hello and welcome to chapter 22 toxicology lecture from the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will be familiar with the classes of compounds involved in substance abuse and poisoning the rats by which poisons enter the body and the sign symptoms and assessment and treatment for various poisoning emergencies so let's get started every day we come into contact with things that are potentially poisonous acute poisonings affect over 2 million people each year so acute meaning a sudden onset of or chronic poisonings they are more common so a longer term poisoning and we'll talk about this yes caused by poisonings are fairly rare and deaths rates of deaths as a result of poisonings in children have decreased steadily since the 1960s due to child resistant caps and deaths caused by chronic poisoning in adults have been rising as a result of drug abuse okay so what is toxicology toxicology is the study of toxic or poisonous substances a poison is any substance whose chemical action can damage body structures or impair body function a toxin specifically is a poisonous substance produced by a bacteria animals or plants that acts by changing the nat the normal metabolism of cells or destroying them and toxins can have acute so fast or chronic slower effects substance abuse is the misuse of any substance that prod to produce a desired effect so a common complication of substance abuse is overdosing and that's when the patient takes a toxic dose of a substance your primary responsibility to the patient who has been poisoned is to recognize that a poisoning has occurred so for your own safety you must pay attention to your surroundings or you could become exposed to the same substance very small amounts of some poisons can cause considerable damage or death if you suspect that ingestion or exposure to a toxic substance has occurred you need to notify your medical control and begin emergency treatment at once the signs and symptoms of poisoning vary according to the specific agent so the table on this slide shows the signs and symptoms of specific types of overdoses okay and we're going to talk about them throughout this lecture so if possible while obtaining the sample history ask the patient what substance did they take when did they take it how much did they ingest did you have anything to eat or drink before or after you took it has anyone given you an antidote or substance orally since you've ingested it and how much do you weigh and we'll talk about the reasons why you ask those questions okay try to determine the nature of the poison so you want to look around the immediate area for any overturned bottles maybe a syringe or scattered pills chemicals or remains of food or drink items or even an overturned turned or damaged plant so take any suspicious material with you to the emergency department containers at the scene can provide critical information such as the name and concentration of the drug ingredients the number of pills originally in the bottle in the name of the manufacturer or this prescribed dose if the patient vomits examine the contents for pill fragments and note and document anything unusual that you see how you provide treatment depends on how the poison got into the patient's body in the first place so let's talk about how the poisons get into the body and there are four main routes okay so there's inhalation absorption and that's the surface contact you could have ingestion or injection all four routes of poisonings can lead to life-threatening conditions the figure on this slide shows the four routes of poison and how they can enter the body okay so inhalation absorption ingestion and injection so let's break those down okay so first is the inhaled poisons and they move the patient what you want to do is move the patient into fresh air immediately the patient may require supplemental oxygen and if you suspect the presence of a toxic gas please call for spread specialized resources such as the hazmat team okay some patients may need decontamination by the hazmat team after removal from the toxic environment all patients who have inhaled poison require immediate transport to the emergency department be prepared to use supplemental oxygen via a non-rebreather mask or ventilatory support with a bag valve mask if necessary so make sure a suction unit is also available in case the patient vomits some patients use inhaled poisons to commit suicide in a vehicle so what happens is they leave a car engine running in an enclosed garage and it can cause the exhaust fumes which contain high levels of carbon monoxide to cause the patient to lose consciousness and eventually stop breathing all right so next we're going to talk about absorbed or surface contact poisons okay so this is the next route um they can affect the patient in many ways so a skin mucous membrane or eye damage chemical burns rashes or lesions or systemic effect okay it's important to to distinguish between a contact burn and a contact absorption signs and symptoms of absorbed poisonings include a history of exposure liquid or powder on the patient's skin burning itching irritation redness of the skin or a typical odor of some type of substance okay emergency treatment for a topical contact poisoning include you want to avoid contaminating yourself or others and while protecting yourself you want to remove the substance from the patient as rapidly as possible and also remove all contaminated clothing and flush and wash the skin if it's dry powder and it's spilled the first thing you want to do is brush off the powder then flood the area with water for 15 to 20 minutes then wash the skin with soap and water okay if liquid has been skilled uh spilled onto the skin flood for 15 to 20 minutes if a chemical agent is introduced into the eyes you need to irrigate them quickly and thoroughly many chemical burns occur in an industrial setting safety showers and specific protocols for handling surface burns may be available so a hazmat team should be available to assist you ensure you your team members and the exposed patient are thoroughly decontaminated after decontamination promptly transport to the emergency department for definitive care you also want to obtain a material safety data sheet on the chemical that was spilled all right so now we're into ingested poisons so the third type of way that it could get to the body is ingested about 80 of poisonings are by mouth okay so the highest concentration they could be liquids household cleaners contaminated food plants or drugs ingested poisoning is usually accidental in children and deliberate in adults so signs and symptoms are going to vary greatly because of the it could the type of poison the age of the patient and the time that's passed since that ingestion okay signs and symptoms include burns around the mouth gi pain vomiting you can have cardiac dysrhythmias and seizures treat the signs and symptoms and notify poison control and medical control of the patient's condition if the patient has an altered mental status protect the patient from aspirating on vomit and consider whether there is an unabsorbed poison remaining in the gi tract and whether you can safely and effectively prevent that absorption okay and this is how so activated charcoal it comes in this premix suspension and some ems systems allow the emts to administer activated charcoal you should always immediately assess the abcs of every patient who has been poisoned okay and next the fourth way is injected so injected poisons exposure by injection includes iv or intravenous drug abuse and envenomation by insects arachnoids and reptiles so injected poisons are usually absorbed very quickly into the body or cause intense tissue destruction okay they cannot be diluted or removed from the body in the field signs and symptoms of this injected poisons are include weakness dizziness fever chills unresponsiveness or excitability you want to monitor the airway provide high flow oxygen and be alert for nausea and vomiting you want to remove any rings or watches or bracelets from the area around the injection site because if swelling occurs it could cut off the circulation okay so now that we've covered those uh four routes let's do the patient assessment talk about our patient assessment of these toxins okay so scene size up of course always first thing standard precautions and you're looking for clues that might indicate that substance involved is there an odor in the room if so is the scene safe right so are the medication bottles laying around the patient on the scene if so is there a medication missing that might indicate an overdose say for example the patient got there some type of of opiate filled yesterday and all the pills are missing from the bottle right so or are there alcoholic beverage containers around the patient are there syringes or other drug paraphernalia on scene and is there a suspicious odor or drug paleophonia present that may indicate the presence of some type of dry drug laboratory keep a constant eye on the surroundings and keep an open mind when questioning the patient or bystanders to avoid mistaken conclusions okay next is the primary assessment so determine the severity of the patient's condition so you want to obtain that general impression assess his or her level of consciousness determine any life threats do not assume a conscious alert and oriented patient is in stable condition next is the abc and d so the airway and breathing so you need to quickly ensure that the patient has an open airway and adequate ventilation if the patient has any difficulty breathing begin oxygen therapy and consider inserting an airway adjunct in unresponsive patients have suction available these patients are susceptible to vomiting okay so circulation you need to assess the pulse and skin condition and you will find variations depending on the substance involved okay and then your d of the abcd and that's your transport decision you want to consider prompt transport for patients with obvious alterations to the abcs or for patients who you've determined have a poor general impression okay everyone who is exposed to hazardous material must be thoroughly deconned by the hazmat team before arriving on scene next is that history taking so moving right down your patient assessment form if you're following along so history taking you want to investigate that chief complaint so if your patient's responsive begin um by the evaluation of the exposure and the sample history um and if your patient is unresponsive attempt to obtain history from other sources the sample history in addition to that sample history ask some questions okay so what substance is involved when did the patient ingest or become exposed to the substance how much did the patient ingest or what was the level of exposure over what period did the patient take or was exposed to the substance and was a patient or a bystander performed any intervention and has the intervention helped and how much does the patient weigh okay next is that secondary assessment so you may not have the time to conduct that on scene um or you could you might not have the time to do it in route however if you do physical examinations focus on the area of the body involved with that poison or the route of exposure in general review all of the body systems may not help or may help to identify systemic problems okay a complete set of baseline vitals is important of course and alterations in that level of consciousness pulse respirations blood pressure and skin are the more sensitive indicators that something serious is wrong and then of course your reassessment so continually reassess the adequacy of the patient's abcs repeat vital signs and compare them to that baseline set that you've received and then evaluate the effectiveness of the inventor the interventions that we've performed right and we know that we're going to for every 15 minutes we're going to do the vital signs for a stable patient for an unstable patient or for a patient who has consumed a harmful or lethal dose of something we want to consistently take vital signs every five minutes okay and then the treatment so we're going to support the abcs that's the most important task we're going to contact medical control or a poison center to discuss treatment options manage airborne exposures with oxygen and remove the contact exposures with copious amounts of water or unless it's contraindicated of course and consider activated charcoal for ingested poisons okay and then of course we're going to communication and documentation so we're going to try and report as much information as we have about the poison or chemical to that hospital and if the poison poisoning or exposure occurred in a work setting we want to bring the material data safety sheet to the hospital okay emergency care of course we're going to do the scene secure follow our standard precautions we're going to perform that external decon we want to remove tablets or fragments from the patient's mouth and wash or brush the poisons from the patient's skin and then treatment will focus on support assess and maintain the abcs provide oxygen and perform assistant assisted ventilations if we need to and then of course treat for shock if necessary and transport promptly some ems systems allow emts to give activated charcoal we mentioned that earlier and so what activated charcoal is going to do is it binds to specific toxins and prevents the absorption in the body the toxins are then carried out of the body in the stool activated charcoal is not indicated for certain patients though and so these patients are ones that have ingested some type of alkali poison cyanide ethanol iron lithium methanol mineral acids or organic solvents you cannot use activated charcoal for those also patients who have a decreased level of consciousness they will not be able to perfect protect their own airway so we can't give them anything to drink okay if local protocol permits you will likely carry plastic bottles of this pre-mixed suspension what and it contains 50 grams of activated charcoal the usual dose for an adult or child is one gram of activated charcoal per kilogram of body weight before you give this uh patient-activated charcoal we have to call medical control and obtain per approval okay then you're going to shake that bottle vigorously to mix the suspension you may need to convince the patient to drink it but never force them and then you want to record the time when you administered that activated charcoal if the patient refuses to drink the activated charcoal document the refusal and your attempts to counsel the patient and transport the patient for further evaluation now some of the side effects of activated charcoal are constipation and black stools if the patient has ingested a poison that causes nausea he or she may vomit after taking the activated charcoal and the dose will have to be repeated okay so now let's talk about specific poisons okay so over time a person who routinely misuses a substance may need increasing amounts to achieve the same result so this is called developing a tolerance for that substance so a person with an addiction has an overwhelming desire to need to continue using that substance at whatever cost with a tendency to increase the dose almost any substance can be abused the importance of safety awareness and standard precautions for caring for patients of drug abuse cannot be overemphasized known drug abusers have a fairly high incidence of serious and undiagnosed infections including hiv and hepatitis expect the unexpected and remember the drug user not the drug can pose the greatest threat so let's talk about these different drugs so alcohol many calls for service have a connection to alcohol use alcohol can damage the liver whether through chronic overuse or occasional heavy use we can call this binge drinking now binge use can be more damaging than chronic use and it's depending on the frequency of the binging and the surrounding circumstances alcohol is a powerful central nervous system depressant it is a sedative and a hypnotic in general alcohol dulls the sense of awareness slows reflexes and reduces reaction time it may also cause aggressive and inappropriate behavior and lack of coordination so a person who appears intoxicated may have other medical problems as well so don't forget that so look for signs of head trauma mental illness toxic reactions or uncontrolled diabetes do a bgl blood sugar check okay severe acute alcohol ingestion may cause hypoglycemia so they could go hand in hand alcohol increases the effects of other drugs and is commonly taken with other substances as well if a patient exhibits signs of serious central nervous system depression provide respiratory support if needed depression of the respiratory system can also cause emesis or vomiting okay so patients in alcohol withdrawal may experience frightening hallucinations or delirium tremens and those are those are known as dts delirium tremens okay so dts are characterized delirium tremors are characterized by agitation restlessness fever sweating tremors confusion delusions or even seizures these conditions may develop after a person stops drinking or when alcohol consumption levels are decreased suddenly and what you need to do is you need to provide transport and reassure the patient and provide necessary care and emotional support so withdrawal from alcohol can be just as dangerous as too much alcohol okay we talked about alcohol now let's talk about opiates okay so opiates are and the necrotic narcotic um and it's a drug that produces sleep and altered mental consciousness okay an opiate is a type of narcotic medication used to relieve pain an opiate is a subset of the opiate opioid family and refers to it could either be natural or non-synthetic opiates okay so prescription opiate drugs are among the most commonly abused drugs right now in the united states some people become physically dependent on opioids after taking an approx appropriate medical prescription and then they get they get physically dependent on them okay so it's a named after opium in the poppy seeds from which copedine and morphine are derived okay so um on this slide you're going to see the common opioids or opiates okay 22-2 table prescription opioid drugs are the most commonly abused like i said and these are usually formed by that physical dependence after you are given a medical prescription okay these agents are central nervous system depressants and can cause severe respiratory depression and then of course when you're not breathing you go into cardiac arrest if it's not treated and so what happens is tolerance develops quickly some users may require more doses up to massive doses to experience the same high these drugs often cause nausea and vomiting and may lead to a development of hypotension low blood sugar or low blood pressure although seizures are uncommon they can occur patients appear typically sedated or unconscious and cyanotic with pinpoint pupils so narcan narcan or naloxone is what reverses the effects of opiate or opioid overdoses and they can be given narcan can be given intravenously intramuscularly or intranasally in many ems systems emts administer narcan or naloxone by the i n route so intranasally and it should be used when the patient has agonal respirations or is apneic okay so so when we use narcan is only because of decreased respirations respiration depression as a result of opioids okay in some area lay people are permitted to administer naloxone and find out from bystanders if that patient was given it prior to your arrival next we're going to talk about sedative hypnotic drugs and these drugs are barbiturates or benzodiazepines and they're easily obtained and relatively cheap these drugs are essential nervous system depressants and alter the level of consciousness with similar effects of alcohol the patient may appear drowsy peaceful or intoxicated in general these agents are taken by mouth so orally and occasionally the capsules or and suspensions or dissolved in water or even ejected so iv sedative hypnotic drugs quickly induced tolerance and so the pain the person will require increasingly larger doses these drugs may be given to people as knockout drugs or mickey finn to incapacitate them without their knowledge general generally your treatment is just to ensure the airway is is patent so assist ventilations and then we're going to provide prompt transport get him to the hospital okay so now we're going to move on we're in abused inhalants okay so these agents are inhaled instead of being ingested or injected some are far more common um it includes acetone or um or other inhilants some are found in glue cleaning compounds paint thinners or lacquers okay gasoline and various um hydrocarbons such as freon used uh in aerosols air solar sprays are also abused okay and these are commonly abused by teenagers effects of those inhalants range from mild drowsiness to coma and often cause seizures so hydrocarbon solvents can make the heart hypersensitive to a patient's own adrenaline so try to keep the patients from struggling with you or exerting themselves and use a stretcher to move that patient give them oxygen and transport the patient to the hospital all right so hydrogen silified so this is a highly toxic odorless inflammable gas with a distinctive rotten egg odor so when you think of hydrogen sulfide think of that rotten egg odor it affects the organs but it is most impact on the lungs and lungs and central nervous system okay it's used to commit suicide and it's referred to as a chemical or um a detergent suicide okay so if you approach a enclosed vehicle with an unconscious patient inside be alert for warning signs as well as containers buckets or pots okay so if you suspect the presence of a toxic substance please you need to wait for that hazmat team to tell you that the scene is safe signs and symptoms includes nausea and vomiting confusion dypsnia a loss of consciousness seizures shock coma or cardiopulmonary arrest okay so once the patient has been deconned management is largely just supporting them you need to monitor and assist the patient's respiratory and cardiovascular functions and you want to provide rapid transport okay so now we're going to talk about another class and this is a central nervous system stimulant and it mimics the effects of that sympathetic nervous system and so we call them basically sympathy pathomimetic so it mimics the sympathetic nervous system okay they're frequently they frequently cause hypertension tachycardia and dilated pupils it's a stimulant and it produces an excited state so examples of these are amphetamines methamphetamines or designer drugs such as mdna which is also known as ecstasy or mali okay cocaine can be taken in a number of different ways and this is a sympathomimetic and it can be absorbed through mucous membranes or even across the skin so immediate effects include excitement and euphoria and lasts less than an hour when you smoke cocaine that's a crack and it produces the most rapid means of absorption and therefore it's the most potent effect okay acute overdose is a genuine emergency because the patients will have high risk of seizures cardiac dysrhythmias and stroke patients may be experiencing hallucinations or paranoia paranoia and placing you at risk so law enforcement officers should restrain the patient if necessary do not leave that patient unattended during transport and patients need prompt transport to the emergency department and give them supplemental oxygen and be ready to provide suctioning the next class we're going to talk about is the bath salts and this is a synthetic type drug it's an emerging class of drugs and it's similar to mdna it's sold as bath salts to escape the legal restrictions imposed by illicit drugs this uh type of drugs produce euphoria increased mental clarity and sexual hara arousal and basically most users of this drug snort it and the effects reportedly last as long as 48 hours adverse effects include teeth grinding or appetite loss muscle twitching lip smacking confusion gi conditions they could have paranoia headache elevated heart rates and hallucinations so keep the patient calm and transport and consider advanced life support assistance because some of these patients may require a chemical type of restraint to facilitate safe transport okay and then this is next one we're going to talk about is marijuana so marijuana is abused throughout the world it you'll see it written as thc and it's a chemical in the marijuana plant that produces the high inhaling marijuana smoke produces euphoria relaxation and drowsiness it impairs short-term memory and the capacity to do complex thinking and work the euphoria could progress to depression and confusion with very high doses patients may experience hallucinations or become very anxious or paranoid and marijuana is often used as a vehicle to get other drugs into the body okay several states have legalized the restriction recreational use of marijuana and others allow for medical use of marijuana and products that contain the thc edibles are baked goods or candies or other food additives that have been infused with marijuana ingestion can lead to cannabid hyperemesis syndrome and that's characterized by chronic marijuana use and extreme nausea and vomiting that is relieved only by a hot shower or bath synthetic marijuana or spice refers to a variety of herbal incense or smoking blends that resemble thc and produce a similar effect so powerful and unpredictable effects may result ranging from simple euphoria to complete loss of consciousness next class we're going to talk about is the hallucinogens okay so hallucinogens alter the person's sensory perceptions the classic hallucinogen is lsd or you'll hear it acid okay so these agents they cause visual hallucinations intensify vision and hearing generally separate the user from reality so the the patients experiencing a bad trip they could have hypertension tachycardia anxiety or paranoia care is the same as that for patient who has taken a sympathomimetic so we want to do the same things we want to use a calm professional manner provide emotional support we're not going to use restraints unless we have to and only if the patient is in danger okay we're going to watch the patient carefully throughout the transport and we're never going to leave them unattended and we're going to request advanced life support assistance when appropriate next we're going to need to talk about anti-chilergic agents okay so with anticholergic agents these are medicines that have properties that block the parasympathetic nerve the classic picture of a person who has taken too much anti-cholergic medicines is someone who is hot as a hair blind as a bat dry as a bone red as a beet and mad as a hatter okay and these common drugs are stuff like atropine benadryl gypsum weed or some type of elevil okay so it's often difficult to distinguish between anticholeric overdose and a sympathometic overdose but both groups of patients may be agitated and have a high heart rate and dilated pupils okay and then you have tricyclid antidepressants and they are significant anticleric effects so death from these agents can be rapid and the patient can go from appearing normal to a seizure and death within 30 minutes so we want to transport um these immediately and we need to consider calling advanced life support backup okay then you have the clergic agents so not an anticholergic you have a callergic agent and what these do is they over stimulate the normal body functions that are usually controlled by that parasympathetic nerve and these clergic agents can include nerve gas and usually nerve gas is designed for chemical warfare and organophosphate insecticides okay so callergic overdoses are occasionally nerve gases or it could be some type of organophosphate insecticides okay so um the signs and symptoms of a callergic agent are very easy to remember and you could use a mnemonic called dumbbells okay so if you look at the slide you can see um dumbbells uh is the spells at the beginning of each of these words so diarrhea urination meiosis bradycardia emesis lacrimation and seizures we also use an acronym or mnemonic called sludge and this is one that i remember it's sludge m and it stands for salivation lacrimation urination defecation gastric upsets emesis and then muscle twitching okay so these are those cholergic agents and remember the anti-choleric agents do the exact opposite so anti-cholergic it would be you'd be dry instead of salivating right so um you would instead of urinating you'd be dry okay so it's like the exact opposite the most important consideration is to avoid exposure ourselves right so we want to decon that's the priority in many jurisdictions a hazmat team is going to provide that decon okay so just understand that prior to the call your priorities after decon are to decrease the secretions in the mouth and trachea and to provide airway support okay so there are antidote kits for callergic agents and the most common one is called a duode auto injector the kit consists of a single auto-injector and it contains um two separate medicines the it's called a duo so two medicines dote and it contains atropine and proloxidone okay so if a known exposure to nerve agents organophosphates with manifestation of signs and symptoms have occurred we want to use those uh antidote kits okay and often we might need to use them on ourselves so miscellaneous drugs too and there are some um examples of some miscellaneous drugs and they're in classifications kind of by themselves and so there could be accidental or intentional overdose with cardiac medicines and just understand that car children may ingest them thinking that they're candy and older adults just may forget that they have taken it already and so they may take second doses of their meds that's pretty common signs and symptoms depend on the medication that has been ingested either way whatever it is we want to contact the poison center or poison control as soon as possible okay um and then aspirin that is a common one that is um ingested okay or poisoned so ingesting too much could result in nausea vomiting hyperventilation you could have ringing in your ears patients with this problem frequently have anxiety confusion tachypnea hyperthermia or danger they're in danger of having seizures okay overdosing with acetaminophen and medications that contain acetaminophen are also common its accidental acetaminophen overdose is a serious as an intentional overdose okay and then some alcohols that contain methyl or ethyl glyco glycol are often more toxic than um than drinking alcohol because both will cause severe tachypnea blindness it could cause renal failure or eventually death okay and one organism that produces direct effects of food poisoning is salmonella bacterium okay salmonella is characterized by severe gi symptoms within 72 hours of ingestion it causes nausea vomiting abdominal pain and diarrhea proper cooking will kill that bacteria and proper cleanliness in the kitchen will prevent the contamination of uncooked foods the more common cause of food poisoning is the ingestion of a powerful toxins produced by bacteria it that's often in leftovers so the bacterium staphocalis is quick to grow in and produce toxins in food okay so foods left unrefrigerated are common vehicles they result in sudden gi symptoms which includes nausea vomiting and diarrhea and symptoms usually start within two hours after ingestion or it could take as long as 8 to 12 hours the most severe form of toxic ingestion is botulism botulism can result from eating improperly canned foods the spores of bacteria grow and produce a toxin the symptoms are neurologic and it include blurred blurring of vision weakness difficulty speaking and breathing it can be fatal and symptoms may develop within the first 24 hours of ingestion or as long as four days later in general do not try to determine the specific cause of that acute gi problem whether as much history or gather as much history as we can and from the patient and transport him or her promptly to the hospital when two or more persons in the group have the same illness you should take along some of the suspected food if you can and then poisonings there are plant poisonings so there are tens of thousands of cases of plant poisonings annually many household plants are poisonous if you ingest them some can cause local skin irritation and some can cause acute circulatory system or gi tract or central nervous system they could affect okay it's impossible to memorize so we can't memorize every plan or poison let alone their effects what we want to try and do is assess the patient's airway and vital signs notify poison control center for assistance in identifying the plant and then take the plant with you to the emergency department okay so the figure on this slide shows common poison plants all right and so those are different ones and you could see the names of those okay and the figure on this slide shows common poisonous plants different ones okay okay so that concludes chapter 22 toxicology lecture let's see what we've learned all right so which of the following questions is the least pertinent for an emt to ask a patient who is intentionally overdosed so we do want to know how much they weigh we would like to know how much they ingested and we would like to know what substance they take and why did you so why did you take the medicine i'm pretty sure that's the least important yep so the why okay a 30 year old male who ingested an unknown substance begins to vomit you should what are we looking for so do you want to collect the vomit and bring it to the hospital give a bag valve mask no we're not going to do that if somebody's vomiting analyze the vomit to try and identify the poison or suction the oral pharynx we know we're not doing that so what we want to do is look for pill fragments um so a so collect the vomit bring it to the hospital okay when caring for a patient with a surface contact poisoning what do we want to do what do we want to do okay so um we want the first thing we've got to do is avoid contaminating ourselves so we want to maybe do the other things but right away if you see avoiding contamination you know that that's what they're looking for okay most poisons occur via the and we know it's ingestion lots and lots eighty percent are ingestion how much activated charcoal should you administer to a 55 pound child who has swallowed a bottle of aspirin so right away um we know that charcoal is per kilogram so what we're going to do is we are going to um change this pounds to kilograms and we know that it is going to be about 25 so pounds is divided by uh 2.2 okay to turn into kilograms and so what we're going to do is 25 it's one gram per kilogram so it's about 25 grams okay and it'll show you in this uh in this basically breakdown so first you convert the patient's weight from pounds to kilograms and that's what we did we divided it by 2.2 so 55 pound child is basically 25 kilograms then it's one gram per kilogram and that's what we got so very good after taking vicodin for two years of chronic pain a 40 year old woman finds that her usual dose is no longer effective it goes to the doctor to try and request a high dose this is a example of and we know this is tolerance right she has dependence she probably has an addiction but we know it's tolerance so that build up over a long period of time which of the following effects does binge drinking not produce all right so i would think it's increased sense of awareness that's not really coming with binge drinking right all right so d increase sense of awareness a 21 year old male is found unconscious in an alley our initial assessment reveals that his respirations are slow and shallow and his pulse is slow and weak further assessment reveals his pupils are constricted so this most consistent with an opioid opioid pinpoint pupils reduce respiratory drive that's an opiate yep and he's going to need narcan the pneumonic dumbbells can be used to recall the signs and symptoms of that clergic drug and the ian dumb mel spell stands for and it's going to be emesis yeah so it's it's uh all things um vomiting lacrimating defecating irritating emesis right all right then finally food poisoning is almost always caused by eating foods that contain and we know it's going to be bacteria right bacteria so that's salmonella okay thank you for joining us tonight with toxicology lecture and if you like this lecture go ahead and subscribe to the channel because we're going to be perf we're going to be doing all the lectures in that 12th edition book thank you and have a good night