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46 Cards in this Set
- Front
- Back
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Toxicology?
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is the study of posions and their action and effects, methods of detection, and diagnosist and treatment.
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What is a poision?
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any stubstance that can injure or kill a living organism
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Acute poisoning
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the effects are usually obeserved within a few hours, although may be delayed for many hours.
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Chronic poisoning
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cumulative exposures over time, can produce acute effects as the threshold level of toxicity is exceeded.
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Toxidromes
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anticholinergics (atropine, scopolamine): dry skin, dry mucous membranes, tachycardia, beet-red skin color, agitation, mydriasis (dilated pupils), urinary retention, hyperthermia, and mental status changes including delirium, hallucinations, and/or coma. (A simple mnemonic, “hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter, bloated as a bladder,” describes many of the features of the anticholinergic toxidrome.)
barbiturates, sedative-hypnotics: ataxia, drowsiness, slurred speech (without an alcohol breath odor), respiratory depression, hypotension cholinergics (such as organophosphates), mushrooms (Amanita or Galerina ): salivation, lacrimation, involuntary urination and defecation, diarrhea, miosis, mental status changes, pulmonary congestion, bronchospasm, and seizures. Severe cases present with respiratory muscle depression or paralysis. (Also see the Pharmacologic Issues in an Age of Terrorism box on pp. 432 and 433.) DUMBELS is a mnemonic used to recall many of the muscarinic effects: defecation, urination, miosis, bronchorrhea, bronchospasm, bradycardia, emesis, lacrimation, and salivation. opioids: pinpoint pupils, respiratory depression, hypotension, bradycardia, hypothermia, hyporeflexia, mental status depression, sedation, coma and needle marks may be present. salicylates: fever, vomiting, GI bleeding, dehydration, hypoglycemia, hypokalemia, tinnitus, seizures, central hyperventilation, concretions (solid drug mass), mixed respiratory alkalosis and metabolic acidosis, coma sympathomimetics (cocaine, amphetamine, OTC decongestants [phenylpropanolamine, ephedrine, pseudoephedrine], theophylline, caffeine β2-adrenergic receptor agonists [ephedra, ma huang]): hypertension, diaphoresis, tachycardia, tachypnea, hyperthermia, mydriasis; restlessness, agitation, excessive speech, tremors, and insomnia also occur. Severe cases are associated with dysrhythmias and seizures. This toxidrome may be difficult to distinguish from the anticholinergic syndrome. However, sweating and normal to hyperactive bowel sounds are associated with sympathomimetic overdose, and dry skin and diminished bowel sounds with the anticholinergic toxidrome (Ford, 2001). tricyclic antidepressants: anticholinergic signs and symptoms [see above], vomiting, hypotension (often profound), tachycardia and dysrhythmias (prolonged QRS duration on ECG report), seizures, mental status changes including confusion and coma |
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Coma caused by a drug overdose is characterized by the following categories:
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•Grade I. The individual is asleep but is easily aroused and reacts to painful stimuli. Deep tendon reflexes are present, pupils are normal and reactive, ocular movements are present, and vital signs are stable.
•Grade II. Pain response is absent, deep tendon reflexes are depressed, pupils are slightly dilated but reactive, and vital signs are stable. •Grade III. Deep tendon and pupillary reflexes are absent, and vital signs are stable. •Grade IV. Respiration and circulation are depressed. |
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Abdominal pain/discomfort is a sign of:
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Acetaminophen
Black widow spider bite Heavy metals Mushrooms Withdrawal from opioid |
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Ataxia is an sign for the following:
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Alcohol
Antiepileptic drugs (e.g., carbamazepine, phenytoin) Barbiturates Bromides Carbon monoxide Hallucinogens Heavy metals Organic solvents |
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Acetone sign for:
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Acetone
Alcohol (methyl or isopropyl) Phenol Salicylates |
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Alcohol sign of:
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Alcohol (ethyl)
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Bitter almonds sign of:
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Cyanide
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Garlic sign for:
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Arsenic
Dimethyl sulfoxide (DMSO) Phosphorus Organophosphate insecticides |
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Coma and drowsiness signs of:
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Alcohol (ethyl)
Antiepileptic drugs Antidepressants Antihistamines Barbiturates Carbon monoxide Opioids Salicylates Sedative/hypnotics |
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Oliguria/anuria sign for:
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Carbon tetrachloride
Ethylene glycol (antifreeze) Heavy metals Hemolysis caused by naphthalene, plants, and so on Methanol Mushrooms Oxylates Petroleum distillates Solvents |
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Pupillary changes
Dilated sign of: |
Amphetamines
Antihistamines Atropine Barbiturates (when combined with coma) Cocaine Ephedrine LSD (occasionally) Methanol Withdrawal from opioids (occasionally) |
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Constricted, pinpoint pupils sign of:
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Mushrooms (muscarinic)
Opioids Organophosphate insecticides |
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Nystagmus on lateral gaze sign of
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Barbiturates
Benzodiazepines Phencyclidine (PCP) Phenytoin |
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Respiratory alterations
Increased sign of |
Amphetamines
Aspirin Carbon monoxide Methanol Petroleum distillates |
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Paralysis sign of:
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Botulism
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Slowed or depressed sign of:
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Alcohol (late sign)
Barbiturates Benzodiazepines Opioids Organophosphate insecticides Sedative/Hypnotics |
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Wheezing/pulmonary edema sign of:
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Mushrooms (muscarinic)
Opioids Organophosphate insecticides Petroleum distillates |
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Salivation sign of:
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Alkaline cleaners
Corrosive substances Mercury Nicotine Organophosphate insecticides |
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Seizures or muscle twitching
sign for: |
Alcohol
Amphetamines Antihistamines Camphor Chlorinated hydrocarbon insecticides (DDT) Cyanide Lead Organophosphate insecticides Plants (azalea, iris, water hemlock) Salicylates Strychnine Tricyclic antidepressants Withdrawal from drugs: barbiturates, benzodiazepines |
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Skin color changes
Jaundice |
Aniline dyes/coal tar colors
Arsenic Carbon tetrachloride Castor bean Fava bean Mushroom Naphthalene (moth repellent/insecticide) |
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Flushing
sign for: |
Alcohol
Antihistamines Atropine Boric acid Carbon monoxide Nitrites Sympathomimetics Tricyclic antidepressants Yellow phosphorus |
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Cyanosis sign for?
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Aniline dyes
Carbon monoxide Cyanide Nitrites Strychnine |
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Violent emesis (with or without hematemesis)
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Aminophylline
Bacterial food poisoning Boric acid Corrosives Fluoride Heavy metals Phenol Salicylates |
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The caller to the poison control center should have the following information, if available:
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Physical appearance of the substance
•Odor, color, texture, and distinguishing characteristics of the substance •Trade name or chemical name, if known •Purpose of the substance or how the substance was meant to be used •Label statements relating to “poison” content or flammability •Container or pill to verify identification |
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Nursing management is therefore guided by the four major goals related to poision control are:
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Vital functions (respirations, circulation, and others) will be maintained, supported, or restored.
•The toxic substance will be removed or eliminated from the system as soon as possible. •The action of certain specific poisons may be counteracted, reversed, or antagonized by specific antidotes. •Recurrences will be reduced or prevented. |
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Removal or Elimination of Poison
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The removal of ingested substances can be attempted in several ways: (1) by directly removing it from the stomach, if the poisoning is discovered early; (2) by increasing the rate of transit of the poison through the colon, even though little or no absorption occurs there and thus may not be effective; or (3) by attempting to remove or filter it from the bloodstream if the substance has probably already been assimilated into the system or was injected. Contact poisons may be flushed from the skin, eyes, and other external areas with copious volumes of plain, flowing water from a pitcher or other container. Inhaled toxins are treated by placing the individual in fresh air and by administering artificial respiration or oxygen and other supportive measures as necessary.
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Box 72-2 First Aid for
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Possible Poisoning
Remember: any nonfood substance may be poisonous. a.If a poison is on the skin: Immediately remove affected clothing. Flood involved body parts with water and rinse thoroughly. b.If a poison is in the eye: Immediately flush the eye with water for up to 20 minutes. c.If a poison is inhaled: Immediately get the victim to fresh air. Give mouth-to-mouth resuscitation if necessary. d.Never induce emesis unless specifically directed to do so by the poison control center or qualified practitioner 1.Keep all potential poisons—household products and medicines—out of children's reach. 2.Use “safety caps” (child-resistant containers) to avoid accidents. Keep the phone number of your poison center and your physician handy. If you think an accidental ingestion has occurred, do the following: 1.Keep calm. Do not wait for symptoms. Call the poison center immediately. 2.Have the following information available: a.The name, age, and gender of the poisoning victim. b.The exact name of the product or substance involved in the poisoning. Bring the container to the telephone with you, if possible. c.An estimate of the amount of substance that may have been involved. d.When the poisoning occurred. e.The physical condition of the victim, including any preexisting medical problems f.How the poisoning occurred. g.Any additional information you feel the staff member needs to know. h.Any treatment implemented prior to calling poison control center. 3.Find out if the substance is toxic; the poison control center can tell you if a risk exists and what you should do. 4.Take appropriate action |
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Never induce vomiting in the following situations:
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1.The victim is in a coma (obtunded, reduced level of consciousness).
2.The victim is convulsing (having a seizure). 3.The victim has swallowed a caustic or corrosive substance (e.g., lye). For reemphasis: 1.Call poison control immediately for any event where toxicity is suspected or possible. Do not wait for symptoms to appear. 2.Always call the poison control center before undertaking treatment. 3.Never induce vomiting unless you are instructed to do so. 4.Do not rely on the label's antidote information, because it may be out of date. Instead call poison control. 5.If you need to go to an ED, take the tablets, capsules, container, and/or label with you |
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What interventions are used for removal or elimination in poison management?
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dilution and/or irrigation is by far the most common intervention utilized. Dilution or irrigation often reduces the injury and can usually be implemented immediately in the setting in which the intervention occurs. Plain water is the recommended universal diluent. With health care assistance (e.g., emergency medical services, in a health care setting), activated charcoal is also frequently administered in decontamination procedures (Committee on Injury, Violence, and Poison Prevention, AAP, 2003). Gastric lavage, use of ipecac syrup, alkalinization of the urine, and hemodialysis are also utilized in management, but are usually reserved for severe poisonings not responsive to other modalities in which these interventions demonstrate benefit (Watson et al., 2004).
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Historically, syrup of ipecac was routinely used to induce emesis in many cases. Today, it is rarely used because of complications and lack of efficacy. It should never be used in the following conditions/states
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•Infants up to 1 year of age
•Mental status changes or obtunded states in which excessive sedation or comatose state may occur •Seizure activity •Absent gag and cough reflexes •Presence of hematemesis •Ingestion of the following: Substances inducing seizures Sharp objects (e.g., glass, nails) along with the toxic substance CNS poisons which produce sedation (numerous agents) or require rapid removal by lavage (e.g., camphor, strychnine) Irritants which may cause further injury on emesis or if aspirated (acids, alkalis, or petroleum distillates, such as kerosene, gasoline, or paint thinner) |
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activated charcoal [ak ti vat id char kole]
(Actidose-Aqua) activated charcoal with sorbitol [ak ti vat id char kole with sor bi tole] (Actidose with Sorbitol) |
Activated charcoal adsorbs many substances and therefore is used as an adjunct in the treatment of oral poisonings with heavy metals, mercuric chloride, strychnine, phenol, atropine, phenolphthalein, oxalic acid, poisonous mushrooms, aspirin, and most drugs. It is not effective for poisoning with ethanol, methanol, caustic alkalis, ferrous sulfate, boric acid, gas, kerosene, lithium, and mineral acids. The charcoal mixture need not be removed from the stomach afterward because no serious adverse effects exist. Activated charcoal can also serve as a stool marker to indicate when further GI absorption of the ingested poison has ended. Tablets or capsules of charcoal should not be used to treat poisoning, because they are less effective than the powder.
Indications Activated charcoal is used in the emergency treatment of oral poisonings for a number of drugs and chemicals. The addition of sorbitol results in increased hyperosmotic colonic elimination, but may contribute to fluid and electrolyte imbalance. Contraindications Activated charcoal should not be used in cases of intestinal obstruction or GI perforation. It is not effective for management of acid or alkali, cyanide, organic solvent, iron, ethanol, methanol, or lithium poisonings. Pharmacokinetics/Dosing Activated charcoal remains in the GI tract and is not systemically absorbed. For acute poisonings, approximately 10 g of activated charcoal are administered for each 1 g of ingested toxin. Repeat doses may be needed. Alternately, a single 1 g/kg body weight is given orally. Sorbitol dose should not exceed 1.5 g/kg. Aqueous suspensions of activated charcoal are available in 15-, 25-, and 50-g dosage units. Formulations of activated charcoal suspended in sorbitol are available in 25- and 50-g dosage units as well. Capsule and granular formulations are available, but are generally not recommended for acute poison management because reduced surface area on ingestion reduces their efficacy to bind toxins. Adverse Effects Vomiting and diarrhea are among the more common adverse effects, and may be more pronounced with formulations containing sorbitol. This is an important consideration for toxic ingestions in which vomiting may be contraindicated (e.g., multiple agent ingestion in which petroleum distillates or caustic agents are involved). Altered fluid and electrolyte balance can also be problematic and is more likely with sorbitol use. Black-colored stools are typically observed after administration of activated charcoal. Drug Interactions Ipecac delays the administration of activated charcoal, which is the preferred treatment in most poisonings. Cathartics/laxatives are used in many cases if increased elimination is recommended. Most commonly, sorbitol is used in combination with activated charcoal as noted above. Chapter 40 discusses other cathartic/laxatives. |
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Gastric lavage
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involves washing out the stomach with sterile water or a saline solution. (Refer to a basic nursing text for the procedure.)
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Gastric lavage
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It is important to maintain the client's airway during lavage. Gastric lavage is most effective when initiated within one hour of ingestion, and is almost always conducted with concurrent activated charcoal administration. Lavage may be contraindicated in the presence of cardiac dysrhythmias.
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3 various tubes for lavage?
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Edlich tube
Ewald tube Lavacutor tube pg 1295 |
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ipecac syrup [ip e kak]
(PMS Ipecac Syrup ) |
Ipecac syrup is for emergency use to cause vomiting in poisoning when specifically recommended by a poison control center. Do not use if strychnine, corrosives such as alkalis (lye) and strong acids, or petroleum distillates such as kerosene, gasoline, fuel oil, coal oil, paint thinner, or cleaning fluid have been ingested. It may be considered in an alert, conscious client who has ingested a substantial amount of a toxic substance within 60 minutes of presentation
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Pharmacokinetics/Dosing
ipecac syrup |
The usual dosage for adults is 15 to 30 mL, which is followed immediately by 240 mL of water. Four to 8 ounces of water is given with the following dosages: children 6 months to 1 year of age, 5 to 10 mL (under special circumstances only); and children 1 to 12 years of age, 15 mL. Vomiting usually occurs in 15 to 30 minutes. The dose may be repeated once after 20 minutes if the first dose is not effective
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Adverse Effects
ipecac syrup |
In addition to the expected nausea and vomiting, ipecac syrup is cardiotoxic if absorbed. It may cause conduction disturbances, atrial fibrillation, or myocarditis.
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one way to get rid of toxins in the body?
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Changing the pH of the urine by alkalinization (sodium bicarbonate) may enhance the excretion of certain drugs, such as salicylates and, possibly, tricyclic antidepressants. Forced acid diuresis is probably more potentially hazardous but is often recommended for poisoning with amphetamines and fenfluramine (Pondimin).
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TABLE 72-2 COMMON POISONINGS AND THEIR ANTIDOTES
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Poisoning/Toxin
Antidote Further Discussion in This Text acetaminophen acetylcysteine (Mucomyst) Chapter 14 anticholinergic, neuromuscular blockers physostigmine sulfate Chapter 21 benzodiazepine flumazenil (Romazicon) Chapter 16 β blockers/propranolol glucagon Chapter 49 cholinergics • nerve agent poisoning – Soman atropine Chapter 21 • organophosphates/insecticides pralidoxime [2-PAM] (Protopam) [pretreatment with pyridostigmine limited to military applications] • mushrooms with muscarine • anticholinesterase overdose cyanide amyl nitrate Chapter 72 methylene blue sodium thiosulfate digoxin digoxin immune FAB (Digibind, DigiFab) Chapter 25 heavy metal arsenic, gold, mercury, lead: Chapter 72 • dimercaprol (BAL in Oil) arsenic, lead, mercury: • D-penicillamine (Cuprimine) • succimer (Chemet) iron: • deferoxamine (Desferal) • edetate calcium disodium (Versenate) copper: • trientine (Syprine) heparin protamine sulfate Chapter 30 insulin, oral hypoglycemics dextrose Chapter 49 glucagon isoniazid pyridoxine (Vitamin B6) Chapter 67 methotrexate leucovorin Chapter 56 opioids naloxone (Narcan) Chapters 9, 14 nalmefene (Revex) toxic alcohols: • methanol ethanol Chapter 72 • ethylene glycol fomepizole (Antizol) warfarin fresh frozen plasma (FFP) Chapter 30 phytonadione (Vitamin K) |
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TABLE 72-3 RELATIONSHIP BETWEEN ALCOHOL CONSUMPTION, BLOOD ALCOHOL LEVELS, AND CLINICAL MANIFESTATIONS
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Alcohol Consumption (Drinks) *
Approximate Blood Alcohol Concentrations, mg/dL (mmol/L) † 55-kg person 90-kg person Probable Clinical Manifestations 1–3 2–5 50–100 (10.9–21.7) Impaired sensation, incoordination 3–5 5–8 100–150 (21.7–32.6) Behavioral changes, ataxia, cognitive and memory difficulties 5–7 8–11 150–200 (32.6–43.4) Marked incoordination, worsening ataxia, cognitive impairment 7–9 11–14 200–300 (43.4–65.1) Nausea, vomiting, diplopia, lethargy, aspiration risks (impairment of protective reflexes) More than 10 More than 15 300–400 (65.1–86.8) Decreased respiratory drive, hypoventilation, amnesia, hypothermia, cardiac dysrhythmias Extreme Greater than 400 (greater than 86.8) Coma, respiratory arrest, death |
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For what types of poisonings should the nurse be prepared?
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Ethanol and acetaminophen are among the most common agents associated with significant consequences in overdose for adults.
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How does carbon monoxide (CO) poisoning present
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Carbon monoxide is an odorless gas produced by the incomplete combustion of carbon or carbonaceous materials. Sources of this gas include improperly maintained heating systems, improperly ventilated charcoal cookers, wood stoves, heaters, or fireplaces, and industrial furnaces, such as those in steel mills. Automobile exhaust contains 3% to 7% CO. CO causes more deaths in the United States and Canada than any other poison. The inhalation of automobile exhaust is a common method of suicide, and accidental home and industrial exposure to CO is much more common than generally appreciated.
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