1 - toxicologic emergencies

8/6/2019 1 - ToXICOLOGIC Emergencies

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ACUTE BIOLOGIC CRISIS

TOXICOLOGIC EMERGENCIES




Ingested Poisons/ Swallowed Poisoning

Food Poisoning

Corrosive PoisoningNon-Corrosive Poisoning

Inhaled poisoning

Injected PoisoningSkin Contamination Poisoning/ Chemical Burns

Drug Intoxication/ Abuse




Goals of toxicologic

emergencies are the ff:

First - supportive

Second - to prevent or

minimize absorption &

promote excretionThird -to provide an

antidote



Ingested Poisons/ Swallowed Poisoning

Sudden explosive

illness which may occur after ingestion of

contaminated

substance.



Ingested Poisons: Primary Assessment and

Interventions

Assess for ABC

Maintain an open airway

some ingested substances may cause soft

tissue swelling of the airway.



Ingested Poisons: Subsequent Assessment

Identify the poison/Brief

History taking

Monitor neurologic andFluid and electrolyte

status

Diagnostic: blood and

urine test. Serious cases

gastric contents can be

submitted for evaluation



Ingested Poisons: Treatment and Nursing

Care

Administer oxygen for

respiratory depression

Treat anaphylactic shock

immediately

Seizure precaution




CareMinimizing absorption

of the ingested

content

For conscious:

Administer activated

charcoal with a

catharticInduction of emesis

with syrup of ipecac




CareMinimizing absorption

of the ingested

content:

For obtunded

Gastric lavage




CareMinimizing absorption of the ingested

content:

for deteriorating patients:

Forced diuresis

Hemoperfusion

Hemodialysis

repeated doses of charcoal




Care

Providing an

Antidote that willneutralize the

poison.

Psychiatricevaluation



FOOD POISONING

Sudden explosive

illness which mayoccur after

ingestion of

contaminated

food/drink.



FOOD POISONING: Assessment

Identify the amount and type of food

if possible bring the food/gastriccontents/vomitus/serum or feces to the health

center for further evaluation.

Assess Fluids and electrolyte balance



FOOD POISONING: Treatment and Nursing

Care

Weight the patient

for baseline data

Medications:

Anti-emetics



FOOD POISONING: Treatment and Nursing

Care

Health Teaching:Clear liquid diet or a

low residue diet



CORROSIV POISONING



ALKALINE

PRODUCTS:

Drain cleaners

(NaOH)

Toilet bowl cleaners

Non phosphatedetergent (ex. Surf)



� ACIDICPRODUCTS

Muriatic acid Pool, tiles and

metal cleaners(acetic, sulphuric,oxalic, nitric acid)

Rust remover



� Identify the substance if it is basic or acidic

� Note the amount of substance induced.� Assess for clinical manifestations

S/Sx:

Burning sensation where the substance pass

Dysphagia - due to injures tissue

Vomiting Drooling ± fear of swallowing due to pain

produced

Destruction of mucosa



� Dilute the chemical

substance with MILK

or WATER.

� Avoid inducing

vomiting

� Submit the patient

immediately to the

nearest health facility.



WHEN IN THE

HOS ITAL:

Elective

endoscopy

Insert an NG

Tube for Gastric

lavage.



- Secondary intake of substance SUCH AS

Chalk OR watusi.



� Identify the

substance induced



� Induce vomiting if the nurse is certain that it is

non corrosive.

¾ Bring the container of the induced substance

� Dilute the chemical substance with 3-4 glasses

of MILK or WATER



� Carry out NGT plus

gastric lavage.

� Induce Vomiting using

the syru p of IPECAC,

Heimlich Maneuver

and gag reflexstimulation.



Its toxic effect is by binding to circulatinghemoglobin to reduce the oxygen-carrying

capacity of the blood.

The affinity between carbon monoxide andhemoglobin is 200 to 300 times.



�Risk Factor:

� Environmental exposure (length)

� Underlying disease such as Anemia

� Respiratory and cardiovascular problems that

may aggravate the patient¶s condition.



� Assess adventitious sounds such as

stridor ; may indicate that CO poisoning is

caused by smoke inhalation. rales or

wheezes.

� Assess LOC

�Pink, cherry red or cyanotic pale skin

� Diagnostic: ABG¶s



� Goal:

a.) Reverse cerebral

and myocardialhypoxia

b.) Hasten carbon

monoxide elimination.



� Administer 100% oxygen with a tight fitting

mask

�Observe for possible signs of respiratory

and CNS damage.

�Obtain arterial blood samples for carboxyhemoglobin levels.



Carboxyhemoglobin

levels:

� Normal is less than

12%.

� Severe carbon

monoxide poisoningis present when

levels are greater

than 30% to 40%.



Insect Stings

Snakebites



� Assess Airway,

Breathing and

Circulation� Assess for

ana phylactic reactions

and associated signs

and sym ptoms.

� Remove the stinger

immediately thru

scra ping.



�Drug of choice:

EPINEPHR INE

� Administer Bronchodilator to

hel p relieve the

bronchos pasms.

� IV fluid of Choice:

Lactated Ringer¶s



�Obtain history of insect sting, previousex posure and allergies

�Ins pect skin for local reaction (erythema, pain, and edema on site of injury

�Continue monitoring blood pressure andres piratory status.



�A pply ice packs to

relieve pain.

�Elevate extremity

with large edematous

local reactions.



�Clean the woundthoroughly with

soa p and water or

an antise ptic

solution.



�Pharmacologic intervention: oral anti-

histamine for local reactions

�Administer tetanus pro phylaxis if not u p

to date.



�Health Education:yWhen sting occurs, take e pine phrine

immediately

yDo not squeeze venom sac because This may

cause additional venom to be injected.

yRe port immediately to the nearest health facility.



Snakebites



�Assess airway, breathing, and circulation if

patient is not alert.

�Observe for neurotoxicity accom panied by

res piratory paralysis, shock, coma, or death

during severe envenomation.

�Be pre pared to do CPR



� location. Bites to the head and trunk may progress

more ra pidly.

�Assess for local reactions: burning pain, swellingand numbness.

�WOF systemic reactions including nausea,

sweating, weakness, paralysis, signs of shock

and coma.



�K ee p the patient calm and rest in RECUMBE NT

POSITIO N with the affected extremity.

�Administer O2

� IV Fluid of Choice: Lactated Ringer¶s



�Monitor for bleeding

� administer blood products for coagulo pathy.

� Pharmacologic Treatment:

� Anti venin and be alert to allergic reaction

� Vaso pressor for shock treatment



SKIN CONTAMINATION OISONING/

CH

EMICAL BURNS

- A pplied poisons or chemical substances.



CHEMICAL BURNS: ASSESSMENT

´ Assess the severity of the

affected area.



CHEMICAL BURNS: TREATMENT

´ Immediately ex posed the skin with running H20

´ Please kee p in mind the safety of the health care provider

attending to the patient.

´ Standard burn treatment: Debridement and plastic

surgery (chronic Burn)

´ Administration of pro phylactic medication.

´ Schedule a follow u p check-u p / refer to Dermatologistfor further evaluation



CHEMICAL BURNS: TREATMENT



DRUG ABUSE: RIMARY

ASSESSMENT & INTER ENTIONS

� Assess the presence and adequacy of

res pirations

� Intubate or provide assisted ventilation in

severe res piratory de pressed patients or

lacking cough reflex



DRUG ABUSE: RIMARY

ASSESSMENT & INTER ENTIONS

� Pharmacologic

treatment: Naloxone

HCl ( Narcan is

given)

� Identify the amount

and ty pe of drug

� Conduct history

taking: su pportive,

realistic and em phatic



DRUG ABUSE: SUBSEQUENT

ASSESSMENT

� Perform Physical examination

� If the patient is unconscious consider all the

possible causes of loss of consciousness and

monitor level of LOC.

� Monitor vital signs frequently -Pharmacologic treatment may increase or

decrease the vital signs of the patient.




ASSESSMENT

� Monitor pu pils for

Extreme Miosis

( pin point pu pils)

which may indicatenarcotic overdose.

� Look for needle marks

and external evidenceof trauma.




ASSESSMENT

� Perform a ra pid neurologic survey: LOC, pu pil

size and reactivity and reflexes.

� Examine the patient¶s breath for characteristic

odor of alcohol and acetone.

� K ee p in mind that many drug abusers take

multi ple drugs simultaneously.

� Try to obtain history from the patient and

relative or com panion of the patient.

� Protect one¶s self against HIV and infectious

he patitis among users.



DRUG ABUSE: GENERAL

INTER ENTIONS

� GOAL:

y A. Su pport the res piratory

and cardiovascular

functions.y B. Give definitive treatment

for drug overdose

y C. Prevent further

absor ption, enhance drugelimination and reduce its

toxicity.



DRUG ABUSE: GENERAL

INTER ENTIONS

� Stabilize ABC

- Airway: Insert ET tube

- Breathing: res piratory rate, Ventilation/

ambu bag

- Circulation: CVP line, ECG, Pulse rate

� Remove drug from stomach; immediately if the patient is conscious.

� If unconscious, perform GASTR IC

LAV

AGE



DRUG ABUSE: GENERAL

INTER ENTIONS

� In patients lacking gag reflex or cough reflexes

perform this procedure only after intubation

with cuffed endotracheal tube to prevent

as piration of stomach contents.



DRUG ABUSE: GENERAL

INTER ENTIONS

� Provide comfort measures if

hy pothermia/hy perthermia occurs

� IV fluids of choice: if there is hy potension:

PNSS

� Treat seizures with Diaze pam (Valium) and

promote seizure precautions



DRUG ABUSE: GENERAL

INTER ENTIONS

� Laboratory: Urinalysis

� Provide psychiatric precautionary measures to

the patient or refer to psychiatric consult if

necessary.

� When the patient regained physiologic status,

refer to rehabilitation program.



� Cocaine

� Amphetamines

� Designer Drugs� MDA

� Ecstasy

� Ice� Eve



� S/Sx:

¾ Pyrexia

¾ seizure episodes¾ Ventriculardysrrhythmia

¾ Paranoia of being persecuted

¾ produces hallucinations and delusions.



� Ensure airway and ventilation

� Control seizure episodes by administering

diazepam (Valium)

� Monitor for cardiovascular effect of

drugs/hemodynamic monitoring e.g. ECG

� Give medications for the hyperthermic state and

antiarrhythmics for ventricular dysrrhythmia� When the patient regained physiologic status,

refer to rehabilitation program.



� Lysergic acid diethylamide

(LSD)

�

Phencyclidine HCl (PCP)� Mescaline

� Psilocybin mushrooms

� Jimson weed seeds



� S/Sx:

¾ Nystagmus

¾ mild HPN

¾ mild confusion¾ Incoherence

¾ Hyperactive

¾ may have combative behaviour

¾ may have delirium manic stage

¾ hallucinations regarding body image

¾ hypothermic



� Assess for any physical trauma

� Determine the real cause of hallucination



� Evaluation and maintenance of ABC

� Guide the patient to calm down

� Reassure the patient that everything he

experience is due to drug intoxication.

� Remind the patient ³fear´ is common and a

natural manifestation.



� Keep the client¶s eyes open to prevent

hallucination.

� Decrease sensory stimuli and sudden

movement

� Medication: Administer diazepam (Valium) if

hyperactivity cannot be controlled.



� Heroine acute intoxication

� Morphine

� Codeine



� S/Sx:

¾ Hypotension

¾respiratory depression leading to apnea

¾ Miosis

¾ and drowsiness progressing to stupor and coma.



� Administer naloxone (Narcan) 0.4 to 2 mg I.V. or by

endotracheal tube (effective in 1 to 2 minutes).

� Maintain an open airway but defer intubation until

naloxone is given, if possible.

� Monitor for reappearance of symptoms and readminister

naloxone.

� Protect the patient from harm (may be combative on

awakening).



� Barbiturates, such as amobarbital ( Amytal)

and secobarbital (Seconal)

� Benzodiazepines, such as diazepam

(Valium) and flurazepam (Dalmane)

� Other sedative/hypnotics, such as chloral

hydrate (Noctec) and glutethimide (Doriden).



� S/Sx:

¾ Incoordination

¾ Ataxia

¾ impaired thinking and speech¾ lethargy to coma

¾ early miosis; later, fixed and dilated pupils

¾ Hypoventilation

¾ Hypotension

¾ Hypothermia

¾ decreased reflexes.



� Administer flumazenil

(Romazicon) to reverse or

diminish effects of

benzodiazepines.

� Administer activated charcoal.

� Protect the airway.

� For hypotension, infuse withRinger's lactate and give

vasopressors.



� Intoxication generally occurs with blood

levels greater than 100 mg/dL. Levels more

than 400 mg/dL are due to rapidconsumption of alcohol and represent a

medical emergency.



� S/Sx:

¾ Slurred speech

¾

Incoordination¾ Ataxia

¾ belligerent behavior progressing to stupor and

coma

¾ odor of alcohol on breath and clothing¾ and respiratory depression.



� Protect the airway.

� Closely monitor for CNS and respiratorydepression.

� Draw blood for ethanol concentration,electrolytes, glucose, and drug screen, using

nonalcohol skin cleanser .



� Assess for head injury and other trauma, as

well as organic disease.

� Administer I.V. Fluids� magnesium sulfate (to reduce risk of

seizures)

�

thiamine (to preventW

ernicke-K

orsakoff syndrome)

� glucose (to treat hypoglycemia).



� Patient will present alert, unless

experiencing a seizure.

� If patient is having a seizure, ensure the

airway.



� Assess for major symptoms

¾ Shakes

¾

Seizures¾ hallucinations

� Obtain drinking history and recent drug

intake.



� Assess for

¾ Nausea and vomiting

¾ Malaise

¾ Weakness

¾ anxiety or fear

¾ Talkativeness

¾ restlessness agitation

¾ preoccupation



� Perform physical examination for

¾ signs of autonomic hyperactivity such as

xtachycardia

x Diaphoresis

x elevated temp.

x dilated but reactive pupils.

Al h l Withd l D li i



Alcohol Withdrawal Delirium:

Treatment & Nursing Care� Protect the patient from injury.

� Place the patient in a private room for closeobservation.

�Maintaining electrolyte balance andhydration through oral or IV route due to

profuse perspiration, vomiting and agitation.





Treatment & Nursing Care� Monitor VS every 30 minutes.

� Observe for hypoglycaemia.

¾ Hypoglycemia may accompany alcoholic withdrawal

because alcohol depletes liver glycogen stores andimpairs gluconeogenesis.

¾ Administer thiamine followed by parental dextrose if

liver glycogen is depleted.¾ Give orange juice, Gatorade or other carbohydrates

to stabilize blood sugar.





Treatment & Nursing Care� Pharmacologic interventions:

¾ Diazepam (Valium) or chlordiazepoxide (Librium)x for sedation to produce adequate relaxation and

reduce agitation of the patient.

¾ Diazepam (Valium) or phenytoin (Dilantin)x for seizure control.

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