Poisoning/Overdose Universal Care

Table of Contents

Aliases

Toxin, overdose, poison, exposure

Patient Care Goals

  1. Remove patient from hazardous material environment. Decontaminate to remove continued sources of absorption, ingestion, inhalation, or injection
  2. Identify intoxicating agent by toxidrome or appropriate environmental testing
  3. Assess risk for organ impairments (heart, brain, kidney)
  4. Identify antidote or mitigating agent
  5. Treat signs and symptoms in effort to stabilize patient

Patient Presentation

Inclusion (Suspect Exposure) Criteria

  1. Presentation may vary depending on the concentration and duration of exposure. Signs and symptoms may include, but are not limited to, the following:
    1. Absorption:
      1. Nausea
      2. Vomiting
      3. Diarrhea
      4. Altered mental status
      5. Abdominal pain
      6. Rapid heart rate
      7. Dyspnea
      8. Wheezing
      9. Seizures
      10. Arrhythmias
      11. Respiratory depression
      12. Sweating
      13. Tearing
      14. Defecation
      15. Constricted/dilated pupils
      16. Rash
      17. Burns to the skin
    2. Ingestion:
      1. Nausea
      2. Vomiting
      3. Diarrhea
      4. Altered mental status
      5. Abdominal pain
      6. Rapid or slow heart rate
      7. Dyspnea
      8. Seizures
      9. Arrhythmias
      10. Respiratory depression
      11. Chemical burns around or inside the mouth
      12. Abnormal breath odors
    3. Inhalation:
      1. Nausea
      2. Vomiting
      3. Diarrhea
      4. Altered mental status
      5. Abnormal skin color
      6. Dyspnea
      7. Seizures
      8. Burns to the respiratory tract
      9. Stridor
      10. Sooty sputum
      11. Known exposure to toxic or irritating gas
      12. Respiratory depression
      13. Sweating
      14. Tearing
      15. Constricted/dilated pupils
      16.  Dizziness
    4. Injection:
      1. Local pain
      2. Puncture wounds
      3. Reddening skin
      4. Local edema
      5. Numbness
      6. Tingling
      7. Nausea
      8. Vomiting
      9. Diarrhea
      10. Altered mental status
      11. Abdominal pain
      12. Seizures
      13. Muscle twitching
      14. Hypoperfusion
      15. Respiratory depression
      16. Metallic or rubbery taste
  2. Toxidromes (constellations of signs and symptoms that add in the identification of certain classes of medications and their toxic manifestations). These toxidrome constellations may be masked or obscured in poly pharmacy events
    1. Anticholinergic
      1. Red as a beet (Flushed skin)
      2. Dry as a bone (Dry skin)
      3. Mad as a hatter (Altered mental status)
      4. Blind as a bat (Mydriasis)
      5. Hot as a pistol (Hyperthermia)
      6. Full as a flask (urinary retention)
      7. “Tachy” like a pink flamingo (tachycardia and hypertension)
    2. Cholinergic (DUMBELS) DUMBELS is a mnemonic used to describe the signs and symptoms of acetylcholinesterase inhibitor agent poisoning – all patient age groups are included where the signs and symptoms exhibited are consistent with the toxidrome of DUMBELS
      1. Diarrhea
      2. Urination
      3. Miosis/Muscle weakness
      4. Bronchospasm/Bronchorrhea/Bradycardia (the killer Bs)
      5. Emesis
      6. Lacrimation
      7. Salivation/Sweating
    3. Opioids
      1. Respiratory depression
      2. Miosis (pinpoint pupils)
      3. Altered mental status
      4. Decreased bowel sounds
    4. Sedative Hypnotic
      1. Central nervous system depression
      2. Ataxia (unstable gait or balance)
      3. Slurred speech
      4. Normal or depressed vital signs (pulse, respirations, blood pressure)
    5. Stimulants (Sympathomimetic)
      1. Tachycardia, tachydysrhythmias
      2. Hypertension
      3. Diaphoresis
      4. Delusions/paranoia
      5. Seizures
      6. Hyperthermia
      7. Mydriasis (dilated pupils)
    6. Serotonin Syndrome (presentation with at least three of the following)
      1. Agitation
      2. Ataxia,
      3. Diaphoresis
      4. Diarrhea
      5. Hyperreflexia
      6. Mental status changes
      7. Myoclonus
      8. Shivering
      9. Tremor
      10. Hyperthermia
      11. Tachycardia

Exclusion Criteria

No recommendations

Patient Management

Assessment

  1. Make sure the scene is safe. Consider using environmental Carbon Monoxide (CO) detector on “first in” bag if possible
  2. Consider body substance isolation (BSI) or appropriate PPE
  3. Assess ABCD and, if indicated, expose patient for assessment, and then re-cover to assure retention of body heat
  4. Vital signs including temperature
  5. Attach cardiac monitor and examine rhythm strip for arrhythmias (consider 12-lead EKG)
  6. Check blood glucose level
  7. Monitor pulse oximetry and ETCO2 for respiratory decompensation
  8. Perform carboxyhemoglobin (CO) device assessment, if available
  9. When indicated, identify specific medication taken (including immediate release vs sustained release), time of ingestion, dose, and quantity.
  10. Obtain an accurate ingestion history (as patient may become unconscious before arrival at ED):
    1. Time of ingestion
    2. Route of exposure
    3. Quantity of medication or toxin taken (safely collect all possible medications or agents)
    4. Alcohol or other intoxicant taken
  11. Obtain pertinent cardiovascular history and other prescribed medications
  12. Check for needle marks, paraphernalia, bites, bottles, or evidence of agent involved in exposure, self-inflicted injury, or trauma
  13. Law enforcement should have checked for weapons and drugs, but you may decide to re-check
  14. Obtain pertinent patient history
  15. Perform physical examination

Treatment and Interventions

  1. Assure a patent airway
  2. Administer oxygen as appropriate with a target of achieving 94-98% saturation and, if there is hypoventilation noted, support breathing
  3. Initiate IV access for infusion treatment medication and/or normal saline if indicated
  4. Fluid bolus (20 mL/kg, max of 1 L bolus) if evidence of hypoperfusion
  5. Early contact with Regional Poison Control Center for treatment recommendations if time allows. The phone number is (800) 222-1222
    1. First arriving providers should contact and relay information to transporting EMS providers and ED staff
    2. They are allowed to give you orders for treatment, assist with patient destination, and if ED evaluation is even required.
  6. Administration of appropriate antidote or mitigating medication (refer to specific agent guideline if not listed below)
    1. Dystonia (symptomatic), extrapyramidal signs or symptoms, or mild allergic reactions
      1. Consider administration of diphenhydramine
        1. Adult: diphenhydramine 50 mg IV or IM
        2. Pediatric: diphenhydramine 1 mg/kg IVP or IM (maximum single dose of 50 mg)
    2. Opiate overdose, treat per the Opioid Poisoning/Overdose guideline
    3. Tricyclic Antidepressant (TCA) Overdose:
      1. Consider early airway management
      2. If widened QRS (100 msec or greater), consider sodium bicarbonate 1 mEq/kg IV, this can be repeated as needed to narrow QRS and improve blood pressure
      3. Consider fluid bolus (20 mL/kg, max of 1 Liter) for hypotension
      4. Consider vasopressors after adequate fluid resuscitation for the hypotensive patient [see Shock guideline]
      5. For seizure, treat per Seizures guideline

Notes – Poisoning/Overdose Universal Care