Chapter 22 Toxicology Emergencies PDF

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Toxicology Emergencies...

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Gina Alaniz EMS 111 Mike Smith 04/12/21 Chapter 22 HW Responses: Toxicologic Emergencies 1) Define Poison, Toxicology and Overdose. Poison: Any substance- liquid, solid, or gas—that impairs health or causes death by its chemical action when it enters the body or contacts the skin. Toxicology: The study of toxins, antidotes, and the effects of toxins on the body. A toxin is a drug or substance that is poisonous to a human and causes certain adverse effects that can potentially lead to death. Certain toxins might not be poisonous when used properly, such as prescribed narcotic medications, whereas some toxins are poisonous under all circumstances when in contact with the body, such as sulfuric acid. Overdose: A special type of poisoning, where a medication is taken in such excessive quantity that it becomes toxic to the body. Poisons and toxins can enter the body through ingestion, inhalation, injection, or absorption through the skin or mucous membrane. 2) Describe the main ways of determining whether a poisoning has taken place. Even if the patient with a suspected poisoning is currently stable, closely monitor the airway, breathing, circulation, and mental status because acute deteriorations can occur. A sudden decrease in the mental status can indicate rapid patient deterioration. Burns to the lips and inside of the mouth suggest that the patient ingested a corrosive poison. Be as thorough as possible

while gathering the history from the patient. This information might not be available later if the patient lapses into unresponsiveness. 3) Describe the General Emergency Care steps for a poisoning or overdose. •

Establish and maintain a patent airway.

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Determine whether the breathing is adequate or inadequate.

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Provide positive pressure ventilation for inadequate breathing or maintain adequate oxygenation for adequate breathing.

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Assess the circulation

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Reassess the patient every 5 minutes.

4) Give indications, contraindications, dosage and administrative steps for activated charcoal. Indications: Maybe used for a patient who has ingested poison by mouth, upon specific orders from medical direction. It’s most effective when administered within 1 hour after the ingestion of the poison and only in very specific cases of poisoning. Contraindications: •

Patient has altered mental status because it may cause aspiration.

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Has swallowed acids or alkalis (such as hydrochloric, bleach, ammonia, or ethyl alcohol).

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Is unable to swallow.

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Overdoses on cyanide.

Medication Form:

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Premixed in water, frequently available in a plastic bottle containing 12.5 grams of activated charcoal.

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Powder—Should be avoided in the field.

Dosage: Unless directed otherwise by medical direction, give both adults and children 1 gram of activated charcoal per kilogram (1g/kg) of body weight. The usual adult dose is 30-100 grams. The usual dose for infants and children is 12.5--25 grams. Administration steps: 1) Consult medical direction or the poison control, according to local protocol, before administering activated charcoal to any patient. Directions that follow are general. Always follow the orders of medical direction or local protocol. 2) Shake the container of activated charcoal thoroughly; it is too thick to shake well, remove the cap and stir it until well mixed. The activated charcoal settles to the bottom of the bottle and needs to be evenly distributed. 3) Activated charcoal looks like mud. The patient may be more willing to drink it if they can’t see it, such as through a straw from a covered opaque container. 4) If the activated charcoal settles, shake or stir it again before letting the patient finish the dose. 5) Record the time and the patient response. 6) If the patient vomits, notify medical direction to authorize one repeat of the dose. Once you’ve given a patient activated charcoal, don’t let the patient have milk, ice cream, or sherbert. These all decrease the effectiveness of activated charcoal.

5) List the emergency care for an ingested poison, inhaled poison, injected poison, and absorbed poison. Ingested Poison: 1) Ensure that the scene is safe; Prior to entering any scene involving a toxic emergency, ensure the scene is safe and the potential for exposure to any toxic substances is controlled. 2) Maintain the airway; Use gloves to remove any remaining pills, tablets, capsules, or other fragments from the patient’s mouth, taking care not to injure yourself. If the patient’s unresponsive, maintain an open airway with an OPA or NPA with a manual technique for opening the airway. Be sure not to stimulate the gag reflex, which might cause the patient to vomit. Secretions can be profuse following the ingestion of certain poisons, so be prepared to suction. A poisoning patient’s status can change suddenly. Be prepared to protect the patient from aspiration. If possible, place the patient in the lateral recumbent position in case of vomiting. 3) Provide ventilation if there is inadequate tidal volume or respiratory rate. Provide positive pressure via bag valve mask with a high concentration of supplemental oxygen delivered through the ventilation device. 4) Maintain Oxygenation, If the Spo2 is less than 94% or signs of respiratory distress, hypoxia, hypoxemia, or poor perfusion are present, administer oxygen via a nasal cannula to achieve and maintain an SPo2 of 94% or greater. 5) Prevent further injury, If a child has handled or been poisoned by a corrosive, protect yourself while washing the child’s hands and fingers and rinsing the child’s mouth and lips to remove

traces of the corrosive. Be careful when rinsing the mouth that the patient doesn’t swallow the liquid. Don’t flush the mouth of an unresponsive patient because he might aspirate the fluid. 6) During Transport consult Medical Direction, or if your protocols mandate, contact the regional poison control center. You might be instructed to administer activated charcoal. Follow local protocol. 7) Bring suspected poisons to the receiving facility. Bring the container and all it’s remaining contents, the plant portions or parts that might have been ingested, or other specimens to the receiving facility. Bring all possible containers and labels. Prescriptions bottles with remaining pills should be transported because they provide a clue to how much was ingested, bring the remaining roots, leaves, stems, flowers, or fruit. If the patient has vomited, bring a sample of the vomit in a clean, closed container to the receiving facility. Analysis of this material can help the emergency department staff isolate the type of poison involved. Inhaled Poison: 1) Protect yourself from exposure to toxic fumes by wearing self-contained breathing apparatus or waiting for a specialized team to make the rescue. 2) Quickly get the patient out of the toxic environment. 3) Place the patient in a supine position or position of comfort. Loosen all tight-fitting clothing, especially around the neck and over the chest. 4) Establish and maintain and open airway. 5) Start positive pressure ventilation with supplemental oxygen immediately if the patient has an inadequate tidal volume or respiratory rate.

6) Administer a high concentration of oxygen by non-rebreather mask at 15 lpm initially for all inhaled poisoning patients regardless of the Spo2 reading. 7) Bring all containers, bottles, labels, or other clues about the poisoning agent to the receiving facility. Injected poison: 1) In the case of a bite or sting, protect yourself from injury and protect the patient from repeated injection. Move the patient away from any insects that are still swarming. Bees can sting only once and then lose their stinger—wasps, hornets, and yellow can sting repeatedly. 2) Establish and maintain the patient’s airway. If appropriate, insert an OPA if the patient doesn’t have a gag reflex. Use an NPA if the patient has a depressed mental status but doesn’t accept an OPA.Suction vomit and or secretions. 3) Begin positive pressure ventilations with supplemental oxygen if the patient’s are inadequate. 4) Maintain adequate oxygenation. If the Spo2 is less than 94% or signs of respiratory distress, hypoxia, hypoxemia, or poor perfusion are present, administer oxygen via a nasal cannula to achieve and maintain an Spo2 of 94% or greater. 5) Be alert for vomiting. Positioning the patient in a lateral recumbent (coma or recovery) position to help prevent aspiration, and be prepared to suction if necessary. 6) Bring all containers, bottles, labels, or other evidence of poisonous substances to the receiving facility. If the patient was bitten or stung, try to identify the insect, reptile, or animal that caused the injury (without getting close enough to endanger yourself if it is still alive). If it is dead, bring it to the receiving facility with the patient.

Absorbed Poison: 1) Protect your hands with gloves, move the patient from the source of the poison, and remove the patient’s contaminated clothing and jewelry. 2) Establish and maintain an open airway. 3) Being positive pressure ventilations with supplemental oxygen if the patient’s respirations are inadequate. 4) Maintain adequate oxygenation, If the Spo2 is less then 94% or signs of respiratory distress, hypoxia, hypoxemia, or poor perfusion are present, administer oxygen via a nasal cannula to achieve and maintain an Spo2 of 94% or greater. 5) Brush any dry chemicals or solid toxins from the patient’s skin, taking extreme care not to abrade the skin or spread the contamination. Contact medical direction to determine whether to flush the contaminated area. 6) If the poison is liquid, irrigate all parts of the body with clean water for at least 20 minutes. ( A shower or garden hose is ideal.) carefully check hidden” areas, such as the nail beds, skin creases, areas between the fingers and toes, and hair. If the patient is wearing any jewelry, remove it prior to flushing to ensure that no toxin remains trapped between the jewelry and skin. Continue irrigation en route to the receiving facility if possible. If the poison is a dry powder, brush off the substance and continue the treatment for other absorbed poisons. 7) If the poison entered the eye, irrigate the affected eye with clean water for at least 20 minutes; continue irrigation while en route to the receiving facility, if possible. Position the patient so water runs away from the unaffected eye, taking care not to spread the contamination.

6) List the 6 indicators that a drug or alcohol patient is a high priority. •

Unresponsiveness

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Inadequate Breathing

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Fever

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Abnormal heart rate (slow, fast, weak, or irregular.)

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Vomiting with an altered mental status

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Chest pain

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Seizures

7) Describe withdrawal syndrome and the 4 general stages of alcohol withdrawal. Withdrawal syndrome usually consists of problem drinking (during which alcohol is used frequently to relieve tensions or other emotional difficulties) and true addiction (in which abstinence from drinking causes physical withdrawal symptoms). It occurs after a period of abstinence from the drug or alcohol to which a person’s body has become accustomed. It doesn’t require that the alcoholic or drug abuser stop drinking or taking the drug completely. The withdrawal syndrome can also occur when an alcoholic’s alcohol intake falls below the amount usually ingested. It’s does dependent: The more they were drinking, the more severe the syndrome will be. Alcohol Withdrawal syndrome can mimic many psychiatric disorders and is characterized by the following signs and symptoms: •

Insomnia

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Muscular weakness

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Fever

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Seizures or tremors

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Disorientation, confusion, and thought process disorders.

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Transient visual, tactile, or auditory hallucinations.

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Anorexia (life threatening loss of appetite).

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Nausea and vomiting

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Hyperthermia (elevated body temperature)

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Sweating

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Hypertension

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Rapid Heartbeat

8) List the signs and symptoms of Opioid use. •

CNS depression

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Respiratory depression (decreased respiratory rate and tidal volume).

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Miosis (constricted pupils)

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Seizure that can occur due to the hypoxia associated with the respiratory depression.

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Psychomotor delay and disabilities from hypoxia and cell injury.

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Dysarthria (speech disturbance from paralysis of facial muscles) from hypoxia and cell injury.

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Ataxia (incoordination) from hypoxia and cell injury.

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Tremors from hypoxia and cell injury.

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Crackles from acute pulmonary edema associated with leaking pulmonary capillaries thought to be from the related hypoxia.

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Hearing loss from altered metabolism or direct effect on the ear.

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Hypotension from CNS depression

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Bradycardia from CNS depression

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Nausea and vomiting from decreased gastrointestinal motility.

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Urinary retention from urethral sphincter spasm.

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Pruritus (itching), flushing, and urticaria (hives) from histamine release.

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Hypoglycemia (mechanism is unclear).

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Hypothermia (mechanism is unclear).

9) Give Indications, Contraindications, Dosage and Administration steps for Nalaxone (Narcan). Indication: Suspected or known opioid intoxication who have CNS depression with respiratory depression, hypotension or bradycardia. Contraindication: The drug itself has no effects on the body unless an opioid substance is present. Therefore, the only contraindication is a known hypersensitivity to naloxone. Medication Forms: A liquid form that can be administered by intravenous, subcutaneous, intramuscular, intranasal, or endotracheal route. We typically only administer naloxone by an intranasal route; however some may use an intramuscular route also. A naloxone auto injector is available. Follow your local protocol. Dosage: The typical dose is 0.4 mg to 2 mg when given by various route. When administered by an intranasal route, the typical dose is 2 mg—1mg is administered via mucosal atomization device (MAD) in each nostril. Administration Steps:

1) Obtain an order from medical direction, either online or offline as per your local protocol. 2) Confirm the medication is Naloxone. 3) Ensure the nostrils are clear of any obvious obstruction to intranasal administration. If blood, vomit, or secretions are blocking the patency of the nasal passageway, suction prior to intranasal administration of the naloxone. 4) Consider restraining the patient prior to the administration of the naloxone. Many patients suddenly become aggressive and combative upon returning to a conscious state after naloxone administration. 5) Draw up the naloxone if necessary, using a needle and a syringe. Don’t use the needle for nasal administration. Typically, 1 mg is drawn up into the syringe. 6) Assemble the mucosal atomizer device to the syringe containing the naloxone. 7) With the patient in a supine position and the head slightly hyperextended, insert the naloxone firmly into one nostril. 8) Press the syringe plunger firmly and quickly until the 1 mg has been expelled into the nostril. (follow local protocol for dosage). 9) Repeat steps 5 through 8 using the opposite nostril. 10) Record the time, dose, and route of administration....