POISONING & SNAKE/ INSECT BITES LESSON -34 BY
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POISONING SNAKE INSECT BITES LESSON -34 BY PRAVIN DUDHE INSPPH POISONING SNAKE INSECT BITES OBJECTIVES Upon completion of this lesson you will be able to: Define poison and list the modes of entry List the signs symptoms of
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01
POISONING & SNAKE/ INSECT BITES LESSON -34 BY
PRAVIN DUDHE
INSP/PH<br>
PRAVIN DUDHE
INSP/PH<br>
02
POISONING & SNAKE/ INSECT BITES
OBJECTIVES
Upon completion of this lesson you will be able to:
Define poison and list the modes of entry
List the signs & symptoms of poisoning and steps involved in management of poisoning
Discuss CO poisoning and its management
Describe the general signs & symptoms of snake bites and steps in management
Describe the general signs & symptoms of scorpion bites and steps in management<br>
OBJECTIVES
Upon completion of this lesson you will be able to:
Define poison and list the modes of entry
List the signs & symptoms of poisoning and steps involved in management of poisoning
Discuss CO poisoning and its management
Describe the general signs & symptoms of snake bites and steps in management
Describe the general signs & symptoms of scorpion bites and steps in management<br>
03
I. DEVELOPMENT:
POISONS
DEFINITION:
Any substance that can impair or cause death of cell structure or function.
INTRODUCTION:
People are affected differently by the same dose of a poison. Some people may have developed a tolerance to a specific type of poison; however, even a small dose may be lethal to others.
A poison can enter the body four ways:
• Ingestion • Inhalation
• Absorption • Injection<br>
POISONS
DEFINITION:
Any substance that can impair or cause death of cell structure or function.
INTRODUCTION:
People are affected differently by the same dose of a poison. Some people may have developed a tolerance to a specific type of poison; however, even a small dose may be lethal to others.
A poison can enter the body four ways:
• Ingestion • Inhalation
• Absorption • Injection<br>
04
Scene Assessment: Always perform a scene assessment – safety first.
Protect yourself, your crew and others from the poison.
Use universal precautions.
Try to identify the source or substance involved.
Get as much information as you can, as quickly as possible.
Full details about the amount and type of substance that has been taken, including the time of ingestion or exposure have to be recorded
Perform the initial assessment and obtain the patient’s history. Signs and symptoms of poisoning will vary depending on the type of poison.<br>
Protect yourself, your crew and others from the poison.
Use universal precautions.
Try to identify the source or substance involved.
Get as much information as you can, as quickly as possible.
Full details about the amount and type of substance that has been taken, including the time of ingestion or exposure have to be recorded
Perform the initial assessment and obtain the patient’s history. Signs and symptoms of poisoning will vary depending on the type of poison.<br>
05
First ensure that:
The airway is clear
The patient is breathing adequately
The circulation is not compromised<br>
The airway is clear
The patient is breathing adequately
The circulation is not compromised<br>
06
GENERAL SIGNS AND SYMPTOMS OF POISONING
Nausea and/or vomiting
Headache
Abdominal pain
Altered mental status or coma
Seizures
Rapid or slow heart rate
High, normal or low blood pressure
Possible dilation or constriction of pupils<br>
Nausea and/or vomiting
Headache
Abdominal pain
Altered mental status or coma
Seizures
Rapid or slow heart rate
High, normal or low blood pressure
Possible dilation or constriction of pupils<br>
07
Shortness of breath
Injury to skin (discoloration, burns, injection marks, swelling)
Diarrhoea
Excessive salivation, tear from eyes and bronchial secretions<br>
Injury to skin (discoloration, burns, injection marks, swelling)
Diarrhoea
Excessive salivation, tear from eyes and bronchial secretions<br>
08
GENERAL MANAGEMENT FOR POISONING
Use universal precautions and secure the scene.
Use special protective equipment when necessary.
In all cases the airway must be adequately protected to avoid aspiration pneumonitis
Move the patient away from the source of the poisoning, especially in inhalation and absorbed poisoning.
Maintain open airway. Administer oxygen high flow.
Perform initial assessment. Do not perform mouth to mouth ventilation in inhaled or ingested poison cases. Use the BVM.
Call your local poison control centre, if available.
Perform physical exam.<br>
Use universal precautions and secure the scene.
Use special protective equipment when necessary.
In all cases the airway must be adequately protected to avoid aspiration pneumonitis
Move the patient away from the source of the poisoning, especially in inhalation and absorbed poisoning.
Maintain open airway. Administer oxygen high flow.
Perform initial assessment. Do not perform mouth to mouth ventilation in inhaled or ingested poison cases. Use the BVM.
Call your local poison control centre, if available.
Perform physical exam.<br>
09
For absorbed poisons:
Remove the patient’s clothing
Blot the poison from the skin with a dry cloth. If the poison is a dry powder, brush it off.
Flood the affected area with copious amounts of water
For ingested poisons:
Give the patient one or two glasses of water to dilute the poison.
Induced vomiting is contraindicated in poisoning with hydrocarbons, strong acids, alkalis, and corrosives.
Give the patient activated charcoal – 2 or 3 spoonfuls (50g) in eight ounces of water orally or if patient unconscious, through nasogastric tube<br>
Remove the patient’s clothing
Blot the poison from the skin with a dry cloth. If the poison is a dry powder, brush it off.
Flood the affected area with copious amounts of water
For ingested poisons:
Give the patient one or two glasses of water to dilute the poison.
Induced vomiting is contraindicated in poisoning with hydrocarbons, strong acids, alkalis, and corrosives.
Give the patient activated charcoal – 2 or 3 spoonfuls (50g) in eight ounces of water orally or if patient unconscious, through nasogastric tube<br>
10
Bring the suspected source; container, labels, or other evidence of the poison to the hospital.
Treat for shock.
Continuously monitor the patient.
If poison exposure is through direct eye contact, wash eyes thoroughly for at least 15 minutes with normal saline or water. Remove particles from palpebral fissures; and referral to ophthalmologist for further evaluation
Transport the patient to hospital if in periphery; if in hospital prepare for gastric lavage and wait for medical officer’s instructions.<br>
Treat for shock.
Continuously monitor the patient.
If poison exposure is through direct eye contact, wash eyes thoroughly for at least 15 minutes with normal saline or water. Remove particles from palpebral fissures; and referral to ophthalmologist for further evaluation
Transport the patient to hospital if in periphery; if in hospital prepare for gastric lavage and wait for medical officer’s instructions.<br>
11
Ingested Poisons:
An ingested poison is one that is introduced into the digestive tract by way of the mouth. In cases of ingested poison, all information should be obtained as quickly as possible while the initial assessment is performed. Look for signs of spilled liquids, tablets, capsules, poisonous substances or any container that can help you to identify the substance or source of poisoning. Signs and symptoms of ingested poisoning may be related to the digestive system<br>
An ingested poison is one that is introduced into the digestive tract by way of the mouth. In cases of ingested poison, all information should be obtained as quickly as possible while the initial assessment is performed. Look for signs of spilled liquids, tablets, capsules, poisonous substances or any container that can help you to identify the substance or source of poisoning. Signs and symptoms of ingested poisoning may be related to the digestive system<br>
12
Specific signs and symptoms of ingested poisons –
• Burns, swelling or stains around the mouth
• Abnormal breathing
• Diaphoresis
• Excessive salivation or foaming from the mouth<br>
• Burns, swelling or stains around the mouth
• Abnormal breathing
• Diaphoresis
• Excessive salivation or foaming from the mouth<br>
13
Inhaled Poisons:
Poisoning caused by fumes and vapours can be swift. The body absorbs inhaled poisons very rapidly. The longer the exposure, the worse the prognosis.
One may need to use special masks to gain access to the patient in a hazardous environment. Additional expert help may be required. Signs and symptoms of ingested poisoning are more related to the respiratory system.
Though it is important to give care immediately, do not enter the scene unless you are sure it is safe.<br>
Poisoning caused by fumes and vapours can be swift. The body absorbs inhaled poisons very rapidly. The longer the exposure, the worse the prognosis.
One may need to use special masks to gain access to the patient in a hazardous environment. Additional expert help may be required. Signs and symptoms of ingested poisoning are more related to the respiratory system.
Though it is important to give care immediately, do not enter the scene unless you are sure it is safe.<br>
14
Scene Assessment –
Assessment of inhaled poisons can be very dangerous. To ensure your safety, be wary of peculiar odours or visible vapors. If you are not properly equipped or trained, have trained personnel bring the patient to you. Do not enter the scene unless it is safe. Search for other victims. Try to get specific information on the poison and the patient’s medical information as soon as possible.
It is important to obtain the patient’s information or that of witnesses as soon as possible, to look for indications of inhaled poison.<br>
Assessment of inhaled poisons can be very dangerous. To ensure your safety, be wary of peculiar odours or visible vapors. If you are not properly equipped or trained, have trained personnel bring the patient to you. Do not enter the scene unless it is safe. Search for other victims. Try to get specific information on the poison and the patient’s medical information as soon as possible.
It is important to obtain the patient’s information or that of witnesses as soon as possible, to look for indications of inhaled poison.<br>
15
Common inhaled poisons include
• Carbon monoxide
• Carbon dioxide from industrial sites, sewers, and wells
• Chlorine gas (common around swimming pools)
• Fumes from liquid chemicals and sprays
• Ammonia
• Sulphur dioxide (used to make ice)<br>
• Carbon monoxide
• Carbon dioxide from industrial sites, sewers, and wells
• Chlorine gas (common around swimming pools)
• Fumes from liquid chemicals and sprays
• Ammonia
• Sulphur dioxide (used to make ice)<br>
16
• Anaesthetic gases (ether, nitrous oxide, chloroform)
• Dry cleaning solvents, degreasing agents, or fire extinguishers
• Industrial gases
• Incomplete combustion of natural gas
• Hydrogen sulphide (sewer gas)
Specific signs and symptoms for inhaled poisons
• History of inhalation abuse
• Chest pain or chest tightness
• Burning sensation in chest or throat
• Coughing, wheezing or rales<br>
• Dry cleaning solvents, degreasing agents, or fire extinguishers
• Industrial gases
• Incomplete combustion of natural gas
• Hydrogen sulphide (sewer gas)
Specific signs and symptoms for inhaled poisons
• History of inhalation abuse
• Chest pain or chest tightness
• Burning sensation in chest or throat
• Coughing, wheezing or rales<br>
17
Carbon monoxide poisoning:
CO is a colorless, odorless, non-irritant gas
Sources include: smoke from fires, car exhausts and incomplete burning of gas fires or cookers
CO binds to hemoglobin to form carboxyhaemoglobin and impairs the oxygen carrying capacity of blood Signs and symptoms include -
Early: headache, nausea, vomiting ataxia and nystagmus
Late: drowsiness, hyperventilation, shivering, hyper reflexia, central and peripheral cyanosis
Severe: convulsions, coma, hypotension, respiratory depression and death<br>
CO is a colorless, odorless, non-irritant gas
Sources include: smoke from fires, car exhausts and incomplete burning of gas fires or cookers
CO binds to hemoglobin to form carboxyhaemoglobin and impairs the oxygen carrying capacity of blood Signs and symptoms include -
Early: headache, nausea, vomiting ataxia and nystagmus
Late: drowsiness, hyperventilation, shivering, hyper reflexia, central and peripheral cyanosis
Severe: convulsions, coma, hypotension, respiratory depression and death<br>
18
Management:
Remove the patient away from the source of exposure
Ensure ABC is maintained and if not, institute appropriate measures
Start high flow oxygen 12L/mte as early as possible and continue during transport
Establish IV access and start maintenance fluid with NS; take care not to overload the circulatory system
If convulsions occur, give Inj. Diazepam very slow IV<br>
Remove the patient away from the source of exposure
Ensure ABC is maintained and if not, institute appropriate measures
Start high flow oxygen 12L/mte as early as possible and continue during transport
Establish IV access and start maintenance fluid with NS; take care not to overload the circulatory system
If convulsions occur, give Inj. Diazepam very slow IV<br>
19
Absorbed Poisons:
An absorbed poison is one that enters the body through contact with the skin. Examples of natural sources include poison ivy, poison sumac and poison oak.
Man-made sources include corrosives, insecticides, herbicides and cleaning agents. Signs and symptoms of absorbed poisons are more related to skin involvement Specific signs and symptoms of absorbed poisons
• History of exposures
• Liquid or residue on the skin
• Itching or irritation
• Rash or blisters<br>
An absorbed poison is one that enters the body through contact with the skin. Examples of natural sources include poison ivy, poison sumac and poison oak.
Man-made sources include corrosives, insecticides, herbicides and cleaning agents. Signs and symptoms of absorbed poisons are more related to skin involvement Specific signs and symptoms of absorbed poisons
• History of exposures
• Liquid or residue on the skin
• Itching or irritation
• Rash or blisters<br>
20
Injected Poisons:
An injected poison enters the body through a break in the skin. The break can be caused by a needle (drugs), an insect bite/sting or puncture.
Scene Assessment
During scene assessment, look for clues such as syringes and drug paraphernalia.
Inspect surroundings for animals, insects or marine life. Conduct initial assessment, paying close attention to airway breathing. Monitor mental status and priorities patients for transport. Obtain a focused history and perform a physical exam. Get information on the suspected poison or its origin. Try to find answers to the following questions:<br>
An injected poison enters the body through a break in the skin. The break can be caused by a needle (drugs), an insect bite/sting or puncture.
Scene Assessment
During scene assessment, look for clues such as syringes and drug paraphernalia.
Inspect surroundings for animals, insects or marine life. Conduct initial assessment, paying close attention to airway breathing. Monitor mental status and priorities patients for transport. Obtain a focused history and perform a physical exam. Get information on the suspected poison or its origin. Try to find answers to the following questions:<br>
21
• Is there a history of drug abuse?
• Any history of allergic reaction to bites or stings?
• How long from time of injection to onset of signs or symptoms?
Specific signs and symptoms of injected poisons
• Needle tracks
• Pain, swelling, or redness at the injection site
• History of bites or stings
• Bite mark or stinger embedded in the skin
• Numbness at the injury site after a few hours
• Other symptoms similar to ingested poisons<br>
• Any history of allergic reaction to bites or stings?
• How long from time of injection to onset of signs or symptoms?
Specific signs and symptoms of injected poisons
• Needle tracks
• Pain, swelling, or redness at the injection site
• History of bites or stings
• Bite mark or stinger embedded in the skin
• Numbness at the injury site after a few hours
• Other symptoms similar to ingested poisons<br>
22
Management for injected poisons
Use universal precautions and secure the scene.
1) Maintain open airway
2) Administer oxygen. Be alert for possible vomiting.
3) Protect yourself and the patient from repeated injections. Cut off patient’s clothing to protect from possible repeated insect stings or bites
4) For bee stings: remove the stinger together with the poison sac. Use a plastic card and scrape the skin’s surface to keep the sac from breaking inside the patient’s skin. Place a bag of ice or cold pack on the sting.<br>
Use universal precautions and secure the scene.
1) Maintain open airway
2) Administer oxygen. Be alert for possible vomiting.
3) Protect yourself and the patient from repeated injections. Cut off patient’s clothing to protect from possible repeated insect stings or bites
4) For bee stings: remove the stinger together with the poison sac. Use a plastic card and scrape the skin’s surface to keep the sac from breaking inside the patient’s skin. Place a bag of ice or cold pack on the sting.<br>
23
5) Bring all containers, labels, or other evidence of poisoning to the hospital.
6) Conduct a physical examn.
7) Treat for shock.
8) If bee sting or insect bite (other than snake bite) identified, give Inj. Suxamethonium hydrochloride (Efcorlin) 100mg IV stat, Inj, Avil 2cc IM stat and continuously monitor the vitals
8) Continually monitor the patient during transport<br>
6) Conduct a physical examn.
7) Treat for shock.
8) If bee sting or insect bite (other than snake bite) identified, give Inj. Suxamethonium hydrochloride (Efcorlin) 100mg IV stat, Inj, Avil 2cc IM stat and continuously monitor the vitals
8) Continually monitor the patient during transport<br>
24
SNAKE BITES
Quite common in certain areas. Signs and symptoms may be delayed for several hours. Death can occur quickly if the patient has an allergic reaction to the venom.
In India, vipers, cobras and kraits are the common poisonous species present
Treat all snakebites as poisonous.<br>
Quite common in certain areas. Signs and symptoms may be delayed for several hours. Death can occur quickly if the patient has an allergic reaction to the venom.
In India, vipers, cobras and kraits are the common poisonous species present
Treat all snakebites as poisonous.<br>
25
Signs and symptoms of poisonous snake bites
• Nausea and vomiting
• Weakness, paralysis
• Seizures, decreased level of consciousness
• Puncture wound
• Pain and/or burning sensation around the bite mark
• Blood oozing from the bite mark
• Discoloration and swelling
• Excessive salivation<br>
• Nausea and vomiting
• Weakness, paralysis
• Seizures, decreased level of consciousness
• Puncture wound
• Pain and/or burning sensation around the bite mark
• Blood oozing from the bite mark
• Discoloration and swelling
• Excessive salivation<br>
26
MANAGEMENT FOR SNAKE BITES
Use universal precautions and secure the scene.
Move the patient to a safe place.
Calm the patient and try to place him/her in a comfortable position.
Locate the bite marks and clean them with water and soap.
Immobilise the bitten part to minimize the spread of venom
Remove rings, bracelets and any restrictive garments from the affected extremity.<br>
Use universal precautions and secure the scene.
Move the patient to a safe place.
Calm the patient and try to place him/her in a comfortable position.
Locate the bite marks and clean them with water and soap.
Immobilise the bitten part to minimize the spread of venom
Remove rings, bracelets and any restrictive garments from the affected extremity.<br>
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Do not apply tourniquets, do not make incisions around the bite marks, and do not suck the venom from the wound.
Treat for shock and provide basic life support as needed.
Do not give the patient any food or drink.
If possible, capture the snake for species identification.
Administer oxygen
Establish IV access through wide bore venflon in unaffected limb and start 5% D or DNS maintenance.
Pain and vomiting managed symptomatically but do not give narcotic analgesics
Continually monitor the patient during transport.<br>
Treat for shock and provide basic life support as needed.
Do not give the patient any food or drink.
If possible, capture the snake for species identification.
Administer oxygen
Establish IV access through wide bore venflon in unaffected limb and start 5% D or DNS maintenance.
Pain and vomiting managed symptomatically but do not give narcotic analgesics
Continually monitor the patient during transport.<br>
28
Only anti-venin works as an antidote for a poisonous snake bite and hence transport the patient as early as possible for hospital care. Anti-venin serum must be administered on the basis of three criteria:
Specificity (appropriate to the snake species)
Appropriate quantity
Within the shortest possible time
Due to possibility of anaphylactic reaction, must be administered only under medical supervision<br>
Specificity (appropriate to the snake species)
Appropriate quantity
Within the shortest possible time
Due to possibility of anaphylactic reaction, must be administered only under medical supervision<br>
29
SCORPION BITES
Some species are lethal, though common species found in India cause only peripheral effects; However, the site of sting, age of the victim (like infants & geriatric pts) may adversely affect outcome
Signs & Symptoms:
Sharp pain followed by numbness, parathesiae at sting site
Sweating
Piloerection/ Muscle fasiculations
Tachycardia/Hypertension
Pulmonary oedema
Drowsiness<br>
Some species are lethal, though common species found in India cause only peripheral effects; However, the site of sting, age of the victim (like infants & geriatric pts) may adversely affect outcome
Signs & Symptoms:
Sharp pain followed by numbness, parathesiae at sting site
Sweating
Piloerection/ Muscle fasiculations
Tachycardia/Hypertension
Pulmonary oedema
Drowsiness<br>
30
Management:
Local compresses at bite site; Remove, if sting still embedded
Oral Analgesics for pain
In severe cases, airway support and oxygen
Referral to hospital care<br>
Local compresses at bite site; Remove, if sting still embedded
Oral Analgesics for pain
In severe cases, airway support and oxygen
Referral to hospital care<br>
31
ANY QUESTIONS ?<br>