Toxic Substances Reference Table

Name	Description	Route of Exposure	Signs and Symptoms	Treatment
Narcotics	Narcotics are addictive drugs that reduce the perception of pain and induce euphoria (a feeling of exaggerated and unrealistic well-being). The English word is derived from the Greek narkatikos, which means “numbing” or “deadening”. The term is commonly applied to the opioids – that is, to all natural or synthetic drugs that act like morphine.	Ingestion, Inhalation, Injection	Overdose causes CNS depression, respiratory depression, constricted pupils (in most cases), bradycardia, and hypotension. In some cases, pulmonary edema may occur. Untreated, significant overdoses are fatal.	Treatment includes managing the airway, assisting with positive pressure ventilations when appropriate, and inserting a blind airway device if indicated. Be prepared for possible vomiting and aspiration. Obtain IV access. Administer Naloxone, 04.-2.0 mg; titrate to improved respiratory status, but continue to monitor respirations.
Benzodiazepines	Benzodiazepines enhance the effect of the neurotransmitter GABA, resulting in sedative, hypnotic, anxiolytic, anticonvulsant, and muscle relaxant properties; benzodiazepines are useful in treating anxiety, insomnia, agitation, seizures, muscle spasms, alcohol withdrawal and as a premedication for medical or dental procedures.	Ingestion	On their own, benzodiazepines rarely result in death in overdose. They can cause AMS, slurred speech, sedation, respiratory depression, and hypotension.	Manage the airway and consider assisting with ventilations if respirations appear inadequate. Obtain IV access and provide fluid as indicated to maintain adequate perfusion. Perform an EKG.
Acetominophen	Acetaminophen is used to relieve minor aches and pain and reduce fever. It is found under a number of brand names including Tylenol. It comes in many forms and is an ingredient in formula medications for colds and flu. Acetominophen does not have a wide margin of safety. Acetominophen is hepatotoxic at relatively low levels (7-15 times the normal recommended dose).	Ingestion	Initially, acetominophen overdose is relatively asymptomatic, although nausea is common. Within 24 hours, signs of liver failure can begin: low blood sugar, low blood pH, easy bleeding, and hepatic encephalopathy.	Contact poison control. Provide supportive care. An antidote can be given if the patient presents soon after ingestion.
Salicylates	Salicylates are compounds found in many fruits and vegetables. They are chemically related to the active ingredient in aspirin, and they can be used in the treatment of a number of medical conditions. In addition to aspirin, salicylates are also found in PeptoBismol and oil of wintergreen. Salicylate toxicity may occur chronically through acumulation over time or acutely in overdose.	Ingestion	Salicylates are acidic, and toxicity may lead to metabolic acidosis and impaired cellular energy production. Signs and symptoms may include tachypnea, gastrointestinal distress, dizziness, tinnitus, hyperprexia, confusion, abdominal pain, and vomiting. In severe cases, heart failure, dysrhythmia, and pulmonary edema may occur. In aspirin overdose, also anticipate decreased platelet aggregation.	Manage the airway and anticipate vomiting. Provide oxygen if indicated. Perform an EKG. Contact ALS in anticipation of cardiac problems. Obtain IV access and provide fluids as indicated.
Organophosphates	Organophosphate is the general name for esters of phosphoric acid. Many important biochemicals are organophosphates, including DNA and RNA. Organophosphates are the basis of many insecticides, herbicides, and nerve gases. The EPA lists organophosphates as very highly acutely toxic to bees, wildlife, and humans. Organophosphates are widely used as solvents, plasticizers, and EP additives.	Inhalation, Absorption, Ingestion	The effects of organophosphates can be remembered using the pheumonic SLUDGE: Salivation, Lacrimination, Urination, Defecation, Gastric Distress, Emesis. Other effects include muscle twitching, paralysis, seizures, AMS, bradycardia, hypotension, bronchospasm, and pulmonary edema.	Irrigate the patient with copious amounts of water, using soap if available. Suction as needed for airway management. Use the antidote kit if available.
Food toxins	Food poisoning is a general term for health problems arising from eating contaminated food. Food may be contaminated by bacteria, viruses, environmental toxins, or toxins present within the food itself, such as the poisons in some mushrooms or certain seafood. Symptoms of food poisoning usually involve nausea, vomiting and/or diarrhea. Some food-borne toxins can affect the nervous system.	Ingestion	Symptoms may include gastrointestinal problems: abdominal pain, nausea, vomiting, and diarrhea; signs mimicking an allergic reaction: flushing of the skin, severe headache, palpitations, itching/hives, dry mouth, and dizziness; cardiovascular and respiratory symptoms: hypotension, bronchospasm, angioedema, respiratory distress, and chest tightness	Consider albuterol for angioedema and bronchospasm. Contact ALS for possible diphenhydramine and antiemetics. Manage the airway. Obtain IV access and consider fluid administration, particularly in those with gastrointestinal complaints who may be dehydrated. If the patient has severe signs including airway obstruction, respiratory distress, or hypotension, treat for anaphylaxis.
Caustic Substances (Alkalis)	Alkalis are all Arrhenius bases, which form hydroxide ions when dissolved in water. Common properties of alkaline aqueous solutions include: Concentrated solutions are caustic (causing chemical burns). Alkaline solutions are slippery or soapy to the touch, due to the saponification of the fatty substances on the surface of the skin. Alkalis are normally water soluble.	Ingestion, Absorption, Inhalation	Strong alkalis result in liquification necrosis. Ingested, alkalis are more likely to erode tissue of the espohagus and stomach resulting in hemorrhage and severe pain. Patients may have skin irritation, burns of the mouth, drooling and difficulty swallowing, hematemesis, stridor, hoarseness, and difficulty breathing.	Remove all clothing and jewelry. Flush dermal and occular exposures with copious amounts of water. Water may be used to rinse away particles in the esophagus (check with Poison Control). Focus on supportive care and managing immediate life threats. Blind airways are contraindicated. Consider calling for ALS if available.
Corrosive Substances (Acids)	Corrosive acids are acids that are able to damage objects and materials over time, eventually completely destroying them. Sulfuric acid is an example, it’s so corrosive that it can literally melt steel in under a couple minutes.	Ingestion, Absorption, Inhalation	Contact with the skin may result in coagulation necrosis. Hydrogen fluoride causes symptoms of hypocalcemia including muscle spasm, irritability, tetany, paresthesias, seizures, and cardiac dysrhythmias. Significant ingestion can result in metabolic acidosis. Patients may have skin irritation, burns of the mouth, drooling and difficulty swallowing, hematemesis, stridor, hoarseness, and difficulty breathing.	Remove all clothing and jewelry. Flush dermal and occular exposures with copious amounts of water. Water may be used to rinse away particles in the esophagus (check with Poison Control). Focus on supportive care and managing immediate life threats. Blind airways are contraindicated. Consider calling for ALS if available.
Marine Animal Bites and Stings	Both freshwater and saltwater marine animals can be venemous. In most cases, they are painful, but do not cause serious illness. In warmer saltwater, beachgoers may encounter jellyfish, Portuguese man-of-war, stingrays, corals, or sea urchins. Catfish can be found in both fresh and saltwater.	Injection	Signs and symptoms may include a visible bite or sting with localized itching and a raised wheal. Severe cases may also present with nausea, vomiting, diarrhea, abdominal pain, parasthesia, lymphadenopathy, difficulty breathing or swallowing, chest pain, and muscle cramps.	For saltwater bites and stings, flush the area with saline, 70% isopropyl alcohol, or vinegar; avoid flushing with fresh water. Remove the stinger or nematocysts from the skin by scraping. Follow by flushing again. Apply heat to inactivate venom and relieve pain in localized reactions. In more severe cases with systemic symptoms, a loose constricting band (NOT a tourniquet) can help to slow the spread of the venom.
Hydrocarbons	Hydrocarbons include gasoline, butane, kerosene, lamp oils, mineral oil, and toluene. They are found in lighter fluid, stain remover, spray lubricant, glue, paint, and aerosol propellant. Toxicity of these substances varies widely.	Inhalation, Absorption, Inestion, Injection	Nervous system symptoms may include dizziness, confusion, ataxia, AMS, unresponsiveness, and apnea. Cardiovascular signs may include hypotension and sudden cardiac arrest. Gastrointestinal problems may include nausea, vomiting, diarrhea, and burning of the oropharynx. Skin contact may result in erythmia, dermatitis, and burns. Ingestion carries a high risk of aspiration, pneumonitis, dyspnea, and hypoxia.	Stabilize the airway. Contact Poison Control prior to administering sympathetic agonists like albuterol. Monitor the cardiac rhythm and anticipate dysrhythmias. Minimize the risk of vomitting and aspiration. Decontaminate skin by removing clothing and washing with soap and water.
Ethanol and Toxic Alcohols	Ethanol is a widely used andculturally accepted intoxicating substance; it is a CNS depressant. Methanol is used in many commercial products like windshield de-icer; It is also used for the illegal manufacture methamphetamine. Isopropanol is used as a household disinfectant and an industrial solvent. It is also used in cold medicine and personal care products. Ethylene glycol is used in antifreeze.	Ingestion, Absorption	Ethanol: slurred speech, ataxic gait, poor coordination, nystagmus, AMS, and behavioral changes. Methanol: symptoms of ethanol ingestion PLUS blindness, blurry, or cloudy vision; abdominal pain, and AMS (including coma). Isopropanol: AMS, ataxia, slurred speech, and abnormal behavior, abdominal pain, and GI bleeding. Ethylene glycol: unconsciousness, ataxia, slurred speech, seizures, tachypnea, tachycardia, nausea, and vomitting	Manage the airway and anticipate vomiting. Consider ventilating the patient in the case of respiratory depression. Anticipate hypotension and dysrhythmia. Perform an EKC. Obtain IV access and consider the need for fluids to maintain perfusion.
Plant Toxins	Plant toxins are substances produced by plants that is similar in its properties to extracellular bacterial toxin. These toxins may be present throughout the plant, or located only in one part of the plant. Some plants that are commonly eaten contain parts that are toxic. (eg. rhubarb). Toxins commonly found in plants include cyanide, colchicine, oxalic acid, amygdalin, bella donna alkaloids, glycosides, and solanine.	Ingestion, Absorption	Depending on the substance, signs and symptoms may include AMS, dehydration, flushing skin, blurred vision, hyperthermia, arrhythmias, changes in visual perception, skin irritation, anaphylaxis, and death.	Ensure an adequate airway, ventilation, and oxygenation. Anticipate vomiting. Obtain an IV in anticipation of hypotension, providing fluids as necessary. Perform an EKG. Call for ALS due to the high risk of cardiac changes treatable with in the paramedic’s scope of practice.