POISONING / OVERDOSE

DESIGNATION OF CONDITION

Look for evidence of inhalation, ingestion, or injection of a substance causing negative effects. Signs and symptoms may include any one or all of the following: respiratory depression, apnea, tachycardia, bradycardia, cardiac arrhythmias, altered mental status, unconsciousness, nausea, vomiting, and cardiac arrest. During scene size up, identify potential hazards and take appropriate protective measures.  Initiate the response of other agencies as needed.  Remove the patient from a dangerous environment but do not expose yourself to dangerous chemicals or poisons.

EMPHASIS ON PATIENT CARE

Airway management, adequate oxygenation and maintain adequate perfusion.

First Responder Pre-Hospital Management

1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
2. Focused H&P - History, physical exam, vital signs, including pupils and skin appearance (burns, chaffing, etc.). Check BGL.

• If medications overdose:
  • Amount of and type.
  • Time taken.
  • Accidental vs. intentional.
  • Mixed OD (Have other drugs or medications been taken?).
  • Route.
  • History of underlying illness, if appropriate.
  • Treatment prior to arrival.
• If poisoning:
  • Identify substance and quantity taken.
  • Method taken.
  • Underlying conditions.
  • Has the patient vomited?
  • Flushing with copious amounts of water is generally indicated for wet exposures and brushing is indicated for dry exposures.

3. Contact Poison Control [1-800-222-1222] and transport the patient to an appropriate medical facility. Consider ILS/ALS intercept.

4. If organophosphate poisoning or other chemical nerve agent is suspected, (i.e. increased salivation, lactation, urination, defecation, and gastrointestinal cramping and emesis):

• Administer ATROPINE and PRALIDOXIME (2PAM) [600 mg]) using an auto-injector device.

BASIC PRE-HOSPITAL MANAGEMENT

5. If narcotic overdose is suspected with serious signs and symptoms:

• Administer NALOXONE [0.4 mg] IM, SQ or [2 mg (1 mg per nostril)] IN. If no improvement, repeat every 2-5 min. [0.4mg] until 2 mg. has been administered.

6. Consider activated charcoal at 1 gm/kg may be administered with on-line Medical Control orders.

INTERMEDIATE PRE-HOSPITAL MANAGEMENT

7. At scene, initiate a large bore IV of an isotonic solution at TKO:

• Adult: Administer NALOXONE [0.4 mg] IVP, titrated to improvement in respiratory rate and effort. If no improvement, repeat every 2-5 min. [0.4mg] until 2 mg. has been administered. Contact medical control prior to administering subsequent doses. If IV access is not available, consider IM, SQ or IN administration.
• Pediatric: Administer NALOXONE [0.1 mg/kg up to 5 years of age or 20 kg] IVP, titrated to improvement in respiratory rate and effort. If no improvement, repeat in 10 min. at [0.1 mg/kg] until 0.8 mg has been administered. Contact medical control prior to administering subsequent doses. May also be administered SQ, IM, IN or IO.
• High doses may be required for synthetic narcotics.
• If the patient remains unresponsive, secure definitive airway, (follow Airway
  Management Protocols) and check BGL.

8. If cyanide poisoning is suspected, consider HYDROXYCOBALAMINE:
Adult: 5 grams IV / 70 mg/kg over 30 minutes.
Pediatric: 70 mg/kg IV over 30 minutes.

PARAMEDIC PRE-HOSPITAL MANAGEMENT
9. If organophosphate poisoning or other chemical nerve agent is suspected, i.e. increased salivation, lactation, urination, defecation, and gastrointestinal cramping and emesis:

• If auto-injector device is unavailable, administer ATROPINE [2.0 mg – until symptoms abate].

10. If tricyclic anti-depressant (TCA) overdose is suspected with serious signs/symptoms (widening of the QRS complexes, PVC’s, hypotension, seizures, dysrhythmias, or a combination of any of these), consider SODIUM BICARBONATE [1 mEq/kg] slow IVP.
11. If patient presents with a calcium channel blocker overdose:

• Adult - administer CALCIUM CHLORIDE (CaC12) 10% [10-20 ml] slow IVP. Do not exceed 2ml/min.
• Pediatric - administer CALCIUM CHLORIDE (CaC12) 10% [10-30 ml/kg] slow IVP. Do not exceed 2 ml/min.