3.0 MEDICAL EMERGENCIES

3.13 TOXICOLOGY / SUBSTANCE ABUSE / OVERDOSE

All toxicologic emergencies or "poisonings" involve some form of voluntary or accidental exposure to toxic substances (chemicals) or pharmacological substances. Poisoning may be the result of exposure to toxic substances from ingestion, inhalation, injection or skin absorption. The most common poisoning emergencies include, but are not limited to: corrosive agents (acids/alkalis), hydrocarbons (gasoline, oil, pesticides, paints, turpentine, kerosene, lighter fluids, benzene, and pine-oil products), methanol (wood alcohol), ethylene glycol (anti-freeze), isopropyl alcohol, cyanide, food poisonings (bacterial, viral, and non-infectious) and plant poisonings. Envenomations are also managed as clinical poisonings. The primary goal of physical assessment of the poisoned patient is to identify effects on the three vital organ systems most likely to produce immediate morbidity and/or mortality: respiratory system, cardiovascular system and central nervous system. Major toxicity due to serious poisoning are evident in five (5) clinical signs: coma, cardiac dysrhythmia, gastrointestinal disturbance, respiratory depression, and hypotension or hypertension. Therefore, clinical management should be directed toward managing these system disorders.

An "overdose" is the result of an individual's intentional/accidental exposure to a pharmacological substance(s). The most common drugs of abuse resulting in overdose are: narcotics, central nervous system depressants, central nervous system stimulants and hallucinogens.

General management principles should be directed towards patient's clinical status and suspected cause for their clinical condition. ALS personnel must constantly be aware of immediate need for potential antidote (e.g., Narcan for narcotic overdose). Due to the complex nature of poisonings and substance abuse emergencies, it is strongly recommended that Medical Control/Poison Control Center be utilized in the initial management of these patients. The following protocol is a general treatment / management protocol.

ASSESSMENT / TREATMENT PRIORITIES

1. Maintain universal precautions for toxic chemicals and blood and body fluids (gloves, face mask etc.).

2. Assure scene safety, i.e. by ascertaining the source and type of poisoning. This is especially important when responding to industrial and/or farm accidents. Call appropriate public service agencies: fire, rescue, or HAZMAT teams to properly stabilize the scene and rescue the victim(s) from the source of contamination. The patient will need to be removed from point of exposure and must be properly decontaminated. Rescuers will need to place patient in a safe environment such that the EMTs and/or Paramedics may administer emergency care.

3. Maintain an open airway and assist ventilations as needed. Assure spinal stabilization/immobilization if indicated. Airway may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated.

4. Administer high concentration oxygen by non-rebreather mask as determined by patient's condition.

5. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs.

6. Obtain appropriate history related to event, including Past Medical History, Medications, Drug Allergies, Substance abuse or Trauma.

7. General management principles should be directed towards patient's clinical status and suspected cause for their clinical condition.

8. Envenomations: immobilize the extremity in a dependent position. May utilize cold packs and/or constricting bands, as indicated.

TREATMENT

BASIC PROCEDURES

1. Maintain scene safety and universal precautions for toxic chemicals and blood and body fluids (gloves, face mask etc.). If patient presents as an IV drug abuse/overdose, be cautious for needles and other drug paraphernalia and dispose of appropriately (legal implications may require EMS providers to give the drug paraphernalia to law enforcement authorities). Never place your hands in patient's pockets.

2. Maintain an open airway and assist ventilations as needed. Airway may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated.

3. Administer high concentration of oxygen by non-rebreather mask.

4. Identify offending agent and route of exposure.

5. Contact MEDICAL CONTROL. Medical Control may order:

a. Administration of syrup of ipecac (15 ml pediatrics age 1-7; 30 ml over age 7) by mouth followed by 4 oz glass of water for pediatric and 8 oz glass of water for patient over 7 yrs ONLY if the patient is fully conscious, has a normal gag reflex, is not seizing, is not pregnant and has NOT ingested hydrocarbon, petroleum distillate, corrosive/caustic substances, ammonia, cyanide, strychnine and tricyclic anti-depressants.

b. Administration of activated charcoal 1 gram per kg by mouth mixed with water or sorbitol ONLY if the patient is fully conscious and has NOT ingested hydrocarbon, petroleum distillate, corrosive substances.

6. Activate ALS intercept, if deemed necessary and if available.

7. Initiate transport as soon as possible with or without ALS.

8. Notify receiving hospital.

INTERMEDIATE PROCEDURES

1. Maintain scene safety and universal precautions for toxic chemicals and blood and body fluids (gloves, face mask etc.). If patient presents as an IV drug abuse/overdose, be cautious for needles and other drug paraphernalia and dispose of appropriately (legal implications may require EMS providers to give the drug paraphernalia to law enforcement authorities). Never place your hands in patient's pockets.

2. Maintain an open airway and assist ventilations as needed. Airway may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated.

3. Administer high concentration of oxygen by non-rebreather mask.

4. Identify offending agent and route of exposure.

5. ALS STANDING ORDERS

a. Provide advanced airway management (if indicated).

b. Draw red top blood sample and initiate IV Normal Saline while in transport. Titrate IV to patient's hemodynamic status.

6. Contact MEDICAL CONTROL. Medical Control may order:

a. Administration of syrup of ipecac (15 ml pediatrics age 1-7; 30 ml over age 7) by mouth followed by 4 oz glass of water for pediatric and 8 oz glass of water for patient over 7 yrs ONLY if the patient is fully conscious, has a normal gag reflex, is not seizing, is not pregnant and has NOT ingested hydrocarbon, petroleum distillate, corrosive/caustic substances, ammonia, cyanide, strychnine and tricyclic anti-depressants.

b. Administration of activated charcoal 1 gram per kg by mouth mixed with water or sorbitol ONLY if the patient is fully conscious and has NOT ingested hydrocarbon, petroleum distillate, corrosive substances.

7. Activate Paramedic intercept, if deemed necessary and if available.

8. Initiate transport as soon as possible with or without Paramedics.

9. Notify receiving hospital.

PARAMEDIC PROCEDURES

1. Maintain scene safety and universal precautions for toxic chemicals and blood and body fluids (gloves, face mask etc.). If patient presents as an IV drug abuse/overdose, be cautious for needles and other drug paraphernalia and dispose of appropriately (legal implications may require EMS providers to give the drug paraphernalia to law enforcement authorities). Never place your hands in patient's pockets.

2. Maintain an open airway and assist ventilations as needed. Airway may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated.

3. Administer high concentration of oxygen by non-rebreather mask.

4. Identify offending agent and route of exposure.

5. ALS STANDING ORDERS

a. Provide advanced airway management (if indicated).

b. Draw red top blood sample (at a minimum) and initiate IV Normal Saline. Titrate IV to patient's hemodynamic status.

c. Cardiac Monitor: manage dysrhythmias per protocol.

d. Narcan 0.4-2.0 mg IV Push or IM, SQ or ET. May be repeated as indicated.

e. Thiamine 100 mg IV or IM

f. Determine Blood Glucose level:

g. If no IV access, administer Glucagon 1-2 mg IM for suspected/known hypoglycemia

6. Contact MEDICAL CONTROL. Medical Control may order:

a. Administration of syrup of ipecac (15 ml pediatrics age 1-7; 30 ml over age 7) by mouth followed by 4 oz glass of water for pediatric and 8 oz glass of water for patient over 7 yrs ONLY if the patient is fully conscious, has a normal gag reflex, is not seizing, is not pregnant and has NOT ingested hydrocarbon, petroleum distillate, corrosive/caustic substances, ammonia, cyanide, strychnine and tricyclic anti-depressants.

b. Administration of activated charcoal 1 gram per kg by mouth mixed with water or sorbitol ONLY if the patient is fully conscious and has NOT ingested hydrocarbon, petroleum distillate, corrosive substances.

c. Dextrose 50%, 25 gm IV Push

d. Narcan 0.4-2.0 mg IV Push or IM

e. Further Normal Saline bolus.

f. Calcium Chloride 10%, 2-4 mg/kg IV Push SLOWLY OVER FIVE (5) MINUTES (i.e., for calcium blocker toxicity).

g. Sodium Bicarbonate 0.5 - 1.0 mEq/Kg IV Push.

h. Atropine 2.0- 5.0 mg I V Push.(i.e., organophosphate poisoning management)

i. Albuterol 0.5% (i.e., bronchospasm management)

j. Lasix 40 mg IV bolus (i.e., pulmonary edema management)

k. Valium (Diazepam) 5 mg-10 mg slow IV push or Ativan (Lorazepam) 2mg-4mg slow IV push.

l. If Atropine is ineffective in patient(s) with known organophosphate poisoning and if available: Pralidoxime Chloride (2-PAM Chloride): Adult: 1 gram IV over 15-30 minutes Pedi: 20-50 mg/kg IV over 15-30 minutes

m. Amyl nitrite: administer vapors of a crushed inhalant or pearl under the patients nose for 15 out of every 30 thirty seconds with intermittent 100% oxygen administration.

n. CYANIDE ANTIDOTE KIT if available by EMS service and/or industrial site:

o. Flumazenil (Mazicon) (i.e., for ACUTE benzodiazepine overdose management): 0.2 mg IV over 30 Seconds; additional dose 0.3 mg may be given in 30 seconds followed by 0.5 mg at 1 minute intervals to maximum dose of 3 mg. NOTE: NOT recommended for pediatric nor pregnant patients.

p. Glucagon 1.0 - 5.0 mg IM, SC, IV for known or suspected beta blocker overdose.

7. Initiate transport as soon as possible.

8. Notify receiving hospital.






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