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113 Cards in this Set
- Front
- Back
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The most common classification system divides exposures into
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Deliberate and Accidental
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Include abuse and misuse exposures, self- harming (suicidal) exposures, and malicious exposures, where a poison is used to harm another individual.
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Deliberate Exposures
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Involves taking a substance with a nontherapeutic,nonself-harming intent.The most common example is using a drug to get high.
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Drug Abuse
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Occurs when a patient takes a substance with therapeutic intent but knowingly uses it in a nonstandard (usually excessive) dose.
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Drug Misuse
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With self-harming (suicidal) intent often result in significant poisoning.
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Intentional Exposures
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Uncommon, but when they occur, the patients are often very ill. These poisoning usually involve exposure to high doses of dangerous poisons. (Terrorist attack)
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Malicious Poisonings
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Very common, includes mistaken ingestion, therapeutic errors, environmental exposures, and adverse drug reactions.
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Accidental Exposure
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Occurs when a medication is accidentally given in the wrong dose or by the wrong route
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Therapeutic Error
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Occurs when a patient has an adverse event while using a medication appropriately and may occur from an allergic reaction, from a drug-drug interaction, from a change in drug metabolism, or because the patient is unusually sensitive to a medication.
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Adverse Drug Reaction (ADR)
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The study of how medication and poisons move in and out of the body
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Pharmacokinetics
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Pharmacokinetic Principles are commonly divided into
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Absorption, Distribution, Metabolism, and Excretion
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What is another term for absorption into the blood?
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Systemic Absorption
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For poison to cause injury or dysfunction to the body's organs what must occur?
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It must be absorbed into the blood (Systemic Absorption), so they can be carried to the target organs.
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What are the most common routes of exposure
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Ingestion, Inhalation, Injection, and Transdermal Absorption
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The extent of absorption is dependent on the following:
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1. The properties of the poison
2. The route of exposure 3. The duration of contact |
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When a poison is inhaled, it moves through the lung capillaries into the systemic circulation. Inhalation of poison results in a rate of absorption similar to intravenous exposure, but less of the poison may be absorbed because
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some may remain in the mouth and be exhaled before absorption occurs.
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The principal of limiting absorption by shortening the duration of exposure.
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Decontamination
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What is Gastric Lavage?
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Stomach Pumping. Large OG tube is place, 100-200ml of NS is used; and then suction
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Most commonly used method of gastric decontamination. Adsorbs many poisons and remains in the intestines, effectively trap-ping the poison and preventing systemic absorption.
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Activated Charcoal (AC)
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What common poisons are not bound by charcoal?
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Ethanol, Methanol, Ethylene Glycol, Iron, and Lithium
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Describe Cathartics
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Medications that increased intestinal movement;were used to try to move poisons through the intestines before systemic absorption can occur.
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What is Whole Bowel Irrigation (WBI)
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Is the administration of a polyethylene glycol bowel preparation; Used to move poisons through the intestines before systemic absorption can occur.
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As the poison moves from the blood to the peripheral organs, the blood level of the poison will ____ while the organ levels will ____.
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Decrease; Increase
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High Flow Organs Include
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Liver, Brain, Kidneys, and Heart
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Low Flow Organs Include
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Fat, and Skeletal Muscle
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The major site of poison metabolism is the ____, but poisons are also metabolized in the ______, ______. and _____ in the blood
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Liver; Intestine; Kidneys; Enzymes
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Poisons (and medications) that are ingested must pass through the liver before moving to the rest of the body. If the poison (or medication) is cleared effectively by the liver, much of the oral dose may be cleared before it reaches the rest of the body. This is known as a
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First-Pass Effect
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Most poisons are eliminated from the body in the ____ and _____. Other routes of elimination include _____, ____, ____, and _____.
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Urine; Bile; Lungs; Sweat; Tears; Lactation
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The study of how medications and poisons cause their effects.
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Pharmacodynamics
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The difference between the dose of a medication that causes the desired effects and the dose that causes toxic effects
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Therapeutic Window
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Some life-threatening symptoms that are often caused by poisoning include the following
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-Decreased Level of Consciousness
-Seizures -Dysrhythmias -Shock |
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A characteristic combination of symptoms that can be used to identify the poison
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Toxidromes
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Patients who have dermal exposure should have their clothing removed and skin decontaminated; this is called
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Personal Decontamination
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Sedative Poisoning will cause what type of airway obstruction
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Loss of Gag Reflex
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Acid or Alkali Ingestion will cause what type of Airway Obstruction
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Airway Swelling
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Organophosphate Poisoning will cause what type of airway obstruction
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Secretions
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Ventilatroy failure most commonly occurs from _____ poisoning but may occur if the poison causes _____ _____ (as seen with some snake venom)
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Opiate; Muscle Weakness
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Decreased environmental oxygen, bronchospasm, pulmonary edema (most commonly noncardiogenic), or abnormalities of hemoglobin can each cause
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Inadequate Oxygenation
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The most common cardiac abnormalities associated with poisoning and overdose are
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Tachycardia and Bradycardia
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Treatments that specifically reverse the effects of a poison
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Antidotes
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Acidic and Alkaline (Basic) Substances
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Description
- Acids are substances with a low pH, and alkalis (or bases) are substances with a high pH - Strong acids (pH less than 3) or bases (pH greater than 11) may cause chemical burns - Exposure: pain and may have visible tissue necrosis - Ingested: airway swelling - Inhalation: Pulmonary irritation and bronchospasm and may cause pulmonary edema - Extent of injury is directly related to the duration of exposure Treatment - Decontamination ASAP - Dermal and eye exposures should be treated with irrigation until the symptoms have resolved and for a minimum of 15 to 20 minutes - Ingestion should rinse their mouth, and if they can easily swallow, it is reasonable to have them swallow one to two ounces of water Special Consideration - Hydrofluoric acid (HF) causes severe systemic toxicity with minimal dermal injury - Fluoride binds calcium with such affinity that less than one ounce of 5% HF will bind all of the free calcium in a human - Treated with prophylactic calcium gluconate (1-3 grams IV over 20 minutes) - Repeat dosing is required if the patient develops hypocalcemia - Cardiac arrest following HF poisoning should be treated with multiple doses of calcium |
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Food Poisoning
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Description
- Nonspecific term - Cause: bacterial toxins from bacteria such as Staphylococcus aureus, Bacillus cereus, and Clostridium perefringens - Signs and Symptoms: Nausea, Vomiting, Abdominal Pain, and Diarrhea Treatment - There is no specific treatment beyond supportive care |
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Plant Exposures
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- Rarely result in significant toxicity
- Ingestion will produce no symptoms or nausea and vomiting |
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Metals (Iron, Lead, Mercury)
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Description
- Large ingestions of iron (greater than 60 mg/ kg of elemental iron) will cause gastrointestinal symptoms (including GI bleeding) and can progress to coma and shock - Chronic exposure may cause slowed learning and headaches and can progress to cerebral edema - Metallic mercury (quicksilver, liquid silver mercury found in thermometers) exposure rarely causes acute toxicity unless heated and inhaled - Ingestion of mercury salts, such as mercuric chloride, will produce severe gastroenteritis, GI bleeding, and shock Treatment - Supportive, but deferoxamine is occasionally administered in the hospital to bind and detoxify the iron - Dimercaptosuccinic acid (DMSA) is an antidote that binds and inactivates lead and mercury - Patients with shock will require fluid resuscitation and may need vasopressor support |
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Cyanide and Hydrogen Sulfide
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Description
- Cyanide is produced when many plastics are incinerated and is used in industry - Hydrogen sulfide (HS) is formed by bacteria that are present in sewers and swamps - HS at Lower concentrations: Strong sulfur odor; Toxic Concentration: No odor - Bind to proteins in the mitochondria and prevent the formation of ATP - Cyanide and HS both cause a rapid onset of headache, nausea, seizures, hypotension, and coma Treatment - HS reversed by stopping the exposure - Cyanide poisoning requires being placed on oxygen and may require intubation, they should have an IV established, and they should be placed on a cardiac monitor. Hypotension is treated with fluids and vasopressors - Cyanide antidote kit includes amyl and sodium nitrite and sodium thiosulfate; The nitrites are used to induce methemoglobinemia, which binds the cyanide and removes it from the mitochondrial proteins - Amyl nitrate is administered by breaking open the ampules and having the patient inhale the vapors. - Sodium nitrite is administered by intravenous infusion. The adult dose is one ampule; administration of an adult dose to a child can cause life- threatening methemoglobinemia.After the nitrite is given, sodium thiosulfate is administrated, which creates thiocyanate, which is then excreted in urine. |
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Cholingeric Poisons
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Description
- Include carbamate and organophosphate pesticides and nerve agent chemical weapons (such as sarin, tabun, and VX) - Inhibit acetylcholinesterase, the enzyme that breaks down acetylcholine causing salvation, lacrimation, urination, defecation, gastrointestinal upset, and emesis. - Other symptoms include miosis (constricted pupils), bronchospasm, and pulmonary edema, fasciculations (twitching muscles) and muscle weakness occur from acetylcholine excess at the neuromuscular junction - Severity range from mild gastrointestinal symptoms to seizures, coma, and cardiovascular collapse Treatment - High doses of Atropine (up to 1 gm) - Seizures are treated with standard doses of benzodiazepines - Weakness may progress to loss of airway protection and respiratory failure, so patients with severe poisoning will require intubation and mechanical ventilation. |
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Pulmonary and Mucous Membrane Irritants
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Description
- Common examples include ammonia, chlorine, acids, bases, and capsaicin - Symptoms are upper airway burning, eye and nose irritation, and cough - Prolonged exposure may develop pulmonary edema and bronchospasm Treatment - Moving the patient to fresh air and irrigation of the mucous membranes |
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Pepper Spray
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Description
-Signs and symptoms: Include intense lacrimation (tearing); intense burning sensation to the eyes, mucous membranes, and skin that come into contact with the chemical; chest tightness; sore throat; coughing; shortness of breath; and vomiting. Possible loss of corneal epithelium -Duration: 15-30 minutes; Painful skin inflammation may last for hours -Be cautious of overspray, walking into a closed or confined space with the chemical still in the air, and clothing from the patient may contain chemicals, and moving around the clothes may result in additional exposure, called off- gassing Treatment -Clothing removal (placed in plastic bags) -Move patient away from the chemical and into fresh air -Irrigate the eyes, mucous membranes, and skin with copious amounts of plain water, sterile water, or normal saline solution for 15 minutes; repeat as needed Administer oxygen and assist ventilation, if required -Monitor the patient for respiratory distress, and suspect it if a cough develops -May develop bronchitis or pneumonia -Treat bronchospasm with beta 2 agonists such as Albuterol |
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Methanol and Ethylene Glycol
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Description
-Methanol: In Windshield Wiper Fluid, Various Fuel Produces Used to Heart Food Trays -Ethylene Glycol: Major ingredient of automotive radiator antifreeze -Both produce some degree of intoxication when ingested, major effects occur hours after once they have been metabolized to formic acid and oxalic acid; both of these acids cause a life-threatening metabolic acidosis with serum pH often below 7.2 (normal pH is 7.35 to 7.45) -Formic acid will cause blindness, and oxalic acid will cause renal failure Treatment -Administration of ethanol or fomepizole to prevent the formation of the toxic metabolites and hemodialysis to increase the elimination of methanol or ethylene glycol -No specific pre-hospital interventions beyond supportive care |
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Carbon Monoxide (CO)
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Description
-Odorless, Colorless gas that is produced by combustion -Common cause of deaths in fires, but it is also produced by heaters, gas stoves, and internal combustion engines -Often occurs during the first cold snap of a season when faulty furnaces and heaters are turned on -Binds to hemoglobin and forms carboxyhemoglobin, which blocks oxygen binding and the major toxic effects of CO occur when it binds to proteins in the brain and heart -Symptoms: headache, nausea, and dizziness; confusion, seizures, coma, and hypotension Treatment -High-flow oxygen and cardiac monitoring are the main pre-hospital interventions -Determine duration of exposure, identify if the exposure was in a closed space, and note when the patient was removed from the carbon monoxide -Pulse oximetry will give a normal reading -Transport time is prolonged; it is helpful to obtain a heparinized blood sample to determine baseline carboxyhemoglobin levels. Hyperbaric oxygen is used to treat severe carbon monoxide poisoning |
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Hydrocarbons
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-Diverse class of substances that have a carbon chain
-Huffing or Glue Sniffing: Deliberate inhalation to produce intoxication -Direct aspiration of hydrocarbon liquids is the second type of hydrocarbon poisoning. Lamp oil, kerosene, and paint thinner are hydrocarbons that are frequently aspirated. -Gasoline is often ingested -CNS effects including somnolence (Desire to Sleep), ataxia (Loss of Coordination), slurred speech, and euphoria, and they will often smell like petroleum products -Pulmonary effects only if patient vomits or aspirates -Aspiration is the most common cause of pediatric poisoning death reported to poison centers Treatment -Removal of the patient from the exposure -Identify the product that the patient is abusing because there may be other toxic ingredients that require specific treatment -Suspect aspiration if a patient has choking, vomiting, or a cough after ingesting a hydrocarbon liquid -Oxygen and should be transported for monitoring. It is also important that any patient with vomiting be placed on their side to help minimize the risk of aspiration |
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What should you not do when treating a patient that has been huffing gasoline?
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Avoid using beta agonistic broncho-dilators (such as albuterol) to treat patients with inten-tional inhalation of gasoline. The bronchodilator will dilate the airways and allow for more absorption of the toxin, which can make the patient even sicker.
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Cardiovascular Medications
Calcium Channel Blockers |
-Treat: Hypertension and occasionally for refractory migraine headaches
-Act by inhibiting voltage-gated calcium channels. The resultant effect is vasodilatation via contraction of vascular smooth muscle and slowing of cardiac conduction by inhibition of the SA and AV nodes. -Verapamil and diltiazem primarily slow both sinus node (SA) firing and atrioventricular (AV) nodal conduction and cause mild peripheral vasodilatation; Likely to cause Bradycardia and conduction delays -Nifedipine causes prominent vasodilatation with little inhibition of the SA and AV nodes -Other calcium channel blockers include amlodipine, felodipine, and isradipine. These have effects similar to nifedipine. - Expect hypotension, bradycardia, and myocardial conduction delays with an acute CCB intoxication; may also develop drowsiness (with hypotension), vomiting, mild hyperglycemia, and acidosis Treatment -Initiate gastrointestinal decontamination; slows gastrointestinal motility and is very toxic -Consider Whole Bowel Irrigation -Endotracheal intubation if any significant cardiovascular compromise is apparent -Treatment for hypotension includes isotonic crystalloid fluid and vasopressors -Atropine can be used for bradycardia -Intravenous calcium and glucagon are also adjunct therapies for hypotension -Occasionally, cardiac pacing is needed -High- dose insulin with dextrose infusion is also used for patients that are refractory to standard therapy |
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Cardiovascular Medications
Beta Adrenergic Blockers |
Beta Receptor Blockers
-Competitively block the beta adrenergic receptor -Used to treat hypertension, acute coronary syndrome, and occasionally migraine headaches -Beta 1 receptors affect heart contraction and heart rate and are the most relevant to cardiac function -Beta 2 receptor agonists increase bronchodilatation, arterial vasodilatation, insulin release, and influx of potassium into cells -Agents that affect both receptors (nonselective beta- blockers) are propanolol (Most Toxic, inhibits myocardial sodium channels and can cause wide complex dysrhythmias), labetalol, and timolol -Beta 1 selective drugs are more commonly prescribed and are used for their cardioselective effects. Examples are metoprolol, atenolol, and esmolol. Beta- blocker (BB) intoxication usually manifests with hypotension and bradycardia. Heart block and myocardial conduction delay are also seen. -Labetalol and carvedilol also inhibit alpha receptors, which can worsen hypotension -Possible seizures have been reported after propanolol intoxication -Carvedilol, a newer BB, has similar characteristics to propanolol Treatment -Supportive care is important -Perform endotracheal intubation in the somnolent patient -Treat bradycardia with atropine -Treat hypotension with intravenous fluids and vasopressors -Intravenous glucagon and calcium are adjunct treatments -Cardiac pacing if needed -Remedy seizures with benzodiazepines, and administer sodium bicarbonate bolus for widened QRS |
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Cardioactive Steroids (Digoxin and Related Substances)
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-Derived from plants
-Digoxin is the most commonly prescribed cardioactive steroid. Produced from the foxglove plant; increases contractility of the heart by increasing intracellular calcium while simultaneously slowing the rate of ventricular contraction by slowing conduction through the AV node and is used to treat congestive heart failure by increasing cardiac contractility and atrial fibrillation to slow rate of ventricular contractions. -Other plants have cardioactive steroids, including red squill, yew berry, and oleander -Vomiting, bradycardia, heart block, dysrhythmias, and hyperkalemia Treatment -Cardiac monitor and perform a 12 lead electrocardiogram, if available, to assess for a dysrhythmia -Laboratory testing for serum potassium, digoxin level, and renal function are important to assess for toxicity -Consider atropine for symptomatic bradycardia -Unstable patient with a ventricular dysrhythmia, use parenteral calcium with caution - Supplemental calcium with digoxin toxicity could lead to cardiac tetany and Asystole -Because digoxin also causes myocardial irritability, electrical cardioversion could induce ventricular fibrillation; therefore, cardioversion should start at low levels, if needed urgently, or otherwise delayed until after antidotal therapy -Administration of digoxin immune antibody fragments is the in-hospital treatment foundation of digoxin toxicity -Larger doses (approximately 10 vials) are given for acute toxicity and lower doses (approximately two vials) for chronic toxicity |
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Type I Antidysrhythmic Medications
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-Class I antidysrhythmic agents block fast myocardial sodium channels
-Treat ventricular dysrhythmias and are divided into three categories, based on additional mechanisms of action -Class IA agents are disopyramide, procainamide, and quinidine -Class IB agents are the most common and include lidocaine and its oral analog, mexiletine -Class IC medications are flecainide and propafenone -Symptoms of intoxication also include hypotension, somnolence, and generalized seizures Treatment -Oxygen -Cardiac Monitor -Monitor for QRS widening and QT prolongation -Endotracheal intubation or bag-mask ventilation for respiratory failure -Treat seizures with parenteral benzodiazepines -Hypotension with crystalloid infusion -Recalcitrant hypotension requires a vasopressor such as dopamine or norepinephrine -Treat wide complex dysrhythmias with sodium bicarbonate bolus |
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ACE Inhibitors and Angiotensin Receptor Blockers
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ACE Inhibitors
-Prevents the conversion of angiotensin I to angiotensin II (vasoconstrictor) - Captopril, Lisinopril, Enalapril, and Ramipril -Prescribed for hypertension -Beneficial for patients with concomitant diabetic nephropathy, congestive heart failure, or post- myocardial infarction -Mild hypotension -Mild tachycardia and hyperkalemia can occur -Occasionally adverse effects of ACE inhibitors include a nonproductive cough, hyperkalemia, mild renal insufficiency, and, rarely, angioedema (facial and upper airway swelling) Angiotensin receptor blockers (ARBs) -Impede the effect of angiotensin II but act by directly blocking the angiotensin receptor -Losartan, Valsartan, Irbesartan, and Candesartan -Prescribed for similar indications as ACE inhibitors but are considered when ACE inhibitors are not tolerated by the patient -ARBs may also produce mild hypotension and tachycardia. Cough and angioedema less common Treatment -Hypotension is usually mild, crystalloid infusion -Angioedema can cause airway obstruction and can be life-threatening -Early intubation may be needed -Antihistamine and antiallergic medications, such as diphenhydramine and prednisone, are not effective. -Intramuscular epinephrine may be helpful to decrease severe edema -Patients should be monitored closely for progression of upper airway edema. |
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Clonidine and Alpha 2 Adrenergic Agonists
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-Clonidine is the most common alpha2 adrenergic agonist; decrease sympathetic flow, resulting in hypotension, sedation, and bradycardia.
-Attention deficient and hyperactivity disorder, control hypertension, Tourettes syndrome, and to mitigate alcohol or opioid withdrawal -Lessened sympathetic stimulation of the pupillary muscles also produces miosis (Pupil Constriction) -Hypothermia is also common. Symptomatic patients often present with miosis and sedation Treatment -Naloxone (Narcan) for possible opioid intoxication -Determine the blood glucose level, or administer glucose empirically to exclude hypoglycemia -Supportive Care -Endotracheal intubation may be required if the patient is profoundly sedated -Administer atropine for bradycardia and crystalloid fluid and vasopressors for hypotension -No proven antidote exists |
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Alpha 1 Adrenergic Antagonists
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-Decrease vascular tone and bladder sphincter tone
-Prazosin and terazosin; routinely prescribed for urinary retention associated with benign prostatic hypertrophy -Orthostatic hypotension, mild tachycardia, dizziness, and occasionally syncope. Mild sedation and nasal congestion may also occur -Phentolamine inhibits both alpha 1 and alpha 2 receptors and is administered subcutaneously for accidental epinephrine injections into a digit -Given parenterally for severe hypertension from cocaine or other sympathomimetic agents Treatment -Supportive. Crystalloid infusion is usually the only treatment needed for hypotension |
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Over-the-Counter Medications
Acetaminophen |
-Common, mild analgesic and antipyretic
-Often combined with opioids such as codeine, hydrocodone, or oxycodone to treat moderate pain -Overdose causes no symptoms initially, but liver injury occurs 24 to 72 hours after the ingestion Treatment -Antidote: N-acetylcysteine -No specific pre-hospital interventions beyond supporting the vital signs |
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Over-the-Counter Medications
Nonsteroidal Anti- inflammatory Drugs (NSAIDs) |
-Treat inflammation, pain, and fever
-Common NSAIDs Ibuprofen, naproxen, ketoprofen, piroxicam, diclofenac, indomethacin, and ketorolac - Adverse effects during therapeutic use (GI bleeding and kidney failure) are relatively common -Acute NSAID ingestion can cause coma and metabolic acidosis, but these effects are only seen following massive ingestion Treatment -No specific prehospital interventions beyond supportive care |
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Over-the-Counter Medications
Acetylsalicylic acid (aspirin) |
-Commonly used for analgesia and antipyresis; antiplatelet agent in the treatment of acute coronary syndrome and cerebrovascular disease
-Nausea, vomiting, and abdominal pain are frequent symptoms after ingestion. Muffled hearing and tinnitus are also common. Moderate toxicity will induce hyperpnea, tachypnea, somnolence, and mild acidosis. Severe toxicity will produce cerebral and pulmonary edema, coma, and seizures -One of the most common poisonings reported to poison centers and is perennially one of the most lethal Treatment Transport patients promptly to the emergency department. -Intravenous fluids for mild dehydration -Endotracheally intubate the comatose patient, and hyperventilate to prevent worsening acidosis -Most moderately intoxicated patients will require a sodium bicarbonate infusion -Severely ill patients will need hemodialysis |
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Over-the-Counter Medications
Antihistamines and Anticholinergics |
-Prescribed and obtained over-the-counter
-Histamine2 (H2) blockers, such as ranitidine, cimetidine, famotidine, and nizatidine, decrease acid efflux into the stomach and are used for gastric and duodenal ulcers and gastroesophageal reflux disease -Sedating histamine1 (H1) blockers include diphenhydramine, doxylamine, brompheniramine, and hydroxyzine; are used to treat allergic reactions; motion sickness, vertigo, pruritus, and as a sleeping aide -Less- sedating H1 blockers include cetirizine, loratadine, desloratadine, and fexofenadine; used primarily for allergic reactions -Sedating H1 blockers produce significant sedation, tachycardia, and anticholinergic effects -Occasionally, seizures occur after large ingestions -Less- sedating H1 antagonists cause mild sedation and tachycardia Treatment -Transport, provide supplemental oxygen and cardiac monitoring -Administer benzodiazepines to agitated or delirious patients for sedation -Manually ventilate or endotracheally intubate somnolent patients -Treat seizures with parenteral benzodiazepines |
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Over-the-Counter Medications
Herbal Remedies and Dietary Supplements |
-Consist of an array of medications and products
-Few supplements and remedies have adverse effects beyond gastrointestinal upset -Aconite from the Aconitum plants can cause hypotension, dysrhythmias, and heart blocks (Treatment is supportive) -Jimsonweed seeds contain anticholinergic alkaloids and can produce toxicity, including prolonged delirium, tachycardia, dry skin, mydriasis, and urinary retention -Cardiac glycosides from foxglove, oleander, lily of the valley, and squill can produce ventricular dysrhythmias and death (Treatment is the same as for cardiac glycoside poisoning from digoxin) -Kava can cause sedation and, rarely, liver injury -Pennyroyal oil is used as an abortifacient and can induce hepatotoxicity. (N-acetylcysteine may be beneficial for the hepatoxicity) -Ginseng and ginkgo biloba may cause problems with bleeding. Vomiting, sedation, and nystagmus are common symptoms of nutmeg toxicity. -Parenteral benzodiazepines for delirium and supportive care are sufficient pre-hospital treatment |
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Psychiatric Medications
Benzodiazepines |
-Treats anxiety, seizures, insomnia, and ethanol withdrawal
-Includes midazolam, diazepam, lorazepam, alprazolam, clonazepam, chlordiazepoxide, clorazepate, and many others -Overdose causes CNS depression, but isolated benzodiazepine overdoses are rarely fatal, even without treatment -Mixed ingestions, such as benzodiazepines and ethanol, can be fatal Treatment -Patients should be monitored for CNS depression and should be intubated if they have airway compromise |
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Psychiatric Medications
Tricyclic Antidepressants (TCAs) |
-The tricyclic antidepressants are a second- line therapy for depression
-Commonly used to treat chronic pain, bedwetting, and insomnia -Common tricyclic antidepressants include amitriptyline, imipramine, desipramine, doxepin, and nortriptyline -Causes coma, seizures, hypotension, and wide complex cardiac dysrhythmias Treatment -Require constant cardiac monitoring, and paramedics must be prepared to treat any complications. -Treatment of coma includes intubation and ventilation -Seizures usually respond to standard doses of benzodiazepines -Hypotension is treated with crystalloid infusion and dopamine or epinephrine infusions -Cardiac dysrhythmias are due to antagonism of cardiac sodium channels -Patients should be treated with hypertonic sodium bicarbonate boluses, repeated, as needed -Hyperventilation may also be useful for preventing and treating dysrhythmias |
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Psychiatric Medications
Selective Serotonin Reuptake Inhibitors (SSRIs) |
-Commonly used to treat depression and other psychiatric disorders
-SSRIs include fluoxetine, paroxetine, sertraline, citalopram, escitalopram, and fluvoxamine -Other medications such as venlefaxine, trazodone, and mirtazepine also alter serotonergic neurotransmitters and are used for depression -Effects of overdose are Sedation, agitation, seizures, and tachycardia -Serotonin syndrome is a collection of symptoms that may occur after overdose but is commonly an adverse reaction that occurs when multiple serotonergic medications are taken simultaneously -The effects include CNS depression, fever, muscle rigidity, and tremor. Patients require aggressive sedation and cooling measures to prevent severe hyperthermia |
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Psychiatric Medications
Monoamine Oxidase Inhibitors (MAOI) |
-Cause hyper- or hypotension, seizures, coma, rigidity, and hyperthermia
-Symptoms of MAOI toxicity may be delayed for more than a day after overdose -MAOIs may also cause a syndrome of flushing and severe hypertension when patients ingest tyramine- containing food such as wine, cheese, and smoked meats |
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Psychiatric Medications
Lithium |
-Lithium carbonate is used to treat bipolar mood disorder
-Severe abdominal pain, vomiting, and diarrhea -Develop confusion, seizures, and coma. Chronic lithium toxicity occurs when patient becomes dehydrated (Present with confusion, somnolence, tremors, and muscle rigidity) Treatment -Supportive Care and hydration to increase renal clearance of lithium |
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Psychiatric Medications
Antipsychotic Medications |
-Used to treat schizophrenia and related psychiatric disorders
-Common antipsychotic medications include haloperidol, fluphenazine, risperidol, olanzapine, ziprasidone, aripiprazole, and quetiapine -CNS depression that may be life-threatening and occasionally cause hypotension -Older antipsychotic medications such as haloperidol or fluphenazine also frequently cause dystonic reactions. These are involuntary muscle contractions that most commonly involve the neck but can involve any muscle group. These reactions usually respond to diphenhydramine 50 mg IV or IM -Supportive Care |
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Opioids (Narcotics)
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-One of the most common causes of poisoning death
-Codeine, morphine, fentanyl, meperidine, oxycodone, hydrocodone, hydromorphone, buprenorphine, and methadone; Heroin (morphine derivative) -Combined with over-the-counter analgesics such as acetaminophen, ibuprofen, and aspirin -Treat pain (commonly), cough, diarrhea, and addiction -Clinical effects include analgesia, CNS depression, cough suppression, decreased intestinal mobility, and miosis; overdose causes respiratory depression, which can lead to apnea and death -Chronic opiate users will also become dependent on opiates and may develop withdrawal symptoms such as nausea, diarrhea, abdominal cramping, piloerection, and anxiety -Oxygen (Pulse Oximetry) -Naloxone (Narcan) IV/IM: reverses opioid effects (including analgesia) and will restore normal mental status within one to two minutes of administration -Supportive care such as antiemetics and IV fluids -Monitor responsiveness, respiratory rate, cyanosis, hypoxia, hypotension (from histamine release), and for CNS and respiratory depression -Nalmefene is a longer- acting antidote for opioid poisoning, but it is not commonly used |
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Barbiturates
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-Used as anesthetics and for the treatment of seizures and headaches
-Phenobarbital, pentobarbital, butalbital, and thiopental -Cause intoxication, ataxia, confusion, slurred speech, and coma -Respiratory depression may be life- threatening, and intubation and respiratory support is the mainstay of treatment |
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Hypoglycemic Drugs
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-Insulin, sulfonylurea oral (Treat diabetes)
-Other diabetes medications, such as metformin, pioglitazone and rosi-glitazone, do not cause hypoglycemia -Cause hypoglycemia and hypokalemia -Regular insulin has an onset of action within 60 minutes and duration of action of between two to five hours -Lispro and Aspart insulin have a more rapid onset and shorter duration of action -Most other insulin types (NPH, Lente, etc.) have a slower onset and longer durations of action -Often due to the patient missing a meal rather than from overdose (Treat with oral glucose followed by a meal) -Sulfonylureas have the same major effect as insulin, causes profound, prolonged hypoglycemia that requires large doses of glucose -Patients that ingest these products or diabetics that ingest more than therapeutic amounts should be transported to the hospital and admitted for an observation period with serial glucose monitoring. Treatment -Hypoglycemia should be treated with a dextrose bolus and placed on a dextrose infusion. |
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Methemoglobinemia
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-Condition rather than a specific poison
-Formed when the iron in hemoglobin is oxidized and can no longer transport oxygen -Usually an adverse reaction to a therapeutic dose of a medication in a sensitive patient -Doses of benzocaine, nitrates, dapsone, and sulfonamides -Patients usually present with cyanosis and abnormal oxygen saturations on pulse oximetry; hypoxia, headache, confusion, shortness of breath, and hypotension Treatment -Methylene blue is administered to patients with symptoms to convert methemoglobin back to hemoglobin |
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Ethanol (EtOH)
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-Most common drug of abuse and is the leading cause of drug abuse death
-Beverage, medicinal and cosmetic preparations, including cough suppressants, mouthwash, perfumes, colognes, and industrial solvents -Low Does: Euphoria, disinhibition, dysarthria, and impaired judgment -Moderate Toxicity: Ataxia, disorientation, amnesia, uncoordination, and sedation -Severe Toxicity: Respiratory depression, hypotension, hypothermia, and coma Treatment -Monitor the patient for respiratory depression, hypoxia, hypotension, and mild hypothermia -Endotracheal intubation in the comatose patient -Administer crystalloid for hypotension -Determine if another process is causing the somnolence and altered mental status, such as intracranial hemorrhage, hypoglycemia, head trauma, or psychosis |
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Marijuana and Cannabis
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-Most commonly used illicit drug
-Smoked or put into food -Hashish is the dried resin collected from the flowers of the marijuana plant -Mild tachycardia, ataxia, and conjunctival injection. Euphoria, increased appetite, anxiety, impaired cognition, and, occasionally, dysphoria Treatment -Place the patient in a quiet environment and offer reassurance -Treat agitation and anxiety with benzodiazepines -Assess for concomitant drugs of abuse -Treat mild hypotension with crystalloid infusion |
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Gamma-Hydroxybutrate (GHB)
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-Used for narcolepsy but is also abused for its mild euphoric effects
-Increases muscle mass and is abused by body builders -Other GHB congeners are gamma-butyrolactone and 1,4 butanediol -Coma, myoclonus, and mild bradycardia. Somnolence occurs after an overdose -Withdrawal state similar to alcohol and benzodiazepine withdrawal (treated similarly with benzodiazepines and supportive care) Treatment -Supplemental oxygen and cardiac monitoring -Intubation is needed for respiratory failure -Because of the patients intact airway reflexes, pharmacologic paralysis is usually needed -Bradycardia with atropine -Seizures may also occur and should be treated with benzodiazepines |
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Hallucinogens
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-Lysergic acid diethylamide (LSD), tryptamines (e. g., foxy-methoxy), and psilocybin in the Psilocybe mushrooms
-LSD produces synesthesias, such as feeling color and seeing sound; altered visual perception, are sensitive to sound, and may have mild depression. -LSD also produces mild sympathomimetic effects such as tachycardia, diaphoresis, and mydriasis -Tryptamines and hallucinogenic mushrooms produce visual hallucinations and mild sympathomimetic symptoms Treatment -Provide reassurance in a calm, supportive environment -Treat agitation and anxiety with parenteral benzodiazepines -Monitor for mild tachycardia and hypertension |
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Inhalant Abuse
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-Use of a volatile substance for the purpose of achieving euphoria
-Toluene in paint, methanol in carburetor cleaner and inhaled nitrites (poppers), Gasoline, paint thinner, nail polish, and shoe polish -Huffing is when an individual holds a piece of cloth soaked in a volatile substance and breathes through it -Bagging is when the substance is sprayed into a bag, and the bag is placed over ones head -Produce sedation, mild euphoria, ataxia, and impaired cognition. May cause skin irritation; aspiration of the inhalant can cause bronchospasm, hypoxia, and pneumonitis -Sudden Sniffing Death: lethal dysrhythmias that occurs if the inhalant sensitizes the myocardium and the individual is startled -Abuse of nitrites can cause methemoglobinemia, which manifests as mildly low pulse oximetry, central cyanosis, and tachypnea Treatment -Monitor airway and supplemental oxygen administered; pulse oximetry -Exclude other causes of altered mentation such as hypoglycemia and opioid intoxication -Sedation with benzodiazepines is occasionally needed for agitation -Administer intravenous fluids for dehydration -Treat methemoglobemia with supplemental oxygen -Methylene blue is the antidote and can be administered in the emergency department |
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Stimulants: Amphetamines, Methamphetamines, and Cocaine
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-Amphetamine: methylphenidate and fenfluramine are used medically to treat ADD and obesity
-Methylene-dioxymeth-amphetamine (MDMA, Ectasy) is an amphetamine derivative abused for its euphoric and stimulant effects; (Tachycardia, diaphoresis, agitation, and mild hypertension; Severe toxicity: pyrexia (Fever), seizures, and rhabdomyolysis (Skeletal muscle breakdown) -Complications: MI, intracerebral hemorrhage, intestinal ischemia, and ventricular dysrhythmias. Bradycardia may occur with some amphetamine derivatives such as ephedrine -The drugs that are most commonly packed or stuffed are cocaine, heroin, and methamphetamine -Body Packing: a large amount of well-packaged drugs to smuggle the drug into a secured area -Usually admitted to the ICU for observation, and whole bowel irrigation is used to clear the packets from the GI Tract. -Body Stuffing: ingest drugs (or insert them in another body cavity such as the rectum or vagina) to avoid arrest -Develop mild to moderate symptoms within a few hours of the exposure. However, serious toxicity and even death may occur Treatment -Cardiac monitor to assess for dysrhythmia, tachycardia, hypertension -Administer supplemental oxygen -Sedation with benzodiazepines and hydration for rhabdomyolysis -Treat chest pain after stimulant use with benzodiazepines and nitroglycerin - Hypertension is usually controlled with benzodiazepines, but occasionally, nitroglycerin or phentolamine are used for refractory hypertension - Lower the temperature of hyperthermic patients by administering benzodiazepines, removing the patients clothing, and exposing the patients skin to tepid water and fans -Treat ventricular dysrhythmias after cocaine use with sodium bicarbonate bolus to counteract cocaines myocardial sodium channel blocking effects |
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Which type of toxin generally poses the greatest risk of contaminating emergency care responders?
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Cholinergic agents
are readily absorbed through the skin, thus it is important that providers protect themselves and decontaminate all patients. |
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In the US and Canada, a sporadic drinker typically has his driving abilities impaired
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A sporadic drinker is likely to begin experiencing motor impairment with a blood alcohol reading of .06%. The legal limit in the US and Canada is .08%.
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You are called to assist a 36 year old man who was found unconscious by his 8 year old daughter. Nearby, you find the pictured bottle of pills.(Assortment of Pills) What source can most accurately identify these pills?
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Poison centers can provide assistance identifying pills based on the symptoms and physical description. Because there are so many possible medications, is likely that your medical director may not be able to identify these specific pills. The mix of pill types indicates that at least some of the pills are not in their original packaging
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A regional poison center can be reached anywhere in the United States by calling
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1-800-222-1222
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Toxidrome
Anticholinergic (Parasympatholytic) Causes and Symptoms |
Anticholinergic
Causes: Atropine, jimson weed, sedating antihistamines Symptoms: Dry skin, mouth, and eyes, delirium, dilated pupils, tachycardia, decreased bowel sounds |
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Toxidrome
Cholinergic (Parasympathomimetic) Causes and Symptoms |
Organophosphate and carbamate pesticides, nerve agent chemical weapons
Salivation, vomiting, wheezing, pulmonary edema, diarrhea, small pupils, seizures, fasciculations, muscle weakness |
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Toxidrome
Opioids Causes and Symptoms |
Heroin, morphine, other opioid analgesics
Respiratory depression, small pupils, coma |
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Toxidrome
Symphathomimetic Causes and Symptoms |
Cocaine, amphetamines, other stimulants
Tachycardia, agitation, seizures, diaphoresis, dilated pupils |
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What is a MSDS?
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Material Safety Data Sheet;
A standard sheet that is produced by the manufacturer of common products. Employers are required to maintain copies of the MSDS for products used in the workplace. These sheets will have ingredient information and may have some initial treatment suggestions. However, the MSDS often contain outdated information, and it is often best to contact a poison center to ensure the accuracy of any recommendations beyond initial treatment. |
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Because hydrofluoric acid bonds easily to a certain element in the human body, to treat a patient who has ingested hydrofluoric acid you should administer
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The fluoride in hydrofluoric acid binds calcium with such avidity that less than 1 oz of 5% HF will bind all of the free calcium in a human body. Patients developing hypocalcemia require repeat doses. Patients that have cardiac arrest following HF poisoning should be treated with multiple doses of calcium.
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The set of symptoms known as SLUDGE (Salivation, Lacrimation, Urination, Defecation, Gastrointestinal upset, Emesis) would most likely be caused by
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The SLUDGE symptoms are caused by cholinergic toxins, including carbamate and organophosphate pesticides. Other toxins may produce some of the above symptoms (i.e.; pepper spray generally causes lacrimation) but this collection of symptoms is most associated with the cholinergic toxidrome.
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You are called to a university where a 150lb male patient attempted to drink 24 shots to celebrate his 24th birthday. It is likely that you will have to
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After 24 drinks the patient is likely in a coma. As with any coma patient you should perform endotracheal intubation. Alcohol poisoning may also lead to hypotension, which would benefit from saline, but this is not as certain.
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You are treating a patient who has ingested a toxic amount of aspirin. You may have to administer
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Because moderate aspirin intoxication increases the acidity of the blood, sodium bicarbonate is useful to restore pH levels.
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A 64 year old male complains that his wife has tried to kill him by putting cyanide in his tea. He has an elevated blood pressure and heart rate, and is sweating. What should be your FIRST step in treating him?
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The patient's symptoms are not consistent with cyanide poisoning and may be psychosomatic. However, you should not simply dismiss the patient's complaints. Monitor and transport the patient without further intervention unless symptoms develop.
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Which illegal drug generally poses the LEAST risk of patient overdose?
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Marijuana toxicity is not life threatening and the intoxicant effects are mild and transient
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The MOST common way for the body to excrete poisons is via
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Most poisons are eliminated from the body in the urine or the bile. Some gases may be eliminated through the lungs. Other routes of elimination such as the sweat, tears and lactation contribute little to the elimination of poisons.
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Assuming all other factors are equal, which of these factors increases the number of drinks needed to achieve the same blood alcohol level?
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Overweight patients generally require more alcohol consumption to achieve the same blood alcohol level, while women tend to require less. Someone who is drinking on an empty stomach will also require fewer drinks to achieve the same blood alcohol level. While chronic drinkers present diminished effects from alcohol, their blood alcohol level remains unchanged.
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Roughly what percentage of poison exposures result in death?
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Each year there are approximately 2 million exposures reported to US Poison Centers. Fortunately there are only approximately 1000 deaths reported, suggesting that the overall mortality from poisoning is less than 1%. Most poisoned patients will develop no more than mild symptoms and do well without any treatment.
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Which organ does the most to metabolize and remove poisons?
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The major site of poison metabolism is the liver, but poisons are also metabolized in the intestine, kidney and even by enzymes in the blood.
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Your 37 year old patient is confused, short of breath, and cyanotic. Pulse oximetry indicates that he has an SaO2 of 81%. His wife says that he recently began taking glyceryl trinitrate. What antidote would most likely treat his current condition?
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The patient's symptoms are consistent with methemoglobinemia, which is sometimes caused by an adverse reaction to nitrates. Methylene blue will covert methemoglobin back to hemoglobin.
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Which method of poison absorption generally has the quickest rate and highest percentage of absorption?
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Because injected toxins go directly to the circulatory system, all of the poison is immediately absorbed. Inhalation has a similar rate of absorption, but less of the poison is generally absorbed. Ingestion and transdermal poisons generally take longer to absorb.
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What's the Antidote for Acetaminophen (a common, mild analgesic and antipyretic.)?
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Acetylcysteine
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What's the Antidote for Cholinergic Poisons(inhibit acetylcholinesterase, the enzyme that breaks down acetylcholine)?
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Atropine
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What's the Antidote for Calcium Channel Antagonists and Hydrofluoric Acid?
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Calcium Chorlide or Gluconate
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What's the Antidote for Cyanide?
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Amyl Nitrite, Sodium Nitrite, Sodium Thiosulfate, and Hydroxocobalamin
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What's the Antidote for Calcium Channel Antagonist and Beta-Blocker?
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Glucagon
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What's the Antidote for Insulin, Sulfonylurea Oral Hypoglycemic Drugs?
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Glucose
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What's the Antidote for Methemoglobinemia?
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Methylene Blue
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What's the Antidote for Opioids?
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Naloxone
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What's the Antidote for Organophosphate?
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Pralidoxime
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What's the Antidote for Isoniazid?
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Pyridoxine
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What is the Antidote for Sodium Channel Antagonism?
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Sodium Bicarbonate
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Hallucinogens
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-Common hallucinogens are lysergic acid diethylamide (LSD), tryptamines (e. g., foxy-methoxy), and psilocybin in the Psilocybe mushrooms
-LSD produces synesthesias, such as feeling color and seeing sound. Altered vissual perception, are sensitive to sound, and may have mild depression. -LSD also produces mild sympathomimetic effects such as tachycardia, diaphoresis, and mydriasis -Tryptamines and hallucinogenic mushrooms produce visual hallucinations and mild sympathomimetic symptoms Treatment -Reassurance in a calm, supportive environment -Treat agitation and anxiety with parenteral benzodiazepines -Monitor for mild tachycardia and hypertension |
