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Toxicology is the study of toxic substances, and everything can be toxic depending on the amount. Poison is a substance that can damage the body, while a toxin is a poisonous substance produced by bacteria, animals, or plants. Substance abuse is the misuse of any substance to produce a desired effect. The most widely abused drugs are caffeine, nicotine, and alcohol. Overdose is a toxic dose of a drug, and symptoms of poisoning vary depending on the specific agent. Opiates and opioids can cause hypoventilation, pinpoint pupils, sedation, and hypotension. Stimulants can cause hypertension, dilated pupils, agitation, seizures, and hypothermia. Sedative-hypnotics can cause slurred speech, sedation, hypotension, and hypoventilation. Anticholinergics and cholinergics can have different effects, with cholinergics causing increased bodily functions and anticholinergics causing decreased bodily functions. Organophosphates So, the important thing to remember in toxicology is everything is potentially toxic. You know, you can drink too much milk. Milk can be toxic in high doses, depends on the amount. Some things very small, like cyanide, can be toxic, whereas some things it takes a lot. Water, you can suffer water intoxication. You drink more than two gallons of water in a 24-hour period, you go flush out all your electrolytes, you can die from that. So, anything is potentially dangerous, depending upon the amount. So, every day we come in contact with potentially poisonous things. We do poisonings that affect over two million people each year. But chronic poisoning is far worse. Nicotine, caffeine, diphenhydramine, opiates, and all kinds of different things that we take on a chronic level every day. Deaths caused by poisoning are fairly rare. Poisoning in children has decreased steadily since the 1960s due to child-resisting deaths. Sometimes I can't get any of the things off. Deaths from chronic poisoning has increased from overdose, drug abuse, things like that. So, unfortunately, we've made strides on one side of the equation, and on the other side of the equation we've been far worse. Toxicology is the study of toxic or poisonous substances. So, poison is any substance whose chemical action can damage a body structure or impair a bodily function. So, poison is a type of chemical, whereas a toxin is a poisonous substance produced by bacteria, animals, and plants, which we'll talk about. Substance abuse is the misuse of any substance to produce the desired effect. And the most widely abused drug in the world, believe it or not, is caffeine and nicotine. And then alcohol shortly after that. Overdose is a toxic dose of a drug. And again, anything, you can overdose on anything depending upon the dose. So, your primary responsibility when identifying patients and poisoning is to recognize that a poisoning has occurred. Sometimes your patient may not be able to give you that information. You may have to just surmise that the patient may be altered or whatever the case may be. So, pay attention to your surroundings. Look around you, right? Look for signs of toxic exposure, right? And the most important thing is what? Make sure you don't become exposed to that toxin. Very small amounts of some poison can cause considerable damage. Things like cyanide, right? Signs and symptoms of poisoning vary according to the specific agent. There's no way I can say that, oh, you have shortness of breath, so I know what this poison is. There's no way. Many poisons have multiple symptoms that overlap. So, it's difficult to say with any real certainty what your exposure might be. It's more of a mechanism on what you're exposed to that gives it away than your symptoms themselves. So, I want to talk about some typical signs and symptoms of specific overdoses. So, opiates, things like morphine or codeine and opioids, things like heroin, fentanyl, methadone, oxycodone. An opiate is a pure derivative from the plant, from the opium plant, right? Whereas the opioids are synthetic, they're more manufactured. So, we're going to talk about signs and symptoms would be hypoventilation or respiratory arrest, and that's what kills patients, right? Pinpoint pupils, that's one of the telltale signs, very constricted pupils, okay? Sedation or coma and hypotension. This goes along together because pinpoint pupils, constricted pupils, and blood vessels that are dilated. Pupils are opposite the blood vessels. So, in a stimulant, my pupils will be dilated and my blood pressure will go up because my blood vessels will constrict. So, pupils are opposite blood pressure, always think that. Your sympathomimetics, sympathomimetic, mimic the sympathetic nervous system. You can also say ketocolamine, adrenogenic stimulants. They all mean the same thing. Things like methadone, cocaine, methamphetamines, and believe it or not, methamphetamines have a medicinal purpose. One of the most commonly abused drugs on college campuses is Ritalin and Adderall. Those are methamphetamines, those are amphetamines, and what they do is they cause the patient to hyperfocus so you're able to focus on the particular task. And so, people sell them, we'll talk about that. So, what do they cause? Things like hypertension, that constricted blood vessels with increased heart rate, that tachycardia, dilated pupils, dilated pupils mean constricted blood vessels, agitation of seizures, hypothermia, and this is what kills patients, seizure coma death. They get severe hypothermia, especially when we talk about things like MOLLY or the RAVE drug, and patients will take those and they get severely hypothermic. I've had patients whose seizure activity to body temperature is 106 degrees, and coming out of a RAVE, and that's what ends up killing the patient, is the hypothermia and seizures. Sensitive hypnotics, things like diacetam, ciclobarbital, temazepam, midazolam, midazolam is Versed, we used to use that in EMS. Many of these medications will have an amnesiatic effect. If I give you Versed, you won't remember it. I went to a colonoscopy, two for another one unfortunately, when you get to be 50, you get to have one. Oh, they're lots of fun. So, I went and when they brought me in, they give you the medication, they give you two of Versed, they give you 50 of Benadryl in case you're allergic, and they give you a little bit of Propofol. And they say, okay, we're going to give this medication to you, just relax. And I remember saying to the doctor, hey, I'm really interested in this, can I see, can I watch, and you can tell me what's going on, I'm in the medical field. He said, sure, turn the camera, or turn the TV screen, he said, I'll tell you what's going on. And that's all I remember. And I woke up about an hour later, and I felt like I was floating on a cloud, it felt so good. And he came up to me, he says, how are you doing, I said, oh, I'm feeling great, he said, yeah, you're supposed to. He said, everything's good, everything checked out, I said, was I watching, did I go to sleep? He said, no, you're asking all kinds of questions, you remember nothing. That's the whole point of it, it's an antigenic effect. Great for us in EMS, because let's say we're going to, we use Versed very commonly for cardioversion, when we want to, your heart rate is irregular, and we want to fix it, and we use electricity to do that. So we'll give you a little Versed to take the edge off, you're shocked, oh my God, but then you don't remember it, right? And so you think like slurred speech, sedation or coma, hypotension and hypoventilation, and you'll see some, you'll see some constriction of the pupils as well, although this will, these will not react to, these will not react to opiates. Some of them, like diazepam and temazepam and midazolam and Ativan will react to a medication called Flumazenil, which is the antidote for that. We don't carry that, that's given in the hospital. So opiates will not, Narcan will not affect this. But you can see where it can produce some of the same presentations as opiates. You might even look at the patient and think it's an opiate overdose. But what's the difference between the two? I give Narcan to one, they wake up. I give Narcan to the other, it does no good. So we almost use Narcan like a diagnostic tool. I hit you with Narcan, you don't come around, but maybe it's a really massive dose of opiates, or maybe it's something else. They might even have a mixture of the two. They might put midazolam or diazepam, which is Valium, they might put that in the opiate. Anticholinergenics and cholinergenics, these are two different things. I'm going to actually do it backwards, I'm going to talk about the cholinergenics first because I can't talk about anticholinergenics until I talk about cholinergenics. Think about acetylcholine. Acetylcholine is the parasympathetic neurotransmitter. Feed, breed, or sleep slows everything down. Dilates blood vessels, constricts bronchioles, increases mucus production, increases GI motility. So you get gas and diarrhea and bloating, you get nausea and vomiting, all your body produces fluids, you get fluid filled up in your lungs, you get your eyes, your nose, your mouth, you get rhinitis and runny nose and watery eyes and lacrimation, urination, defecation. So that's your cholinergenics. Cholinergenics, we talk about nerve agents. And that's the big thing that they talk about. At the end of the course they talk about all the different types of nerve agents, the weaponized nerve agents. You're probably never going to see that. What you may see is an organophosphate overdose or organophosphate exposure. That's what a cholinergenic does. It's the number one additive or it's the number one chemical in insecticides. That's why you need to have a license to be a pest killer. It's not that you need a license to kill. You need a license to work with those chemicals because they're very dangerous. So we're going to look at things like organophosphates, pilocarpine, nerve gas. So you're going to look at this. You're going to have another couple of mnemonics. Hint, hint, wink, wink, nudge, nudge. You may see these so pay attention to them. First of all, sludgem. Sludgem is the military one. Salivation and sweating. And I know it's on one of your pages. Salivation and sweating. Lacrimation, that's excessive tearing of the eyes. Urination, defecation, drooling, diarrhea because you have massive amounts of saliva. Your whole GI system goes on hyperactivity. Gastric upset and cramps, emesis, and muscle twitching and meiosis. So what we do is we say meiosis, that's pinpoint pupils, and muscle fascidulation. Your muscle's kind of going crazy. So that's the sludgem. What's that? It's on 842. It's on 842. We're going to get into the... There's another mnemonic. It's the same thing. It's called dumbbells. We'll get into that in a minute. Okay. So we know that cholinergenics will stimulate that parasympathetic response because it will stimulate the production of acetylcholine. Also, some of them, some of the nerve agents or some of the organophosphates, actually There's a chemical that removes acetylcholine from the body. It's called acetylcholinesterase. So you might actually see esterase inhibitors. There are medications that will inhibit acetylcholinesterase, which leaves acetylcholine on the neurosynapses. See, the body absorbs and breaks down epinephrine and norepinephrine, which are the sympathetic responses. But your body's putting out both sympathetic and parasympathetic all the time. The body's constantly putting out both. And that maintains homeostasis. So if my body... If I take an esterase inhibitor, the acetylcholine will stay on the nerve synapses and build up, whereas my body will keep getting rid of the epinephrine and I'll be getting to be overtaken by my parasympathetic response. That's an esterase inhibitor. Or you can get organophosphates, which just stimulate the overproduction of acetylcholine. Either one produces the same type of toxic exposure. And these patients can go from normal to seizure coma death in a very short period of time. Minutes, really. So with that said, that's a cholinergenic. So the opposite of that is an anticholinergenic. So a cholinergenic would be a parasympatholytic... I mean, excuse me, a parasympathomimetic. It mimics the parasympathetic nervous system, which means it stimulates the sympathetic response. So if I say a sympathomimetic, that means it mimics the sympathetic response, epinephrine or epinephrine. If I say a parasympathomimetic, it mimics the parasympathetic nervous system, acetylcholine. So an anticholinergenic, here we go, big word, a parasympatholytic. It shuts off the parasympathetic nervous system, reverses it. So an anticholinergenic is the opposite of a cholinergenic. Things like atropine. Atropine we give in EMS for organophosphate poisoning. We carry it. Matter of fact, there are antidotes that you can carry. When I was in the military, we used to carry atropine and 2-PAM chloride, polydoxine chloride. Atropine, just like that, is an anticholinergenic. It reverses a nerve agent exposure. Diphenhydramine, Benadryl. Benadryl is a parasympatholytic. It's a very potent one. And even though it does produce sedation, it actually reverses the parasympathetic response. And I can prove that because take a child, give them Benadryl, and keep them awake for 20 minutes. It's like a kid on cocaine. They're all over the house. So when you give a child diphenhydramine, put them to bed. Chlorofrenamine, which is also an antihistamine. Doxylamine suconate, that is also a parasympatholytic. Matter of fact, doxylamine suconate, you find that in Dramamine. Dramamine is an antiemetic. It's used for travel. It's motion sickness. It's used for motion sickness. And ginseng weed. The Latin name is Centurostretonium. You can find ginseng weed in your backyard, believe it or not. Or in the woods. You can find it. Especially in the summertime where it grows very well. So what do we get from that? So instead of the opposite of Sludgum. Tachycardia. Hyperthermia. Hypertension. Dilated pupils. Dry skin and mucosal membranes. Sedation. Agitation. Seizure. Coma. Delirium. Possibly death. Along with decreased bowel sounds. It is the opposite of this. Think of feed, breed, or sleep. The reverse of that, which I guess you'd say the fight or flight. But it doesn't stimulate the sympathetic. It just shuts off the parasympathetic. So the sympathetic builds up. See how it works? Anticholinergenics can actually produce very specific and life-threatening conditions in a very rapid period of time. You can go with a diphenhydramine or a Benadryl overdose. You can go from perfectly normal to seizure coma death within 30 minutes. That fast. So if possible, we want to ask the patient, what substance did you take? When did you take it? Or become exposed to it. The patient may not know. How much did you ingest or get exposed to? Did you eat or drink anything before or after you took it? What is the most important reason for that? Why are we worried about what you ate or took in orally? Because what comes in can come out. And we're worried about aspiration. Have suction available. Has anyone given you an antidote or substance orally after you ingested it? Now this is the thing. We're going to talk about the poison control. Poison control is great. If you're a civilian and you have somebody that isn't exposed in a poisoning, absolutely call poison control. The problem with poison control is most things are antidotes are drink copious amounts of water or milk. What happens when I drink copious amounts of water or milk? I vomit. So for us, we don't want that. Right? That's not part of our protocol. We don't want people vomiting in our ambulance. So we're going to talk about for you guys, don't call poison control. Call medical control. Call the doctor on the radio. Hey doc, this is what I came across. We're going to talk about that. And how much do you weigh? Why is weight important? For medication. Well, for an antidote, but also in hazmat, we have a saying. It's called the solution to pollution is dilution. The more you weigh, the more it takes of a toxic substance to hurt you, but the more that is diluted. Right? That would make sense. So we want to know how much the patients weigh because that's going to affect their antidote, plus it would affect how the poison exposed them. The less they weigh, the more toxic an explosion would be. My mother is 100 pounds soaking wet. I'm 220. So she takes half the amount I do to get the same effect. So if she took my dose, it would be toxic to her. Try to determine the nature of the poison. Look around for immediate clues. Take suspicious materials with you. Do not take a kilo of cocaine to the hospital because it's on the front seat. But if you find something, bring it with you. Just remember, if you're going to pick something up, make sure you put it in a bag or you protect yourself. Don't become exposed to it. Wear gloves. Containers at the scene can provide critical information. If you're not going to take it with you, snap pictures. It is not a HIPAA violation to take pictures of a scene. It is if you post them on Facebook afterwards. But when you're just showing them to the doc and then you can attach them to your PCR and then delete them, that's perfectly fine. And sometimes that can give information and clues to the doctor. If there are pill bottles, alcohol bottles, a drug paraphernalia, like lighters, spoons, syringes, scales, cutting agents. We'll talk about cutting agents and what cutting agents are. It's important to get this information to the hospital, right? If you have needles, I don't recommend recapping needles. But if you have a needle, take it with you to the hospital. Just be careful. Don't poke yourself with it. But they can get the information of what it is off the needle. If it's heroin, if it's a heroin overdose, don't bring the needle. They don't want it. They kind of know what it is. If the patient vomits, examine the contents of pill fragments. They talk about the potential for scooping it up and putting it in a bag. Nurses love that when you bring bags of vomit to them. Unless you find something with chunks in it, like pills and stuff like that, don't go digging through the vomit. Unless you see something. But if you see a pill fragment, pick it up with gloves, put it in a bag or something and bring it with you. They can identify it from the pill. Note and document anything unusual that you see. Sometimes the things that are most subjective and subtle are the clues that can give a doctor an idea of what happened. So again, draw a complete picture in your narrative of what you saw and what you did. Take a picture from the scene. Bring any kind of pill bottles or anything with you or at least make note of what you had. So how do you provide treatment? It depends upon how much poison you got into the body. There are four routes. Inhalation, absorption, ingestion, and injection. The quickest would be injection. Within a minute, it's all over my body. The longest could be injection. It can take up to 30 minutes or longer for an ingested poison to really take effect. All four routes can lead to life-threatening conditions. So this is what we call huffing. We're going to talk about that. That's actually a fairly common thing, especially among teenagers. This is an exposure, right? This is absorption. You get it absorbed through the skin. If it burns the hand, that's a surface burn. That's a localized reaction. If it starts developing high, shortness of breath, blood pressure drops, that's a systemic effect. Pills and, of course, injection. So inhaled poisons. The antidote for an inhaled poison is oxygen and fresh air. Get them out of the environment. But that also means don't become exposed yourself. If you walk by a room and the door's closed and it's an office space and there's 10 people in there and they're all in various states of repose, unresponsive, it's probably not nappy time. So be careful walking into rooms, right? Pay attention to that. The patient will require, they will require supplemental oxygen. Any inhalation exposure needs to have oxygen. That is the antidote. If you suspect the presence of a toxic gas, call for the hazmat team. Don't just walk in the room. You may think I can run in there, grab them, and drag them out real quick. That's not how it works. Well, N95, right, true. I put an N95 on it, but an N95 isn't going to filter out gases. It's going to filter out particulates. So things like carbon monoxide, cyanide, or hydrogen sulfide, or bleach, that's not going to, the N95's not going to do anything for that. You'd actually have to have an actual scrubbing respirator. Some patients may need decontamination by the hazmat team before removal from the toxic environment. This means that they have to be decontaminated before I get to them. Because nowhere in my list of job descriptions does it say hazmat mitigation, right? I'm not a hazmat tech or a hazmat operator. My level is hazmat awareness. I can look and go, yep, that looks bad. Hey, I need hazmat. That's my job, okay? So I'm not going to go up and grab the patient from the hot zone and bring him into the cold zone, because that exposes me. All patients with inhaled poisons require immediate transport. The idea is the patient may be, I'm going to be fine now. How am I going to be 10 minutes from now, or 15 minutes from now, when the chemical takes effect in my body? I just breathed it in. It's going to take time. So that's the thing. It's like burns. Just because a burn doesn't bother the patient, an airway burn isn't bothering the patient now doesn't mean it won't bother him in the future. Make sure you get that patient. That's high-priority transport. Oxygen, suction, transport. Call ALS. The patient may go unresponsive on you just like that. Some patients use inhaled poisons to commit suicide in a vehicle. They used to have, when I was a kid, they had this thing. It was sold on TV. And I thought it was a wicked good idea. It was a hose you hooked up to your exhaust. You started your car, and it kicked out the hot exhaust, and you used it to melt the ice on your windshield. Duh! What a beautiful idea! No, it's not. Because people take the hose, stick it in the window, and commit suicide. Needless to say, within about six months, it came off the market. So people will do that. I told you the story about carbon monoxide. Carbon monoxide is cold, odorless, and tasteless. Yeah, I can smell the exhaust from a car, but I can get exposed to carbon monoxide even if I can't smell that because it ekes through the floors and things. Very dangerous. Some patients will actually, they do chemical-assisted suicides. They'll go to Home Depot, right? And they'll grab some spice like that, and they'll get bleach and ammonia and Coca-Cola and gasoline and other chemicals, and they put them in different containers. And they have a bowl next to them in the car, and they drive up in the parking lot, school to parking lot. Sometimes they'll put a sign out warning first responders, chemical-assisted suicides. Sometimes they don't. And they just dump it all into a bucket. And it produces this green smoke, bluish-green smoke. And they succumb to that very quickly. But the smoke dissipates when the chemical reaction ends. And they're like this in the front seat. You knock on the door, hello, hello. Nobody responds. You open the door, and what do you get? And you're done. So it's very important. Don't just walk up to a car, you know, knock on the window. Don't just walk up to a car and open it. If you're going to open the car, make sure you get away from it as you open it. Or just stick your head inside. People commit suicide with all kinds of things. In Gardner, I want to say about, maybe it's about seven years ago now, I had me and my partner responding to...