Poisoning and Overdose

Poisoning and Overdose

• Poison/Toxin• Any substance that usually kills, inures, or impairs an organism

through its chemical actions. • Toxicology

• Study of poisons• Toxic

• Poisonous • Overdose

• Self administration of a drug in excess OR in combination with other agents to the point where poisoning occurs.

• DTs• “Delirium Tremens”• A severe form of alcohol withdrawal that involves sudden and

severe mental or neurological changes

Introduction

Regional Poison Center– 1-800-222-1222

Second leading COD 2004– Exposure every 14 seconds– 2,482,041 exposures in 2007– 51.2% in childrem < 6 yo– 73.3% fatalities bt 20-59 yo– 32,691 poisoning deaths in 2005

Types of Exposure

• Ingestion• Swallowing

• Suicidal pt with pills, Alcoholic with methanol, toddler/animal with antifreeze

• Injection• Opioids – Insulin – Envenomation

• Inhalation• CO is most common• Glue sniffing• Freebasing cocaine

• Absorption • Organophosphate poisoning• Corrosives (acids/alkali)

Poisoning and OverdoseS/S per Route

• Ingested• Hx of ingestions• Nausea • Vomiting• Diarrhea• AMS• Abd pain• Chemical burns around the mouth• Different breath odors

• Emergent care• Remove pills, tablets, fragments from pt mouth with gloved hands as

needed, without injuring yourself• Consult medical direction – Activated Charcoal• Bring ALL containers, bottles, labels, etc of poison agent to hospital

S/S per Route: Inhalation

• S/S• Hx of inhalation of toxic substance• SOB• Chest pain• Cough• Hoarseness • Dizziness• Headache• Confusion• Seizures• AMS• Singed nasal hairs

• Emergent care• Have trained rescuers remove pt from scene• Supplemental O2• Bring ALL containers, bottles, labels, etc of poison agent to hospital

Smoke inhalation

S/S per Route: Absorbed

• S/S• Hx of exposure• Liquid or powder on pt skin• Burns• Itching• Irritation• Redness

• Emergent Care• Remove contaminated clothing while protecting yourself• Brush powders off pt• Irrigate for at least 20 minutes of liquid exposure• If in eyes, irrigate for at least 20 minutes and while en route away

from unaffected eye

S/S per Route: Injection

• S/S• Weakness• Dizziness• Chills• Fever• Nausea• Vomiting• Tack marks

• Emergent Care• Airway patency and ventilation• Be alert for vomiting• Bring ALL containers, bottles, labels, etc of poison agent to

hospital

Sedatives, Hypnotics, Anti-Anxieties

• Sedatives/Hypnotics/Anti anxiety• Sedatives

• Calming, decrease activity• Hypnotics

• Induce Sleep• Examples:

• Barbiturates • Benzodiazepines

• Ativan, Valium, Xanax, Sleeping Pills

• GHB• Rohypnol

• S/S• Resp depression• Depressed LOC• Coma• Death

Opiods

• Opioids• Narcotics• CNS depressants• Made from the Opium Poppy (Papaver somniferum)

• Examples• -Morphine – Codeine – Heroin – Oxycodone (Oxycontin)–

Methadone – Meperidine (Demerol) – Fentanyl - Opium • S/S

• CNS depression• Depressed LOC• Depressed Resp • PINPOPINT PUPILS

Meperidine Meperidine (Demerol)(Demerol)

Methadone

Morphine

Morphine

OpiumHeroin

Stimulants

• Stimulants• Stimulates CNS• Increase alertness and physical activity

• Examples• Amphetamines/Speed, Methamphetamine, Ritalin, Ecstasy, Cocaine, PCP,

Nicotine• S/S

• Excitability• Seizures• Increased heart rate• Increased BP• Chest pain• Dysrhythmia • Death• Ischemia• CVA• MI• Hyperthermia

Amphetamines-Amphetamines-Adderall

Cocaine

MethamphetamineMethamphetamine- Crystal Meth.- Crystal Meth.

Ritalin

Ecstasy

Nicotine

Ecstacy

Alcohol

• Alcohol• Intoxicating agent in fermented and distilled liquors

• S/S• AMS• Motor deficit • Coma• Resp failure• Vomiting• Aspiration• Death

Analgesics

• Analgesic• Pain killers

• Examples• Aspirin• Acetaminophen• Motrin• Advil

• S/S• Few early on• Liver damage within 48 hrs

Organophosphates

• Organophosphates – Inhibit acetylcholinesterase

activity – Initial overstimulation

followed by disruption of nerve transmission

• Examples• Insecticides• Fertilizer• Nerve gases

• S/S• Over stimulation of

secretions• Bronchocontrsiction• Weakness• SLUDGE

Food

• Food• Botulism

• Suspect• When 2 of more people are

ill after eating same food• S/S

• Flu like S/S• Double vision• Trouble moving

eyes/swallowing• Head-to-toe weakness• Paralysis• Resp arrest

Clostridium botulinum

Assessment

• HIGH level of suspicion • Not always obvious• Suspect when large number

of people become ill at once• i.e. Multiple people in a

building with c/o headache, nausea, ALOC = CO poisoning

• Bring containers and labels with you

• Report noticeable odors• Consider trauma • ABC’s

General Approach

Pt Hx– ESSENTIAL– High suspicion

Date of prescription vs medication left– ID/Quantity/Time of exposure/How/

Where exposed/Any treatments tried– Transport pills/bottles

Approach– Vitals, Oxygen, Monitor, IV, Transport (VOMIT)– Supportive care

Aspiration?– Consider AEIOU-TIPS– Traditional approach

Syrup of Ipecac (Airway compromise) Gastic lavage (Manpower, esophageal rupture) Activated charcoal (Relatively safe option)

Scene Size Up/Initial Assessment

• Scene Size-Up• Scene safety/BSI• Decontaminate pt

• Remove contaminated clothing• Irrigate 20 minutes• Brush off powders

• Initial Assessment• General impression• ABC’s• LOC/AVPU• Trauma? • Most deaths are due to Respiratory Compromise

• Aggressively manage airway

Focused Hx/Px

• Hx• What substance?• When did pt ingest/become exposed?• How much did the pt ingest?• Over what time period? • Interventions?• How much does the pt weigh?

• Px• Baseline Vitals• Track marks?• Some poisons present with a classical patter

• Opiods – PINPOINT pupil, AMS, Decreased/Shallow Resps• Organophosphates – SLUDGE

• -Salivation – Lacrimation – Urination – Defecation – GI complaints – Emesis

Toxidromes

Set of clinical S/S that are diagnostic of certain toxins/class of toxins

Narcotics– Decreased LOC, Res Depression, Constricted pupils

Morphine, Codeine, Demerol (no pupil change), etc

Anticholinergics– “Hot as Hades, blind as a bat, dry as a bone, red as a beet, mad

as a hatter” Cholinergics

– Organophosphate poisoning– SLUDGE

Salivation, Lacrimation, Urination, Defecation, GI complaints, Emesis

Opioid Overdose

Salivation Lacrimation Urination

Defecation

GI Complaints Emesis

Organophosphate Poisoning

Management

• Ensure Open Airway• Ensure proper ventilation• Prevent further absorption

• Activated Charcoal

• Treat S/S• O2• Supportive Care• ALS

• Naloxone• Opioids

• Atropine • Organophosphate

Re Assessment

• Re assessment• Be alert for vomiting• Be alert for further deterioration due to poisoning• ABC’s• Vitals• LOC

Activated Charcoal Pharmacology

• Generic• Activated Charcoal

• Trade• SuperChar – InstaChar – Actidose – LiquiChar

• Indications• Poisoning by toxic ingestion

• Contraindications• AMS• Inability to swallow• Ingestions of alkali/acids

• Form• Pre mixed in water with various amounts of charcoal. (12.5 g normal)

• Dose• Adults/Children = 1g/kg of body weight • Usual Adult dose = 25-50 g• Usual child/infant dose= 12.5-25 g

• Route• PO

• Actions• Binds to certain poisons and blocks absorption

• Side Effects• Black Stools• Vomiting• If pt vomits, repeat dose once

Activated Charcoal Administration

• Obtain order from medical control• Shake container thoroughly• Pt may need to be persuaded to drink medication since it

looks like mud• Cover container and supply a straw to aid in

administration • If pt takes a long time to drink the charcoal shake again

as it will settle out of solution• DOCUMENT activity and time• Transport• Re assess pt

Refusals

• Encourage pt to go to hospital• Call police if needed• Pt cannot be assumed to be acting in best

intent if OD/Suicidal/AMS.