17: Substance Abuse and Poisoning

4-6.1 List various ways that poisons enter the body.

4-6.2 List signs and symptoms associated with poisoning.

4-6.3 Discuss the emergency medical care for the patient with possible overdose.

4-6.4 Describe the steps in the emergency medical care for the patient with suspected poisoning.

Cognitive Objectives (1 of 2)

Cognitive Objectives (2 of 2)

4-6.5 Establish the relationship between the patient suffering from poisoning or overdose and airway management.

4-6.6 State the generic and trade names, indications, contraindications, medication form, dose, administration, actions, side effects, and reassessment strategies for activated charcoal.

4-6.7 Recognize the need for medical direction in caring for the patient with poisoning or overdose.

Affective Objectives

4-6.8 Explain the rationale for administering activated charcoal.

4-6.9 Explain the rationale for contacting medical direction early in the prehospital management of the poisoning or overdose patient.

Psychomotor Objectives (1 of 2)

4-6.10 Demonstrate the steps in the emergency medical care for the patient with possible overdose.

4-6.11 Demonstrate the steps in the emergency medical care for the patient with suspected poisoning.

4-6.12 Perform the necessary steps required to provide a patient with activated charcoal.

4-6.13 Demonstrate the assessment and documentation of patient response.

Psychomotor Objectives (2 of 2)

4-6.14 Demonstrate proper disposal of the equipment for the administration of activated charcoal.

4-6.15 Demonstrate completing a prehospital care report for patients with a poisoning/overdose emergency.

Poison

• Any substance whose chemical action can damage body structures or impair body functions

Substance Abuse

• The knowing misuse of any substance to produce a desired effect

Identifying the Patientand the Poison

• If you suspect poisoning, ask the patient the following questions:– What substance did you take?– When did you take it or (become exposed to it)?– How much did you ingest?– What actions have been taken?– How much do you weigh?

Determining the Natureof the Poison

• Take suspicious materials, containers, vomitus to the hospital.

• Provides key information on:– Name and concentration of the drug– Specific ingredients– Number of pills originally in bottle– Name of manufacturer– Dose that was prescribed

Inhaled Poisons

• Wide range of effects– Some inhaled agents cause progressive lung

damage.• Move to fresh air immediately.• All patients require immediate transport.

Absorbed Poisons

• Many substances will damage the skin, mucous membranes, or eyes.

• Substance should be removed from patient as rapidly as possible.

• If substance is in the eyes, they should be irrigated.• Do not irrigate with water if substance is reactive.

Ingested Poison• Poison enters the body by mouth.

• Accounts for 80% of poisonings

• May be accidental or deliberate

• Activated charcoal will bind to poison in stomach and carry it out of the body.

• Assess ABCs.

Injected Poisons

• Usually result of drug overdose• Impossible to remove or dilute poison once

injected• Prompt transport

You are the Provider

• You and your EMT-B partner are dispatched to Grandma Jean’s Day Care Center for an accidental poisoning.

• The center director says one of her toddlers ingested a cleaning product.

• You hear hysterical crying and screaming. You find a 3-year-old girl in the lap of her teacher in obvious distress.

You are the provider (continued)

• What initial treatment should be provided to this child?

Scene Size-up

• Well-trained dispatchers are of great help in a poisoning situation.

• Look for clues of poisons or substances.– Medicine bottles may be an

indication of overdose– Alcoholic beverages/bottles– Syringes or drug paraphernalia– Unpleasant or odd odor in room

• Ensure your safety.

Initial Assessment

• General impression– Do not be fooled into thinking a conscious, alert,

oriented patient is stable.– Systemic reactions may take time to develop.

• Signs of distress and altered mental status suggest a systemic reaction.

Airway and Breathing

• Open airway; provide adequate ventilation.• If patient is unresponsive, use airway adjunct.• Suctioning is critical; poisoned patients may vomit.• BVM may be needed.• Take spinal precautions.

Circulation

• Circulatory status can vary.• Assess pulse, skin color.• Some poisons are stimulants, others depressants.• Some cause vasoconstriction, others vasodilation.• Bleeding may not be obvious.

Transport Decision

• Alterations to ABCs and a poor general impression require immediate transport.

• Check industrial settings for specific decontamination sites/antidotes.

• Consider decontamination before transport.

You are the Provider (continued) (1 of 2)

• You notice a garbage can next to the child containing vomitus.

• Child is conscious and alert. Airway is patent, respirations 34 labored breaths/min.

• Area around mouth is bright red with blisters. • Inside her mouth are red, irritated tissue and

multiple blisters.

You are the Provider (continued) (2 of 2)

• Breath has a strong chemical smell. • You immediately provide high-flow oxygen.• What additional resources do you require?

Focused History and Physical Exam

• SAMPLE history questions:– What is the substance involved?– When did the patient ingest or become

exposed?– How much was ingested or what was the level of

exposure?– Over what period of time did the patient take the

substance? Minutes or hours?– Have any interventions helped? Made it worse?– How much does the patient weigh?

Focused Physical Exam

• Focus on area of body or route of exposure.• Baseline vital signs are important.• Treatment is based on:

– What they were exposed to– When they were exposed to it– Signs and symptoms

• Contact medical control or poison control center to discuss options.

Interventions

• Depends on poison.• Support ABCs.• Some poisons can be easily diluted or

decontaminated before transport.• Dilute airborne exposures with oxygen.• Remove contact exposures with water unless

contraindicated.• Consider activated charcoal for ingested poisons.• Contact medical control to discuss options.

You are the Provider (continued) (1 of 4)

• You learn that your patient ingested CLR cleaner approximately 5 minutes before your arrival.

• Started vomiting almost immediately.• Your partner calls poison control center and

medical control.• The CLR label states:

– Do not induce vomiting but drink a glass of water followed by a glass of milk.

– Call a physician immediately.

You are the Provider (continued) (2 of 4)

• What information should you have for the poison control center or medical control?

• What if you can’t make the phone call to poison control?

You are the Provider (continued) (3 of 4)

• Poison control and medical control recommend giving the patient water.

• Patient’s breathing begins to slow. Vital signs:– Respirations 22 breaths/min– Pulse 90 beats/min, weak– BP 60 by palpation

• Her crying has subsided. She is becoming lethargic and unresponsive to verbal stimuli.

• Dispatch confirms that ALS should be on scene in 2 minutes.

You are the Provider (continued) (4 of 4)• Is this patient getting better?

Detailed Physical Exam

• Perform, at a minimum, on patients: – With extensive chemical burns– With other significant trauma– Who are unresponsive

• ABCs are the priority.

Ongoing Assessment

• Patient conditions can change quickly. • Continually reassess ABCs.• Repeat vital signs.• If exposure level is unknown, reassess frequently.• Communicate as much as possible to receiving

hospital.• Take MSDS with you or have faxed en route.

Emergency Medical Care

• External decontamination is important.• Care focuses on support: assessing and

maintaining ABCs.• You may be permitted to give activated charcoal for

ingested poisons.

Activated Charcoal (1 of 3)

• Charcoal is not indicated for:– Ingestion of an acid, alkali, or petroleum– Patients with decreased level of

consciousness– Patients who are unable to swallow

• Usual dosage is 25 to 50 g for adults and 12.5 to 25 g for pediatric patients.

Activated Charcoal (2 of 3)

• Obtain approval from medical control.• Shake bottle vigorously.• Ask patient to drink with a straw.• Record the time you administered the activated

charcoal.• Be prepared for vomiting.

Activated Charcoal (3 of 3)

Specific Poisons

• Tolerance– Need for increased amount of drug to have

same desired effect• Addiction

– Overwhelming desire or need to continue using an agent

Alcohol (1 of 3)

• Most commonly abused drug in the US

• Kills more than 200,000 people a year

• Alcohol is a powerful CNS depressant.

• Acts as a sedative and hypnotic

• A person that appears intoxicated may have a medical problem.

Alcohol (2 of 3)

• Intoxicated patients should be transported and seen by a physician.

• If patient shows signs of serious CNS depression, provide respiratory support.

• A patient with alcohol withdrawal may experience delirium tremors (DTs).

Alcohol (3 of 3)

• Patients with DTs may experience:– Agitation and restlessness– Fever – Sweating– Confusion and/or disorientation– Delusions and/or hallucinations– Seizures

Opioids (1 of 2)

• Drugs containing opium • Most of these, such as codeine, Darvon, and

Percocet, have medicinal purposes.• The exception is heroin, which is illegal.• Opioids are CNS depressants causing severe

respiratory distress.

Opioids (2 of 2)

• Care includes supporting airway and breathing.

• You may try to wake patients by talking loudly or shaking them gently.

• Always give supplemental oxygen and prepare for vomiting.

Sedative-Hypnotic Drugs

• These drugs are CNS depressants and alter level of consciousness.

• Patients may have severe respiratory depression and even coma.

• The main concern is respiratory depression and airway clearance, ventilatory support, and transport.

Abused Inhalants (1 of 2)

• Common household products inhaled by teenagers for a “high”

• Effects range from mild drowsiness to coma

• May often cause seizures

Abused Inhalants (2 of 2)

• Patient is at high risk for sudden cardiac arrest.• Try to keep the patients from struggling or exerting

themselves.• Give oxygen and use a stretcher to move patient.• Prompt transport is essential.

Sympathomimetics

• CNS stimulants cause hypertension, tachycardia, and dilated pupils.

• Amphetamine and methamphetamine are commonly taken by mouth.

• Cocaine can be taken in may different ways.– Can lead to seizures and cardiac disorders

• Be aware of personal safety.

Marijuana• Smoked by 20 million people daily in the US• Produces euphoria, relaxation, and drowsiness• Impairs short-term memory and ability to work• Transport to hospital is rarely needed.• Marijuana can be used as vehicle for other

drugs, ie, it can be covered with PCP or crack.

Hallucinogens (1 of 2)

• Alter an individual’s sense of perception

• LSD and PCP are potent hallucinogens.

• Sometimes, people experience a “bad trip.”

• Patient typically are hypertensive, tachycardic, anxious, and paranoid.

Hallucinogens (2 of 2)

• Use a calm, professional manner and provide emotional support.

• Only restrain if danger of injury exists.

• Watch the patient carefully during transport.

Anticholinergics

• “Hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as a hatter”

• Block the parasympathetic nerves

• Patient may go from “normal” to seizure to death within 30 minutes.

• Consider ALS backup.

Cholinergic Agents

• Commonly used as nerve agents for warfare• Overstimulate body functions controlled by the

parasympathetic nervous system• Organophosphate insecticide or wild mushrooms

are also cholinergic agents.

Signs and Symptoms of Cholinergic Poisoning

• D Defecation

• U Urination

• M Miosis

• B Bronchorrhea

• E Emesis

• L Lacrimation

• S Salivation

• S Salivation

• L Lacrimation

• U Urination

• D Defecation

• G GI irritation

• E Eye constriction / Emesis

Care for Cholinergic Poisoning

• Main concern is to avoid exposure

• May require field decontamination

• Priority after decontamination is to decrease the secretions in the mouth and trachea.

• Provide airway support.

• May be treated as a HazMat incident

Aspirin

• Signs and symptoms – Nausea/vomiting– Hyperventilation– Ringing in ears– Confusion– Seizures

• Patients should be transported quickly to the hospital.

Acetaminophen

• Overdosing is common.• Generally not very toxic• Symptoms may not appear until it is too late.• Liver failure may not be apparent for a full week.• Gathering information at the scene is very important.

Other Alcohols

• Methyl alcohol and ethylene glycol are more toxic than ethyl alcohol.

• May be taken by chronic alcoholics who cannot obtain drinking alcohol

• More often taken by someone attempting suicide

• Immediate transport is essential.

Food Poisoning

• Salmonella bacterium causes severe GI symptoms within 72 hours.

• Staphylococcus is a common bacteria that grows in foods kept too long.

• Botulism often results from improperly canned foods.

Care for Food Poisoning

• Try to obtain as much history as possible.

• Transport patient to hospital promptly.

• If two or more persons have the same illness, bring some of the suspected food to the hospital, if possible.

Plant Poisoning• Several thousand cases of plant poisonings occur

each year.

• If you suspect plant poisoning:

– Assess the patient’s airway and vital signs.

– Notify poison control center.

– Take the plant to the emergency department.

– Provide prompt transport.

Review

1. Most poisonings occur via the _______________ route.

A. injection

B. ingestion

C. inhalation

D. absorption

Review

Answer: B

Rationale: Approximately 80% of all poisonings occur by ingestion.

Review

1. Most poisonings occur via the _______________ route.

A. Injection

Rationale: Less than 20% of poisonings occur via injection.

B. Ingestion

Rationale: Correct answer

C. Inhalation

Rationale: Less than 20% of poisonings occur via inhalation.

D. Absorption

Rationale: Less than 20% of poisonings occur via absorption.

Review

2. A 30-year-old male, who ingested an unknown substance, begins to vomit. You should:

A. collect the vomitus and bring it to the hospital.

B. place him in a position that prevents aspiration.

C. analyze the vomitus and try to identify the poison.

D. suction his oropharynx for no longer than 30 seconds.

Review

Answer: B

Rationale: If any patient begins to vomit, your first action should be to position him or her to prevent aspiration. If the patient is lying supine, use the recovery position. If the patient is sitting up, turn his or her head to the side. Use suction as needed to clear remaining vomitus from the mouth; do not exceed 15 seconds during an individual suction attempt. If it is safe and practical, try to retrieve some of the vomitus and take it to the hospital.

Review

2. A 30-year-old male, who ingested an unknown substance, begins to vomit. You should:

A. collect the vomitus and bring it to the hospital.

Rationale: If it is safe and practical, try to retrieve some of the vomitus and take it to the hospital. However, maintain an open airway first.

B. place him in a position that prevents aspiration.

Rationale: Correct answer

C. analyze the vomitus and try to identify the poison.

Rationale: This should be left for the hospital to do.

D. suction his oropharynx for no longer than 30 seconds.

Rationale: You should suction for no longer than 15 seconds.

Review

3. Which of the following questions is of LEAST pertinence for the EMT-B to ask a patient who intentionally overdosed on a medication?

A. “How much do you weigh?”

B. “How much did you ingest?”

C. “What substance did you take?”

D. “Why did you the medication?”

Review

Answer: D

Rationale: Determining what the patient ingested, how much was ingested, and the patient’s weight, are all pertinent and have a direct impact on the care that is provided during the acute phase. Why the patient ingested the medication does not have a direct impact on acute care; therefore, it is the least pertinent question to ask.

Review3. Which of the following questions is of LEAST pertinence for the

EMT-B to ask a patient who intentionally overdosed on a medication?

A. “How much do you weigh?”Rationale: This is a very pertinent question and can impact

treatment.B. “How much did you ingest?”Rationale: This is a very pertinent question and can impact

treatment.C. “What substance did you take?”Rationale: This is a very pertinent question and can impact

treatment.D. “Why did you the medication?”Rationale: Correct answer

Review

4. A 21-year-old male was found unconscious in an alley. Your initial assessment reveals that his respirations are slow and shallow and his pulse is slow and weak. Further assessment reveals that his pupils are bilaterally constricted. His presentation is MOST consistent with an overdose of:

A. cocaine.B. a narcotic. C. a stimulant drug. D. methamphetamine.

Review

Answer: A

Rationale: Narcotics are central nervous system depressant drugs; when taken in excess, they cause respiratory depression, bradycardia, and hypotension. Another common sign is miosis (constricted [pinpoint]) pupils. Cocaine, stimulant drugs (uppers), and methamphetamine have the opposite effect; they stimulate the central nervous system and cause tachycardia and hypertension.

Review

4. A 21-year-old male was found unconscious in an alley. Your initial assessment reveals that his respirations are slow and shallow and his pulse is slow and weak. Further assessment reveals that his pupils are bilaterally constricted. His presentation is MOST consistent with an overdose of:

A. cocaine.

Rationale: This increases the vitals, heart rate, pulse, and breathing.

B. a narcotic.

Rationale: Correct answer

C. a stimulant drug.

Rationale: This increases the vitals, heart rate, pulse, and breathing.

D. methamphetamine.

Rationale: This increases the vitals, heart rate, pulse, and breathing.

Review

5. How much activated charcoal should you administer to a 55-pound child who swallowed a bottle of aspirin?

A. 12.5 g.

B. 25 g.

C. 2 g/kg.

D. 50 g.

Review

Answer: B

Rationale: The usual dose of activated charcoal for adults and children is 1 g/kg. To convert a patient’s weight from pounds to kilograms, simply divide their weight in pounds by 2.2 Therefore, a 55-pound child should receive 25 g of activated charcoal (55 [pounds] ÷ 2.2 = 25 [kg]). The average pediatric dosing range for activated charcoal is 12.5 to 25 g.

Review

5. How much activated charcoal should you administer to a 55-pound child who swallowed a bottle of aspirin?

A. 12.5 g.

Rationale: 12.5g at 1g/kg dose would be given to a 27 lbs child.

B. 25 g.

Rationale: Correct answer

C. 2 g/kg.

Rationale: The standard dose is 1g/kg.

D. 50 g.

Rationale: 50g at 1g/kg dose would be given to a patient weighing 110 lbs.

Review

6. After taking Vicodin for 2 years for chronic pain, a 40-year-old woman finds that her usual dosage is no longer effective and goes to the doctor to request a higher dosage. This is an example of:

A. addiction.

B. dependence.

C. tolerance.

D. drug abuse.

Review

Answer: C

Rationale: A person who takes a medication for a prolonged period of time often finds that higher doses of the medication are required to achieve the same effect. This is called tolerance.

Review6. After taking Vicodin for 2 years for chronic pain, a 40-year-old

woman finds that her usual dosage is no longer effective and goes to the doctor to request a higher dosage. This is an example of:

A. addiction. Rationale: This is a physiological or psychological dependence on a

potentially harmful drug.B. dependence. Rationale: This is a physical or psychological need to use a drug. C. tolerance. Rationale: Correct answerD. drug abuse. Rationale: This is the deliberate use of an illegal drug or too much of a

prescribed drug.

Review

7. Food poisoning is almost always caused by eating food that contains:

A. fungi.

B. viruses.

C. bacteria.

D. protozoa.

Review

Answer: C

Rationale: Food poisoning is almost always caused by eating food that contains bacteria. Salmonella and botulism—two common forms of food poisoning—are both bacteria.

Review7. Food poisoning is almost always caused by eating food that

contains:

A. fungi.

Rationale: Fungi include mildews, molds, mushrooms, rusts, smuts, and yeasts.

B. viruses.Rationale: Viruses are not considered to be independent living

organisms. Viruses need a living host and are not found on food.

C. bacteria.Rationale: Correct answerD. protozoa. Rationale: A protozoa is a single-celled organism.

Review

8. The mnemonic DUMBELS can be used to recall the signs and symptoms of a cholinergic drug poisoning. The “E” in DUMBELS stands for:

A. emesis.

B. erythema.

C. ecchymosis.

D. elevated blood pressure.

Review

Answer: A

Rationale: The mnemonic “DUMBELS,” which can help you recall the signs and symptoms of cholinergic drug poisoning (ie, organophosphates), stands for excessive defecation, urination, miosis (pupillary constriction), bronchorrhea, emesis, lacrimation, and salivation.

Review8. The mnemonic DUMBELS can be used to recall the signs and

symptoms of a cholinergic drug poisoning. The “E” in DUMBELS stands for:

A. emesis. Rationale: Correct answerB. erythema. Rationale: Erythema is a redness of the skin usually caused by

fever or inflammation.C. ecchymosis. Rationale: Ecchymosis is bleeding from broken blood vessels into

surrounding tissue. D. elevated blood pressure. Rationale: Elevated blood pressure usually causes bradycardia and

hypotension.

Review

9. Which of the following effects does ethyl alcohol NOT produce?

A. Induction of sleep

B. Slowing of reflexes

C. Inappropriate behavior

D. Increased sense of awareness

Review

Answer: D

Rationale: Ethyl alcohol (ETOH) is both a sedative (decreases activity and excitement) and a hypnotic (induces sleep). It dulls the sense of awareness, slows reflexes, and reduces reaction time. It may also cause aggressive or inappropriate behavior and lack of coordination.

Review9. Which of the following effects does ethyl alcohol NOT produce?

A. Induction of sleepRationale: It is a hypnotic and induces sleep.B. Slowing of reflexesRationale: It is a sedative and reduces reaction time.C. Inappropriate behaviorRationale: It may cause aggressive or inappropriate behavior.D. Increased sense of awarenessRationale: Correct answer

Review

10. When caring for a patient with a contact poisoning, it is important to remember to:

A. prevent contamination of the patient.

B. avoid contaminating yourself or others.

C. let the hospital remove the surface poison.

D. immediately flush dry chemicals with water.

Review

Answer: B

Response: Emergency care for a patient with a contact poisoning includes avoiding contaminating yourself and others and removing the irritating or corrosive substance from the patient as rapidly as possible. Dry chemicals must be brushed from the body prior to flushing with water.

Review

10. When caring for a patient with a contact poisoning, it is important to remember to:

A. prevent contamination of the patient.

Rationale: The patient is already contaminated and you must try to minimize further contamination.

B. avoid contaminating yourself or others.

Rationale: Correct answer

C. let the hospital remove the surface poison.

Rationale: Remove irritating or corrosive substances as rapidly as possible.

D. immediately flush dry chemicals with water.

Rationale: You must brush off dry chemicals first before washing.