1 Madison County EMD Andrew Scordato EMT-PToxicology Madison County EMD Andrew Scordato EMT-P

2 Toxic Exposure 10% of ED visits and EMS responses involve toxic exposures. 70% of accidental poisonings occur in children under 6 years old. Drug Abuse In million 4.6 million ED visits 46% involved abuse Mortality-100, in 4 Cost ½ trillion dollars Common Rx’s=Alcohol, Stimulants, Hallucinogens, Prescription medications

3 Routes of Exposure InhalationExample-Huffing-paint, gasoline, nitrous oxide, Carbon monoxide, ammonia, chlorine, Tear gas, Freon, methyl chloride, Carbon tetrachloride A&P- Capillary exchange Assessment-Evaluate the scene and respiratory, CNS, cardiac systems Management-Safety, Remove Pt. from environment, Poison Control Evaluate the scene. Central nervous system effects include dizziness, headache, confusion, seizure, hallucinations, coma. Respiratory effects include cough, hoarseness, stridor, dyspnea, retractions, wheezing, chest pain or tightness, crackles, rhonchi. Cardiac effects include dysrhythmias.

4 Routes Ingestion Examples-prescription medications, Household/Cleaning agents , Petroleum-based agents, Cosmetics, plants, or foods A&P- absorption in stomach and small intestine Assessment- What, When and How much? Did you drink any alcohol? Have you attempted to treat yourself? Have you been under psychiatric care? Why? Weight Physical exam Management-ABC use AEIOUTIPS

5 Routes Surface AbsorptionExamples-Poison ivy, Organophosphates, drug patches=fentanyl, nitro A&P-Drug and patient dependent Assessment-Respiratory, Neurologic Management-Safety, Removal of drug

6 Routes Injection Examples-IV drug abuse-Heroin/Steroid usersA&P-Intravenous VS. Intramuscular Assessment-Physical findings- Sites? Management-ABC treat with Antidote if possible Watch for anaphylactic reactions

7 Poison Control CentersProvide detailed information 24hr staffed Id pills and toxicity Effects

8 Toxidromes Similar toxins typically have similar signs and symptoms.In some cases it may be difficult to identify a specific toxin. Types Anticholinergic Cholinergic Hallucinogenic Opiate/Narcotic Sedative/Hypnotic Sympathomimetic

9 Anticholinergic Signs and Symptoms CausesDelirium, Flushed Skin, Dilated Pupils, Urinary Retention, Decreased Bowel Sounds, Memory Loss, SZR, Hyperthermia, HTN, Tachycardia Causes Antihistamines Scopolamine Jimson Weed Angel Trumpet Benztropine CyclicAntidepressants Atropine “Hot as a Hare, Dry as a Bone, Red as a Beet, Blind as a Bat”

10 Cholinergic Signs and Symptoms Causes SLUDGE MMConfusion, Weakness, Salivation, Lacrimation, Defecation, Emesis, Diaphoresis, Muscle Fasciculations , Miosis , SZR, Bradycardia, Hypothermia, Tachypnea Causes Organophosphates Carbamates Mushrooms SLUDGE MM Carbamates are insecticides

11 Hallucinogenic Signs and Symptoms CausesDisorientation, Hallucinations, Visual Illusions, Panic Reaction, Moist Skin, Hyperactive Bowel Sounds, SZR, Tachycardia, Tachypnea, HTN Causes Amphetamines Cannabinoids Cocaine Phencyclidine (PCP)

12 Sedative/Hypnotic Signs and Symptoms CausesComa, Stupor, Confusion, Sedation, Progressive Deterioration of CNS Function, Apnea Causes Barbiturates Benzodiazepines Ethanol Anticonvulsants

13 Opiate/Narcotic Signs and Symptoms CausesAltered Mental Status, Unresponsiveness, Miosis, Shock, Shallow & Slow Respiratory Rate, Bradycardia, Hypothermia, Hypotension Causes Opiates Propoxyphene Dextromethorphan Opiate and narcotics are deratives of the poppy plant

14 Sympathomimetic Signs and Symptoms CausesDelusions, Paranoia, Diaphoresis, Piloerection, Mydriasis, Hyperreflexia, SZR, Anxiety , Tachycardia, Bradycardia (if pure alpha agonist)HTN Causes Cocaine Amphetamines Methamphetamine Phenylpropanolamine Ephedrine Pseudoephedrine Albuterol Ma huang

15 Inhaled Toxins Carbon Monoxide Inhaled colorless, odorless gasPoorly ventilated heating systems Confined spaces Signs and Symptoms Headache N&V altered mental status Tachypnea Management Prev. discussed Initiate supportive measures. High-flow, high-concentration oxygen Hyperbaric therapy

16 Inhaled Hydrocarbons Compounds of Carbon and HydrogenMay be ingested, inhaled, or adsorbed Signs and Symptoms Burns due to local contact Wheezing, dyspnea, hypoxia, pneumonitis Headache, dizziness, slurred speech, ataxia, ALOC, cardiac dysrhythmias Foot and wrist drop with numbness and tingling Management Standard emergency procedures

17 Ingested toxins Alcohol Physiologic Effects General Alcoholic ProfileCNS depressant Alcoholism Susceptible to methanol or ethylene glycol ingestion Peripheral vasodilation, diuresis General Alcoholic Profile Drinks early in the day, alone, or secretly Binges, blackouts, GI problems, “green tongue syndrome,” chronic flushing of face and palms Cigarette burns, tremulousness, and odor of alcohol

18 Ingested Alcohol cont Chronic Alcohol Ingestion Poor nutritionAlcohol hepatitis Liver cirrhosis, pancreatitis Sensory loss in hands/feet Loss of balance and coordination Upper GI hemorrhage Hypoglycemia Falls (fractures and subdural hematoma)

19 Ingested Withdrawal Delirium Tremens (DTs)- “Shaking Frenzy”Signs and Symptoms Tremor of hands, tongue, eyelids N&V, general weakness, anxiety Tachycardia, sweating, hypertension, hallucinations, irritability or depressed mood, poor sleep Increased sympathetic tone, orthostatic hypotension TX ABC/O2,IV,EKG. Determine if other drugs are involved. Consider medications. 25g D50W if hypoglycemic 100mg thiamine IV or IM Benzos for DT’s

20 Ingested Medications Commonly due to dosage errorsExample-Beta Blocker overdose Signs and Symptoms Nausea, vomiting, headache, dizziness, confusion Profound hypotension, cardiac dysrhythmias Bronchospasm, pulmonary edema Management Standard procedure BB/TCA-Sodium , Calcium, Glucagon

21 Surface absorbed poisonsCaustic Substances Typically occurs by ingestion or surface absorption. Acids Cause significant damage at sites of exposure. Are rapidly absorbed into the bloodstream. Alkalis Slower onset of symptoms allows for longer contact and more extensive tissue damage Signs and Symptoms Facial burns Pain in the lips, tongue, throat, or gums Drooling, trouble swallowing Hoarseness, stridor, or shortness of breath Shock Manage-Airway

22 Surface Example Hydrofluoric Acid Signs and Symptoms ManagementToxic; used to clean and etch glass. Signs and Symptoms Burning at site of contact. Confusion, palpitations, muscle cramps. Management standard toxicologic emergency procedures. Irrigate and immerse the affected area.

23 Specific Drugs And Drug abuse

24 Definitions Drug abuse-nontherapeutic Overdose-in excessAddiction-overwhelming need Tolerance-larger doses Withdrawal-psychological/physical effects

25 Why? Pleasurable Social Anxiety Performance enhancing Curiosity

26 Specific Drugs Hallucinogens Mind altering/CNSCommon agents-LSD, PCP, Mescaline Example-Jimson Weed Anticholinergic effects Atropine Effects hours Assessment-Hallucinations, Hyperthermia, Photophobia Tx-ABC, Rapid transport, beware of Seizures and Violent Behavior

27 Specific SympathomimeticExamples-Cocaine, Bath Salts, Khat, AlphaPVP and Gravel IPOD cleaner Effects-extreme sympathetic arousal Assessment-Cocaine=Chest pain/Bath Salts=Delusions, Paranoia/Khat=Anxious-----Excited Delirium? Treatment-Safety, Sedation?, Calm The term ‘bath salts’ refer to commercially available products that have as part of their composition a legal stimulant called 3, 4-Methylenedioxypyrovalerone, or MDPV (sometimes another synthetic stimulant called Mephedrone and less commonly a synthetic stimulant called Methylone). These synthetic stimulants are in a class of drug known as synthetic cathinones. Synthetic cathinones are related to the parent compound cathinone (found naturally in the plant Khat, which has cathinone producing a mild stimlative effect) Alpha-PVP - a-Pyrrolidinopentiophenone (alpha-Pyrrolidinovalerophenone,a-PVP, O-2387,alpha-PVP) is a stimulant compound developed in the 1960s and related to pyrovalerone. The mechanism of action is unknown for a-pyrrolidinopentiophenone. a-PVP is believed to act similarly to the designer drug MDPV, which acts as a norepinephrine-dopamine reuptake inhibitor (NDRI), although no substantial research on this compound has been conducted. The horrible thing is that the people creating these drug are custom making them or better know as designer drugs. They use slight different chemicals with the same effect sell it under a new name and they are constantly changing there formula.

28 Bath Salts Video

29 Specific Amphetamines Example-Crystal Meth,Contains- Ephedrine/Pseudoephedrine Assessment-rapid speech, violence and paranoia, Meth mouth Treatment-ABC, treat signs and Symptoms-----Excited Delirium

30 Methamphetamine

31 Specific Cannabis compounds Example- K2 and SPICE “Ear Wax”More potent hard to control dosages Assessment-Loss of Control, Decreased pain response, delusions Treatment-Safety, Supportive Concentrated super concentrated THC commonly known as hash, hash oil, or earwax (that is what it looks like). It is made by collecting the resin, usually by shaking or brushing it from the leaves and buds of the plant, letting it dry and then compressing it. The THC is extracted from the plant and made into a concentrated form. Just a drop or two of the concentrate is enough to create a powerful high.

32 Brands

34 Specific Club/Rave Drugs Examples-Ecstasy, Roofies (rohypnol)Effects-Ecstasy=Reduces inhibitions and eliminates anxiety/Roofies=Relaxation and drowsiness, Dangerous when consumed with alcohol (Date Rape Drug) Assessment-Ecstasy=Constant motion, Excessive talking/Roofies=If mixed with alcohol coma Decreased HR and RR Treatment-Ecstasy-monitor temperature/hydration. Roofies=SANE capable hosp.

35 Specific Prescription and OTC medicationsExamples-Robotussin, Corcidin, Krocodill, Skittles Parties Effects-Dextromethorphan long acting anesthetic and depressant/Krocodil=tissue necrosis/Skittles Parties=Clean out the medicine cabinets. Assessment-Loss of motor control(like they are intoxicated) Seizures Treatment-ABC- Supportive-treat signs and symptoms, PCC

37 Prescription AntidepressantsTCA Include amitriptyline, amoxapine, doxepin, nortriptyline, imipramine, clomipramine. TCAs have a narrow therapeutic index. Assessment Dry mouth, blurred vision, urinary retention, constipation, Confusion, hallucinations, hyperthermia, Respiratory depression, SZR, hypotension, cardiac dysrhythmias. Tx Monitor and treat cardiac dysrhythmias. Avoid use of flumazenil, which may precipitate seizures.

38 Prescription MAO Inhibit the activity of Monoamine Oxidase which breaks down neurotransmitters like epinieprhine, seritonin, and dopamine. Infrequently Prescribed Antidepressant Only if TCA or SSRI don’t work High mortality with overdose because of drug’s action Signs and Symptoms Headache, Nausea, agitation, restlessness, tremor, hyperthermia Palpitations, severe hypertension and tachycardia Progresses to bradycardia, hypotension, coma, and death Tx Standard

39 Prescription Trazodone, Bupropion, and SSRIs Signs and SymptomsDrowsiness, tremor, nausea, vomiting, tachycardia Serotonin syndrome Triggered by increasing the dose or by adding selected drugs Marked by agitation, anxiety, confusion, insomnia, headache, coma, salivation, diarrhea, abdominal cramps, “goose bumps”, flushed skin, hyperthermia, rigidity, shivering, incoordination, and myoclonic jerks Tx Standard

40 OTC ASA Tylenol, Acetometophin Common Overdose DrugIncludes aspirin, oil of wintergreen Signs and Symptoms Tachypnea, hyperthermia, confusion, lethargy, coma, cardiac failure, and dysrhythmias, Abdominal pain, vomiting, pulmonary edema, ARDS Tx Activated charcoal indicated Tylenol, Acetometophin Common OTC Antipyretic and Analgesic

41 ASA/Tylenol Tylenol cont’d

42 OTC NSAIDS Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)Include ibuprofen, keterolac, naproxen sodium Signs and Symptoms Headache, tinnitus, nausea, vomiting, abdominal pain, drowsiness, Dyspnea, wheezing, pulmonary edema, swelling of extremities, rash, itching

43 Specific Plants Decorative PlantsCommon source of accidental poisoning in children Signs and Symptoms Excessive salivation, lacrimation, diaphoresis, abdominal cramps, nausea, vomiting, diarrhea, and altered mental status Examples- Intentional-Salvia Divinorium aka Magic Mint, Sally-D Effect-Hallucinogenic, users report it is just intense as Mescaline. Not controlled by DEA. Assessment-Hallucinations, Delusion

44 Sally-D

45 Opiates Heroin Names-smack, skag, horse, brown, black, tarOrigin-Heroin is an opiate drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant Action-Works on opiate receptor in the brain specifically mu, kappa, and delta receptors in the central nervous system Onset-Intravenous heroin peaks in the serum in less than 1 minute while intranasal and intramuscular heroin peaks in 3 to 5 minutes Routes-injected, snorted/sniffed, or smoked Problems- Heroin's lipid solubility 7 times more toxic than morphine when IV Concurrent Rx use

46 Heroin Effect

48 Herbals Complimentry medicineHerbal-used to treat illness or disease, considered safe Supplements-Product used to supplement the diet, may also contain herbs Often used for conditions such as Arthritis, Asthma,Diabetes Common herbals-Ginseng, Garlic Common supplements-Fish oil, Glucosaimine

49 Herbals What to expect Patient is often taking many of these Herb/SuppSide effect of these medication-Cardiac, Fluid loss Locate and take with you to Hospital Example-Cascara Sagrada Used for Constipation, Indigestion Adverse effects-Vomiting, Dysrhythmias Treat for Fluid loss monitor EKG Chondroitin Use-joint damage Adverse effect-Nausea and Diarrhea can enhance the effect of blood thinners

50 General Management Scene Size-Up What is the callBe alert to the potential for violence. Restraints Look for signs of hazardous material/Drugs/suspicious material Pill bottles Meth equipment Resources Suicidal Patients and Protective Custody Involve law enforcement/medical direction. Know local laws and procedures

51 General Management Primary Assessment Secondary ABC Transport decisionObtain Hx Identify the toxin and length of exposure Rapid head to toe assessment Monitor vital signs closely Hx from Family members/Poison control

52 General Management Drug removalReduce intake/Remove the individual from the toxic environment. Reduce absorption of toxins in the body. NG tube and activated charcoal. Enhance elimination of the toxin Antidotes

53 Drugs for treatment Names-naloxone, NarcanAction-Narcotic Antagonist, competes for opiate receptors in the brain. It also displaces narcotic molecules from receptors IV Narcan has an onset of 1-2 minutes and a duration of minutes. Indications-For reversal of depression cause by the following (MSO4, Demerol, Heroin, Dilaudid, codeine, Percodan, Fentanyl, Methadone. Tx of coma of unknown origin Dose and Route- 1 to 2 mg SIVP, IM, and SQ. 2mg IN Contraindications/Precautions/Side-effect-Hypersensitivity, Narcan should be admin cautiously to patient who are known to be physically dependent on narcotics

54 Drugs Names- Sodium Bicarbonate, BicarbAction-Alkanlinizing agent, salt that provides bicarbonate to buffer metabolic acidosis Indication-TCA overdose Dosage and Route-1meq/kg initial followed by .5 meq/kg q 10 min IV for persistent or prolonged QRS Contraindications/Precaution-None in TCA overdose, do not admin with calcium chloride. Weight important when calculating doses

55 Drug Calcuim Chloride Name-Action-Reverse symptoms of Calcium Channel blockers Indications-Calcuim Channel od, Hydrofluroic acid exposure with cardiac arrest or Tetany(Overactive neurological reflexes, cramping.) Dosage and Route-1,000mg IV, hydrofluoric 400mg iv Contraindications- renal-cardiac disease no arrest, hypercalcemia, Precatuions/Side-effects-hypotension, watch for inflitration, sodium bicarbonate and calcium precipitate

56 Drugs Names-GlucaGen Action-Glucagon has direct myocardial action and has been investigated as an inotrope in both ischemic and non-ischemic heart failure Indications-Calcium Channel Blocker and Beta Blocker OD Dosage and Route-1mg IV or IM Contraindications-Allergies to Protein

57 Drugs Names-RomaziconAction-Benzo. Antagonist, inhibits action on GABA/Benzo. Complex. Reverses sedation Indication-Complete and partial reversal of CNS and respiratory depression. From the following agents Valium , Versed, Ativan, Restoril, Ambien, Klonopin, Xanax Dosage and Route-.2mg up 1.0mg Contraindication-TCA overdoses or people with a hx of szr. Precaution-Causes szr.

58 Drugs Benadryl Names-diphenhydramineActions –blocks histamine receptors Indications-Extrapyramidal reactions Dosage and route-50mg iv or IM Contraindications-MAO, Nursing mothers, Newborns Precautions/Side effects-drowiness,hypotension,palpations use with caution in patients with Asthma

59 Nerve Agents Affect nerve impulse conduction Examples GB (sarin) VXGD (soman) GA (tabun) Organophosphates

60 General CharacteristicsMilitary Tabun (GA), Sarin (GB), Soman (GD), VX Commercial Parathion, Sevin Therapeutic Drugs Antilirium® Prostigmine ® Mestinon ® G agents represent a German scientist – all of these were synthesized by Germany. Military - Tabun (GA) - Colorless to brown; fruity odor Sarin (GB) - Colorless; odorless; easiest to make Soman (GD) - Colorless; fruity, camphor odor *(“NOTION THAT THIS HAS A FRUITY SMELL, BUT I WOULDN’T WANT TO TEST THAT…”) VX - Colorless to straw-colored; odorless; liquid skin hazard; consistency of motor oil Commercial – (Kids are commonly exposed to commercial agents) Parathion - organophosphate insecticide Sevin - carbamate insecticide Therapeutic Drugs Antilirium® Prostigmine ® Mestinon ®

61 ACh Normal Nerve FunctionWhen a nerve impulse reaches the synapse, ACh is released from the nerve ending and diffuses across the synaptic cleft to combine with receptor sites on the next nerve, and the electrical message continues. NOTE: Emphasize that the effect of unwanted electrical message propagation depends on the receiving end organ. A gland will continue to secrete, a muscle will continue to contract, a nerve will continue to generate additional electrical impulses.

62 AChE GB ACh Nerve Agent ActionHOW NERVE AGENTS WORK The term “nerve agents” refers to chemicals that produce biological effects by inhibiting the enzyme AChE, thus allowing the neurotransmitter ACh to accumulate. Included among the “nerve agents” are some drugs (such as physostigmine and pyridostigmine) and some insecticides (Sevin®, malathion, and related insecticides). These compounds cause the same biological effects as the nerve agents developed for military use, but the latter are more than a hundred-fold more potent. As a result of inhibition of AChE, the neurotransmitter ACh accumulates to over-stimulate the organs it normally stimulates in the portion of the nervous system. This causes hyperactivity in these organs. These are all innervated by the cholinergic portion of the nervous system and have muscarinic receptors, nicotinic receptors, or a combination (central nervous system and cardiovascular system). ACh GB

63 Nerve Agents Absorption or inhalation Assessment: SLUDGE MM ManagementAtropine Pralidoxime chloride

64 Agent Release Possible cloud, puddle strange or unusual odorDead or damaged plants and/or animals Potential targets Key: manifestation of common signs and symptoms occurring rapidly among a large group of individuals

65 Protect yourself Approach from uphill. Maintain distance. Evacuate.Decontaminate. Provide appropriate medical treatment

66 Drugs Atropine Name Action-AnticholinergicIndication-symptomatic bradycardia or Organophosphate poisoning/nerve agent Dosage and Route-.5mg up to 3 for brady iv. For poisoning 2mg q IV,IO, or IM until lungs are clear. Contraindications- obstructive disease of the GI tract, neuropathy, glaucoma Precaution/Side effects-paradoxical bradycardia when pushed to slowly.

67 Drugs 2-pam Names-PralidoximeAction-reactivates cholinesterase after poisoning with anticholinesterase agents, reverse muscle paralysis Indications-to be used after atropine in nerve agent posioning Dosage and Route-600mg IM auto-injector Contraindications- Precautions/side effects-use in caution with pregnant female or those nursing

68 THE END