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99 Cards in this Set
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What are some facts about poisons and overdoses in Canada?
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=Over 4 million poisonings occur annually.
=10% of ED visits and EMS responses involve toxic exposures. =70% of accidental poisonings occur in children under 6 years old. =80% of attempted suicides involve a drug overdose. |
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What are the Routes of Toxic Exposure?
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Ingestion
Absorption Inhalation Surface Injection |
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What are some examples of Ingested poisons?
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-Household products
-Petroleum-based agents -Cleaning agents -Cosmetics -Drugs, plants, or foods |
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Where does absorption take place with ingested poisons?
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The stomach and small intestine.
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What are some common inhaled agents?
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-Toxic gases, vapors, fumes, aerosols
-Carbon monoxide, ammonia, chlorine -Tear gas, freon, nitrous oxide, methyl chloride -Carbon tetrachloride |
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Where does absorption take place with inhaled poisons?
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Absorption occurs via the alveolarcapillary membrane in the lungs.
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What are some common surface absorped agents?
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-Poison ivy, oak, or sumac
-Organophosphates |
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Where does absorption take place with surface absorped poisons?
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Absorption occurs through
capillaries in the skin. |
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What are some common agents of injection?
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-Animal bites or stings
-Intentional injection of illicit drugs |
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How does the substance enter the body with injection?
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Substance enters directly into the body through a break in the skin.
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What are Standard Toxicologic Emergency
Procedures? |
-Recognize a poisoning promptly.
-Assess the patient thoroughly to identify the toxin and measures required to control it. -Initiate standard treatment procedures. -Protect rescuer safety. -Remove the patient from the toxic environment. -Support ABCs. -Decontaminate the patient. -Administer antidote if one exists. |
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What should you do at size up?
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-Be alert to the potential for violence.
-Look for signs of hazardous-material involvement. -Enter a hazardous-materials scene only if properly trained and equipped to do so. |
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What are your priorities in the initial assessment?
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-Airway and respiratory compromise are common in toxicologic emergencies.
-Manage life-threatening conditions. |
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What are you looking for with History, Physical Exam, and
Ongoing Assessment? |
-Identify the toxin and length of exposure.
-Contact Poison Control and Medical -Control according to local policy. -Complete appropriate physical exams. -Monitor vital signs closely. |
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What is General Treatment for poisonings and overdoses?
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-Initiate supportive treatment.
-Decontamination: -Reduce intake of the toxin. Remove the individual from the toxic environment. -Reduce absorption of toxins in the body. -Use gastric lavage and activated charcoal. -Enhance elimination of the toxin. -Use cathartics. |
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What is the procedure with antidotes?
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-Useful only if the substance is known.
-Rarely 100% effective. -Must be used in conjunction with other therapies to ensure effectiveness. |
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What are general guidelines for Suicidal Patients and Protective Custody?
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-Involve law enforcement.
-Involve Medical Control. -Know local procedures and laws. -Laws for protective custody vary widely. |
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What are some history questions to ask for ingested poisons?
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-What was ingested?
-When was it ingested? -How much was ingested? -Did you drink any alcohol? -Have you attempted to treat yourself? -Have you been under psychiatric care? -Why? -What is your weight? |
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What are procedures for Surface-Absorbed Toxins?
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-Ensure your personal safety.
-Do not enter a hazardous scene unless properly trained and equipped to do so. -Remove the patient from the environment. -Remove the patient’s contaminated clothing. -Perform the initial assessment, history, and physical exam. -Initiate supportive measures. -Contact Poison Control and Medical Control according to local protocol. |
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What are some examples of stimulants?
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Amphetamines, methamphetamine, cocaine, diet aids, nasal decongestants
What are some signs and symptoms? |
Restlessness and agitation Incessant talking
Insomnia Anorexia Dilated Pupils Tachycardia Tachypnea Hypertension or hypotension Paranoia Seizures Cardiac Arrest |
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What are some examples of Narcotics (opiate and opioid)?
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Heroin, opium, morphine, hydromorphone (Dilaudid), fentanyl, oxycodone-aspirin combination (Percodan)
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Constricted (pinpoint) pupils Marked respiratory depression Needle tracks (IV abusers)
Drowsiness Stupor Coma |
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What are some examples of Sympathomimetic drugs?
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Pseudoephedrine, Phenylephrine, amphetamine and methamphetamine
What are signs and symptoms ? |
Hypertension
Tachycardia Dilated Pupils Agitation Seizures Hyperthermia |
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What are some examples of sedative and hypnotic drugs?
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Phenobarbital, diazepam (Valium), thiopental
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Drowsiness
Disinhibition Ataxia Slurred Speech Mental Confusion Respiratory Depression Progressive CNS depression Hypotension |
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What are some examples of Cholinergic Drugs?
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Diazinon, Orthene, Parathion, Sarin, VX, Tabun
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Increased Salivation
Lacrimation GI distress Diarrhea Respiratory Depression Apnea Seizures Coma |
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What are some examples of Anticholinergic drugs?
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Atropine, scopolamine, antihistamines, antipsychotics
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Dry flushed skin
Hyperthermia Dilated Pupils Blurred Vision Tachycardia Mild Hallucinations Dramatic Delirium |
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What is Drug abuse?
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Any use of drugs that causes physical, psychological, economic, legal or social harm to the user or to others affected by the drug users behaviour
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What is Habituation?
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Psychological dependence on a drug or drugs
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What is Physical Dependence?
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A physiological state of adaptation to a drug, usually characterized by tolerance to the drugs effects and by a withdrawal syndrome if the drug is stopped especially if this is abruptly.
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What is Psychological dependence?
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The emotional state of craving a drug to maintain a feeling of well being.
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What is Tolerance?
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Physiological adaptation to the effects of a drug such that increasingly larger doses of the drug are required to achieve the same effect.
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What are withdrawal symptoms?
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A predictable set of signs and symptoms usually involving altered CNS activity. Occurs after abrupt cessation of a drug or rapidly decreasing the usual dosage of a drug
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What is drug addiction?
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A chronic disorder characterized by the compulsive use of a substance resulting in physical, psychological or social harm to the user. They continue to use the substance despite the harm.
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What is an Antagonist?
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Something that counteracts the action of a substance.
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What is Potentiation?
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Enhancement of the effect of one drug by another drug.
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What is Synergism?
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The action of two drugs in which the total effects are greater than the sum.
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What are the two phases of alcoholism?
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Phase 1 - Problem drinking, gradually more dependent on the effect of alcohol.
Phase 2 - True addiction, abstinence causes major withdrawal symptoms. |
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What are signs of Phase 1 alcoholism?
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Problems at work, with family, auto crashes, emotional disturbances.
Physical problems - restlessness, anxiousness, sleeping problems, agitation and tremors. Depends on the length and intensity of the alcohol habit |
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What are signs of Phase 2 alcoholism?
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Withdrawal can lead to...
Increased blood pressure Vomiting Hallucinations Delirium Tremens can lead to... Fever Disorientation Confusion Seizures Possibly death |
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What are red flags pointing towards alcohol abuse?
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Drinking early in the day
Drinking alone or in secret Periodic binges Loss of memory or blackouts Tremulousness and anxiety Chronically flushed face and palms |
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What are some problems to which alcoholics are susceptible?
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-subdural hematome (frequent falls and impaired clotting mechanisms)
-GI bleeding (Irritant effect of alcohol, cirrhosis of the liver) -Pancreatitis (Indirect effect of alcohol on the pancreas) -Hypoglycemia (Damage to the liver) -Pneumonia (aspiration of vomitus and suppression of the immune system) -Burns (reduced sensation of pain) -Hypothermia (Not noticing extremes of temperature) -Seizures (Effect of withdrawal from alcohol) -Arrhythmias (Toxic effects of alcohol on the heart) -Cancer (More likely to develop) -Esophageal varices (Blood flow to the liver is blocked due to damage, can be fatal if not controlled) |
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What is Acute Alcohol Intoxication?
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-Form of poisoning
-Dangers from death by respiratory depression and/or aspiration of stomach contents due to depressed gag reflex. |
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How should it be treated?
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-Establish and maintain the airway
-Position left lateral if gag reflex is intact (suction on standby) -Give high flow oxygen and assist ventilation as needed -Establish vascular access -Monitor ECG -Get BGL and treat hypoglycemia if found |
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What are alcohol withdrawal seizures?
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When a person who has been drinking for an extended period stops drinking they may have a variety of withdrawal phenomena.
-Seizures normally occur within 12-48 hours of the last drink. -Simple seizures are normally short lived. |
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What are Delirium Tremens?
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One of the most serious and lethal complications of alcohol withdrawal.
Symptoms usually start 48-72 hours after the last alcohol intake although it can take week to 10 days before start of symptoms. Mortality can be as high as 15% and symptoms are similar to excess catecholamine release. |
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What are the symptoms of DT?
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Confusion
Tremors Restlessness Tachycardia Fever Diaphoresis Hallucinations (can be extremely frightening) Hypotension (due to dehydration) |
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What is the treatment for DT?
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-Protect the patient from injury
-Provide supportive pre-hospital care -Patient may be agitated often combative -Give O2 by nasal cannula -Establish vascular access (if hypotension then give fluids) |
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What is the agent?
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Try and determine what the patient has ingested or overdosed on.
Bring pills, bottle, packaging, sample of plant, name tag. If patient vomits then save a sample but do not delay transport to do so. |
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When was the poison ingested, injected dermally absorbed or inhaled?
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The decision to decontaminate the GI tract is influenced by the amount of time that has elapsed since the exposure. Chances of binding poison decrease rapidly after the first 30-60 minutes in most circumstances
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How much was taken, ingested, injected dermally absorbed or inhaled?
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Street drugs are sold in single does hits. There is usually a correlation between dose and toxic effects
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What else was taken?
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A majority of intentional self poisonings or illicit drug overdoses involve polydrug ingestions often alcohol being one of the drugs.
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Has the patient vomited or aspirated?
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If so how soon after the ingestion did the vomiting occur? How much? Was their evidence of toxin, pills, tablets in the vomitus?
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Why was the substance taken?
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May not get a reliable answer but still worth asking the question. Put the reason in "quotation marks" on the PCR
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What are important considerations at the scene assessment?
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Patients who have overdosed can be extremely dangerous, ensure to do a scene assessment.
Call for law enforcement if needed. Be aware of the danger of exposure to dermal or airborne toxins, may need PPE or Hazmat and decontamination |
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What are some things to note about stimulants?
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High potential for abuse particularly cocaine and amphetamines.
Users can become addicted to these substances within a few days. |
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What is the clinical presentation of the stimulant user?
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-excitement
-delirium -tachycardia -hypertension or hypotension -dilated pupils -Wild eyed and cachectic with nervous or jittery movements. - |
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What can happen as toxic levels are reached?
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-Outright psychosis
-Hyperpyrexia -Tremors -Seizures -Cardiac arrest |
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What about the chronic user?
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Can have long stretches without sleeping. Little or no attention paid to normal nutrition or self care.
May appear wild eyed with nervous or jittery movements. Patients can be very agitated it often takes little to provoke someone. |
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What are some particular concerns regarding cocaine?
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Can cause lethal ECG arrhythmiac, AMI, seizures, stroke, apnea and hyperthermia.
A crack smoker risks pneumothorax and pneumomediastinum |
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What are some particular concerns with Methamphetamine?
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Low cost and very long acting (up to 12 hours)
Meth labs are dangerous and should be treated as hazmat Be prepared to contact law enforcement as meth users can be very dangerous |
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What is management for stimulant abuse?
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-Establish and maintain the airway
-Give high concentration O2 -Establish IV and monitor ECG -Pulse oximeter and capnography -Manage any hypotension -Transport |
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What is the treatment for marijuana use?
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-Supportive care
-Psychological first aid and reassurance |
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What are hallucinogens divided into?
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Two categories
Synthetic= PCP, LSD and Ketamine Natural= Marijuana, mescaline, psilocybin containing mushrooms and the seeds of the Jimson weed plant |
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What are the effects of LSD?
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Causes crossing of the senses.
Users can have a bad trip resulting in an anxiety attack Can last up to 12 hours although 3-4 is more common |
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How is LSD treated?
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-Mainly supportive care
-Try to limit sensory input dim lights and avoid the flashing lights and sirens -Psychological support is important |
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What is PCP?
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Also known as angel dust.
It is actually an anesthetic. Can cause mind body separation and related hallucinations and violent outbreaks. Users can take pain with no reaction and exhibit almost superhuman strength. |
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How is PCP abuse managed?
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-protect the patient and the EMS team from attacks
-oxygen -IV access -Cardiac monitoring |
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What is ketamine?
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Presents the user with dreamy or erotic thoughts.
At higher doses the patient may have nausea, difficulty moving and a complaint of "entering another reality" Treatment is similar to PCP |
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What are some symptoms of Psilocybin mushrooms?
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-Nausea
-Vomiting -Mydriasis -Mild Tachycardia -Mild Hypertension as doses increase -Frank Psychosis -Wild agitation |
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What should you be aware of with mushrooms?
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The patient may have taken a hepatotoxic mushroom. Look for...
-delayed action vomiting -diarrhea -absence of hallucinations |
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How should patients who have taken shrooms be treated?
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-Supportive pre-hospital care
-ABC's -Monitor vital signs -Vascular access if time allows |
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What are sedative and hypnotic drugs?
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Sedatives are used to reduce anxiety and calm agitated patients
Hypnotics are used as sleep aids helping produce drowsiness and sleep. They function primarily as CNS depressants. |
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What are barbiturates?
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Used to be used as sleep aids. Became abused and used with alcohol for suicide.
Abusers develop tolerance quickly and require increasing doses. |
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What about withdrawal?
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Patients can exhibit similar withdrawal symptoms to alcohol.
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What are symptoms of barbiturate intoxication?
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-Drowsy
-Decreased inhibitions -Ataxia -Mental confusion -Staggering gait increased doses will cause CNS depression until coma. |
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What is treatment?
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-Maintain airway
-Support breathing (may need advance airway -Suctioning if needed -IV access and ECG monitoring |
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What are narcotics?
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Drugs that produce sleep of altered mental status
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How do narcotics produce their effects?
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Their major effects are produced on the CNS by binding with receptor sites in the brain and other tissues.
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What are the signs and symptoms of opioid use?
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-Euphoria
-Hypotension -Respiratory depression -Pinpoint pupils Depending on the agent -nausea -vomiting -constipation With increased dose -coma -seizures -cardiac arrest |
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What is pre-hospital care for Opioid use / overdose?
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-Establish and maintain an airway
-Ensure adequate ventilation -Establish vascular access and monitor on an ECG |
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What are the signs and symptoms of carbon monoxide poisoning?
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-Can resemble that of flu
-headache, nausea and vomiting With acute poisoning -confusion, unable to think clearly -bounding pulses -dilated pupils -pallor and cyanosis |
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When should you consider the possibility of CO poisoning?
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When you are confronted with several patients who have shared the same accommodations for any period especially a small space such as during winter
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What do you need to do for CO poisoning?
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-Remove the patient from the exposure environment
-Maintain Airway -Give supplemental oxygen non-rebreather -Establish IV access -Monitor ECG -Keep the patient in a position of rest |
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What if the patient has CO poisoning from fire?
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Consider that they may also have cyanide poisoning
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What are the signs and symptoms of Chlorine gas exposure?
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Minor = burning sensation in the eyes, nose and throat along with a slight cough
Moderate = Chest tightness, paroxysmal cough, headache, nausea, vomiting and diffuse wheezing More severe exposure = Cyanosis, crackles in chest, shock, seizures and loss of consciousness |
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What is treatment for chlorine gas exposure?
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-Ensure safety of the crew
-Get patients out using specialized teams and equipment if needed -Triage patients (respiratory distress are the priority patients) -Maintain aiway -Support breathing (high flow O2) -Irrigate itching and burning eyes with water as well as any areas of skin in contact with the chlorine |
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How does cyanide work?
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Prevents the utilization or oxygen at the cellular level.
Death is within seconds if the cyanide was inhaled and 1-2 hours if ingested. |
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What are signs and symptoms of Cyanide poisoning?
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-Altered LOC
-Headache -Palpatations -Dyspnea -Bitter almonds on breath -Rapid and labored respirations early on -Slow and gasping as it develops -vomiting seizures and coma can develop |
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Why is venous and arterial blood still bright red?
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The cells cannot uptake the O2 but the hemoglobin is still saturated. Patients who are cyanotic are either close to death or not poisoned by cyanide.
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What is treatment for cyanide poisoning?
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-Establish and maintain the airway
-Support breathing with high flow O2 and ventilation if needed -IV access -Transport to ED for antidote kit |
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What do organophosphates do?
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Exert their effects at the synapses. They prevent the breakdown of acetycholine.
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What are signs and symptoms or organophosphate poisoning?
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Signs of cholinergic excess
DUMBELS D- Diaphoresis and diarrhea U- Urination M- Miosis B- Bronchospasm, bradycardia E- Emesis L- Lacrimation S- Salivation Also marked muscle weakness |
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What else is to bear in mind?
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Commercially available organophosphates are usually dissolved in hydrocarbon vehicles. Respiratory toxicity can result from the aspiration of the hydrocarbon.
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What is treatment for organophosphate poisoning?
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-Establish and maintain the airway (suction as needed)
-High flow supplemental oxygen (ventilate if needed) -IV access -ECG access -Pulse oximeter and capnography |
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What do you need to do when dealing with poisonous plants?
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Bring samples or parts of the plant or fungus with you to the ER
Get good history from the patient or parent and consult the regional poison center. What plant or plant parts were eaten? If seeds were ingested, were they chewed? When was the ingestion? What symptoms have developed? |
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What is important to note with regards to mushrooms?
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Onset of gastrointestinal symptoms can predict prognosis.
Within 1-2 hours can mean benign exposure. Greater than 6 hours of exposure can be more ominous |
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What are some considerations with acetaminophen?
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A total dose of 150-200mg per kilo can be toxic.
Symptoms occur in phases. It is possible that a lethal amount may be taken and the patient have no symptoms. Need to try an estimate the time of ingestion as treatment works best if initiated within 8-10 hours of exposure. |
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What about overdoses of NSAID's?
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Patients taking lithium and NSAID's can overdose on lithium as it takes longer to eliminate.
Long term use can lead to GI bleeding and kidney disfunction Acute ingestions and symptomatic overdoses are rare. |
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What about ASA?
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Overdose can change based on age, dose and duration of exposure.
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What are the signs and symptoms?
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150mg/Kg or less
-"mildly toxic" -nausea -vomiting -abdominal pain 150-300mg/Kg -"moderate toxicity" -vomiting -diaphoresis -hyperpnea -tinnitus / ringing in ears -acid-base disturbances 300mg/Kg+ -severe toxicity -respiratory alkalosis -metabolic acidosis -pulmonary and cerebral edema |
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