TOXICOLOGY

EMERGENCIES
Epidemiology
 Over 4 million poisonings occur
annually.
 10% of ED visits and EMS responses
involve toxic exposures.
 70% of accidental poisonings occur in
children under 6 years old.
 80% of attempted suicides involve a
drug overdose.
Poison Control Centers
 Poison Control (PUSAT RACUN NEGARA)
National network of specially trained providers.
Typically regional or statewide.
Accessed by telephone.
 Contact poison control early.
Assist in determining potential toxicity.
Advise on prehospital treatment.
Advise the receiving facility and medical
direction.
Routes of Toxic Exposure (1 of 4)
 Ingestion
 Common agents:
○ Household products
○ Petroleum-based
agents
○ Cleaning agents
○ Cosmetics
○ Drugs, plants, or
foods
 Absorption occurs in
the stomach and
small intestine
Routes of Toxic Exposure (2 of 4)
 Inhalation
 Common agents:
○ Toxic gases, vapors,
fumes, aerosols
○ Carbon monoxide,
ammonia, chlorine
○ Tear gas, freon, nitrous
oxide, methyl chloride
○ Carbon tetrachloride
 Absorption occurs
via the capillary-
alveolar membrane
in the lungs.
Routes of Toxic Exposure (3 of 4)
 Surface Absorption
 Common agents:
○ Poison ivy, oak, or
sumac
○ Organophosphates
 Absorption occurs
through capillaries in
the skin.
Routes of Toxic Exposure (4 of 4)
 Injection
 Common agents:
○ Animal bites or stings
○ Intentional injection of
illicit drugs
 Substance enters
directly into the body
through a break in the
skin.
General Principles of Toxicologic
Assessment and Management
 Standard Toxicologic Emergency
Procedures
Recognize a poisoning promptly.
Assess the patient thoroughly to identify the
toxin and measures required to control it.
Initiate standard treatment procedures.
○ Protect rescuer safety.
○ Remove the patient from the toxic environment.
○ Support ABCs.
○ Decontaminate the patient.
○ Administer antidote if one exists.
General Assessment (1 of 2)
 Scene Size-up
Be alert to the potential for violence.
Look for signs of hazardous material
involvement.
○ Enter a hazardous materials scene only if
properly trained and equipped to do so.
 Initial Assessment
Airway and respiratory compromise are
common in toxicologic emergencies.
Manage life-threatening conditions.
General Assessment (2 of 2)
 History, Physical Exam, and Ongoing
Assessment
Identify the toxin and length of exposure.
Contact poison control and medical
direction according to local policy.
Complete appropriate physical exams.
Monitor vital signs closely.
General Treatment (1 of 4)
 Initiate supportive treatment.
 Decontamination
Reduce intake of the toxin.
○ Remove the individual from the toxic
environment.
Reduce absorption of toxins in the body.
○ Use gastric lavage and activated charcoal.
Enhance elimination of the toxin.
○ Use cathartics.
General Treatment (2 of 4)
 Antidotes
Useful only if the substance is known.
Rarely 100% effective.
Must be used in conjunction with other
therapies to ensure effectiveness.
General Treatment (3 of 4)
General Treatment (4 of 4)
 Suicidal Patients and Protective Custody
Involve law enforcement.
Involve medical direction.
Know local procedures and laws.
○ Laws for protective custody vary widely.
Management principles
 GI decontamination
Gastric
○ Ipecac
○ Activated Charcoal
○ Gastric Lavage
Gastro-Intestinal
○ Cathartics
○ Whole Bowel Irrigation
 Enhances elimination
 Antidotes
Syrup of ipecac
 Little evidence that ipecac prevents drug absorption or systemic
toxicity
 Considered only in fully alert patients
 Never indicated after hospital admission
 Contraindications:
altered mental status
prior vomiting
caustic ingestions
pulmonary toxicity e.g hydrocarbons
toxins that causes seizures
 Complications
Aspiration
Boerhaave syndrome
Mallory-Weiss tear
Intractable vomiting
Activated Charcoal
 The effectiveness of activated charcoal decreases with
time; the greatest benefit is within 1 hour of ingestion.
 There is no evidence that the administration of
activated charcoal improves clinical outcome.
 Contraindication
Gastric or oesophageal perforation
When endoscopy is required
Poorly adsorbed substances: iron, lithium,
lead, hydrocarbons and toxic alcohols
 Complications
aspiration
intraluminal impaction in patients with
abnormal gut motility
Substances that are not absorb by
charcoal
 Mnemonic: CHARCOAL
Caustics & corrosive
Heavy metals
Alcohol & glycols
Rapidly absorbed substances
Cyanide
Other insoluble drugs
Aliphatic hydrocarbobs
Laxatives
Gastric lavage
 Insert a 36 - 40 F tube
 From patient’s chin to xyphoid process
 Left lateral decubitus, head down 20
 degrees
 Reported complication:
Aspiration pneumonia -most common
Laryngospasm with cyanosis
Kinking of lavage tube in eosphagus
Esophageal perforation
Whole bowel irrigation (WBI)
 Performed by administration of polyethylene glycol in
an osmotically balanced electrolyte solution
 Produces rapid catharsis by mechanically pushing out
the ingested substances
 Infused through a nasogastric tube
 Dose: 1.5 - 2L / hour
 Indications:
 body stuffers, packers
 sustained release formulations
 iron, heavy metals; lithium, lead
 Contraindications: diarrhoea, bowel
obstruction
Enhance Elimination
 Alkalinization – goal of urine pH 7.5 – 8
Achieved by administration of IV bicarbonate
Toxins that are weak acids will be ionised,
trapping the substance in the urine
The urine is then eliminated
Dose:
○ 1-2 mEq/kg IV bolus
○ 3-4 mEq/kg IV infusion over 1 hour
 Hemodialysis
severe salicylate ingestions
methanol
ethylene glycol
lithium
theophylline
carbamazepine
amanita mushrooms
 Indications:
ability to remove toxins already absorbed by gut
remove substances that are not absorbed by charcoal
 Contraindications (relative)
Haemodynamically unstable
Small children
Poor IV access
Bleeding diasthesis
Toxidrome
 A constellation of signs
and symptoms that
suggest a type of toxin
Carbon Monoxide (1 of 2)
 Exposure
Inhaled colorless, odorless gas
○ Poorly ventilated heating systems
○ Confined spaces
 Signs and Symptoms
Headache (most common),
dizziness, weakness, nausea, vomiting,
confusion.
“Cherry red” skin and mucus membranes.
Carbon Monoxide (2 of 2)
 Management
 Ensure rescuer
safety.
 Remove the patient
from the
contaminated area.
 Initiate supportive
measures.
○ High-flow, high-
concentration oxygen
 Hyperbaric therapy

© James Kingholmes/Science Photo Library/

Photo Researchers, Inc.
Caustic Substances (1 of 2)
 Exposure
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.
Caustic Substances (2 of 2)
 Signs and Symptoms
Facial burns
Pain in the lips, tongue, throat, or gums
Drooling, trouble swallowing
Hoarseness, stridor, or shortness of breath
Shock from bleeding, vomiting
 Management
Perform standard toxicologic emergency
procedures.
Maintain an adequate airway.
Salicylates
 Common Overdose Drug
Includes aspirin, oil of wintergreen
 Signs and Symptoms
Tachypnea, hyperthermia, confusion, lethargy, coma,
cardiac failure, and dysrhythmias
Abdominal pain, vomiting, pulmonary edema, ARDS
 Treatment
 Maintain A,B,Cs and provide supplemental oxygen
 Establish IV access for meds and fluids
 activated charcoal
 IV crystalloids for renal clearance and hydration
 Sodium bicarbonate to correct acidosis or alkalinize urine
 Replace electrolytes
Acetaminophen
 Common Antipyretic and Analgesic
 Signs and Symptoms
1/2 hour –
Stage 1 Nausea, vomiting, weakness, and fatigue
24 hours
Abdominal pain, decreased urine, elevated liver
Stage 2 24–48 hours
enzymes

Stage 3 72–96 hours Liver function disruption

Stage 4 4–14 days Gradual recovery or progressive liver failure

Treatment
• Maintain A,B,Cs and provide supplemental oxygen
• Establish IV access
• Activated charcoal within one hour of ingestion, IV Fluids (NS)
• N-acetylcysteine (Mucomyst) orally, by NGT or intravenous
(Acetadote)
• IV Calcium Gluconate, Glucagon or vasopressors,
Other Nonprescription
Pain Medications
 Nonsteroidal Anti-Inflammatory Drugs
(NSAIDs)
Include ibuprofen, ketorolac, naproxen sodium
 Signs and Symptoms
Headache, tinnitus, nausea, vomiting,
abdominal pain, drowsiness
Dyspnea, wheezing, pulmonary edema, swelling
of extremities, rash, itching
 Treatment
Standard toxicologic emergency procedures
Tricyclic Antidepressants (1 of 2)
 Antidepressants
Include amitriptyline, amoxapine, doxepin,
nortriptyline, imipramine, clomipramine.
TCAs have a narrow therapeutic index.
 Signs and Symptoms of Toxicity
Dry mouth, blurred vision, urinary retention,
constipation
Tricyclic Antidepressants (2 of 2)
 Signs and Symptoms of Severe Toxicity
Confusion, hallucinations, hyperthermia.
Respiratory depression, seizures.
Tachycardia, hypotension, cardiac dysrhythmias.
 Management
Perform standard toxicologic emergency
procedures.
Monitor and treat cardiac dysrhythmias.
Avoid use of flumazenil, which may precipitate
seizures.
Common Drugs of Abuse (1 of 5)
Common Drugs of Abuse (2 of 5)
Common Drugs of Abuse (3 of 5)
Common Drugs of Abuse (4 of 5)
Common Drugs of Abuse (5 of 5)
 Drugs Used for Sexual Purposes
Ecstasy (MDMA)
○ Signs and symptoms include anxiety, nausea,
tachycardia, and hypertension, followed by
relaxation and euphoria.
○ Provide supportive care.
Rohypnol (“Date Rape Drug”)
○ Potent benzodiazepine, illegal in the U.S.
○ Treat as a benzodiazepine overdose and
sexual assault victim.
Alcohol Abuse (1 of 4)
 Physiologic Effects
CNS 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
Alcohol Abuse (2 of 4)
 Consequences of
Chronic Alcohol
Ingestion
 Poor nutrition
 Alcohol hepatitis
 Liver cirrhosis,
pancreatitis
 Sensory loss in
hands/feet
 Loss of balance and
coordination
 Upper GI hemorrhage
 Hypoglycemia
 Falls (fractures and
subdural hematoma)
Alcohol Abuse (3 of 4)
 Withdrawal Syndrome
Delirium Tremens (DTs)
Signs and Symptoms
○ Coarse tremor of hands, tongue, eyelids
○ Nausea, vomiting, general weakness, anxiety
○ Tachycardia, sweating, hypertension,
hallucinations, irritability or depressed mood,
poor sleep
○ Increased sympathetic tone, orthostatic
hypotension
Alcohol Abuse (4 of 4)
 Withdrawal Syndrome
Treatment
○ Establish and maintain the airway.
○ Determine if other drugs are involved.
○ Establish IV access.
 Lactated Ringer’s or normal saline
○ Consider medications.
 25g D50W if hypoglycemic
 100mg thiamine IV or IM
○ Transport, maintaining a sympathetic attitude,
and reassure the patient.