Chapter 21: Chapter 21 Poisoning Emergencies


21: 21 Topics Poisons and Poisoning Ingested Poisons Inhaled Poisons Injected Poisons Absorbed Poisons Enrichment


21: 21 Introduction Thousands of people in the US die or become ill from intentional or accidental poisonings each year. Many materials can cause poisoning, including medications, industrial chemicals, hazardous fumes, pesticides, and normal household materials. Most poisonings occur at home with a significant number involving children who get into and swallow poisonous substances while exploring their environment. Prompt and appropriate emergency care can be the difference between a successful and poor outcome.


21: 21 Poisons and Poisoning A poison is any substance that impairs health or causes death by its chemical action(s) when it enters the body or contacts the skin.


21: 21 Poisons and Poisoning There are literally thousands of poisons that can harm the human body. Poisonous substances can be found everywhere including in the home, workplace, and nature.


21: 21 Poisons and Poisoning Key terms related to poisoning: Toxicology Toxin Antidote Exposure Overdose


21: 21 Poisons and Poisoning Route of Exposure There are four (4) routes by which a poison can enter the body: Ingestion Inhalation Injection Absorption


21: 21 Poisons and Poisoning Ingested Poisons Poisons that are swallowed and enter the gastrointestinal (GI) system Poison enters the stomach and is then passed on into the small intestine where the majority of absorption occurs.


21: 21 Poisons and Poisoning Commonly Ingested Poisons Prescription and over the counter medications Illegal drugs Household products Cleaning agents Foods Insecticides Petroleum products Plants


21: 21 Poisons and Poisoning Ingested Poisons Ingested poisonings can be intentional as well as accidental. Some examples are: Intentional Suicide Homicide Accidental Taking too much medication Combining alcohol with medications or illegal drugs Storing poisons in food or drink containers Keeping poisons within reach of children Keeping poisonous plants within reach of children


21: 21 Poisons and Poisoning Ingested Poisons Scene Size-Up Actively look to the scene for clues that a poison has been ingested: Overturned or empty medicine containers Scattered pills or capsules Spilled chemicals or cleaning solvents Vomitus Burns to the patient’s mouth


21: 21 Poisons and Poisoning Ingested Poisons Initial Assessment Mental status Normal - Poison in large quantity has not been ingested, or full absorption into the blood stream has yet to occur. Altered - Poison has already absorbed into the bloodstream. Can rapidly deteriorate with the poisoned patient. Airway - Assure patency by appropriate methods. Evaluate for burns and swelling in the mouth that can be caused by caustic or corrosive poisons.


21: 21 Poisons and Poisoning Ingested Poisons Initial Assessment Breathing Adequate - Provide high flow oxygen. Inadequate - Provide positive pressure ventilations. Circulation Heart rate Skin color, temperature, and condition


21: 21 Poisons and Poisoning Ingested Poisons Focused History and Physical Exam SAMPLE History - Determine the following in addition to the standard information collected: What substance(s) and how much was ingested? Was any alcohol taken with the substance? When did the patient ingest the substance? Has anyone attempted to treat the patient prior to EMS? Does the patient have a history of suicide or other behavioral problems? How much does the patient weigh?


21: 21 Poisons and Poisoning Ingested Poisons Focused History and Physical Exam Look for the following signs and symptoms during the focused or rapid medical assessment: Swelling of tissues in the mouth Nausea, vomiting, and diarrhea Abdominal pain or distention Pain during swallowing Unusual breath or body odors Respiratory distress Abnormal vital signs Dilated or constricted pupils


21: 21 Poisons and Poisoning Ingested Poisons Possible indications that a child has ingested a poison include:


21: 21 Poisons and Poisoning Ingested Poisons Emergency Care If not yet provided, consider the following care measures: Maintain a patent airway by the appropriate means. Provide high concentration oxygen or assist ventilations as needed. Prevent further injury by removing any residual poison from the hands, mouth, or other body region. Do not rinse the mouth if the patient has a decreased mental status! Bring the suspected poison(s) or containers to the emergency department as well as a sample of any vomitus. Consider activated charcoal.


21: 21 Poisons and Poisoning Activated Charcoal Action: Adsorbs specific poisons in the stomach Indication: A patient who has ingested certain poisons and authorization by medical direction Contraindications: Altered mental status Ingestion of an acid or alkali Ingestion of cyanide Patient unable to swallow


21: 21 Poisons and Poisoning Activated Charcoal Dose: 1 gram/kg Administration: Obtain authorization from medical direction. Prepare the activated charcoal. Have the patient drink the charcoal. Record the time and dose.


21: 21 Poisons and Poisoning Activated Charcoal Side Effects: Blackening of the stool Vomiting If the patient vomits the activated charcoal, contact medical direction and consider repeating the administration if no contraindications are present.


21: 21 Poisons and Poisoning Ingested Poisons Detailed Physical Exam and Ongoing Assessment Perform the detailed exam if time or patient condition permit. When performing the ongoing assessment, pay attention to any decrease in mental status indicating overall patient deterioration. Watch for progressive airway swelling if caustic or corrosive poisons were ingested. Repeat vital signs every 5 minutes if the patient is unstable.


21: 21 Poisons and Poisoning Inhaled Poisons Poisons that are inhaled into the respiratory system Poisons that are inhaled enter the alveoli then cross to the blood stream and are distributed throughout the body.


21: 21 Poisons and Poisoning Commonly Inhaled Poisons Carbon monoxide Carbon dioxide Chlorine gas Fumes from liquid chemicals or sprays Ammonia Sulfur dioxide Solvents used in cleaning or dry cleaning Industrial gases Hydrogen sulfide


21: 21 Poisons and Poisoning Inhaled Poisons Inhaled poisonings can be intentionally used in an attempt to get “high.” Examples include: Paints Freon Gas propellants Glue Nitrous oxide Amyl nitrate Butyl nitrate


21: 21 Poisons and Poisoning Inhaled Poisons Scene Size-Up Ensure safety before entering a scene where a poison(s) has been inhaled. Actively look to the scene for clues that include: Patient(s) visibly in respiratory distress Strong odor or cloud of gas or smoke Containers of hazardous materials Multiple patients Never enter the scene unless safe or trained to do so with specialized equipment.


21: 21 Poisons and Poisoning Inhaled Poisons Initial Assessment Mental status Poisons absorbed through inhalation can reach the brain very quickly causing altered mental status. Airway - Assure patency by appropriate methods. Evaluate for burns and swelling in the mouth that can be caused by caustic or corrosive fumes or superheated gases.


21: 21 Poisons and Poisoning Inhaled Poisons Initial Assessment Breathing - Since fumes are taken directly into the respiratory system, respiratory distress is very common. Adequate - Provide high flow oxygen. Inadequate - Provide positive pressure ventilations. Circulation Heart rate Skin color, temperature, and condition


21: 21 Poisons and Poisoning Inhaled Poisons Focused History and Physical Exam SAMPLE History - Determine the following in addition to the standard information collected: Does the patient have any history that suggests a suicide attempt (carbon monoxide poisoning)? Did the exposure occur in an open or confined space? How long was the patient exposed? Does the patient suffer from other medical conditions that may be aggravated by exposure to the inhaled substance(s)?


21: 21 Poisons and Poisoning Inhaled Poisons Focused History and Physical Exam Look for the following signs and symptoms during the focused or rapid medical assessment: Difficulty breathing or shortness of breath Chest pain or tightness Cough, stridor, wheezing, or crackles Hoarseness Oral or pharyngeal burns Dizziness Headache Confusion


21: 21 Poisons and Poisoning Inhaled Poisons Focused History and Physical Exam Signs and symptoms (continued): Seizures Altered mental status Cyanosis Respiratory rate faster or slower than normal Singed nasal hairs Soot in the sputum or in the throat Obtain baseline vital signs. The onset of signs and symptoms may be delayed or progressive.


21: 21 Poisons and Poisoning Inhaled Poisons Emergency Care If not yet provided, consider the following care measures: Remove or have the patient removed from the toxic environment. Maintain a patent airway by the appropriate means. Provide high concentration oxygen or assist ventilations as needed. Loosen or remove tight fitting clothing. Attempt to identify the poison(s) and relay this information to the hospital


21: 21 Poisons and Poisoning Inhaled Poisons Detailed Physical Exam and Ongoing Assessment Perform the detailed exam if time or patient condition permit. When performing the ongoing assessment, pay attention to any decrease in mental status indicating overall patient deterioration. Watch for progressive airway swelling if irritating poisons were inhaled. Remember that the development of conditions like respiratory compromise may be progressive. Repeat vital signs every 5 minutes if the patient is unstable.


21: 21 Poisons and Poisoning Injected Poisons Poison that enter the body through a break in the skin (needles or animal bites and stings) Poison enters the skin or muscle and is absorbed into the blood stream and is distributed throughout the body.


21: 21 Poisons and Poisoning Commonly Injected Poisons Bee, wasp, hornet, ant, and other insect stings Spider and tick bites Snakebites Marine animal bites Illegal drugs taken by needle


21: 21 Poisons and Poisoning Injected Poisons Scene Size-Up Ensure safety before entering a scene where a poison(s) has been injected. Actively look to the scene for clues that include: Outdoor environment (e.g. garden, campground) Discarded syringes or drug paraphernalia


21: 21 Poisons and Poisoning Injected Poisons Initial Assessment Perform the initial assessment as you would for a patient who ingested or inhaled a poison. Look for signs and symptoms of an allergic or anaphylactic reaction that includes swelling of the airway, respiratory distress, weak pulses, and flushed skin.


21: 21 Poisons and Poisoning Injected Poisons Focused History and Physical Exam SAMPLE History - Determine the following in addition to the standard information collected: Does the patient have a history of drug use? Does the patient have a history of an allergic reaction to bites or stings? What was the time lapse between the injection and onset of the signs and symptoms? What type of drug did the patient take, or what type of insect or animal bit the patient?


21: 21 Poisons and Poisoning Injected Poisons Focused History and Physical Exam Look for the following signs and symptoms during the focused or rapid medical assessment: Weakness and dizziness Chills and fever Nausea and vomiting Elevated or decreased blood pressure Pupillary changes Needle tracks Pain, redness, or swelling at the site of injection Respiratory distress Paralysis


21: 21 Poisons and Poisoning Injected Poisons Focused History and Physical Exam Obtain baseline vital signs


21: 21 Poisons and Poisoning Injected Poisons Emergency Care If not yet provided, consider the following care measures: Maintain a patent airway by the appropriate means. Provide high concentration oxygen or assist ventilations as needed. Loosen or remove tight fitting clothing. Protect the patient from continued bites or stings. Attempt to identify the drug taken or animal responsible for the bite or sting


21: 21 Poisons and Poisoning Injected Poisons Detailed Physical Exam and Ongoing Assessment Perform the detailed exam if time or patient condition permits. When performing the ongoing assessment, pay attention to any decrease in mental status indicating overall patient deterioration. Watch for the onset of signs and symptoms related to an allergic reaction or anaphylactic shock. Repeat vital signs every 5 minutes if the patient is unstable.


21: 21 Poisons and Poisoning Absorbed Poisons Chemicals or Substances from poisonous plants that are absorbed through the skin Poison is absorbed through the skin and crosses into the blood stream for distribution throughout the body.


21: 21 Poisons and Poisoning Absorbed Poisons Scene Size-Up Assure that you will not contact an absorbed poison prior to entering the scene. Actively look to the scene for clues that include: Open containers of chemicals. Poisonous plants. Actual chemicals, burns, or lesions on a patient indicating exposure. Never touch a chemical with bare hands or without knowing what it is.


21: 21 Poisons and Poisoning Absorbed Poisons Initial Assessment Perform the initial assessment as you would for any other patient that has been poisoned. Some absorbed poisons can cause muscular paralysis leading to respiratory distress and/or respiratory arrest.


21: 21 Poisons and Poisoning Absorbed Poisons Focused History and Physical Exam SAMPLE History - Determine the following in addition to the standard information collected: To what was the patient exposed? What was the time lapse between the absorption and onset of the signs and symptoms? Were any care measures provided prior to the arrival of EMS? Does the patient suffer from other medical conditions that may be aggravated by exposure to the absorbed substance(s)?


21: 21 Poisons and Poisoning Absorbed Poisons Focused History and Physical Exam Look for the following signs and symptoms during the focused or rapid medical assessment: History of exposure to a poisonous substance Traces of liquid or powder on the patient’s skin Burns or pain at the site of exposure Itching or irritation Redness at the exposure site Swelling to the exposure site Fluid filled blisters Obtain baseline vital signs.


21: 21 Poisons and Poisoning Absorbed Poisons Emergency Care If not yet provided, consider the following care measures: Protect yourself from exposure to the patient and his clothing and jewelry. Maintain a patent airway by the appropriate means. Provide high concentration oxygen or assist ventilations as needed. Carefully remove contaminated clothing. Brush away any dry chemicals.


21: 21 Poisons and Poisoning Absorbed Poisons Emergency Care If not yet provided, consider the following care measures: If the poison is a liquid , irrigate all parts of the body with clean water for 20 minutes. If the eye is involved, irrigate with clean water for 20 minutes.


21: 21 Poisons and Poisoning Absorbed Poisons Detailed Physical Exam and Ongoing Assessment Perform the detailed exam if time or patient condition permits. Perform the ongoing assessment looking for signs of improvement or deterioration. Repeat vital signs every 5 minutes if the patient is unstable.


21: 21 Enrichment Food Poisoning Food poisoning is an illness caused by the ingestion of food containing bacteria or toxins produced by bacteria. The signs and symptoms of food poisoning vary but include: Nausea Vomiting Diarrhea Fever Chills


21: 21 Enrichment Food Poisoning The patient with suspected food poisoning is treated similarly to any other patient who has ingested a poison. Activated charcoal is not indicated. Do not allow the patient to eat or drink anything .


21: 21 Enrichment Carbon Monoxide (CO) CO is a colorless, odorless gas that displaces oxygen from the red blood cells. As a result, the tissues do not receive oxygen and will die, along with the patient. Early signs of CO poisoning include headache, tachypnea, nausea, vomiting, and altered mental status. Late signs of CO poisoning include blindness, hearing loss, convulsions, coma, and death.


21: 21 Enrichment Carbon Monoxide The patient with CO poisoning should be treated like any other patient who has inhaled a poison. Remove or have patient removed from the source. Provide high flow oxygen. Hyperbaric chamber therapy may be needed.


21: 21 Enrichment Cyanide Cyanide is a deadly poison found in a variety of materials including pesticides, household cleaning products, fruit pits, and plastics. Cyanide interferes with the ability of the cells to use oxygen, resulting in death of the victim.


21: 21 Enrichment Cyanide Early signs/symptoms of cyanide poisoning include: Headache Confusion Agitation or combativeness Burning in the mouth and throat Dyspnea Hypertension Bradycardia or tachycardia Smell of bitter almonds


21: 21 Enrichment Cyanide Late signs/symptoms of cyanide poisoning include: Seizures Coma Hypotension Pulmonary edema Cardiac dysrhythmias Acidosis Death


21: 21 Enrichment Cyanide The patient with cyanide poisoning should be treated like any other patient who has ingested or inhaled a poison. Remove or have the patient removed from the toxic environment. Remove any contaminated clothing and rapidly decontaminate the patient. Consider contacting ALS backup for the administration of a cyanide antidote. Rapid transport.


21: 21 Enrichment Acids and Alkalis Many household cleaning and industrial items contain acids or alkalis. These agents are referred to as caustic since they can cause burns. Acids tend to cause immediate and severe burning on contact with the body. Burned tissue forms a protective barrier and keeps the burn from progressing deep into the tissues. Alkalis tend not to produce a severe burning sensation, allowing them to burn deep into the tissues.


21: 21 Enrichment Acids and Alkalis The patient who has been exposed to an acid or alkali should be treated like any other person who has been exposed to a poison. Ensure that you do not touch the acid or alkali without proper protective equipment. Remove contaminated clothing and rapidly decontaminate the patient with large amounts of water. Maintain a patent airway. Provide oxygen and support ventilations as needed. Transport.


21: 21 Enrichment Hydrocarbons Hydrocarbons are found in products like kerosene, turpentine, mineral oil, toluene, benzene, lighter fluid, glues, paints, lubricants solvents, and spot removers. Exposure can occur by ingestion, inhalation, or absorption.


21: 21 Enrichment Hydrocarbons The signs and symptoms of hydrocarbon poisoning include: Coughing and choking Burns to the mouth Dyspnea including stridor and/or wheezing Tachypnea Cyanosis Abdominal pain Nausea and vomiting Altered mental status Seizures and/or coma


21: 21 Enrichment Hydrocarbons The patient who has been exposed to hydrocarbons should be treated like any other person who has been exposed to a poison. Ensure that you are not exposed to the hydrocarbon. Remove or have the patient removed from the toxic environment. Remove contaminated clothing and rapidly decontaminate the patient as needed. Maintain a patent airway. Provide oxygen and support ventilations as needed. Activated charcoal is not effective and should not be administered.


21: 21 Enrichment Methanol (Wood Alcohol) Methanol is a clear odorless liquid found in a variety of substances like gasoline, fuel line antifreeze, windshield washer fluid, paints, shellac, and canned fuels. Consumption of methanol causes the liver to produce massive quantities of acid that damage and destroy the cells of the body and can result in permanent disability or death of the patient.


21: 21 Enrichment Methanol (Wood Alcohol) The signs and symptoms associated with methanol poisoning include: Altered mental status Seizures Nausea and vomiting Abdominal pain Blurred vision Dilated pupils that are sluggish to respond Visual disturbances Dyspnea and tachypnea The development of signs and symptoms may be delayed up to 72 hours post consumption.


21: 21 Enrichment Methanol (Wood Alcohol) The patient who has been exposed to methanol should be treated like any other person who has ingested a poison. Maintain a patent airway. Provide oxygen and support ventilations as needed. The use of activated charcoal in methanol poisoning is controversial. An antidote (fomapizole) exists and may be administered in the hospital.


21: 21 Enrichment Isopropanol (Isopropyl Alcohol) Isopropanol is known as rubbing alcohol and is found in many household products. The liver takes isopropanol and creates acetone which is toxic to the cells and tissues. The signs and symptoms of an isopropanol ingestion include: Altered mental status Respiratory depression Abdominal pain Bloody vomitus Signs of shock (hypoperfusion)


21: 21 Enrichment Isopropanol (Isopropyl Alcohol) The patient who has been exposed to isopropanol should be treated like any other person who has ingested a poison. Maintain a patent airway. Provide oxygen and support ventilations as needed. Provide transport to the most appropriate medical facility.


21: 21 Enrichment Ethylene Glycol Ethylene glycol is found in a variety of products including detergents, radiator antifreeze, windshield deicers, and coolants. A very small amount of ethylene glycol can prove toxic to the cells and tissues of the body, especially those of the brain, heart, and kidneys.


21: 21 Enrichment Ethylene Glycol The signs and symptoms of ethylene glycol poisoning can be broken into stages: First stage (1 to 12 hours post ingestion). The first stage generally affects the central nervous system: Uncoordinated movements Slurred speech Altered mental status Nausea and vomiting Seizures Hallucinations


21: 21 Enrichment Ethylene Glycol The signs and symptoms (continued): Second stage (12 to 36 hours post ingestion). The second stage of poisoning generally affects the heart and lungs: Respiratory distress Tachypnea Crackles indicating pulmonary edema Cyanosis Dyspnea Heart failure


21: 21 Enrichment Ethylene Glycol The signs and symptoms (continued): Third stage (24 to 72 hours post ingestion). The third stage affects the kidneys: Decreased urine production (oliguria) Bloody urine (hematuria) Pain to the flank areas


21: 21 Enrichment Ethylene Glycol The patient who has been exposed to ethylene glycol should be treated like any other person who has ingested a poison. Maintain a patent airway. Provide oxygen and support ventilations as needed. Administer activated charcoal. Provide rapid transport to the most appropriate medical facility.


21: 21 Enrichment Poisonous Plants Some plants contain irritating substances that can be absorbed into the skin resulting in localized inflammation and irritation. These plants include: Poison ivy Poison oak Poison sumac Others When burned, irritating agents from these plants can enter and similarly irritate the airway.


21: 21 Enrichment Poisonous Plants The patient who has been exposed to a poisonous plant should be treated like any other person who has absorbed or inhaled a poison: Maintain a patent airway if inhalation has resulted in inflammation and edema. Provide oxygen and support ventilations as needed if airway involvement exists. Keep the patient from scratching the affected region to minimize the opportunity for infection.


21: 21 Enrichment Poison Control Centers Poison control centers exist across the U.S. and Canada and provide a valuable resource in the treatment of patients who have been poisoned. Poison control centers provide information regarding complications and specific treatment measures. Always clear any care recommended with local medical direction!