9.1. UNIVERSAL ASSISTANCE IN CASE OF POISONING/OVERDOSE

Related titles

Toxin, overdose, poisoning, exposure to a substance.

Objective of providing assistance

1. Moving the patient away from the area of toxic materials. Decontamination to eliminate a persistent source of ingestion, consumption, inhalation, or injection.
2. Identification of toxic agents by the presence of toxicosis or appropriate environmental testing.
3. Assessment of risks of organ dysfunction (heart, brain, kidneys).
4. Identification of an antidote or reliever.
5. Treatment of signs and symptoms to stabilize the patient’s condition.

Patient description

Inclusion criteria (suspected exposure to toxic substances)

1. The clinical presentation may vary depending on the concentration and duration of exposure. Symptoms and signs include, but are not limited to, the following:

a) absorption of toxic substances:

• • • • nausea
      • vomiting
      • diarrhea
      • disturbance of the state of consciousness
      • abdominal pain
      • tachycardia
      • shortness of breath
      • wheezing
      • convulsions
      • arrhythmia
      • respiratory depression
      • sweating
      • lacrimation
      • defecation
      • narrowed / dilated pupils
      • rash
      • skin burns;

b) use of toxic substances:

• • • •  
      • nausea
      • vomiting
      • diarrhea
      • disturbance of the state of consciousness
      • abdominal pain
      • brady- or tachycardia
      • shortness of breath
      • convulsions
      • arrhythmia
      • respiratory depression
      • chemical burns around or inside the mouth
      • a specific odor from the mouth;

c) inhalation of toxic substances:

• • • •  
      • nausea
      • vomiting
      • diarrhea
      • disturbance of the state of consciousness
      • abnormal skin color
      • shortness of breath
      • convulsions
      • burns of the respiratory tract
      • stridor
      • saliva with soot
      • the fact of inhalation of toxic or irritating gas
      • respiratory depression
      • sweating
      • lacrimation
      • constricted/dilated pupils
      • dizziness;

d) injection of a toxic substance:

• • • •  
      • local pain
      • wound in the injection area
      • redness of the skin
      • local swelling
      • numbness
      • tingling
      • nausea
      • vomiting
      • diarrhea
      • altered state of consciousness
      • abdominal pain
      • cramps
      • muscle twitching
      • hypoperfusion
      • respiratory depression
      • metallic or rubbery taste in the mouth.

2. Toxic poisoning syndrome (a set of signs and symptoms that allow to identify certain classes of drugs and their toxic effects). These signs may be masked or hidden in the case of multiple drugs:

a) anticholinergic:

• • • •  
      • red as beets (redness of the skin)
      • dry as a bone (dry skin)
      • as if out of his mind (altered mental state)
      • blind as a mole (mydriasis)
      • hot as a frying pan (hyperthermia)
      • full as a barrel (delayed diuresis)
      • “fussy” as a pink flamingo (tachycardia and hypertension);

b) cholinergic (DUMBELS mnemonic).

The DUMBELS mnemonic is used to describe the signs and symptoms of acetylcholinesterase inhibitor poisoning – poisoning with these drugs includes patients of all ages with signs of poisoning with these drugs and whose symptoms correspond to the DUMBELS mnemonic:

D – Diaphoresis/Diarrhea – Diarrhea
U – Urination – Diuresis
M – Miosis – Muscle weakness/muscle cramps
B – Bronchospasm/Bradycardia – Bronchospasm/Bronchitis/Bradycardia (killer B)
E – Emesis – Vomiting
L – Lacrimation – Lacrimation
S – Salivation – Excessive saliva/sweat secretion;

c) opioids:

• • • •  
      • respiratory depression
      • miosis (severely constricted pupils)
      • altered state of consciousness
      • weakened peristalsis;

d) sedative hypnotic drugs:

• • • •  
      • CNS depression
      • ataxia (impaired gait or coordination)
      • slurred speech
      • normal or decreased vital signs (pulse, heart rate, blood pressure);

e) stimulants (sympathomimetics):

• • • •  
      • tachycardia
      • hypertension
      • sweating
      • hallucination / paranoia
      • convulsions
      • hyperthermia
      • mydriasis (dilated pupils);

f) serotonin syndrome (presence of at least 3 of the following signs):

• • • •  
      • excitement
      • ataxia
      • sweating
      • diarrhea
      • hyperreflexia
      • changes in the state of consciousness
      • myoclonus
      • trembling
      • tremor
      • hyperthermia
      • tachycardia.

Exclusion criteria

None.

Patient management

Condition assessment

1. Make sure the scene is secure. Use a CO2 sensor if available.

2. Wear a special protective suit or appropriate personal protective equipment.

3. Perform an initial examination (ABCDE), undress the patient for the examination, and then cover the patient to maintain warmth.

4. Assess vital signs, including temperature.

5. Connect a cardiac monitor and assess for arrhythmia (you can record a 12-lead ECG).

6. Check your glucose level.

7. Monitor pulse oximetry and ETSO2 for respiratory depression.

8. Use a carboxyhemoglobin measurement device (if available).

9. If indicated, identify the medication used (including immediate-release vs. sustained-release), time of administration, dose, and quantity. If possible, collect all medications (prescribed and over-the-counter) at the scene.

10. Take a detailed history of the admission (as the patient may have lost consciousness before arriving at the emergency department):

a) time of administration;
b) route of administration;
c) amount of drug or toxin administered (carefully collect any residual drug/substance);
d) intake of alcohol or other substances.

11. In case of detection and collection of the substance, take care of your own safety and the safety of others in the receiving department.

12. Take a detailed history of cardiovascular disease and other prescribed medications.

13. Check for holes from needles, personal items, bites, bottles, or evidence of exposure to a drug or self-inflicted damage or injury.

14. Law enforcement is supposed to check for weapons and drugs, but you can check again.

15. Check the details of the patient’s history.

16. Perform a physical examination.

Treatment and interventions

1. Make sure the airway is clear.

2. Provide oxygen therapy with a target saturation of 94-98%. If hypoventilation is detected, support breathing.

3. Provide IV access for infusion therapy and/or a combination of sodium chloride + potassium chloride + sodium lactate + calcium chloride or saline, if indicated, and obtain blood samples if the patient’s treatment for EMD may have altered values (e.g., glucose, lactate, cyanide).

4. Fluid bolus (20 ml/kg) in the presence of hypoperfusion.

5. Administer the appropriate antidote or inhibitor (use the specific instructions for use if not listed below).

5.1. Paracetamol overdose:

a) use activated charcoal without sorbitol (1 g/kg) orally only if no more than one hour has passed since the moment of administration and the emergency room is far away;
b) based on suspicions about the amount and timing of ingestion, administer acetylcysteine (adults and children):

• • • •  
      • the initial dose is 150 mg/kg IV; dissolve in 200 ml of 5% glucose solution and administer over 1 hour;
      • then reduce the dose to 50 mg/kg in 500 ml of 5% glucose solution over 4 hours;
      • if intravenous access is not available, administer the dose of acetylcysteine 140 mg/kg orally;

c) if there is a risk of rapid impairment of consciousness, do not use the drugs orally.

5.2. Overdose of acetylsalicylic acid:

a) take activated charcoal without sorbitol (1 g/kg) orally:

• • • •  
      • since acetylsalicylic acid is absorbed, it is recommended to give activated charcoal as early as possible;
      • in case of impaired consciousness or risk of rapid impairment of consciousness, do not use oral medications (including activated charcoal);

b) in case of acetylsalicylic acid poisoning, allow the patient to breathe on their own, even if there is dyspnea, as long as there are no signs of decompensation and decreased saturation. Acid-base balance and subsequent manifestations worsen if the patient is manually ventilated.

5.3. Overdose of benzodiazepines

a) supportive ventilation;
b) bolus fluid therapy (20 ml/kg) in case of hypotension;
c) use vasopressors after adequate fluid resuscitation (1-2 liters of crystalloids) in case of hypotension.

5.4. Use of caustic substances (acids and alkalis):

a) Assess for airway obstruction due to spasm or direct burn damage to the oropharynx;
b) in the first few minutes after ingestion of the substance, give milk or water if available, 240 ml for adults and a maximum of 120 ml for children to minimize the risk of vomiting:

• • • • Do not attempt to dilute substances (acids, alkalis) if the patient has respiratory failure, impaired consciousness, acute abdominal pain, nausea and vomiting, or if the patient is unable to swallow and control the airways independently;
      • Do not force fluids.

5.5. Dystonia (symptomatic), extrapyramidal signs and symptoms, mild allergic reactions:

a) administer diphenhydramine:

• • • •  
      • Adults – 25-50 mg by IV or IM
      • children – 1-1.25 mg/kg by IV or IM (maximum single dose – 25 mg).

5.6. Overdose with monoamine oxidase inhibitors (symptomatic; e.g: MAOIs, isocarboxazide, phenelzine, selegiline, tranylcylproline):

a) use midazolam (benzodiazepine of choice) to control the temperature;
b) adults and children: midazolam 0.1 mg/kg with an increase to 2 mg slowly IV over 1-2 minutes for each dose increase, max. single dose 5 mg – reduce the dose by 50% if the patient is 69 years of age or older.

5.7. Treat an opiate overdose according to the guideline Opioid Overdose/Poisoning.

5.8. Poisoning by unknown substances due to oral ingestion:

a) in case of rapid deterioration of consciousness or in case of consumption of gasoline-containing compounds, do not use oral medications;
b) use activated charcoal without sorbitol (1 g/kg) orally if no more than one hour has passed since the time of administration (including paracetamol) and the emergency room is far away;
c) patients who have taken long-acting drugs or delayed onset of absorption should also receive activated charcoal.

5.9. Selective serotonin reuptake inhibitors:

a) conduct an early airway assessment;
b) treat arrhythmia according to the ACLS guidelines of professional life support;
c) aggressive control of hyperthermia using cooling methods;
d) infusion bolus therapy (20 ml/kg) for hypotension;
e) use vasopressors after adequate infusion therapy (1-2 liters of crystalloids) for hypotension (see Shock guideline);
f) in an agitated state, use midazolam (benzodiazepine of choice):

• • • •  
      • adults: midazolam 0.1 mg/kg in increments of up to 2 mg slowly over 1-2 minutes for each dose increase, maximum single dose 5 mg; reduce the dose by 50% if the patient is 69 years of age or older;
      • children: midazolam 0.1 mg/kg with an increase to 2 mg slowly over 1-2 minutes for each dose increase, maximum single dose 5 mg, or midazolam 0.2 mg/kg nasally, maximum dose 4 mg;

g) in case of seizures, treat according to the guideline “Seizures”.

5.10. Overdose of tricyclic antidepressants:

a) perform early airway management;
b) in case of a wide QRS complex (100 m/s or longer), administer sodium bicarbonate 1-2 mEq/kg IV, repeat as needed until the QRS complex is narrowed or blood pressure stabilizes;
c) infusion therapy, bolus (20 ml/kg) in case of hypotension;
d) use vasopressors after adequate infusion therapy (1-2 liters of crystalloids) in hypotension (see Guideline “Shock”);
e) in case of agitation, use midazolam (benzodiazepine of choice):

• • • • adults: midazolam 0.1 mg/kg in increments of up to 2 mg slowly over 1-2 minutes for each dose increase, maximum single dose 5 mg; reduce the dose by 50% if the patient is 69 years of age or older;
      • children: midazolam 0.1 mg/kg with an increase to 2 mg slowly over 1-2 minutes for each dose increase, maximum single dose 5 mg, or midazolam 0.2 mg/kg nasally, maximum dose 4 mg;

Patient safety

1. Safety of the patient and EMS workers at the scene/environment.
2. Apply carbon dioxide monitoring.
3. Monitor the airway, breathing, pulse oximetry, ETSO2, and adequate ventilation as they may change.
4. Check vital signs frequently.
5. Monitor the level of consciousness.
6. Monitor the ECG, especially the frequency, rhythm, duration of the QRS complex and the QT interval.
7. Maintain or normalize the patient’s body temperature.
8. The regional poison control center should be involved as soon as possible to assist with appropriate therapy and tracking patient outcomes to be more aware of toxic effects. The national 24-hour toll-free number for poison control centers is (800) 222-1222, and it is a resource for free, confidential expert advice from anywhere in the United States.

Useful information for training

Key points

1. Each toxin or overdose has unique characteristics that should be considered in individualized protocols.
2. Activated charcoal (which does not combine with other drugs or agents) is still effective for poisoning, provided there is no risk of rapid depression of consciousness or airway obstruction/aspiration (additional measures are needed to prevent and manage aspiration).
3. Ipecac is no longer recommended for any poisoning or ingestion of toxic substances – the manufacturer has discontinued its production.
4. Flumazenil is not indicated for suspected benzodiazepine overdose, as it can provoke treatment-resistant seizures if the patient is dependent on benzodiazepine.

Relevant evaluation results

Periodic check-ups are important because the patient’s condition can quickly deteriorate and become catastrophic.

Key elements of documentation

1. Re-examination and documentation of signs and symptoms, as the patient’s clinical condition may deteriorate dramatically.
2. Identification of possible causes of poisoning.
3. Initial measures to limit the spread of the substance to others/passers-by upon arrival at the scene using appropriate means.
4. Time of symptom onset and time to start treatment based on the specifics of the poisoning.

Criteria for the effectiveness of assistance

1. Early monitoring of airway patency in patients with a sharp deterioration in general condition.

2. An accurate history of exposure to the substance:

а) time of administration/exposure;
b) the way of contact;
c) the amount of the drug or substance received (carefully collect the remains of all possible drugs and substances);
d) consumption of alcohol or other substances.

3. Select and use appropriate protocols.

4. Frequent documentation of the results of reassessment of the patient’s condition.