Poisons

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Introduction

Toxicology is defined as the study of the adverse affects of chemicals or physical agents on living organisms. A poison is a substance capable of causing toxicity when absorbed into the body in a relatively small quantity. A toxin is a specific substance produced by certain plants, animals, or microorganisms that is toxic to other organisms (e.g. snake venom). The terms "poison" and "toxin" may be used interchangeably during this lesson. Exposure to toxins or poisons can occur in a variety of ways. Some poisonings result from deliberate actions such as suicide attempts or substance abuse, but the majority of poisonings are accidental. Accidental poisonings can involve everyday materials such as pesticides, medications, petroleum products, or house plants. Other routes of exposure can include snake bites, insect stings, or hazardous materials releases. One thing to keep in mind is that anything can be toxic if you become exposed to too much of it. Ten percent of all emergency room visits are caused by poisonings, so you should know how to access resources for treatment of the various poisonings and overdoses.

History of Exposure

Whenever you are called upon to treat a patient with a possible exposure to a poison, regardless of the route by which the patient has been exposed, there are some basic steps to consider. Follow these general guidelines:

·        ABOVE ALL, PROTECT YOURSELF AND YOUR CREW. Never enter a scene unless you have the appropriate equipment, have been properly trained, or until the scene has been declared safe by other trained personnel. Be sure to wear the appropriate body substance isolation gear: gloves, mask, gown, and goggles as needed to prevent exposure.

·        When it is safe to do so, conduct the initial assessment of the patient paying particular attention to the airway, breathing, and circulation.

·        Next, conduct the focused history and physical exam and obtain a SAMPLE (Signs and symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading up to the emergency) history from the patient or bystanders.

·        Get a set of baseline vital signs at this time. Be sure to note the time the vital signs were taken so you can compare later vital sign measurements to the baseline.

·        Perform the detailed physical exam when deemed appropriate and perform the ongoing assessment a minimum of every 5 minutes for unstable patients and every 15 minutes for those patients considered stable. Be prepared for changes in the patient`s status.

·        Maintain an accurate document of all observations, past medical history, and treatment.

As a general rule, try to gather the following information:

·        Identify the source of the problem

·        Determine the time the exposure occurred

·        Identify the type and amount of the substance the patient has been exposed to, if possible

·        Try to find out how long the patient has been exposed to the substance if it is an external exposure

·        Ask the patient what type of symptoms they have been experiencing as a result of the exposure

·        Find out how much the patient weighs or estimate the patient`s weight, since this could be important if an antidote or some other medication is to be given

Effects

Toxins may have two basic effects on the body, they may have a local effect, causing only local irritation or they may cause systemic effects causing a more serious problem to the exposed patient. Some toxins may have both local and systemic effects.

Local Effects

Local toxic effects are those caused by contact with the skin or mucous membranes of the eyes, nose, mouth, or respiratory tract. Irritant gases such as chlorine and ammonia can produce a localized toxic effect in the respiratory tract. Corrosives can cause localized skin damage. If the toxin is in contact with the skin long enough it can be absorbed into the bloodstream and can cause more serious systemic effects.

Systemic Effects

Toxins that are absorbed into the bloodstream may cause systemic effects when they are distributed to the body by the blood. Systemic poisons can cause harm to the entire body or to an entire organ system. Some substances may not cause harm until they are metabolized by the liver (biotransformation). Pesticides may penetrate through the skin and go on to cause neurological problems such as seizure activity. Think about what pesticides are made to do: kill. Watch what happens to a roach when it is sprayed with a pesticide, it almost immediately goes into a type of seizure then rolls over and dies. If you become exposed to enough of a pesticide, you may do the same thing.

Certain chemicals when introduced into the body may not be harmful until they go through the metabolic process (biotransformation). Once the body metabolizes the chemical, it becomes toxic. The liver and kidneys play a vital role in this metabolic process.

Poison Control

A poison control center is typically staffed by physicians, pharmacists, nurses, or toxicological specialists, and is available 24 hours a day to offer information on treatment of specific exposures to toxins. The centers often offer other services, in addition to treatment information, such as training, consultation, public education, research, and other services. The center should have the most up-to-date information available on treatment of exposure to toxins.

Useful information to have on hand before contacting your local poison control center is as follows:

·        What substance is involved. Note and report any containers at the scene of the poisoning

·        How much has been ingested

·        How long the patient has been exposed, or the time of the ingestion

·        Age of the patient

·        The patient`s weight

·        The patient`s past medical history

·        Any treatments given since the poisoning occurred

·        An accurate description of the patient`s signs and symptoms

·        Has the patient vomited? Describe the vomitus, if possible

Typically, in about 80% of the cases handled by poison control centers, definitive treatment procedures can be given to emergency personnel and treatment can begin in the field.

There are four major routes by which toxins can enter the body: inhalation, ingestion, absorption, and injection. The effects of exposure to toxins will vary according to the amount of the material the patient has been exposed to, the concentration or strength of the material, the amount of time the patient has been exposed, and the route of exposure.

Inhalation

When a toxin is inhaled, the effects are often felt very rapidly. This will depend on the amount, concentration, toxicity, and the individual`s ability to metabolize the substance. There are several factors to consider when inhalation has occurred. When assessing the patient for severity of exposure consider the following:

·        Airway patency

·        Respiratory effort

·        Length of exposure

·        Patient`s general health

·        Type of toxin

·        Was the patient in an enclosed area?

Toxic compounds introduced into the respiratory system are usually gases or vapors of volatile liquids. Solids and liquids may also be inhaled in the form of dust or aerosols. The result of the inhalation of a toxic substance is usually rapid absorption into the bloodstream due to the extensive blood supply and the large surface area associated with the lungs. The lungs are the only internal organ system that remains in direct contact with the environment. The lungs have a surface area of about 70 - 100 square meters versus only about 2 square meters of surface area of the skin and about 10 square meters of surface area for the digestive system. There are approximately 100 million alveoli in the human lungs allowing for rapid absorption of inhaled substances. Inhaled toxins may also irritate the upper respiratory tract causing edema (swelling) or irritation resulting in possible airway spasm or obstruction. Below is a list of different types of inhaled toxins and their effects.

Asphyxiants

A poisonous gas can act as an asphyxiant, or a suffocating agent, displacing oxygen in the air. A common chemical asphyxiant is carbon monoxide, or CO. Other asphyxiants include simple asphyxiants such as methane, ethane, or carbon dioxide, and chemical asphyxiants such as cyanide or hydrogen sulfide.

Carbon Monoxide

Carbon monoxide is an odorless, colorless, tasteless gas is produced by incomplete combustion, and anytime there is a flame present, carbon monoxide is being produced. Common sources of carbon monoxide include automobile exhaust systems, gas hot water heaters, and gas furnaces. Carbon monoxide chemically bonds to the hemoglobin in the blood about 220 times easier than oxygen, forming carboxyhemoglobin. This blocks the oxygen from being absorbed by the hemoglobin, causing asphyxiation even when there is sufficient oxygen available in the air.

Note: You may find a pulse oximetry reading of 99 - 100% even if there is little oxygen in the blood. The pulse oximeter is simply detecting the saturation of the hemoglobin and is unable to distinguish between oxygenated hemoglobin and carboxyhemoglobin

Cyanide

Cyanide can be found in many forms. Accidental exposure to cyanide gas can occur in industrial settings. Cyanide is also released by combustion of certain materials. Cyanide is also found in silver polish, rat poison, and the seeds of certain fruits such as cherries or peaches contain a substance that releases cyanide when metabolized by the body. Cyanide prevents the transport of oxygen by hemoglobin and carbon monoxide and cyanide potentiate the effects of each other. Whenever you are treating a victim for smoke inhalation, you should assume the patient inhaled cyanide gas as well as carbon monoxide. Remember, you should not induce vomiting in cases of cyanide poisoning.

Irritants

Irritant gases can cause inflammatory damage to the airway resulting in bronchoconstriction and possible airway obstruction. Irritants react with the water in the airway causing coughing, tearing, burning sensation, upper airway swelling, and pulmonary edema. Irritants usually react almost immediately with the mucosa of the upper airway. Unless the victim was in an enclosed area, is unconscious, or the irritant was inhaled in extreme concentrations, the extent of damage is usually confined to the upper airway. Irritant gases include industrial and agricultural chemicals such as ammonia or chlorine, and gases such as sulfur dioxide, hydrogen chloride, phosgene, or nitrogen dioxides produced from the combustion of various materials.

Organophosphates

Inhalation of organophosphates can initially produce bronchoconstriction and excessive pulmonary secretions. Industrial and household insecticides are common sources of organophosphates. There is an acronym commonly used to describe symptoms of patients exposed to this type of toxin,

SLUDGE:

S - salivation

L - lacrimation

U - urination

D - diarrhea

G - gastrointestinal distress

E - emesis

Assessment

When assessing a victim of toxic inhalation look for the following:

·        Respiratory distress

·        Coughing, hoarseness, wheezing, abnormal breath sounds

·        Cyanosis

·        Altered level of consciousness

·        Pain or burning sensation in the mouth, nose, or throat

·        Pulmonary edema, blood-tinged sputum

·        Excessive mucus or tear production

·        Irritated or burning eyes

·        Severe headache

·        Seizure activity

·        Singed facial hair or soot in the nose or mouth

Note: the cherry red skin color that is associated with carbon monoxide poisoning is a rare, late sign

Management

Ensure scene safety, call for additional trained rescue assistance if needed.

Remove the patient from the toxic atmosphere.

Assess ABC`s. Assist ventilations and intubate if necessary.

Position the patient in a position of comfort.

Administer high-concentration humidified oxygen.

Draw blood samples for testing at the hospital.

Establish an IV of normal saline or Lactated Ringer's per protocol.

Transport to the nearest appropriate facility.

Obtain vital signs, perform the detailed assessment, obtain SAMPLE history.

Record all observations, past medical history, and treatment.

Bring any containers or the Material Safety Data Sheets (MSDS) with you to the hospital, if possible.

Ingestion

Ingestion of poisons is the most common route of exposure to toxins. Ingestion of poisons or toxins can be intentional or accidental. Toxins can be intentionally ingested such as in suicide attempts. Accidental poisonings can occur when a child tastes a poison because it had an interesting color or scent. Commonly ingested poisons include household cleaners, petroleum products, agricultural products, spoiled or improperly prepared foods, medications, and plants.

Most people would not think of ingesting a toxic substance on purpose, however there are many activities that a person undertakes that expose them to ingestion of toxins that they don't even consider. Most people who work around toxic substances for a living are very respectful of the substances and take proper precautions when dealing with them. Sometimes though, routine activities can cause small amounts of toxins to be ingested if proper hygiene is not performed. Simple personal hygiene, such as hand washing, can avoid many potential problems. Eating, drinking, or smoking should be done at the proper time and place to help avoid accidental exposure to harmful toxins.

Numerous substances are intentionally or accidentally ingested. Below is a list of commonly encountered ingested toxins.

Methanol and Ethylene Glycol

Ingestion of methanol or ethylene glycol can cause altered mental status and eventually lead to coma and death if left untreated. Methanol is found in windshield washer fluid or Sterno heating fluid. Ethylene glycol is found in antifreeze. Antifreeze has a sweet odor and taste, therefore it is especially dangerous because children may drink more of it than something that has a foul odor or bitter taste.

Caustics

Acids and alkalis are both considered caustics. These products can cause severe irritation or burns to the mouth and throat, followed by heavy vomiting. Acid products include bleach, toilet bowl cleaners, or battery acid. Alkalis include lye (found in drain cleaners such as Drano) or the tablets diabetics use to test for sugar in their urine.

Organophosphates

Organophosphates can be found in most industrial and household insecticides. Organophosphates can cause bronchoconstriction, overstimulation of secretions (saliva, tearing, pulmonary secretions, sweating), nausea and vomiting, excessive urination and diarrhea. A most notable sign of organophosphate poisoning is a slow heart rate.

Plants

Several common household and wild plants can cause adverse reactions if ingested. Examples of poisonous plants are mistletoe, holly berries, oleander, poinsettias, dieffenbachia, daffodil, philodendron, azaleas, rubber plants, and wild mushrooms. Effects are varied, depending on the specific plant ingested. Treatment depends on the signs and symptoms the patient is exhibiting. Be sure to bring the plant with you to the hospital for identification.

Food Poisoning

Food poisoning can be caused by spoiled or improperly prepared foods and contaminated water. Food poisoning is often suspected when two or more persons become ill after eating the same foods. Symptoms include nausea, vomiting, diarrhea, and weakness. The patient may become dehydrated and hypotensive. The most severe form of food poisoning is botulism, which can lead to weakness, paralysis, and respiratory arrest. Botulism is rare and initial symptoms may be mistaken for a minor illness, so later symptoms may present a true medical emergency for the prehospital care provider.

Assessment

When assessing a victim of a toxic ingestion look for the following:

·        History of ingestion

·        Obvious swelling of the mouth or throat

·        Nausea /vomiting

·        Diarrhea

·        Altered mental status

·        Abdominal pain

·        Obvious signs of ingestion around the mouth such as stains or burns

·        Unusual odors on the breath

·        Unusual breathing patterns

·        Abnormal vital signs such as an abnormal heart rate or blood pressure

Management

Ensure scene safety, call for additional trained rescue assistance if needed.

Assess ABC`s. Assist ventilations and intubate if necessary.

Position the patient in a position of comfort.

Administer high-concentration oxygen.

Carefully wipe away any residue from the mouth area to reduce any further damage to the tissues.

Be aware for possible vomiting, have suction available.

Obtain vital signs, perform the detailed assessment, obtain SAMPLE history.

Draw blood samples and establish an IV.

Administer naloxone 2 mg IV for narcotic overdose, if allowed by local protocol.

Transport to the nearest appropriate facility.

Administer activated charcoal or Syrup of Ipecac (discussed below) as indicated by local protocols.

Record all observations, past medical history, and treatment.

Bring any containers, pills, plants, or the Material Safety Data Sheets (MSDS) with you to the hospital, if possible.

Drug Abuse

Drug abuse can be defined as the self-administration of a medication or street drug in a manner that is not prescribed or for the purpose of achieving an altered state of mind. The drug can be considered a poison when it causes a medical emergency to arise. In addition to ingestion, drugs or other substances of abuse can be administered by injection or inhalation. In many ways you will treat the drug overdose the same way you would treat any ingested toxin. There may be some other problems that are associated with illegal drug use and overdose that are not common with accidental ingestions. Many people who are chronic drug abusers will have a myriad of other medical problems you must consider in addition to the drug abuse. Some of these patients may be difficult to deal with due to behavioral problems, they may be aggressive or violent. As in any other situation, your own personal safety is the first concern when dealing with these patients. Allow the local law enforcement to secure the scene if necessary so that you can concentrate on treating the patient.

Drug reactions are not always the result of drug abuse. Some can occur as a result of miscalculation of dosage, forgetfulness, confusion, or a reaction to a newly prescribed medication. This section will concentrate on the drug abuser and the special situations they are likely to present.

Some of the medical problems you may encounter with the chronic drug abuser are:

Hypothermia

Hyperthermia

Seizures

Trauma due to falls or criminal activity

Altered mental status

Respiratory problems

Different types of drugs can cause different reactions. The following is a list of types of commonly abused substances and their effects:

Category

Examples

Street Names

Effects

Depressants

barbiturates, benzodiazepines, alcohol, other sedatives

Barbs, Sleepers, Blues and Reds, Stumblers, Idiot pills

constricted pupils, confusion, drowsiness, slurred speech, clammy skin, respiratory depression, coma

Narcotics

opium, morphine, codeine, heroin, methadone, fentanyl, propoxyphene

Hop, Black stuff, Gum, Aunti Emma, Chick, Schmack

euphoria, drowsiness, respiratory depression, constricted pupils, clammy skin, seizures, coma

Stimulants

amphetamines, cocaine, nicotine

Coke, Flake, Speed, Black Beauties, Snow, Crack, Bennies, Dexies, Uppers

dilated pupils, irritability, nervousness, hypertension, tachycardia, increased energy

Hallucinogens

PCP, LSD, psilocybin, mescaline

Acid, Hog, Buttons, Mesc, Angel dust

confusion, hallucinations, mood swings, panic reactions, dilated pupils, aggression

Cannabis

marijuana, hashish

Pot, Hash, Reefer, Grass, Acapulco gold

euphoria, increased appetite, confusion, relaxed inhibitions, fatigue, paranoia

Inhalants

paint thinner, aerosols, freon, nitrous oxide, amyl nitrate

Snort, Amys

 hilarity, dizziness, lightheadedness, cyanosis

Alcohol Abuse

Alcohol is perhaps the most prevalent drug abused in the world today. A person can be a chronic alcoholic regardless of the type of alcohol they prefer to use. The person who drinks too much beer is just as much an alcoholic as the person who abuses wine or liquor. Chronic alcoholics have been known to seek alcohol in many other forms when the standard source is not available. Alcoholics will turn to Sterno, shoe polish, antifreeze, rubbing alcohol, and any other form of alcohol in order to get a drink.

Advanced stages of alcoholism may result in withdrawal symptoms if the person fails to acquire alcohol in a timely manner. This can result in periods of memory loss (blackouts), tremors, seizures, or the last and most dangerous withdrawal condition, delirium tremens (DT's). Most alcoholics do not eat properly, are prone to injury from falls, and have a myriad of health problems related to the chronic ingestion of alcohol.

Delirium Tremens

This is the last stage of alcohol withdrawal, it is considered a life-threatening condition which kills about 5 - 15% of chronic alcoholics who experience DT's. It usually occurs between 1 - 14 days after the patient has stopped ingesting alcohol. The condition may last from 1 - 3 days. During this time the patient may suffer from:

·        Mental confusion

·        Hallucinations

·        Tremors

·        Profuse sweating

·        Nausea/vomiting

·        Insomnia

·        Diarrhea

·        Memory loss

·        Anxiety

Wernicke's Syndrome and Korsakoff's Psychosis

This disorder is not reserved for chronic alcoholics alone, but they are at higher risk of developing this disorder than those who are not chronic alcohol abusers. This is basically a chronic thiamine (vitamin B1) deficiency in combination with the inability to utilize thiamine due to the intestine's inability to absorb it.

There are two stages of this disorder, the first being Wernicke's Syndrome which is an acute and reversible disorder in which the patient experiences weakness of the eye muscles, mental derangement, stupor, coma, speech disturbances, and other neurological disorders. The second, and perhaps more serious stage, is Korsakoff's Psychosis, where the patient experiences memory loss, muttering, insomnia, delusions, delirium, hallucinations, pain in the extremities, possible bilateral foot drop and, on a more rare occasion, bilateral wrist drop. This stage, once established, may be irreversible.

Nutritional Problems

When it comes to nutritional value of the alcoholic's diet, there isn't much that alcohol can offer. The chronic drinker eventually loses their appetite for real food because alcohol has an irritating effect on the stomach. The body will attempt to make use of the alcohol in order to obtain calories but that is only a temporary fix. This nutritional deficit eventually leads to multiple vitamin deficiencies and that eventually leads to many physiological disorders. The chronic alcoholic may experience a myriad of health problems such as seizures, cardiac dysrhythmias, muscle cramps, tremors, anorexia, and many other health problems.

The body will tend to use thiamine stores in order to metabolize sugar This is why the intravenous administration of thiamine should be given prior to the administration of glucose in patients suffering coma due to unknown causes and the chronic alcoholic. The field administration of thiamine is 100 mg IV push. If an IV can not be established, thiamine may be given IM 

Acute Alcohol Poisoning

If a person ingests a sufficient amount of alcohol over a short period of time, the results can be accumulation of toxic levels of alcohol. The effects of alcohol toxicity are similar to ingestion of sedatives in large amounts. The symptoms can be hypotension, respiratory depression, and hypothermia.

The patient may also have a conglomeration of pre-existing medical conditions as well. Always stay alert for the possibility of underlying causes or conditions when treating the chronic alcoholic.

Fluid and Electrolyte Disorders

As the patient continues to increase their intake of alcohol, the body responds by increasing urinary output. As the kidneys excrete a portion of the ingested alcohol it also excretes many needed electrolytes. The diuretic effect of alcohol consumption is partially due to the slowing effect the alcohol has on the secretion of anti-diuretic hormones, which may lead eventually to dehydration of the chronic drinker.

Gastrointestinal Problems

There are many gastrointestinal disorders that may be caused by chronic ingestion of alcohol. Most emergencies concerning the GI tract will be associated with cirrhosis, hemorrhage from esophageal varices or bleeding ulcers, and pancreatitis. The hemorrhage is a result of the alcohol irritating the lining of the GI tract and blood may continually ooze from these irritated areas. The hemorrhaging can be a result of continuous vomiting which may traumatize the tissues.

Cirrhosis

Cirrhosis of the liver is a common problem with the chronic drinker due to the damage to the cells of the liver which eventually leads to scarring, and interruption of the normal function of the liver. The liver not being able to metabolize wastes as usual, leads to toxins accumulating which eventually have a deleterious effect on the brain.

Neurological Problems

The cirrhosis as mentioned above eventually leads to neurological disorders due to the buildup of toxins in the bloodstream. Alcohol is also a potent central nervous system depressant which is the major attraction to the beverage in the first place. The effect it has on the individual's reflexes, judgement, drowsiness, memory, coordination, and general feeling of well-being is dose dependent, and depends on the individual tolerances. The long term effects of alcohol ingestion are similar to the aging process.

Immune Suppression

The chronic use of alcohol eventually causes the immune system to become less effective by reducing the production of white blood cells. Alcohol also effects the lung tissue adversely which results in the chronic drinker becoming more susceptible to infection. There is also evidence that alcoholics have an increased risk of getting cancer.

Tricyclic Antidepressants

Tricyclic antidepressants are some of the most commonly prescribed medications. Ironically, these medications are prescribed for patients suffering from depression and these medications have very dangerous cardiotoxic effects if taken in excess. Examples of tricyclic antidepressants are:

amitriptyline (Elavil)

doxepin (Sinequan)

imipramine (Tofranil)

nortriptyline (Aventyl)

Early signs and symptoms of tricyclic antidepressant overdose include dry mouth, confusion, and hallucinations. Later signs and symptoms are delirium, respiratory depression, hypotension, hyperthermia, cardiac dysrhythmias, seizures, and coma.

Activated Charcoal

Activated charcoal is the medication of choice in the field for treating ingested poisons. The action of activated charcoal is to absorb the toxin while it is in the stomach or small intestine. Activated charcoal can be given up to four hours after the ingestion has occurred and still be beneficial in some cases, depending on the poison involved. There are a variety of different brands on the market and they are not all created equal. Some brands contain a laxative, others do not. Some brands come pre-mixed in water, others need to mixed with water. You should get together with your medical director to choose what you believe to be the most effective brand.

When administering activated charcoal, there are some things to keep in mind. One is the fact that this substance is not very appetizing and it will take some ingenuity on your part to convince your patient to drink it. Another thing to remember is that the cleaner your uniform, the bigger the mess when dealing with activated charcoal. One other important item is that the patient will almost always give the charcoal back to you in various ways, usually by vomiting or spitting it out.

Contraindications

Activated charcoal is NOT indicated for patients who have a decreased level of consciousness or are experiencing seizure activity. Do not give activated charcoal to patients who have ingested alcohol, petroleum products, caustics, cyanide, or iron (vitamins). Activated charcoal is ineffective with these substances. Do not allow the patient to drink or eat anything after ingesting the activated charcoal as this will diminish its effects. Do not administer activated charcoal simultaneously with Syrup of Ipecac (discussed below), because the charcoal with absorb the Ipecac and render it ineffective.

Side Effects

Side effects of activated charcoal include nausea and vomiting, constipation, or diarrhea, and black stools.

Dosage

The usual dose of activated charcoal is 1 gram per kilogram by mouth (PO). That is usually between 25 - 50 grams for the average sized adult and 12.5 - 25 grams for the infant or child. Activated charcoal is most effective if administered within 30 minutes of the ingestion.

Syrup of Ipecac

Syrup of Ipecac is administered to induce vomiting to rid the stomach of ingested poisons in an alert patient. The action of Syrup of Ipecac is to irritate the gastrointestinal mucosa and stimulate the emetic center in the brain, thus causing vomiting. Some EMS agencies no longer carry Syrup of Ipecac, but some still do.

Something to remember, Syrup of Ipecac is used to induce vomiting, and they will vomit! Be prepared for a violent reaction to this medication, have towels or sheets handy to cover the patient and yourself. (Don`t withhold treatment, but if you time it just right, the hospital will have to worry about the mess and not you.)

Contraindications

Syrup of Ipecac is NOT indicated for patients who have a decreased level of consciousness, have a diminished or absent gag reflex, or are experiencing seizure activity. Do not give Ipecac to patients who have ingested caustic agents or petroleum products. The last thing you want is these agents to cause further damage coming back up, or increase the chance of aspiration.

 Side Effects

Side effects of Syrup of Ipecac include CNS depression, cardiac dysrhythmias (irregular heart rate), hypotension, and diarrhea.

Dosage

The adult dosage for Syrup of Ipecac is 15 - 30 ml by mouth (PO), followed by several glasses of warm water. Use juice or sodas if warm water is not available or is not tolerated by the patient. Milk is not advised because milk will delay the onset of action. You may repeat once after 20 minutes, if necessary.

The pediatric dosage is 15 - 25 ml by mouth, and the infant dosage (less than 1 year of age) is 5 - 10 ml by mouth. 

Absorption

Absorption of toxins is usually a result of skin contact. The longer the substance remains on the skin, the better chance it has of becoming absorbed. The skin is usually a very good barrier to foreign substances but there are some compounds that are absorbed very easily. The most common substances that are absorbed through the skin are the organophosphates, or pesticides. These substances are designed to absorb rapidly through the protective outer barrier of the targeted pest. The pesticide doesn't know that you are not the pest for which it was designed and it doesn't care.

In addition to pesticides, contact with certain plants, such as poison ivy, poison sumac, or poison oak can cause severe irritation and blistering. Contact with some forms of marine life, such as jellyfish, can also cause pain and irritation.

Assessment

When assessing a victim of toxic absorption look for the following:

·        History of exposure

·        Local effects such as burns, rashes, swelling, blisters

·        Abnormal vital signs

·        Altered mental status

·        Nausea/vomiting

Management

Ensure scene safety, call for additional trained rescue assistance if needed.

Assess ABC`s. Assist ventilations and intubate if necessary.

Position the patient in a position of comfort.

Administer high-concentration oxygen.

Be aware for possible vomiting, have suction available.

Draw blood samples and establish an IV.

Administer diazepam for seizure activity.

Administer atropine for organophosphate poisoning.

Remove all contaminated clothing and jewelry and place in a secure container.

Brush away any dry substances.

If the toxin is a liquid, irrigate the exposed areas with water for at least 20 minutes.

Transport to the nearest appropriate facility.

Obtain vital signs, perform the detailed assessment, obtain SAMPLE history.

Record all observations, past medical history, and treatment.

Bring any containers or the Material Safety Data Sheets (MSDS) with you to the hospital, if possible.

When assessing the patient who is suspected of being contaminated by a toxic substance, be sure to decontaminate the patient to reduce further adverse reactions to the substance and to avoid secondary contamination of others. Decontamination may be as simple as brushing a dry substance off the individual and then washing with a solution of soap and water, or it may be a more complex procedure of total decontamination if gross contamination has occurred. Decontamination should only be performed by qualified rescuers with the appropriate equipment.

Injection

Injection of toxins is perhaps the least common form of accidental exposure. Commonly, injections occur with contact of sharp objects such as nails, torn metal, needles, broken glass, etc. There are times when injection can occur when a high pressure line ruptures and injects its substance into the skin by the sheer force of the pressure. Then there are the many purposeful injections of possible poisons by the drug abuser.

Another form of injection occurs when the patient is bitten or stung by an insect, marine life, or reptile. The most common insect bites are from spiders such as the "brown recluse" and the "black widow", or from stings from flying insects such as bees or wasps. Some types of marine life, such as jellyfish or sea anemone can have poisonous tentacles. Contact with these creatures can be very painful. The pit vipers and coral snake are the two types of snakes that are poisonous in North America.

Most instances of poisoning by injection are a result of the bites or stings from critters on the land, in the air, or in the sea. Some poisonings by injection are the result of drug overdose, some accidental , some deliberate. The general idea behind the management of the patient who has suffered an injection of a toxin is to make sure, first of all, that you don't become the next victim. Look around to see if the perpetrator of the sting or bite is still in the neighborhood, and if it is still alive. If there are bees or other flying insects around you will probably want to relocate.

The major problem that these offending animals produce is the allergic reaction to their sting or bite. You will want to assess the patient's respiratory status and monitor it closely for changes. If the offending organism has bitten the patient, you may want to place a constricting band between the bite and the heart if the wound is on an extremity. If the critter has deposited a stinger, recent studies show that rapid removal is more vital than taking the time to find something to scrape the stinger away. The longer the stinger remains the more venom is introduced. Just get the stinger off quickly.

Brown Recluse Spider

If the patient has suffered a brown recluse spider bite, the patient may not even be aware that they have been bitten until symptoms begin to show up. Brown recluse spider bites cause symptoms such as a small blister on the skin surrounded by a white ring soon after the bite occurs. There may be localized pain, swelling, and redness within hours after the bite. In a few days skin tissue begins to show signs of necrosis. The patient begins to have chills, fever, nausea, vomiting, pain in the joints, and bleeding disorders. The treatment for this condition is to get the victim to the hospital while supporting their vital functions as necessary.

Black Widow Spider

If the bite is from a black widow spider, the signs and symptoms differ somewhat from the brow recluse spider bite. The bite of the black widow spider is characterized by immediate localized pain, redness, and swelling. Muscle spasms are usually felt in the abdomen or lower back initially and may progress to other areas of the body. The patient may exhibit nausea, vomiting, sweating, seizure activity, paralysis, hypertension, and altered mental status. Treatment in the field is to give psychological support, monitor and support vital signs, and transport.

Pit Vipers

Snakes belonging to the pit viper family are rattlesnakes, cottonmouths (water moccasin), and copperheads. The pit vipers are characterized by a triangular shaped head, elliptical eyes, heat-sensing pits (thus the name, pit vipers) on the sides of the head near the nostrils, and fangs. The fangs are very sharp and hollow and are used by the snake to inject venom into its victim. The pit viper bite will cause one or two puncture wounds at the site and the following signs and symptoms vary with the degree of envenomation that has occurred:

·        Localized swelling and pain

·        Oozing at the site of the bite

·        Weakness

·        Chills and sweating

·        Thirst

·        Nausea and vomiting

·        Diarrhea

·        Tachycardia

·        Hypotension

·        Shallow, rapid respirations

Treatment is aimed at trying to slow the absorption rate of the venom injected. Apply a light constricting band above the site of the bite. Keep the patient lying down and as still as possible. Immobilize the affected limb. Give high flow oxygen, provide emotional support, transport to an appropriate medical facility where anti-venom may be available. Keep in mind that many snake bites are ones in which no venom is injected. The snake may not have been able to stay attached long enough to inject the venom or the snake's venom has recently been used to kill prey prior to the bite.

Coral Snake

The coral snake is in a different species, the Elapidae. It is somewhat smaller than the pit viper and has distinguishing colored bands of red, yellow, and black. There is a saying that you can commit to memory to distinguish the coral snake from its many non-poisonous imitators; "red on yellow, kill a fellow, red on black, venom lack". The coral snake is not as well equipped to bite as the pit viper and usually needs to bite a smaller object like a finger or toe in order to get a good bite. The coral snake needs to hang on and chew a while to inject enough venom to cause permanent damage and they are not as aggressive as pit vipers. The signs and symptoms of the coral snake bite may take longer to show up than the pit viper bite. The venom of the coral snake affects the nervous system affecting respiratory and skeletal muscle functions. Signs and symptoms of coral snake bite include:

·        Localized numbness

·        Slurred speech

·        Dilated pupils

·        Drooping of eyelids

·        Eventual paralysis if left untreated

Marine Life

There are many forms of marine life, such as jellyfish, sea anemone, or catfish, that have the ability to produce a painful sting or injection. They can be found in both salt water and fresh water. Most injuries caused by marine life do not cause serious damage unless the wound becomes infected by bacterial or viral organisms that may populate the water. In general the treatment of such injuries are best treated by the application of heat which tends to break down the toxins and relieves the pain. Jellyfish stings can be treated by rubbing alcohol over the affected area. Remove any stingers or tentacles found on the patient being careful not to allow the jellyfish to touch your skin. Some stingers or spines left in the skin may require surgical removal. Some signs and symptoms of marine life injuries are:

·        Intense localized pain

·        Weakness

·        Dyspnea

·        Tachycardia

·        Nausea and vomiting

·        Possible shock in severe cases

Always treat the patient with a suspected sting or bite by paying close attention to the status of the airway. Apply a light constricting band between the bite or sting and the heart if the wound is on an extremity. Treat the affected area with hot water or heat from a safe source. Remove any stingers or tentacles being careful not to touch them yourself. If the stinger is embedded in the skin deeply, treat it as an impaled object, it may need to be surgically removed in the ER. Transport the patient to the hospital if there are any doubts as to the severity of the reaction to the sting or bite.

Assessment

Look for the following:

·        Nausea/vomiting

·        Weakness, dizziness

·        Needle tracks (they may be found on the lower extremities or upper extremities)

·        Fang marks if a snake is suspected

·        Blisters, redness, tissue necrosis

·        Fever, chills

·        Pupillary abnormalities

·        Respiratory abnormalities

·        Abnormal blood pressure

·        Allergic reactions

Management

Ensure scene safety, call for additional trained rescue assistance if needed.

Assess ABC`s. Assist ventilations and intubate if necessary.

Position the patient in a position of comfort.

Administer high-concentration oxygen.

Be ready for possible vomiting, have suction available.

If the injection is from an insect or marine animal, protect yourself from being injured.

Draw blood samples and establish an IV.

Bring all substances with you to the hospital that are safe to do so for analysis.

Transport to the nearest appropriate facility. Notify the hospital of the need for the appropriate anti-venom.

Obtain vital signs, perform the detailed assessment, obtain SAMPLE history.

Record all observations, past medical history, and treatment.

Summary

Management of patients suspected of being exposed to poisons should always begin with making sure that you and your crew do not become a part of the problem by becoming exposed, you are there to be a part of the solution, if you become contaminated or injured, you have simply made the situation worse.

The actual management of the exposed patient is generally the same for each different type of exposure with very few exceptions. Be sure to remember the following points:

·        Protect yourself and your crew

·        Always remember the ABC`s

·        Prevent further absorption of the toxin by removing the patient from the toxic atmosphere, administering activated charcoal or Syrup of Ipecac, decontaminating exposed areas, or removing stingers or tentacles

·        Perform an organized patient assessment

·        Administer high-concentration oxygen

·        Transport to the nearest appropriate facility

·        Be aware for changes in the patient`s status

·        Document, document, document!