2. OBJECTIVES
Upon completion of this lecture, the learner will be
able to:
Describe what is a toxicological emergency.
Identify specific types of toxicological agents.
Explain how to handle toxicological emergencies
utilizing the nursing process.
Describe the symptoms and treatment of
overdoses involving alcohol, cocaine, amphetamines,
inhalants, salicylates, acetaminophen, sedatives,
hypnotics, digoxin, and acid/alkali burns.
3. WHAT IS ATOXICOLOGICAL EMERGENCY
Toxicological emergencies involve acute poisonings, overdoses
or intake of abuse/illegal substances, over-the-counter
medications and prescription drugs. According to the
American Association of Poison Control Centers, about 2.5
million cases of poison exposure was reported in 2009
(Badillo, Hovesth & Schaffer, 2013). Toxicological emergency
visits are due to use of remedies such as antihistamines, anti-
diarrheal, prescription drugs such as digoxin, inhalants and
illicit street drugs (cocaine, PCP, GHB). Emergency care
involves rapid identification of the substances used with
treatment is directed towards preventing/decreasing
absorption and symptoms.
4. TOXICOLOGICAL EMERGENCIES
Exposures can be occupational, environmental,
recreational, or therapeutic.
Exposures occur through inhalation, ingestion,
injection, or contact with skin and mucous
membranes.
Antidotes are available for a variety of
substances.An antidote is physiological
antagonist that reverses the signs and
symptoms of poisoning (Badillo, Hovseth, & Schaffer,
2013).
7. ASSESSMENT
Begin with primary assessment: airway, breathing, circulation, disability (A,
B,C, Ds). Resuscitation if necessary.
History of Present Illness- information regarding use/abuse/ingestion.
Route of exposure, reason for exposure,
Past Medical History- current meds, hospitalizations.
Psychological/social/environmental factors – suicide, addictions
Objective Data: General appearance, level of
consciousness, vital signs, odors, auscultation of
heart/breath/abdominal sounds.
Diagnostics: Drug levels, glucose, serum/urine
toxicology, CBC, CMP,ABG, Chest xray
8. ANALYSIS: DIFFERENTIAL DIAGNOSES
Anxiety/fear
Ineffective coping
Risk for injury/falls
Risk for poisoning
Risk for self/other-directed violence
Disturbed sensory/perception: visual, auditory, kinesthetic
Risk for impaired gas exchange
Risk for ineffective airway clearance
Risk for seizures
9. PLANNING, IMPLEMENTATION AND
INTERVENTIONS
Priorities of Care: Maintain airway, breathing, circulation,
disability
Provide supplemental oxygen as needed
Obtain intravenous access
Administer pharmacological therapy as ordered
Allow loved ones to remain with patient if supportive
Educate patients and significant others
Notify Poison Control for reporting and treatment
recommendations.
10. PLANNING, IMPLEMENTATION AND
INTERVENTIONS
Poison control center experts help clinicians to assess patients and can
suggest management practices.
The center uses POISINDEX and other toxicological databases, which
are updated regularly.
Notifications help them to track patients and gather demographic and
statistical information
11. INTERVENTIONS
Gastrointestinal Decontamination – Activated Charcoal
Substances NOT absorbed by Activated Charcoal : Caustics,
heavy metals (lead, zinc, mercury), hydrocarbons, iron
preparations, lithium, toxic alcohols.
Gastric Lavage- indicated if substances were consumed within 1
hour
Cathartics – magnesium sulfate, magnesiun citrate, sorbitol
Whole Bowel Irrigation – GoLYTELY, CoLyte orally or gastric tube
Hemodialysis
Charcoal Hemoperfusion- filtering blood through a cartridge
containing activated charcoal.
12. EVALUATION AND DOCUMENTATION
Continuously monitor and treat as indicated
Monitor treatment responses and modify care plan
as necessary
Document patient response accurately (positive
and negative)
13. AGE-RELATED CONSIDERATIONS
Pediatrics
Decreased renal clearance of children <6months old effects half-life of
drugs
Most poisoning occur in children <6years old and usually in the home
Poison Prevention Packaging Act of 1970 reduced the number of
pediatric exposure related deaths by mandating child-resistant caps on
toxic substances (Badillo et al., 2013)
Geriatrics
Poly-pharmacy puts this population at high risk for therapeutic
medication errors
Slowed metabolism leads to greater chance of toxicity
Cognitively impaired adults may accidentally take extra medications
14. SPECIFICTOXICOLOGICAL EMERGENCIES:
ALCOHOL INTOXICATION
Symptoms
Altered mental status, nystagmus, flushed skin,
bradypnea, vomiting, Impaired judgment,
impaired gait/coordination, coma
Treatment
Thiamine and multivitamins to prevent
Wernicke-Korsakoff syndrome
Dextrose 50%(D50W) if hypoglycemic
IV access for crystalloid fluids
100% oxygen
Benzodiazepines: Librium, Lorazepam,
Diazepam
15. SPECIFICTOXICOLOGICAL EMERGENCIES:
OPIATE USE
Symptoms
Drowsiness, apathy, seizures, apnea/respiratory
arrest, hypotension, bradycardia, and miosis.
Treatment
Maintain A,B,C, Ds
Provide supplemental oxygen
Establish IV access
Administer Naloxone (short acting narcotic
antagonist)- may need to repeat doses
Activated charcoal if indicated
16. SPECIFICTOXICOLOGICAL EMERGENCIES:
COCAINE USE
Symptoms
Irritability, anxiety, hallucinations such as “bugs” crawling under skin,
mydriasis, tachycardia, hypertension, hyperthermia or heart attacks.You
may also find perforated nasal septum from snorting.
Treatment
Maintain A,B,Cs and provide supplemental oxygen
Establish IV access
Haldol for delirium/psychosis
NGT andWhole bowel irrigation
ECG and Continuous cardiac monitoring
17. SPECIFICTOXICOLOGICAL EMERGENCIES:
AMPHETAMINES
Symptoms
Changed level of consciousness and bizarre behavior,
paranoia, delusions, seizure activity, hypertension, mydriasis,
tachycardia, tremors.Thin, appears emaciated and unkempt
Treatment
Maintain A,B,Cs and provide supplemental oxygen
Establish IV access for medications and/or crystalloids
Activated charcoal (if indicated) prevents systemic absorption
Benzodiazepines provides sedation; Haldol for psychotic symptoms
18. SPECIFICTOXICOLOGICAL EMERGENCIES:
INHALANT
Symptoms
Behavior ranges from euphoria to depression,
suicidal ideations (Perron & Howard, 2009) , ataxia or
wide-based gait, bloodshot eyes. Respiratory
wheezing, circumoral red spots on mouth and nose
if using spray paint, decreased peripheral reflexes.
Treatment
Maintain A,B,Cs and provide supplemental oxygen
Establish IV access
Sodium bicarbonate for metabolic acidosis
Electrolyte replacements (especially potassium)
19. SPECIFICTOXICOLOGICAL EMERGENCIES:
CARBON MONOXIDE POISONING
Symptoms
Headache (most common),
dizziness, weakness, nausea,
vomiting, confusion.“Cherry red”
skin and mucus membranes.
Treatment
Maintain A,B,Cs
High flow100% oxygen
(decreases half-life of COHb)
Establish IV access
Hyperbaric oxygen therapy for
severe cases
20. SPECIFICTOXICOLOGICAL EMERGENCIES:
SALICYLATE (ASPIRIN) POISONING
Symptoms
Respiratory alkalosis, electrolyte imbalances, nausea,
vomiting, tinnitus, tachypnea, tachycardia, diaphoresis,
respiratory crackles.
Treatment
Maintain A,B,Cs and provide supplemental oxygen
Establish IV access for meds and fluids
activated charcoal
IV crystalloids for renal clearance and hydration
Sodium bicarbonate to correct acidosis or alkalinize
urine
Replace electrolytes
21. SPECIFICTOXICOLOGICAL EMERGENCIES:
ACETAMINOPHEN POISONING
Symptoms
3 stages: Initial (0-24 hrs), Dormant (24-48 hrs after),
Hepatic (48-96 hrs).
Malaise, nausea/vomiting, Palpitations, syncope,
bradycardia, hypotension, metabolic acidosis, hepatic
failure, Jaundice and electrolyte imbalances
Treatment
Maintain A,B,Cs and provide supplemental oxygen
Establish IV access
Activated charcoal within one hour of ingestion, IV
Fluids (NS)
N-acetylcysteine (Mucomyst) orally, by NGT or
intravenous (Acetadote)
IV Calcium Gluconate, Glucagon or vasopressors,
22. SPECIFICTOXICOLOGICAL EMERGENCIES:
ACID AND ALKALI BURNS
Symptoms
Stridor, drooling, burn blister in oral cavity or skin, corneal erosion, pale conjunctiva,
respiratory crackles
Treatment
Maintain A,B,Cs and provide supplemental oxygen as indicated
Establish IV access
Alkali exposure: diluted with small amounts of water if ingested. For Ocular injuries,
Irrigate with NS for one hour
Acid exposure: Do not use water for ingestions as it will create heat. For ocular injuries,
irrigate with NS for 15 minutes.
Pain medications/analgesics
Steroids for alkali burns
Activated charcoal if indicated
Calcium Chloride for hydrofluoric acid burns
23. SPECIFICTOXICOLOGICAL EMERGENCIES:
DIGOXINTOXICITY
Symptoms
Unusual visual changes (seeing spots, blurred vision), nausea, vomiting, diarrhea,
irregular pulse, confusion, loss of appetite, fatigue. Pupil mydriasis and
photophobia.
Exams andTests
ECG, serum digoxin level(0.5-2.0 ng/L), chemistries, renal function studies
Treatment
Maintain A, B, Cs and establish intravenous access
Discontinuation of drug
Possible external cardiac pacing or pacemaker insertion
hydration with IV crystalloid fluids
Digoxin Immune Fab (intravenous)
Activated charcoal for acute ingestions
Dialysis for severe cases
(Felicilda-Reynaldo, 2013)
24. CONCLUSION
Toxicological poisonings are increasing in the number of emergency
room visits each year.With the rise and evolution of new illicit
drugs, the poly-pharmacy of geriatric medications and increased
access of home medications to young children, nurses must be
adequately educated to handle these type of situations.This
presentation involved only a small number of substances in
existence and included the major symptoms and treatments
related to each one. It is the professional responsibility of every
medical and nursing provider in emergency care to familiarize
themselves with various toxicological agents, symptoms and
treatment interventions.
25. REFERENCES
Badillo, R. B., Hovseth, K., & Schaffer, S. (2013).Toxicological Emergencies. In
B. Hammond, & P. G. Zimmerman (Eds.), Sheehy’s Manual of Emergency Care
(7th ed. (pp. 319-332). St. Louis, Missouri: Elsevier Mosby.
Felicilda-Reynaldo, R. F. (2013). Cardiac glycosides, digoxin toxicity and the
antidote. MedSurge Nursing, 22(4), 258-261.
Olson, K. R. (Ed.). (2012). Poisoning and Drug Overdose (6th ed.). San Franciso,
California: McGraw-Hill.
Paulozzi, L. J., Logan, J., Hall ,A. J., Mckinstry, E., Kaplan, J.A., & Crosby ,A. E.
(2009).A comparison of drug overdose deaths involving methadone and
other opiod analgesics in the west virginia. Addiction: Research Report, 104,
1541-1548. doi: doi:10.1111/j.1360-0443.2009.02650.x
Perron, B. E., & Howard, M. O. (2009).Adolescent inhalant use, abuse and
dependence. Addiction: Research Report, 104, 1185-1192. doi:
doi:10.1111/j.1360-0443.2009.02557.x
Phillips, M. (2007).Toxicological Emergencies. In K. S. Hoyt, & J. Selfridge-
Thomas (Eds.), Emergency Nursing: Core curriculum (6th ed. (pp. 604-658). St.
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