Intentional inhalation of volatile chemicals Many of these substances can be bought in hardware stores.

– May cause drowsiness, unresponsiveness, seizures, or sudden cardiac death – Try to keep the patient from struggling.

Drugs

(7 of 9) • Abused inhalants (cont’d) – – – Support the patient’s ABCs.

Give high-flow oxygen.

Carefully monitor the patient’s vital signs.

– Arrange for prompt transport.

Drugs

(8 of 9) • Toxic injection from drugs – The patient’s reaction depends on the quantity and type of drug injected.

– Signs and symptoms include: • Weakness • Dizziness • Fever • Chills

Drugs

(9 of 9) • Toxic injection from drugs (cont’d) – – – Support the patient.

Treat the symptoms.

Provide transport to a medical facility.

– Check the injection site for redness, swelling, and increased skin temperature (indications of infection).

Treatment for a Drug Overdose

• • Provide basic life support.

• • Keep the patient from hurting self and others.

• Provide reassurance and psychological support.

Arrange for prompt transport.

Avoid classifying or judging the patient.

Summary

(1 of 3) • • • The four primary routes by which poisons enter the body are ingestion, inhalation, injection, and absorption.

An ingested poison is taken by mouth.

An inhaled poison is breathed in and absorbed through the lungs.

Summary

(2 of 3) • • The two major causes of poisoning by injection are (1) animal bites and stings and (2) toxic injection.

Poisoning by absorption occurs when a poisonous substance enters the body through the skin.

Summary

(3 of 3) • Many nerve agents are the same types of chemicals as insecticides. Your role in incidents involving nerve agents is to keep yourself and others from becoming exposed.

• Pay special attention to scene safety and do not enter a hazardous environment without the proper training and equipment.

Review

1.

The most common route for poisonings is: A.

injection. B.

ingestion. C.

inhalation. D.

absorption.

Answer: B. ingestion.

Review

Review

2.

Which of the following would NOT be considered appropriate management of anaphylactic shock? A.

Administer oxygen if it is available.

B.

Remove the allergen. C.

Induce vomiting. D.

Immediately arrange for transport.

Review

Answer: C. Induce vomiting.

Review

3.

Which of the following are common causes of carbon monoxide poisoning?

A.

air conditioning units B.

cleaning supplies C.

improperly vented heating appliances D.

paints and paint thinners

Review

Answer: C. improperly vented heating appliances

Credits

• © Mark C. Ide • Background slide image (ambulance): © Comstock Images/Alamy Images • Background slide images (non-ambulance): © Jones & Bartlett Learning. Courtesy of MIEMSS.