class 20 substance abuse and behavioral emergencies ch10 partial ch17 ch19
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Class 20 (Substance Abuse and Behavioral Emergencies) Ch10 (Partial) , Ch17 & Ch19. Poison Any substance whose chemical action can damage body structures or impair body functions Substance Abuse The knowing misuse of any substance to produce a desired effect.

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  • Any substance whose chemical action can damage body structures or impair body functions

Substance Abuse

  • The knowing misuse of any substance to produce a desired effect
identifying the patient and the poison
Identifying the Patientand the Poison
  • If you suspect poisoning, ask the patient the following questions:
    • What substance did you take?
    • When did you take it or (become exposed to it)?
    • How much did you ingest?
    • What actions have been taken?
    • How much do you weigh?
determining the nature of the poison
Determining the Natureof the Poison
  • Take suspicious materials, containers, vomitus to the hospital.
  • Provides key information on:
    • Name and concentration of the drug
    • Specific ingredients
    • Number of pills originally in bottle
    • Name of manufacturer
    • Dose that was prescribed
inhaled poisons
Inhaled Poisons
  • Wide range of effects
    • Some inhaled agents cause progressive lung damage.
  • Move to fresh air immediately.
  • All patients require immediate transport.
absorbed poisons
Absorbed Poisons
  • Many substances will damage the skin, mucous membranes, or eyes.
  • Substance should be removed from patient as rapidly as possible.
  • If substance is in the eyes, they should be irrigated.
  • Do not irrigate with water if substance is reactive.
ingested poison
Ingested Poison
  • Poison enters the body by mouth.
  • Accounts for 80% of poisonings
  • May be accidental or deliberate
  • Activated charcoal will bind to poison in stomach and carry it out of the body.
  • Assess ABCs.
injected poisons
Injected Poisons
  • Usually result of drug overdose
  • Impossible to remove or dilute poison once injected
  • Prompt transport
emergency medical care
Emergency Medical Care
  • External decontamination is important.
  • Care focuses on support: assessing and maintaining ABCs.
  • You may be permitted to give activated charcoal for ingested poisons.
activated charcoal
Activated Charcoal
  • Suspension used to absorb ingested poisons
  • Often combined with a laxative
  • Administered orally as a suspension
activated charcoal 1 of 3
Activated Charcoal (1 of 3)
  • Names
    • InstaChar
    • Actidose
    • LiquiChar
  • Dosage
    • 1 g/kg
    • Adult: 25-50 g
    • Peds: 12.5-25 g
activated charcoal 2 of 3
Activated Charcoal (2 of 3)
  • Charcoal is not indicated for:
    • Ingestion of an acid, alkali, or petroleum
    • Patients with decreased level of consciousness
    • Patients who are unable to swallow
  • Usual dosage is 25 to 50 g for adults and 12.5 to 25 g for pediatric patients.
activated charcoal 3 of 3
Activated Charcoal (3 of 3)
  • Obtain approval from medical control.
  • Shake bottle vigorously.
  • Ask patient to drink with a straw.
  • Record the time you administered the activated charcoal.
  • Be prepared for vomiting.
specific poisons
Specific Poisons
  • Tolerance
    • Need for increased amount of drug to have same desired effect
  • Addiction
    • Overwhelming desire or need to continue using an agent
alcohol 1 of 3
Alcohol (1 of 3)
  • Most commonly abused drug in the US
  • Kills more than 200,000 people a year
  • Alcohol is a powerful CNS depressant.
  • Acts as a sedative and hypnotic
  • A person that appears intoxicated may have a medical problem.
alcohol 2 of 3
Alcohol (2 of 3)
  • Intoxicated patients should be transported and seen by a physician.
  • If patient shows signs of serious CNS depression, provide respiratory support.
  • A patient with alcohol withdrawal may experience delirium tremors (DTs).
alcohol 3 of 3
Alcohol (3 of 3)
  • Patients with DTs may experience:
    • Agitation and restlessness
    • Fever
    • Sweating
    • Confusion and/or disorientation
    • Delusions and/or hallucinations
    • Seizures
opioids 1 of 2
Opioids (1 of 2)
  • Drugs containing opium
  • Most of these, such as codeine, Darvon, and Percocet, have medicinal purposes.
  • The exception is heroin, which is illegal.
  • Opioids are CNS depressants causing severe respiratory distress.
  • Pinpoint pupils
opioids 2 of 2
Opioids (2 of 2)
  • Care includes supporting airway and breathing.
  • You may try to wake patients by talking loudly or shaking them gently.
  • Always give supplemental oxygen and prepare for vomiting.
sedative hypnotic drugs
Sedative-Hypnotic Drugs
  • These drugs are CNS depressants and alter level of consciousness.
  • Patients may have severe respiratory depression and even coma.
  • The main concern is respiratory depression and airway clearance, ventilatory support, and transport.
abused inhalants 1 of 2
Abused Inhalants (1 of 2)
  • Common household products inhaled by teenagers for a “high”
  • Effects range from mild drowsiness to coma
  • May often cause seizures
abused inhalants 2 of 2
Abused Inhalants (2 of 2)
  • Patient is at high risk for sudden cardiac arrest.
  • Try to keep the patients from struggling or exerting themselves.
  • Give oxygen and use a stretcher to move patient.
  • Prompt transport is essential.
  • CNS stimulants cause hypertension, tachycardia, and dilated pupils.
  • Amphetamine and methamphetamine are commonly taken by mouth.
  • Cocaine can be taken in may different ways.
    • Can lead to seizures and cardiac disorders
  • Be aware of personal safety.
  • Smoked by 20 million people daily in the US
  • Produces euphoria, relaxation, and drowsiness
  • Impairs short-term memory and ability to work
  • Transport to hospital is rarely needed.
  • Marijuana can be used as vehicle for other drugs, ie, it can be covered with PCP or crack.
hallucinogens 1 of 2
Hallucinogens (1 of 2)
  • Alter an individual’s sense of perception
  • LSD and PCP are potent hallucinogens.
  • Sometimes, people experience a “bad trip.”
  • Patient typically are hypertensive, tachycardic, anxious, and paranoid.
hallucinogens 2 of 2
Hallucinogens (2 of 2)
  • Use a calm, professional manner and provide emotional support.
  • Only restrain if danger of injury exists.
  • Watch the patient carefully during transport.
  • “Hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as a hatter”
  • Block the parasympathetic nerves
  • Patient may go from “normal” to seizure to death within 30 minutes.
  • Consider ALS backup.
cholinergic agents
Cholinergic Agents
  • Commonly used as nerve agents for warfare
  • Overstimulate body functions controlled by the parasympathetic nervous system
  • Organophosphate insecticide or wild mushrooms are also cholinergic agents.
signs and symptoms of cholinergic poisoning







S Salivation




GGI irritation

EEye constriction / Emesis

Signs and Symptoms of Cholinergic Poisoning
care for cholinergic poisoning
Care for Cholinergic Poisoning
  • Main concern is to avoid exposure
  • May require field decontamination
  • Priority after decontamination is to decrease the secretions in the mouth and trachea.
  • Provide airway support.
  • May be treated as a HazMat incident
  • Signs and symptoms
    • Nausea/vomiting
    • Hyperventilation
    • Ringing in ears
    • Confusion
    • Seizures
  • Patients should be transported quickly to the hospital.
  • Overdosing is common.
  • Generally not very toxic
  • Symptoms may not appear until it is too late.
  • Liver failure may not be apparent for a full week.
  • Gathering information at the scene is very important.
other alcohols
Other Alcohols
  • Methyl alcohol and ethylene glycol are more toxic than ethyl alcohol.
  • May be taken by chronic alcoholics who cannot obtain drinking alcohol
  • More often taken by someone attempting suicide
  • Immediate transport is essential.
food poisoning
Food Poisoning
  • Salmonella bacterium causes severe GI symptoms within 72 hours.
  • Staphylococcus is a common bacteria that grows in foods kept too long.
  • Botulism often results from improperly canned foods.
care for food poisoning
Care for Food Poisoning
  • Try to obtain as much history as possible.
  • Transport patient to hospital promptly.
  • If two or more persons have the same illness, bring some of the suspected food to the hospital, if possible.
plant poisoning
Plant Poisoning
  • Several thousand cases of plant poisonings occur each year.
  • If you suspect plant poisoning:
    • Assess the patient’s airway and vital signs.
    • Notify poison control center.
    • Take the plant to the emergency department.
    • Provide prompt transport.
myth and reality
Myth and Reality
  • Everyone has symptoms of mental illness problems at some point.
  • Only a small percentage of mental health patients are violent.
  • Perfectly healthy people may have symptoms occasionally.
defining behavioral emergencies
Defining Behavioral Emergencies
  • Behavior
    • What you can see of a person’s response to the environment and his or her actions
  • Behavioral crisis
    • Any reaction to events that interferes with activities of daily living or that becomes unacceptable to the patient, family, or others
    • A pattern, not an isolated incident
causes of behavioral emergencies
Organic Brain Syndrome

Caused by disturbance in brain tissue function

Functional Disorder

Cannot be traced to change in structure or physiology of the brain

Causes of Behavioral Emergencies
causes of organic brain syndrome
Causes of Organic Brain Syndrome
  • Sudden illness
  • Recent trauma
  • Drug or alcohol intoxication
  • Diseases of the brain
  • Low blood glucose
  • Lack of oxygen
  • Inadequate blood flow to the brain
  • Excessive heat or cold
safety guidelines
Safety Guidelines
  • Be prepared to spend extra time.
  • Have a plan of action.
  • Identify yourself.
  • Be calm.
  • Be direct.
  • Assess the scene.
  • Stay with patient.
  • Encourage purposeful movement.
  • Express interest.
  • Do not get too close.
  • Avoid fighting.
  • Be honest and reassuring.
  • Do not judge.
  • Depression is the single most significant factor that contributes to suicide.
  • An attempted suicide is a cry for help.
  • Immediate intervention is necessary.
  • Suicidal patients will usually exhibit warning signs.
critical warning signs of suicide
Critical Warning Signs of Suicide
  • Does the patient have an air of tearfulness, sadness, deep despair, or hopelessness?
  • Does the patient avoid eye contact, speak slowly, or project a sense of vacancy?
  • Does the patient seem unable to talk about the future?
  • Is there any suggestion of suicide?
  • Does the patient have any specific plans relating to death?
additional risk factors for suicide
Additional Risk Factorsfor Suicide
  • Are there any unsafe objects in the patient’s hands or nearby?
  • Is the environment unsafe?
  • Is there evidence of self-destructive behavior?
  • Keep in mind the suicidal patient may be homicidal as well.
medicolegal considerations
Medicolegal Considerations
  • Mental incapacity may take many forms.
  • Once a patient has been determined to have an impaired mental capacity, you must decide if care is needed.
  • Do not leave the patient alone.
  • Obtain help from law enforcement as necessary.
  • When a patient is not mentally competent, the law assumes that there is implied consent.
  • The matter is not always clear-cut with psychiatric emergencies.
  • If you are not sure about the situation, request law enforcement assistance.
limited legal authority
Limited Legal Authority
  • As an EMT-B, you have limited legal authority to require or force a patient to undergo care.
  • Police may put a patient in protective custody to allow you to provide care.
  • Know your local laws and protocols.
  • You cannot restrain a patient unless it is an emergency.
  • Transport a disturbed patient without restraints if possible.
  • If you must restrain the patient, use only reasonable force.
    • Law enforcement personnel should be involved.
potentially violent patients
Potentially Violent Patients
  • Use a list of risk factors to assess the level of danger:
    • Past history
    • Posture
    • Scene
    • Vocal activity
    • Physical activity
other factors to consider for potential violence
Other Factors to Considerfor Potential Violence
  • Poor impulse control
  • History of uncontrollable temper
  • Low socioeconomic status
  • Substance abuse
  • Depression
  • Functional disorders
poisoning suicide walk through
Poisoning & Suicide Walk Through

The following slides walk the studentthrough both a poisoning and an attempted suicide call.

you are the provider
You are the Provider
  • You and your EMT-B partner are dispatched to Grandma Jean’s Day Care Center for an accidental poisoning.
  • The center director says one of her toddlers ingested a cleaning product.
  • You hear hysterical crying and screaming. You find a 3-year-old girl in the lap of her teacher in obvious distress.
you are the provider continued
You are the provider (continued)
  • What initial treatment should be provided to this child?
scene size up
Scene Size-up
  • Well-trained dispatchers are of great help in a poisoning situation.
  • Look for clues of poisons or substances.
    • Medicine bottles may be an indication of overdose
    • Alcoholic beverages/bottles
    • Syringes or drug paraphernalia
    • Unpleasant or odd odor in room
  • Ensure your safety.
initial assessment
Initial Assessment
  • General impression
    • Do not be fooled into thinking a conscious, alert, oriented patient is stable.
    • Systemic reactions may take time to develop.
  • Signs of distress and altered mental status suggest a systemic reaction.
airway and breathing
Airway and Breathing
  • Open airway; provide adequate ventilation.
  • If patient is unresponsive, use airway adjunct.
  • Suctioning is critical; poisoned patients may vomit.
  • BVM may be needed.
  • Take spinal precautions.
  • Circulatory status can vary.
  • Assess pulse, skin color.
  • Some poisons are stimulants, others depressants.
  • Some cause vasoconstriction, others vasodilation.
  • Bleeding may not be obvious.
transport decision
Transport Decision
  • Alterations to ABCs and a poor general impression require immediate transport.
  • Check industrial settings for specific decontamination sites/antidotes.
  • Consider decontamination before transport.
you are the provider continued 1 of 2
You are the Provider (continued) (1 of 2)
  • You notice a garbage can next to the child containing vomitus.
  • Child is conscious and alert. Airway is patent, respirations 34 labored breaths/min.
  • Area around mouth is bright red with blisters.
  • Inside her mouth are red, irritated tissue and multiple blisters.
you are the provider continued 2 of 2
You are the Provider (continued) (2 of 2)
  • Breath has a strong chemical smell.
  • You immediately provide high-flow oxygen.
  • What additional resources do you require?
focused history and physical exam
Focused History and Physical Exam
  • SAMPLE history questions:
    • What is the substance involved?
    • When did the patient ingest or become exposed?
    • How much was ingested or what was the level of exposure?
    • Over what period of time did the patient take the substance? Minutes or hours?
    • Have any interventions helped? Made it worse?
    • How much does the patient weigh?
focused physical exam
Focused Physical Exam
  • Focus on area of body or route of exposure.
  • Baseline vital signs are important.
  • Treatment is based on:
    • What they were exposed to
    • When they were exposed to it
    • Signs and symptoms
  • Contact medical control or poison control center to discuss options.
  • Depends on poison.
  • Support ABCs.
  • Some poisons can be easily diluted or decontaminated before transport.
  • Dilute airborne exposures with oxygen.
  • Remove contact exposures with water unless contraindicated.
  • Consider activated charcoal for ingested poisons.
  • Contact medical control to discuss options.
you are the provider continued 1 of 4
You are the Provider (continued) (1 of 4)
  • You learn that your patient ingested CLR cleaner approximately 5 minutes before your arrival.
  • Started vomiting almost immediately.
  • Your partner calls poison control center and medical control.
  • The CLR label states:
    • Do not induce vomiting but drink a glass of water followed by a glass of milk.
    • Call a physician immediately.
you are the provider continued 2 of 4
You are the Provider (continued) (2 of 4)
  • What information should you have for the poison control center or medical control?
  • What if you can’t make the phone call to poison control?
you are the provider continued 3 of 4
You are the Provider (continued) (3 of 4)
  • Poison control and medical control recommend giving the patient water.
  • Patient’s breathing begins to slow. Vital signs:
    • Respirations 22 breaths/min
    • Pulse 90 beats/min, weak
    • BP 60 by palpation
  • Her crying has subsided. She is becoming lethargic and unresponsive to verbal stimuli.
  • Dispatch confirms that ALS should be on scene in 2 minutes.
you are the provider continued 4 of 4
You are the Provider (continued) (4 of 4)
  • Is this patient getting better?
detailed physical exam
Detailed Physical Exam
  • Perform, at a minimum, on patients:
    • With extensive chemical burns
    • With other significant trauma
    • Who are unresponsive
  • ABCs are the priority.
ongoing assessment
Ongoing Assessment
  • Patient conditions can change quickly.
  • Continually reassess ABCs.
  • Repeat vital signs.
  • If exposure level is unknown, reassess frequently.
  • Communicate as much as possible to receiving hospital.
  • Take MSDS with you or have faxed en route.
you are the provider71
You are the Provider
  • You and your partner are dispatched for an attempted suicide.
  • You arrive to a young woman screaming for you to help her friend who is threatening to kill herself.
  • What additional information do you need?
  • Should you enter this residence prior to obtaining law enforcement assistance?
scene size up72
Scene Size-up
  • Scene safety is most important. Consider calling appropriate resources if needed.
  • Take BSI precautions at all times.
  • Avoid tunnel vision.
you are the provider continued 1 of 273
You are the Provider (continued) (1 of 2)
  • The friend tells you that the patient does not a have any kind of weapon.
  • Your partner radios for law enforcement. You find a girl in her early teens sitting on the couch sobbing.
  • She is conscious, alert, and oriented. Breathing labored, 26 breaths/min.
you are the provider continued 2 of 274
You are the Provider (continued) (2 of 2)
  • Both parents are out of town. She is staying alone until tomorrow afternoon.
  • Her boyfriend called a short time ago and told her that he no longer wanted to be with her. She begins crying and saying that she does not want to live.
  • Based on your initial assessment, is this patient a priority patient?
initial assessment75
Initial Assessment
  • Start from the doorway.
  • State why you are there.
  • Be calm and relaxed.
  • Provide appropriate interventions.
  • Transport to appropriate facility based on condition.
you are the provider continued 1 of 276
You are the Provider (continued) (1 of 2)
  • You calmly explain to the patient that you need to ask some questions and examine her to get her the help she needs.
  • She allows you to obtain baseline vital signs.
    • Breathing 20 breaths/min
    • Skin is pink, warm, and dry
    • Pulse 88 beats/min
    • No obvious bleeding
    • BP 120/82 mm Hg
you are the provider continued 2 of 277
You are the Provider (continued) (2 of 2)
  • She has no known allergies and takes birth control pills daily but no other medication. She attempted suicide last year by taking an entire bottle of her mom’s diazepam (Valium).
  • What is your next step?
focused history and physical exam78
Focused History and Physical Exam
  • If unconscious, do rapid exam for life threats.
  • Assess three major areas as contributors:
    • Is patient’s CNS functioning properly?
    • Are hallucinogens or other drugs or alcohol a factor?
    • Are psychogenic circumstances, symptoms, or illness involved?
  • Use reflective listening: repeating what the patient has said in question form to help patient expand thoughts.
focused physical exam79
Focused Physical Exam
  • Use facial expressions, pulse, and respirations to help make determination.
  • Tears, sweating, blushing may be indicators.
  • Look at patient’s eyes.
  • Coping mechanisms are stressed; perception of reality may be distorted.
  • Be caring and careful.
  • Intervene only to safely transport.
you are the provider continued81
You are the Provider (continued)
  • She states that although she has not done anything to injure herself today, she wants to kill herself and will attempt to do so if she gets a chance.
  • Law enforcement arrives. Your patient becomes hysterical. She runs into the bathroom, slamming the door.
  • She refuses to open the door. Afraid of what she may do to herself, the police officer breaks the door down and restrains her.
  • Should EMS participate in patient restraint?
detailed physical exam82
Detailed Physical Exam
  • Rarely called for
ongoing assessment83
Ongoing Assessment
  • Never let your guard down.
  • Use law enforcement personnel with transport if available.
  • Give advance warning to hospital.
  • Can involve legal matters; document clearly and well.
  • Be clear and specific on restraint use.