(Poisoning and Drug Overdose)

A. General Guidelines maintain adequate airway, breathing and cardiac output Patients who ingested large amounts of toxic agents may require intubation immediately. - Perform gastric lavage - Contact local poison control center at UP College of Medicine 524-1078, 524-5651 loc 2311 - East Ave Med Ctr 928-0611 -Consider possibility of suicide -All female with chemical ingestion should undergo pregnancy test

B. Principles of Decontamination External Decontamination - Wash skin with soap and water - Remove cloths - Keep warm, use blankets

 Gastric Lavage - contraindications includes strong ingestion of strong acids, alkalis, petroleum and distillates. - Airway must be protected with endotracheal tube unless awake, alert and has a gag reflex - Position head on one side of he bed to prevent aspiration - If with severe DOB stat intubation - Perform gastric lavage unless overdose with acid - Lavage is useful within two hours of ingestion Activated Charcoal - Always consider giving charcoal after emesis or lavage until specifically contraindicated - Multiple doses of charcoal in (+) metamphetamine, phenothiazines, digoxin, theophylline, phenobarb, and organophosphates - Activated charcoal is not effective for alkalis, cyanide, mineral acid and ferrous sulfate

 Cathartics - contraindicated with infants (risk for dehydration), intestinal obstruction, electrolyte imbalance - sodium sulfate is contraindicated in HPN and heart failure

 Forced Diuresis - forced neutral diuresis may be helpful for isoniazid, bromide and ethanol intoxification - make sure to monitor electrolytes - forced alkaline diuresis may be useful for Phenobarbital, salicylates and lithium using sodium bicarbonate.

C. Guidelines for Nurses when antidotes are ordered, it is meant to be given immediately or at least reasonably within the hour in some cases.

 Amphetamine/ Metamphetamine Toxicity - start charcoal and cathartics - emesis has no role - WOF for seizure, psychosis, agitation, hypertensive crisis, arrhythmias - Secure ABG, CBC with PC, PT, PTT, RBS, BUN, Crea, Na, K, UA - Diazepam and Phenytoin for seizure - Beta-blockers, Lidocaine for dysrythmias

Specific Substance Ingestion Acid Ingestion - provide airway control, ventilation, circulatory support, and fluid resuscitation - wash the oral cavity (controversial) - emesis, lavage and charcoal are contraindicated - secure serial CBC and cross-matching - maintain NPO Alkali Ingestion - immediately rinse oral cavity - administer oxygen and IVF - secure serial CBC, CXR, and monitor electrolytes - esophagoscopy and gastroscopy should be performed immediately if there is drooling, stridor and painful swallowing

 Anticoagulant Overdose - Secure lab results such as CBC with PC, PT, PTT and Creatinine - For Heparin: Give protamine sulfate at 1mg iv for every 50-100 units of heparin infused in the preceeding 2 hours, dilute in 25-50ml fluid over 10 minutes - For Warfarin: perform gastric lavage and give activated charcoal if recently ingested; give vitamin k 5-10 mg every 8-12 hours; give FFP 2-6units for severe bleeding

 Diazepam Overdose - Place NGT and do gastric lavage - Protect airway - Instill activated charcoal, followed by repeated doses of 20-25 gm via NGT - Secure RBS, ABG, ECG and CXR - Watched out for hypotension, CNS and respiratory depression and withdrawal syndrome such as agitation, seizure, restlessness and insomnia.

 Digitalis Overdose - considered NGT insertion and gastric lavage - secure digitalis assay, CBC, Ca, K, Mg, CXR and ECG/ cardiac monitor - the treatment goal would be to correct hypokalemia. Hypomagnesemia or hypocalecemia. - The doctor may prescribe charcoal and cathartics - Watch out for hypotension; fluid challenge my be instituted - For arrythmias, lidocaine may

 Ethanol Toxicity - maintain adequate airway, ventilation, circulation and administer oxygen - Thiamine is useful to protect/ prevent liver damage - Phynetoin my be given in cases of seizure, but make sure to give it SIVP and hook the patient to the cardiac monitor

 Narcotic Overdose - maintain airway, ventilation and circulation - may start on Naloxone 2mg every 5 minutes , max 10mg IV, IM SQ - Activated charcoal if (+) for bowel sounds and cathartics - Watch out for signs of pneumonia, infections and rhabdomyolysis - Watch out for complications such as seizure, pulmonary edema and hypotension

 Hydrocarbon/ Kerosene Ingestion - Respiratory support - Treatment is not required in the absence of symptoms - Promote gastric emptying - Remove contaminated clothing and wash affected skin with soap and water. - Provide supplemental oxygen - secure CBC, ABG abd CXR Isoniazid Overdose - place an NGT and do gastric lavage is clean - watch out for seizure, lactic acidosis may give sodium bicarbonate - consider mannitol administration for forced diuresis - secure CBC, RBS, K, ABG

 Narcotic Overdose - maintain airway, ventilation and circulation - may give naloxone 2.0mg q 5 minutes initially max of 10mg IV, IM SQ - start activated charcoal if (+) with BM and cathartics - watched out for complications, PNA, hypotension, and seizures is (+) norpethidine

 Insecticides/ Pesticides Therapeutics 1. Decontamination - make he patient rinse with alkaline or baking soda (10gm in 100cc) - change cloths and wash the patient with gloves - insert NGT and do gastric lavage with activated charcoal - In cases of seizure; consider Phenytoin - wof for hypoglycemia - Give mannitol if with good urine output - secure CBC, RBS, ABG, SGOT and SGPT

 Paracetamol Overdose - Insert NGT - Activate charcoal about 30-100mg and then remove via NGT suction prior to acetylcysteine - Sodium Sulfate to induce vomiting - Antidote: N-acetylcysteine (NAC) . the initial administration would be 150mg/kg body weight infused in 200ml 5% dextrose over 15 minutes followed by IV infusion of 50mg/kg in 500ml of 5% dextrose water - NAC is very effective in preventing paracetamol-induced hepatotoxicity when administered; when administered with in 8 hours from the time of ingestion, the better. But beyond 8 hours, the protective effect diminishes progressively as the treatment interval increases

 Salicylate Poisoning Diagnostics: - CBC, K, RBS, ABG and UA - PT, PTT, SGOT, SGPT and alk Posh with 48 hours post ingestion Therapeutics: - Stabilize respiratory and cardiac functions - Avoid diluting the gastric contents since this mayincease gastric absorption - Consider NGT insertion - Give activated charcoal 1gm/ kg body weight every 6 hours - Sodium sulfate 15-30 gm in 100cc H20 orally if tolerated or with NGT with every other doses of activated charcoal to prevent charcoal constipation or fecal impaction - To increase urine ph, consider sodium bicarbonate - Glucose and KCl should be infused with other fluids

 Treatment Plan - if with dehydration and hypokalemia, manage with vigorous and with electrolyte replacement - Cerebral edema can be best avoided using hypertonic rehydration solution - Alkaline diuresis to maintain urinary ph at approx 8 - Monitor urine output - Assess hydration status - Watch closely for signs of fluid overload - Hemodialysis is indicated for initial salicylate level of >160ml/dl or with profound acidosis of below 7; or when there is renal failure, severe CNS dysfunction, pulmonary edema or deterioration despite supportive therapy

 SHOCK (Multisystem Stressor) Pathophysiology - Shock is a multisystem stressor that involves inadequate tissue perfusion and altered metabolism. - Inadequate tissue perfusion can lbe a result of nay condition that alters heat function (cardiogenic), blood volume(hypovolemic), blood pressure (neurogenic) and distribution of blood volume (septic/ anaphylactic) - Shock is a very complex clinical syndrome in which tissue perfusion is inadequate to meet the demands for oxygen - It alters cellular functions and eventually impairs body organ functions - Multi Organ Dysfunction Syndrome (MODS) is a term used to describe several impairment of the human functions

 Sepsis and Septic Shock - Sepsis is an acute systemic clinical syndrome caused by bacteria, viruses or fungi in the blood, most commonly gram (-) bacilli - At an early phase, generalized inflammatory response is triggered, causing widespread vasodilation - The progression to septic shock is due to the toxins released from the organism involved - Bacterial endotoxins activates the complement, coagulation and fibrinolytic system; inceases vascular permeability and trigger the vasoactive kinins causing vasodilation and increased capillary permeability thereby decreasing the vascular resistance and facilitating fluid shifting from intravascular to interstitial - Another response would be due to the histamine release causing increase in vascular permeability - This changes are further stimulated by the catecholamine and prostaglandins that are released from ischemic tissues - COLD SHOCK is he term used during the stage in which tissue perfusion becomes severely compromised and ischemic cellular damage occurs. - In addition the, fever is present due to the pyrogens released by the organism

 Anaphylactic Shock - systemic anaphylactic shick is potentially life threatening situation - it is he result of an exaggerated hypersensitivity response to an antigen - the classic form of anaphylaxis occurs in a sensitized person usually 1-20 minutes after the exposure to the antigenic substance - the most common substance that can cause reactions would be, drugs, antibiotics, foods, anesthetics, antisera and blood products - hypersensitivity reaction occurs over the surface of he mast cells which are located primarily in the lungs, small blood vessels and connective tissues - it also attacks basophils circulating in the blood - the antigenic substance triggers the release of kinins, histamines, prostaglandins, eosinophils, neutrophils - sow reacting substance of anaphylaxis (SRSA) such as prostaglandins and leukotrienes produces deleterious results icluding profound shock - Histamine is he primary mediator of anaphylactic attack. Leukotrienes produces vasoconstriction that is even worst than histamine - The prostaglandins exaggerate the bronchoconstriction; kinins increases the vascular permeability - The combined effects of the substance causes respiratory distress and obstruction

 Toxic Shock - it is another syndrome of shock believed caused by bacterial toxins e.g. Staph A enters he blood steam from the site of infection, commonly the vagina, diffusing across the mucus membranes. - They are then circulated throughout the body - these toxins causes massive vasodilatation

 Collaborative Management (Septic) - antibiotic therapy specific to he organism - Hemodynamic monitoring - Fluid resuscitation - Inotropic Agents - Ventilatory Support - Alkaline Support - Nutritional Support - Steroids - Antipyretic Agent - Naloxone - GI solution

 Collaborative Management (Anaphylaxis) - Airway maintenance - Epinephrine - Supplemental Oxygen - Fluid Resuscitation - Vasopressors - Angi-histamine - Bronchodilator - Steroids - Mast cell stabilizer - Glucagon - ECG monitoring

Multiple Injury This includes: 1. Major Trauma 2. Craniocerebral Trauma 3. Chest Trauma 4. Abdominal Trauma 5. Renal and Lower Tract Trauma Mechanisms of Injury: - Objects Producing Injury (ex. MVA, handgun, glass, wood, metal) - Type of Energy (ex. Kinetic, thermal, chemical, radiation) - Force of Energy (ex. Velocity, tension force, shearing force) - Use of Protective devices (ex. Helmet, airbags, seat belt)

Types of Injury: Blunt Injury occurs without interruption on the skin integrity Penetrating are produced from the motion of the objects that penetrate the tissue causing direct damage.

 Environmental EmergenciesHeat Stroke A failure of heat regulating mechanisms Types Exertional: occurs in healthy individuals during exertion in extreme heat and humidity Hyperthermia: the result of inadequate heat loss Elderly, very young, ill, or debilitatedand persons on some medicationsare at high risk Can cause death Manifestations: CNS dysfunction, elevated temperature, hot dry skin, anhydrosis, tachypnea, hypotension, and tachycardia

Management of Patients With Heat Stroke Use ABCs and reduce temperature to 39 C as quickly as possible Cooling methods Cool sheets, towels, or sponging with cool water Apply ice to neck, groin, chest, and axillae Cooling blankets Iced lavage of the stomach or colon Immersion in cold water bath Monitor temperature, VS, ECG, CVP, LOC, urine output Use IVs to replace fluid losses Hyperthermia may recur in 3 to 4 hours; avoid hypothermia

 Environmental EmergenciesFrostbite Trauma from freezing temperature and actual freezing of fluid in the intracellular and intercellular spaces Manifestations: hard, cold, and insensitive to touch; may appear white or mottled; and may turn red and painful as rewarmed The extent of injury is not always initially known Controlled but rapid rewarming; 37 to 40 C circulating bath for 30- to 40-minute intervals Administer analgesics for pain Do not massage or handle; if feet are involved, do not allow patient to walk

 Hypothermia Internal core temperate is 35 C or less Elderly, infants, persons with concurrent illness, the homeless, and trauma victims are at risk Alcohol ingestion increases susceptibility Hypothermia may be seen with frostbite; treatment of hypothermia takes precedence Physiologic changes in all organ systems Monitor continuously Management of Patients With Hypothermia Use ABCs, remove wet clothing, and rewarm Rewarming Active core rewarming Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, and warm peritoneal lavage Passive external rewarming Warm blankets and over-the-bed heaters Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances

 Management Patients With Carbon Monoxide Poisoning Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which does not transport oxygen Manifestations: CNS symptoms predominate Skin color is not a reliable sign and pulse oximetry is not valid Treatment Get to fresh air immediately Perform CPR as necessary Administer oxygen: 100% or oxygen under hyperbaric pressure Monitor patient continuously

 Management of Patients With Chemical Burns Severity of the injury depends upon the mechanism of action of the substance, the penetrating strength and concentration, and the amount of skin exposed to the agent Immediately flush the skin with running water from a shower, hose, or faucet Lye or white phosphorus must be brushed off the skin dry Protect health care personnel from the substance Determine the substance Some substances may require prolonged flushing/irrigation Follow-up care includes reexamination of the area at 24 hours, 72 hours, and 7 days

 Management of Patients With Substance Abuse Acute alcohol intoxication: a multisystem toxin Alcohol poisoning may result in death Maintain airway and observe for CNS depression and hypotension Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated Use a nonjudgmental, calm manner Patient may need sedation if noisy or belligerent Examine for withdrawal delirium, injuries, and evidence of other disorders

Management of Patients With Substance Abuse Acute alcohol intoxication: a multisystem toxin Alcohol poisoning may result in death Maintain airway and observe for CNS depression and hypotension Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated Use a nonjudgmental, calm manner Patient may need sedation if noisy or belligerent Examine for withdrawal delirium, injuries, and evidence of other disorders

 Radiation Exposure Radiation exposure may occur due to nuclear weapons, nuclear reactor incidents, or exposure to radioactive samples Exposure to radiation is affected by time, distance, and shielding Types of radiation exposure: External radiation: all or part of the body is exposed to radiation; as decontamination is not necessary, it is not a medical emergency Contamination: exposure to radioactive gases liquids or solids; requires immediate medical management to prevent incorporation Incorporation: uptake of the radioactive material into the body Radiation Decontamination Triage outside the hospital Cover floor and use strict isolation precautions to prevent the tracking of contaminants Seal air ducts and vents Waste is double bagged and put in a container labeled radiation waste Staff protection Water-resistant gowns, 2 pairs of gloves, caps, goggles, masks, and booties

 Dosimetry devices Patients are surveyed for radiation and directed to the decontamination area Each patient is decontaminated with a shower outside the ED Water, tarps, towels, soap, gowns, all the patients belongings, etc., must be collected and contained Patients are surveyed and showered again as necessary Showering should be performed so as not to contaminate clean areas with runoff from the showering Biologic samples: nasal and throat swabs; blood Internal contamination requires additional treatment: catharsis and gastric lavage with chelating agents Radiation Injuries Acute radiation syndrome (ARS): dose of radiation determines if ARS will develop All body systems are affected by ARS Presenting signs and symptoms determine predicted survival Probable survivors have no initial symptoms or only minimal symptoms Possible survivors present with nausea and vomiting that persists for 24 to 48 hours Improbable survivors are acutely ill with nausea, vomiting, diarrhea, and shock; neurologic symptoms suggest lethal dose; and survival time is variable