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Chapter 33 Nancy Caroline's Emergency Care in the Streets Sixth edition

A class of drugs that increase alertness and excitation (stimulants)


Something that counteracts the action of something else


Potent sedative-hypnotics historically used as sleep aids, antianxiety drugs, and as part of the regimen for seizure control


The family of sedative-hypnotics most commonly used to treat anxiety, seizures, and alcohol withdrawal


A seed that contains the poison ricin

castor bean

Chemicals that are acids or alkalis; cause direct chemical injury to the tissues they contact


A severe withdrawal syndrome seen in people with alcoholism who are deprived of ethyl alcohol

delirium tremens (DTs)

A substance that has some therapeutic effect when given in appropriate circumstances and approproate dose


Any use of drugs that causes physical, psychological, legal, or social harm to the user or others affected by the user's behavior

drug abuse

A chronic disorder characterized by the compulsive use of a substance that results in physical, psychological, or social harm to the user who continues to use the substance despite the harm

drug addiction

A plant that contains cardiac glycosides used in making digitalis


The situation in which there is physical tolerance and psychological dependence on a drug or drugs


An agent that produces false perceptions in any one o. the five senses


Compounds made up principally of hydrogen and carbon atom mostly obtained from the distillation of petroleum


The cornerstone drug for treatment of bipolar disprder


Psychiatric medication used primarily to treat atypical depression by increasing norepinephrine and serotonin levels in the CNS

Monoamine oxidase inhibitors (MAOIs)

The generic term for opioids and opiates, drugs that act as a CNS depressant and produce insensibility or stupor


A class of chemical found in many insecticides used in agriculture and in the home


A physiologic state of adaptation to a drug, usually characterized by tolerance to the drug's effects and a withdrawal syndrome if use of the drug is stopped, especially abruptly

physical dependence

A substance whose chemical action could damage structures or impair function when introduced into the body


Enhancement of the effect of one drug by another drug


The emotional state of craving a drug to maintain a feeling of well-being

psychological dependence

Aspirin like drugs


A class of antidepressants that inhibit the reuptake of serotonin

Selective serotonin reuptake inhibitors (SSRIs)

An idiosyncratic complication that occurs with antidepressant therapy in which patients have lower extremity muscle rigidity, confusion or disorientation, and/or agitation

serotonin syndrome

The act of two substances such as drugs, in which the total effects are greater than the sum of the independent effects of the two substances


Physiologic adaptation to the effects of a drug such that increasingly larger doses of the drug are required to achieve the same effect


The syndrome-like symptoms of a poisonous agent


A group of drugs used to treat severe depression and manage pain; minimal dosing errors can cause toxic results

tricyclic antidepressants (TCAs)

A predictable set of signs and symptoms, usually involving altered central nervous system activity, that occurs after the abrupt cessation of a drug or after rapidly decreasing the usual dosage of a drug

withdrawal syndrome

What two general headings do toxicologic emergencies fall under?

intentional or unintentional

What are the four primary methods of entry?

ingestion, inhalation, injection, absorption

What assessment clues may point towards ingestion of a toxin or drug?

a plant with partially chewed leaves or a section of plant with berries missing, stained fingers, lips, or tongue, empty pill bottles, the date the prescription was filled and number of pills left

What are toxidromes useful for?

remembering the assessment and management of different substances that fall under the same clinical umbrella

What are signs and symptoms of stimulants?

restlessness, agitation, incessant talking, insomnia, anorexia, dilated pupils, tachycardia, tachypnea, hypertension or hypotension, paranoia, seizures, cardiac arrest

What are examples of stimulants?

amphetamine, methamphetamine, cocaine

What are signs and symptoms of narcotics (opiate and opioid)?

constricted (pin-point pupils), marked respiratory depression, needle tracks, drowsiness, stupor, coma

What are examples of narcotics (opiate and opioid)?

heroin, opium, morphine, hydromorphone (Dilaudid), fentanyl, oxycodone-aspirin combo (Percodan), Ambien

What is the most widely abused drug in the US?


What are the two distinct phases of alcoholsim?

first phase: problem drinking
second phase: true addiction, abstinence causes major withdrawal symptoms

What are medical consequences of alcohol abuse?

chronic damage to the CNS, damage to the cerebellum which results in problems of balance, damages stomach lining, gastritis, poor clotting ability, hypoglycemia, GI bleeding,

What is the most immediate danger to an acutely intoxicated person?

respiratory depression and/or aspiration of vomitus or stomach contents to a suppressed gag reflex

What drug might medical control direct you to give for alcoholic patients?


What is the dosage of thiamine?

100mg via slow IV push

When do DTs usually start?

48-72 hours after the last alcohol intake

What are signs and symptoms of DTs?

confusion, tremors, restlessness, fever, diaphoresis, hallucinations, hypotension often secondary to dehydration

To choose the appropriate course of action in a toxicologic emergency, what information should you obtain at the minimum?

what is the agent?
when was the agent taken?
how much was taken?
what else was taken?
has the patient vomited or aspirated?
why was the substance taken?

What does the clinical presentation of the stimulant abuser include?

excitement, delirium, tachycardia, hypertension with a fast pulse rate, dilated pupils;
As toxic levels are reached, the patient may develop psychosis, hyperpyrexia, tremors, seizures, and cardiac arrest

What is cocaine?

a local anesthetic and CNS stimulant that has the ability to create a euphoria that features enhanced alertness and a tremendous sense of well-being

What effects does cocaine have on the cardiovascular system?

lethal arrhythmias, AMI, widening of the QRS complex, QT prolongation, wide-complex arrhythmias, negative inotropic effects with decreased cardiac output, hypotension, tachycardia, bradycardia

What is the treatment for patients abusing stimulants (cocaine, amphetamine, or methamphetamine)?

maintain maximum oxygen saturation levels, prevent seizures with adequate sedation, monitor vitals, establish IV access, ECG monitoring, Haldol for violent behavior

What signs and symptoms does smoking marijuana result in?

bronchodilation, slight tachycardia, euphoria, drowsiness, decreased short-term memory, diminished motor coordination, increased appetite, bloodshot eyes

What are synthetic and naturally occuring hallucinogenics?

synthetic incude LSD, PCP, and ketamine;
naturally occurring include mescaline, psilocybin mushroom, and the seeds of the Jimson weed plant

What does LSD do to the body?

It affects the senses rather than changing physiologic functions

What are signs and symptoms of PCP?

slurred speech, staggering gait, tachycardia, hypertension, staring blankly for extended periods, horizontal nystagmus, muscle rigidity (teeth grinding), mind-body separation related hallucinations, violent outbreaks, superhuman strength

Why is there little reason to insert an IV line in a patient who is on PCP?

PCP can cause sme of the most violent and difficult behavior you will encounter in the field and there is no antagonist for PCP. You could always give Haldol is needed IM

What are signs and symptoms of Ketamine use?

mild inebriation, dreamy or erotic thoughts, inscreased sociability, nausea, difficulty moving, complaint of "entering another reality"

What are signs and symptoms of mescaline use?

feelings of increased sensitivity to sensory stimulation, flashes of color (commonly geometric patterns), dilated pupils, increased heart rate, mild hypertension, increased body temperature

What is a long-acting barbiturate that is ideal for its use in seizure control?


What is the management for a patient who has overdosed on barbiturates?

airway control (usually intubation to lrotect against aspiration), oxygen, monitor ECG rhythm, establish IV access,

What are the most common clinical effects of benzodiazepine overdose?

altered mentation, drowsiness, confusion, slurred speech, ataxia, general incoordination

What is the treatment for benzodiazepine overdose?

manage airway, give oxygen, establish IV access, apply ECG monitor, consider administering flumazenil, tansport

What is the dosage of Flumazenil?

0.2mg via slow IV push up to a total of 3mg

What is the difference between opioids and opiates?

opiates are natural drugs derived from opium, opioids are non-opium derived synthetics

What are some narcotic agents?

morphine, codeine, heroin, fentanyl, oxycodone, meperidine, propoxyphene, and dextromethorphan

What are opioids primarily used for in clinical medicine?


How do opioids exert their effects on the CNS?

by binding eith receptor sites in thr brain and other tissues

What is the classic presentation of opioid use?

euphoria, hypotension, respiratory depression, pinpoint pupils

How should you manage opioid overdose?

place an OPA, provide BVM ventilations with oxygen, establish IV access, administer Narcan 0.4-2mg IV.

What is the dosage of Narcan?

0.4-2mg IV, IM, SC, or ET (max 10mg)

What are the major classes or drugs of cardiac medications?

antiarrhythmics, beta blockers, calcium channel blockers, cardiac glycosides, angiotensin-converting enzyme inhibitors

What is the drug of choice for a beta blocker overdose?


What are options for calcium channel blocker overdose?

calcium gluconate and calcium chloride

How do organophosphates exert their toxic effects?

at junctions (synapses) of the nerve cells of the autonomic nervous system

What are the symptoms of organophosphate poisoning?

anxiety and restlessness, headache, dizziness and confusion, tremors or seizures, dyspnea, diffuse wheezing, respiratory depression, loss of consciousness, SLUDGE

What does the SLUDGE mnemonic stand for?

salivation, lacrimation, urination, defecation, gastric upset, emesis,

What is the management for organophosphate poisoning?

decontamination and removal of patient's clothing, manage airway, suction, provide oxygen, establish IV access, administer 1.0mg Atropine IV push nd repeat every 3-5 minutes until symptom reversal, administer 1-2g of 2-PAM infused with normal saline during 5-10minutes, apply ECG monitor, transport

Why do children tend to have more severe smotoms at any given level of exposure compared with adults?

children usually have a higher metabolic rate

What are symptoms and signs of carbon monoxide?

bounding pulses, dilated pupils, pallor and cyanosis, cherry red skin color (late sign), more than one patient complaining of the same complaints in the same environment

What is the management for CO poisoning?

removal of patient, give highest concentration of oxygen

What does cyanide do in the body?

it blocks the utilization of oxygen at the cellular level

What are signs and symptoms of cyanide poisoning?

altered mental status, headache palpitations, dyspnea, unconsciousness

What is the aim of treatment for cyanide poisoning?

to displace the cyanide from the cytochrome oxidase by introducing another chemical that will "attract" the cyanide

What is the treatment for cyanide poisoning?

amyl nitrate and oxygen

What is one of the most common caustic exposures in the agricultural setting ?


What should you not do for caustic ingestions?

dont give any "neutralizing" substances, dont induce vomiting, dont perform gastric lavage, dont give activated charcoal

What are the primary goals when dealing with a patient who has inhaled hydrocarbons?

removal from the noxious environment, giving high-concentration oxygen, prompt transport

What are some tricyclic antidepressants?

amitriptyline, imipramine (Tofranil), doxepin (Sinequan), Zonalon, nortriptyline (Aventyl, Pamelor), and desipramine (Norpramin, Pertofrane)

What are the most common signs and symptoms of a TCA overdose?

AMS, arrhythmias, dry mouth, blurred vision, dilated pupils, urinary retention, constipation, and pulmonary edema

What is the most common cause of death from TCA overdose?

cardiac arrhythmias

What is a major issue with taking MAOIs?

the potential for drug interactions

What are early signs and symptoms of MAOI overdose?

hyperactivity, arrhythmias (usually sinus tachycardia), hyperventilation, nystagmus

What are popular SSRIs?

fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft)

What are early signs and symptoms of lithium overdose?

nausea, vomiting, hand tremors, excessive thirst, slurred speech

What four body systems do exposures to metals and metalloids usually affect?

neurologic, hematologic, renal, GI

Where is 90% of lead stored once in the body?


What is a major cause of mortality and morbidity from lead poisoning?


What can ingestion of foxglove produce?

hyperkalemia, cardiac arrhythmias

What questions should you ask when you encounter a case of plant poisoning?

when was the plant ingested?
what, exactly did the child eat? (parts of the plant)
what signs or symptoms are they having?

What should you think when two or more people are sick at the same time at the same scene?

food poisoning or CO poisoning

What three toxins produce roughly all food-related deaths?

salmonella, listeria, toxoplasma

What dies the Hymenoptera family of insects include?

bees, wasps, hornets, yellow jackets, and ants

What does death from a Hymenoptera sting usually occur from?


What is the treatment for a Hymenoptera sting?

first, determine whether the stinger and vemom sac are still attached to the skin and if so, remove by scraping the stinger off the skin. Do not pinch it to pull it out. Then clean the wound thoroughly with soap and water or an antiseptic solution. Apply cold packs for pain relief

What is the principal treatment for a tick bite?

careful removal of the tick. Grasp it by the head and as close to the skin as possible and pull straight upward using steady gentle traction, dispose of the tick in a container of alcohol

What are the two types of spider bites that are of medical concern in the U.S?

black widow and brown recluse

What might the patient report with a spider bite?

a sudden, sharp prick followed by a cramping or numbing pain that begins at the bite area and gradually spreads

What is the classic sign of the reaction to a black widow spider bite?

extreme restlessness

What are signs and symptoms of a black widow spider bite?

excruciating pain, muscular rigidity especially in the abdomen, severe respiratory distress and dsypnea, nausea and vomiting, hypertension, hypersalivation, and paresthesias

What are signs and symptoms of a brown recluse bite?

painful, reddened area with overlying blister formation and a white surrounding area of ischemia. Over the next few days the area turns dark and becomes deeply ulcerated

What does a scorpion sting cause?

immediate pain at the sting site, followed by numbness or tingling, uncontrolled roving movements of the eyes, difficulty swallowing, slurred speech, severe agitation, nausea, vomiting, muscle twitching or spasms, blurred vision, drooling, possibly seizures

What is the initial field treatment for a scorpion bite?

focuses on pain relief with analgesics and transport

What do pit vipers include?

rattlesnakes, cottonmouths, copperheads, moccasins

What is the snake venom composed of and what does it cause?

a mix of enzymes that cause local tissue damage, hemolysis, increased permeability of the vasculature, coagulopathy, and neuromuscular dysfunction

What are signs and symptoms of pit viper bites?

fang marks, localized pain, and rapidly developing edema around the area of the bite, nausea, vomiting, dizziness or weakness, oral numbness or tingling of the mouth and tongue, tachycardia and hypotension, tachypnea, and muscle fasiculations

How should you treat a pit viper bite?

scene safety, establish and maintain the airway, give high-flow oxygen, establish IV access, keep the patient calm, supine, and motionless to decrease venom spread and absorption. Immobilize extremity with the bite in neutral position below the level of the heart, administer boluses of NS for hypotension, transport

Once signs and symptoms appear in coral snake bites, what should you suspect?

nausea and vomiting, tremors or seizures, drooling, paralysis of the face, mouth, or vocal chords, fixed dilated pupils, blurred vision, ataxia, muscle weakness, dyspnea, respiratory failure, hypotension, loss of consciousness

What does the treatment focus primarily on for marine envenomations?

wound irrigation, removal or foreign bodies (spines, teeth), pain relief, tansport

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